Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.13-003 - Provider Manual Update Transmittal Episode 1-13 and Provider Manual Update Transmittal Sec I-2-13

(17) Psychology Services

V. APPLICATION: Complete details including technical information regarding specific quality and reporting metrics, performance thresholds and incentive adjustments are available in the Episodes of Care Medicaid Manual available at https://www.medicaid.state.ar.us/InternetSolution/Provider/docs/docs.aspx and also at the Arkansas Health Care Payment Improvement Initiative website at http://www.paymentinitiative.org/Pages/default.aspx.

Effective for dates of service on or after October 1, 2012, the defined scope of services within the following episode(s) of care are subject to incentive adjustments:

(1) Rehabilitative Services for Persons with Mental Illness (RSPMI)

A. Episode subtypes:

There are no subtypes for this episode type.

B. Episode trigger:

A live birth on a facility claim

C. Episode duration:

Episode begins 40 weeks prior to delivery and ends 60 days after delivery

D. Episode services:

All medical assistance with a pregnancy-related ICD-9 diagnosis code is included. Medical assistance related to neonatal care is not included.

A. Limited prenatal care (i.e., pregnancy-related claims) provided between start of episode and 60 days prior to delivery

B. Delivering provider did not provide any prenatal services

C. Episode has no professional claim for delivery

D. Pregnancy-related conditions: amniotic fluid embolism, obstetric blood clot embolism, placenta previa, severe preeclampsia, multiple gestation [GREATER THAN OR EQUAL TO]3, late effect complications of pregnancy/childbirth, puerperal sepsis, suspected damage to fetus from viral disease in mother, cerebrovascular disorders

E. Comorbidities: cancer, cystic fibrosis, congenital cardiovascular disorders, DVT/pulmonary embolism, other phlebitis and thrombosis, end-stage renal disease, sickle cell, Type I diabetes

A. Duration of less than 4 months

B. Small number of medical and/or pharmacy claims during the episode

C. Beneficiaries with any comorbid behavioral health condition or developmental disability

D. Beneficiaries age 5 or younger and beneficiaries age 18 or older at the time of the initial claim

A. Episode subtypes:

There are no subtypes for this episode type.

B. Episode trigger:

Inpatient admission with a primary diagnosis code for heart failure

C. Episode duration:

Episodes begin at inpatient admission for heart failure. Episodes end at the latter of 30 days after the date of discharge for the triggering admission or the date of discharge for any inpatient readmission initiated within 30 days of the initial discharge. Episodes shall not exceed 45 days post-discharge from the triggering admission.

D. Episode services:

The episode will include all of the following services rendered within the episode's duration:

E. Continuous Medicaid Enrollment

For the purpose of the CHF episode, the beneficiary must be enrolled in Medicaid beginning at least 30 days before the start of the episode and maintain continuous enrollment in Medicaid for the duration of the episode.

A. Episode subtypes:

There are no subtypes for this episode type.

B. Episode trigger:

A surgical procedure for total hip replacement or total knee replacement

C. Episode duration:

Episodes begin 30 days prior to the date of admission for the inpatient hospitalization for the total joint replacement surgery and end 90 days after the date of discharge.

D. Episode services:

The following services are included in the episode:

A. Episode subtypes:

There are no subtypes for this episode type.

B. Episode trigger:

ODD episodes are triggered by three medical claims with a primary diagnosis of ODD.

C. Episode duration:

The standard episode duration is a 90-day period beginning at the time of the first trigger claim. Claims for a beneficiary are tracked for 180 days following the closure of the 90-day standard episode to determine the episode remission rate quality metric.

D. Episode services:

All claims with a primary diagnosis of ODD. Behavioral health medications will be excluded from the episode, but utilization of medications will be tracked as a quality metric for providers "to pass."

Notwithstanding any other provisions in the provider manual, medical assistance included in an ODD episode shall not be subject to prior authorization requirements.

A. Beneficiaries not continuously enrolled in Medicaid during the 90-day episode

B. Beneficiaries with any comorbid behavioral health condition

C. Beneficiaries age 5 or younger and beneficiaries age 18 or older at the time of the initial claim

A. Quality measures "to pass":

B. Quality measures "to track":

A. The acceptable threshold is $2,671.

B. The commendable threshold is $1,642.

C. The gain sharing limit is $984.

D. The gain sharing percentage is 50%.

E. The risk sharing percentage is 50%.

A. Episode subtypes:

There are no subtypes for this episode type.

B. Episode trigger:

Outpatient colonoscopy procedure (including balloon, biopsy, polypectomy, etc.) and primary or secondary diagnosis indicating conditions that require a colonoscopy (e.g., colorectal bleeding, hemorrhoids, anal fistula, neoplasm of unspecified nature). For a complete list of diagnoses, please see the code sheet associated with the episode.

