Quality in Managed Long-Term Services and Supports Programs. C. Verification of Service Receipt

11/01/2013

Verifying the delivery of home and community-based LTSS services is a critical component of managed care oversight due to the vulnerability of populations served. Late or missed visits, especially those that provide assistance in essential every day activities, place the member at potential risk of untoward outcomes. Moreover, managed care entities are required by federal regulation to monitor delivery of services by providers as well as take corrective action if service delivery is late or missed.15 In MLTSS, this requirement is closely connected to ensuring member safeguards, and important to allaying beneficiary and advocate fears that MCOs "skimp" on services in order to contain costs and maximize profit.

Five out of the eight programs verify service receipt against what was authorized in the service plan (Arizona, Michigan, Pennsylvania, Tennessee, Wisconsin); they compare whether members receive the services identified in their service plans. Two programs (Michigan, North Carolina) verify service receipt against reimbursement; the latter is a proxy approach because verification in this instance is not directly tied to the service plan. In seven out of the eight study states reviewed, states monitor service receipt retrospectively through reports submitted by the MCO.

Only in Tennessee is service verification done on a real-time basis. Tennessee utilizes an electronic visit verification (EVV) system where direct care providers clock-in and clock-out via phone from the member's home. The days and times that providers are expected to arrive are programmed into the system; if the worker does not clock-in within 15 minutes of the scheduled start time, an alert is sent to both the provider and the MCO. The MCO/provider is expected to deploy back-up workers and they, as well as the state, have the ability to track whether and when the replacement worker clocked in. The EVV system produces reports on missed and late visits by MCO, provider and service type.

The frequency of MCO reports on service verification varies from monthly in Arizona, and quarterly in Pennsylvania, to annually in North Carolina and Michigan.

Although its approach is still retrospective in nature, Arizona has implemented a "gap report" strategy that the MCO must submit monthly. What distinguishes Arizona from the other retrospective approaches is that their reporting requirements go beyond counts of missed visits and includes the reason for the service gap as well as actions taken at the individual level to address the missed visit.

While the retrospective validation approach is the most common, unless the MCO has a systematic mechanism for being alerted in a timely fashion when service delivery is late or missed, deployment of needed back-up help cannot be assured. On the other hand, while the EVV system in Tennessee is considered by many as a promising practice, it does have potential cost implications associated with up-front installation, as well as costs associated with staffing resources to monitor the EVV system for no-shows. For this approach to be most effective, it needs to be monitored (by providers and the MCO) in real-time so that when an alert is sent indicating a worker no-show, either the provider or MCO proactively contacts the member to assess the immediate need, and then deploys a back-up worker as necessary. In addition, the EVVs approach may also pose some challenges for verifying self-directed services. One of the features of self-direction is that it allows members to have flexibility about the day and time of day a service is delivered. As currently configured, EVV is driven by the date/time the worker is supposed to arrive and if a member changes this without formally requesting a change, then a worker no-show alert will be triggered. Moving forward it will be instructive to follow how Tennessee addresses this seeming constraint in the EVV system.

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