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Psychiatrist for CA -State, Acute inpatient hospital chart reviews,non-hospital chart reviews

LotusUSA, Inc


Location:
California
Date:
07/26/2018
2018-07-262018-08-25
Work Type:
Contract
Shift:
2nd Shift
Specialties:
  • Psychiatry
LotusUSA, Inc
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Job Details

Period Of Performance:The term of the resulting agreement is expected to be 34 months and is anticipated to be effective from 9/17/2018 through 6/30/2021.

Place of Performance:Throughout the State of California

Onsite Review Hourly Rate $215


Office Review/Consultation $ 215

2nd Level TAR
• Review: 1 billable hour per every five* appealed days reviewed
• Report/Letters: 1 billable hour per every 2 appealed days reported
*any review which is less than five appealed days will be prorated based on the appealed days

Short Doyle/Medi-Cal acute psychiatric hospital appeals review/report
• 1 billable hour per every five appealed days reviewed and reported


Non-Hospital Chart Review appeals review/report
• 1 billable hour per every five appealed days reviewed and reported
Consultation/training from Contractor’s office (no travel involved)
• Reimbursed by the clock hour 

Service Overview

Contractor agrees to provide to the California Department of Health Care Services (DHCS) the services described herein.

The Contractor will perform Short-Doyle/Medi-Cal (SD/MC) acute psychiatric inpatient hospital chart reviews, Mental Health Plan (MHP) Medi-Cal Specialty Mental Health Services (SMHS) non-hospital chart reviews, Mental Health Rehabilitation Center/Psychiatric Health Facility (MHRC/PHF) licensing reviews; second level Treatment Authorization Request (TAR) appeal case summaries, decision letters and lawsuit letters; and professional consultation.

Service Location

The services shall be performed at locations throughout the State of California for SD/MC psychiatric inpatient hospital and MHP non-hospital chart reviews, MHRC/PHF licensing reviews and certain consultative functions requiring travel and at the Contractor's office location for second level TAR appeal case summaries, decision letters and lawsuit letters, and certain consultative functions not requiring travel.

Service Hours
The services shall be provided during normal State agency working hours of 8:00 a.m. to 5:00 p.m., Monday through Friday, excluding official holidays for those services provided in the field and during normal Contractor working days and hours, excluding national and State holidays for contract deliverables generated at the Contractor's main office location

Services to be Performed
The Contractor agrees to perform the following duties during the contract term:
A. Short-Doyle/Medi-Cal (SD/MC) acute psychiatric inpatient hospital chart reviews. The contractor will participate in the chart review of SD/MC acute psychiatric inpatient hospitals in order to

(1) make medical necessity determinations,

(2) assess the appropriateness and adequacy of medication strategies and monitoring;

(3) assess the appropriateness and adequacy of other aspects of medical treatment, and to

(4) assess the effectiveness of utilization management activities.

1) The chart review will consist of an examination of patient records to determine medical necessity (in accordance with the requirements in California Code of Regulations (CCR), Title 9, section 1820.205), appropriateness of care, establishment of a treatment plan, and identification of inappropriate payments for services. The contractor will document chart review findings for each day/claim reviewed and provide documented evidence to support each recoupment or Plan of Correction (POC) in worksheets provided by DHCS.

2) Approximately 6-9 SD/MC psychiatric inpatient hospital chart reviews are scheduled per fiscal year (July-June). The up to five (5) day chart reviews take place at DHCS or onsite at SD/MC hospital campuses located through California. Travel is required for this contract activity and unless provided a different schedule by DHCS, the Contractor is required to be present onsite at the hospital campus or at the department for the duration of the review to perform this contract activity.

3) On the first day of each review the Contractor will attend an entrance conference with hospital and local Mental Health Plan staff. At the conclusion of each review, the Contractor will attend an exit conference. During the exit conference, the Contractor will be responsible for discussing the review findings which relate to the documentation of medical necessity, and for responding to questions about these findings.

 

B. Mental Health Rehabilitation Center (MHRC) and Psychiatric Health Facility (PHF) licensing reviews.
The Contractor will perform MHRC/PHF licensing reviews in order to assess compliance with regulations related to clinical care, medication management, pharmacy, dietary services and nursing services. The Contractor will summarize findings in a written report including recommending Plans of Correction (POC) where the facility fails to meet regulations. Approximately 4-6 licensing reviews located across the state of California are conducted per fiscal year. Contractors are utilized for this work on an as needed basis.

C. Second level Treatment Authorization Request (TAR) appeal case summaries and decision letters and TAR lawsuit letters.

1) The Contractor will review second level TAR appeals for psychiatric inpatient hospital days denied at the first level of appeal by the County Mental Health Plan (MHP) and prepare TAR appeal case summaries that shall contain patient history, patient hospital days appealed and explanations for upholding or reversing first level decisions.

2) The Contractor will prepare decision letters for second level TAR appeals submitted by providers for TARs requesting payment for hospital days denied by the MHP at the first level of appeal. The decision letters shall contain patient history, patient hospital days appealed, and decisions for upholding or reversing first level decisions along with explanations why medical necessity was or was not met for each day appealed.

3) The Contractor will prepare TAR lawsuit letters in response to TAR lawsuits filed by hospital providers against DHCS contending DHCS's denial of hospital providers' second level TAR appeals. TAR lawsuit letters shall summarize documentation for the denied patient days (acute and administrative) and clearly explain why the documentation for each denied day met/did not meet medical necessity criteria for acute days (CCR, Title 9, section 1820.205) and/or met/did not meet criteria for administrative days (CCR, Title 9, section 1820.2200) (5)).

4) Timelines for completion of TAR Appeals:

If it becomes necessary a Contractor on occasion may be issued up to five (5) TAR Appeals at one time. Five (5) is the maximum number of TAR appeals that will be issued to a Contractor at any one time with a maximum of 300 appealed days.

Exception: If an occasion arises where there are more than five (5) appeals that will be sent out to one Contractor the timeline will be set at that time based on the number of records and appealed days.

 

D. SD/MC acute psychiatric inpatient hospital chart review appeals and MHP Medi-Cal SMHS non-hospital chart review appeals.
When requested by DHCS, the Contractor will review and evaluate SD/MC psychiatric inpatient hospital and/or MHP Med-Cal specialty mental health service non-hospital chart review appeal documentation for those claims that were recouped during a DHCS chart review and are being appealed by the MHP. The Contractor will prepare review worksheets on appealed days/claims and provide recommendations (decisions) to uphold or reverse the initial chart review findings including explanations why medical necessity and/or all other requirements were or were not met for each decision
E. Consultation Related to Special Projects.
The Contractor will provide unscheduled/customized clinical consultation for focused reviews or other ad hoc clinically oriented activities required by regulation and statute to maintain public safety and/or regulatory/statutory adherence. Travel may be required to perform this contract activity.
F. Orientation Training.
The Contractor will participate in one day of orientation training addressing the requirements in this Scope of Work. The training may be held onsite at DHCS headquarters or via teleconference/web conference.

Requirements

The Contractor will be in possession of and maintain a current medical license (as physician and surgeon) (M.D., D.O.) in good standing in the State of California and board eligibility or board certification as a Psychiatrist by the American Board of Psychiatry and Neurology for the duration of the contract term AND/OR maintain proof of three years of practicing psychiatry in the State of California or three years of work experience providing and/or administering Medi-Cal mental health/psychiatric services in the State of California for the duration of the contract term.

OR 

Three years practicing psychiatry in the State of California or three years of work experience providing and/or administering Medi-Cal mental health/psychiatric services in the State of California.

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