C. Episode duration:

Episodes begin with the initial consult with the performing provider (within 30 days prior to procedure) and end 30 days after the procedure.

D. Episode services:

The episode will include all of the following services rendered within the episode's duration:

A. Beneficiaries with select comorbid conditions within 365 days prior to procedure or during episode (e.g., inflammatory bowel disease, select cancers, select transplants, etc.). For a complete list of comorbidities, please see the code sheet associated with the episode.

B. Beneficiaries under the age of 18 or over the age of 64 at the time of the procedure

C. Beneficiaries who are pregnant during the episode

D. Beneficiaries with dual enrollment in Medicare/Medicaid (i.e., dual-eligible)

E. Beneficiaries who do not have continuous Medicaid enrollment for the duration of the episode

F. Beneficiaries who die in the hospital during the episode

G. Beneficiaries with patient status "left against medical advice" during the episode

A. Quality measures "to pass":

B. Quality measures "to track":

A. The acceptable threshold is $886.

B. The commendable threshold is $796.

C. The gain sharing limit is $717.

D. The gain sharing percentage is 50%.

E. The risk sharing percentage is 50%.

A. Episode subtypes:

There are no subtypes for this episode type.

B. Episode trigger:

Episode is triggered by an outpatient tonsillectomy, adenoidectomy, or adeno-tonsillectomy procedure, and a primary or secondary diagnosis (Dx1 or Dx2) indicating conditions that require tonsillectomy/adenoidectomy (e.g., chronic tonsillitis, chronic adenoiditis, chronic pharyngitis, hypertrophy of tonsils and adenoids, obstructive sleep apnea, insomnia, peritonsillar abscess). For a complete list of diagnoses, please see the code sheet associated with the episode.

C. Episode duration:

Episodes begin with the initial consult with the performing provider (within 90 days prior to procedure) and end 30 days after the procedure.

D. Episode services:

The following services are included in the episode:

A. Beneficiaries who are under the age of 3 or above the age of 21 at the time of the procedure

B. Beneficiaries with select comorbid conditions (e.g., Down syndrome, cancer, severe asthma, cerebral palsy, muscular dystrophy, myopathies). For a complete list of comorbidities, please see the code sheet associated with the episode.

C. Beneficiaries with an Uvulopalatopharngoplasty (UPPP) on date of procedure

D. Beneficiaries with a BMI[GREATER THAN]50

E. Beneficiaries with dual enrollment in Medicare/Medicaid (i.e., dual-eligible)

F. Beneficiaries who do not have continuous Medicaid enrollment for the duration of the episode

G. Beneficiaries who die in the hospital during the episode

H. Beneficiaries with a patient status of "left against medical advice" during the episode

1) adenoidectomy and

2) tonsillectomy/adeno-tonsillectomy.

A. Quality measures "to pass":

B. Quality measures "to track":

A. The acceptable threshold is $1,069.

B. The commendable threshold is $1,019.

C. The gain sharing limit is $824.

D. The gain sharing percentage is 50%.

E. The risk sharing percentage is 50%.

A. Episode subtypes:

There are no subtypes for this episode type.

B. Episode trigger:

Episode is triggered by open or laparoscopic cholecystectomy procedure, and a primary or secondary diagnosis (Dx1 or Dx2) indicating conditions related to cholecystectomy (e.g., cholelithiasis, cholecystitis). For a complete list of diagnoses, please see the code sheet associated with the episode.

C. Episode duration:

Episodes begin with the cholecystectomy procedure and end 90 days post-procedure

D. Episode services:

The following services are included in the episode:

A. Beneficiaries who are less than or equal to the age of 1 or greater than or equal to the age of 65 at the time of the procedure

B. Beneficiaries with select comorbid conditions or past procedures within 365 days or 90 days after cholecystectomy (e.g., HIV, cancer, sickle cell anemia, transplants). For a complete list of comorbidities, please see the code sheet associated with the episode.

C. Beneficiaries with a pregnancy 30 days prior to a cholecystectomy procedure to 90 days after said cholecystectomy procedure

D. Beneficiaries with ICU care within 30 days prior to the cholecystectomy procedure

E. Beneficiaries with acute pancreatitis, cirrhosis, or cholangitis concurrent with procedure

F. Beneficiaries with open cholecystectomy procedure (includes laparoscopic converted to open and surgeries initiated open)

G. Beneficiaries who die in the hospital during the episode

H. Beneficiaries with a patient status of "left against medical advice" during the episode

I. Beneficiaries with dual enrollment in Medicare/Medicaid (i.e., dual-eligible)

J. Beneficiaries who do not have continuous Medicaid enrollment for the duration of the episode

A. Quality measures "to pass":

B. Quality measures "to track":

A. The acceptable threshold is $2,048.

B. The commendable threshold is $1,614.

C. The gain sharing limit is $1,190.

D. The gain sharing percentage is 50%.

E. The risk sharing percentage is 50%.

1. An "episode" refers to a defined collection of related Medicaid-covered health care services provided to a specific Medicaid beneficiary.

