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OptumHealth NYC BHO Provider Training. Agenda. Introductions Overview of Optum Review of Contract between Optum and the Offices Provider Tools & Submission Process Initial start up experience Questions and Answers. Optum New York Staff.

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Presentation Transcript
agenda
Agenda
  • Introductions
  • Overview of Optum
  • Review of Contract between Optum and the Offices
  • Provider Tools & Submission Process
  • Initial start up experience
  • Questions and Answers
optum new york staff
Optum New York Staff
  • William Fishbein, Executive Director Optum New York City BHO
    • Amy Freeman, Behavioral Health Clinical Manager
    • Margaret “Peggy” Elmer, Behavioral Health Clinical Manager
    • Joni Richter, Behavioral Health Intake Manager
    • Erik Geizer, Quality Assurance/Training Manager
    • Linda West, Reporting & Technology Manager
    • Michael Silver, Psychiatrist
    • Marc Minick, Community Liaison
    • Mark Simmons, Community Liaison
optum organizational overview
Optum Organizational Overview
  • Optum is a health services business dedicated to making the health system work better for everyone
  • We are comprised of three market-leading business segments:
    • OptumHealth
    • OptumInsight
    • OptumRx
  • Optum serves the entire health ecosystem
    • 250,000 health professionals and physician practices
    • 6,200 hospitals and facilities
    • more than 270 state and federal government agencies
    • over 2,000 health plans; two of every five FORTUNE 500 employers; and one in every five U.S. consumers.
our business context
Our Business Context

UHG

UNH=Publicly Traded Registrant (NYSE)

UnitedHealthcare-Health Benefits

Optum—Health Services

  • Information and technology-enabled health services platform, encompassing:
    • Technology solutions
    • Intelligence and decision support tools
    • Health management and interventions
    • Administrative and financial services
    • Pharmacy solutions
  • Health care coverage and benefits businesses, unified under a master brand
    • Employer and Individual
    • Community and State
    • Medicare and Retirement

Helping to make the health care system work better for everyone

Helping people live healthier lives

populations covered under the program
Populations covered under the program
  • All fee-for-service admissions to OMH-licensed psychiatric units (all ages) in general hospitals (Article 28 hospitals).
  • Fee-for-service children and youth admitted to OMH licensed private psychiatric hospitals (Article 31 hospitals).
  • Fee-for-service direct admissions to OMH State-operated children’s psychiatric centers or children’s units of psychiatric centers.
  • Fee-for-service OASAS Certified Part 816 Inpatient Detoxification Services (Article 28/32).
  • Fee-for-service OASAS certified hospital (Art 28/32) or freestanding (Article 32 only) Part 818 Chemical Dependence Inpatient Rehabilitation Services.
  • Each new episode of care initiated by Article 31 OMH designated Specialty Clinics for children/youth (up to 19th birthday) diagnosed as having a Serious Emotional Disturbance (SED) who are covered by Medicaid Managed Care
functions of the bho include
Functions of the BHO include:
  • Optum will complete initial reviews for applicable services of Fee-For-Service Medicaid members within 72 hours after admission or by 5pm of the next business day following notification of the admission by the provider, whichever is later. Follow-up reviews will be conducted at regular intervals.

Concurrent

Review

Discharge Planning & Tracking

  • Optum will engage with the inpatient provider with respect to discharge planning for applicable admissions
  • Enhanced efforts will be employed for inpatients identified as “High Need Individuals”

Tracking of Children with SED

  • Each new episode of care initiated for a Medicaid Managed Care SED child will be tracked for reporting back to the State

Provider Profiling /Analytics

Community Liaisons

  • Historical Clinical data will be provided by the Offices to the BHOs
  • Data elements specific to each inpatient admission and provider will be collected by the BHO and shared with the Provider and the Offices.
  • Metric Reporting will be provided back to the Offices

Facilitation of Cross System Linkages

  • Optum will work with the Offices and the Providers to determine cross system linkages for adults and children with mental health conditions and substance use disorders

Quality Initiative

  • Optum will devise a quality assurance program to monitor the quality of work performed within the contract
review of contract
Review of Contract

Provider Community

The Offices

Optum

Provider Community

  • Notify Optum of admission
  • (Portal, Fax or Telephonic)
  • Notify Optum regarding Children with SED
  • Performs initial/ concurrent reviews
  • Monitoring discharge planning & post-discharge services
  • Tracking of children with SED
  • Provider profiling
  • Facilitation of cross system linkage
  • Quality Initiative
  • Treatment History Form
  • Follows concurrent review & discharge monitoring processes
  • Supplies Optum with guidance to perform tasks
  • Supplies historical clinical data
  • Supports access to cross systems
what we need from you
What we need from you:

Partner with Us

  • Submit requested information to be used in initial/concurrent reviews, discharge planning/tracking, SED tracking, and cross system facilitation
  • Use your dedicated Care Advocate and Community Liaison as a part of your team

Engage in the Process

  • Follow the concurrent review & discharge planning/trackingprocesses
  • Identify Cross System Linkages
  • Provide data as requested
  • Use the tools provided
  • Don’t hesitate to ask us questions
  • Clinical questions can be directed to the Care Advocate or to: [email protected]
  • General questions can be directed to the Executive Director & Community Liaisons or to [email protected]
  • ProviderConnect technical questions/issues can be directed to: [email protected]

Ask Questions

  • Let us help you!
  • We want your feedback.

Other

provider tool review methods for submission
Provider Tool Review- Methods for submission

Fax

  • Individual Information Matrix
  • - Within 24 hours of admission
  • - Concurrent Review at established intervals
  • - Discharge by the date of discharge but no later than within 24 hours post discharge.

Fax #

  • Clinical Fax: (877) 283-0555

Telephonic

  • Toll-free: (866) 505-3398
  • Dedicated Care Advocate assigned by Facility

Portal

  • New provider portal: www.optumhealthnyc.com
  • ProviderConnect software
submission time frames
Submission time frames
  • Childen with Serious Emotional Disturbance (SED) Report
    • Submitted for each new episode of care for SED children covered by Medicaid managed care
    • Providers to complete and submit within 3 business days of initiation of services
    • Submit via fax, portal, or telephonic
  • Individual Information Matrix Form (inpatient providers)
      • Admission
        • Providers to notify their assigned BHO within 24 hours of admission, except that for admissions which occur on a weekend or holiday such notification would be required by 5 P.M. of the next business day following such week-end or holiday.
      • Concurrent Review
        • Optum will complete initial reviews for applicable services of Fee-For-Service Medicaid members within 72 hours after admission or by 5pm of the next business day following notification of the admission by the provider, whichever is later. Follow-up reviews will be conducted at regular intervals.
      • Discharge Planning
        • Provider to complete and submit by the date of discharge but no later than within 24 hours post discharge.
  • Forms located on the Optum NYC BHO Provider Portal : www.optumhealthnyc.com
experience since start up
Experience since start up
  • Volume
    • 65 admissions per day (average)
    • 40% portal, 38% fax, 22% telephonic
  • Major initial activities
    • Initiating review process
    • Provider outreach
    • Provider training
    • Connecting with stakeholder groups
    • Completion of staff hiring and training efforts
initial challenges
Initial challenges
  • Different review process
  • Provider resources
  • Usage of web portal
  • Data submission for SED children
  • Engagement of some inpatient providers
challenges on the near horizon
Challenges on the near horizon
  • Working with health homes
  • Integration of peer support services
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