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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: NYCBHO.Clinical@optum.com

  • General questions can be directed to the Executive Director & Community Liaisons or to NYCBHO.General@optum.com

  • ProviderConnect technical questions/issues can be directed to: NYCBHO.tech@optum.com.

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