2. An "episode type" is defined by a diagnosis, health care intervention, or condition during a specific timeframe (or performance period).

3. "Thresholds" are the upper and lower reimbursement benchmarks for an episode of care.

1. Performance will be aggregated and assessed over a specified period of time ("performance period"). For each PAP, the average reimbursement across all relevant episodes completed during the performance period will be calculated, based on the set of services included in the episode definition published and made available to providers.

2. Some episodes may be excluded and reimbursement for some episodes may be adjusted in this calculation, based on clinical or other factors, as described in the definition of each episode.

3. The average adjusted reimbursement of all episodes for the PAP during the performance period will be compared to thresholds established by Medicaid with advice from providers.

4. If the average adjusted episode reimbursement is lower than the commendable threshold and the PAP has documented that the quality requirements established by Medicaid for each episode type have been met, Medicaid will make a positive supplemental payment to the PAP. This payment will be equal to the difference between the average adjusted episode reimbursement and the commendable threshold, multiplied by the number of episodes included in the calculation and multiplied by a gain sharing percentage for the episode. Where necessary, a gain sharing limit will be established to avoid incentives for underutilization. PAPs with average adjusted episode reimbursement lower than the gain sharing limit will receive a supplemental payment calculated as though their average adjusted episode reimbursement were equal to the gain sharing limit.

5. If the average episode reimbursement is higher than the acceptable threshold, the PAP will incur a negative supplemental payment. This payment to Medicaid will be equal to the difference between the acceptable threshold and the average adjusted episode reimbursement, multiplied by the number of episodes included in the calculation and multiplied by a risk sharing percentage defined by Medicaid for the episode.

1. The threshold process aims to incentivize high-quality clinical care delivered efficiently, and to consider several factors including the potential to improve patient access, the impact on provider economics and the level and type of practice pattern changes required for performance improvement.

2. The acceptable threshold is set such that average cost per episode above the acceptable threshold reflects unacceptable performance, which could result from a large variation from typical performance without clinical justification (e.g., individual provider variation) or from system-wide variance from widely accepted clinical standards.

3. The commendable threshold is set such that outperforming the commendable threshold represents quality care provided at a lower total reimbursement, which would result from care at meaningfully better than current average reimbursement in Arkansas, consistent with good medical outcomes. Medicaid may take into consideration what a clinically feasible target would be, as demonstrated by historical reimbursement variance in Arkansas.

4. The gain-sharing limit is set to avoid the risk of incentivizing care delivery at a cost that could compromise quality.

5. The gain and risk sharing percentages aim to recognize required provider investment in practice change and will be set at a sustainable level for Medicaid.

1. Supplemental payment incentives for each PAP take into account provider-level adjustments, which may include stop-loss provisions, adjustments for cost-based facilities, adjustments or exclusions for providers with low case volume or any combination thereof.

2. Stop-loss protection: Unless provided otherwise for a specific episode of care, a provider's net negative incentive adjustment (total positive adjustments minus total negative adjustments) for all episodes of care during any performance period shall not exceed ten percent (10%) of the provider's gross Medicaid reimbursements during that performance period.

3. Temporary stop-loss provisions may apply when necessary to ensure access to care.

4. Providers that receive cost-based or PPS-based reimbursement are reimbursed as specified in the corresponding provider manual(s), but are subject to positive and negative supplemental payment incentives in order to achieve statewide improvement in quality and efficiency. For episodes including services furnished by providers who receive at exceptional reimbursement levels, reimbursements attributed to PAPs for the purpose of calculating performance are computed as if the provider did not receive exceptional reimbursement.

5. Minimum case volume thresholds exclude from supplemental payment incentives those providers whose case volume includes too few cases to generate a robust measure of performance. Medicaid will set a minimum case volume for each episode type. PAPs who do not meet the minimum case volume for an episode type will not be eligible for positive or negative supplemental payments for that episode type.

1. For each episode type, there will be a set of quality metrics "to pass" and a set of quality metrics "to track." These quality metrics may be based on claims data or based on additional data specified by Medicaid, which PAPs will be required to report.

2. To quality for positive supplemental payments, PAPs must report all required data and meet specific thresholds for the quality metrics "to pass."

3. Providers who do not report data or who do not meet minimum quality thresholds may still incur negative supplemental payments if their average adjusted episode reimbursement exceeds the acceptable threshold.