For those of you who are new special needs plans effective January 1 of this year, you are very familiar with the new NCQA/CMS Face to Face Encounter requirements. For those plans who did not file a new or service area application, this may have slipped past your MOC radar.
Let’s review and discuss thoughts for clinical operational readiness to what the new MOC scoring guidelines say:
Regulations at 42 CFR § 422.101(f)(1)(iv) require that all SNPs must provide for face-to-face encounters for the delivery of health care, care management or care coordination services. Face-to-face encounters must occur, as feasible and with the individual’s consent, on at least an annual basis beginning within the first 12 months of enrollment.
Considerations: The guidelines do provide the “as feasible” standard, allowing health plans to make their best faith effort to reach out to the enrollee and, should the enrollee refuse or not respond, you must make a reasonable number of attempts. That is all well and good, but is your plan systematically ready to document the reasons for refusal? Is your care management platform configured to support the process you have put into place for attempted outreach tally or the capability to report the reasons the member may have refused? Remember, plans should have a quality improvement process in place to address barriers to member engagement for care management so if you don’t have one today, now may be the perfect time to create one for this purpose as part of MOC 4.
The face-to-face encounter must be between each enrollee and a member of the enrollee’s ICT, the plan’s case management and coordination staff or contracted plan healthcare providers. A face-to-face encounter must be either in-person or through a visual, real-time, interactive telehealth encounter.
The face-to-face encounter is part of the overall care management strategy, and as a result, the MOC must:
Describe in detail the process, including policies, procedures, purpose and intended outcomes of the face-to-face encounter.
Consideration: Intended outcomes of the face-to- face encounter: Are the encounters being used to identify member goals? Completing the HRAs? Conducting care plan overviews? Plans will need to decide what types of clinical functions and/or assessments are to be conducted during the encounter, based upon who is performing the encounter. What does your member need to do most? Completion of the HRA? Care plan review? Decide how you will prioritize for the member the most effective use of the face-to-face encounter.
For instances in which the SNP is providing the encounter, include staff (employed and/or contracted) who may conduct the face-to-face encounter.
Describe how the SNP will verify through data collection that the enrollee has participated in a qualifying face-to-face encounter.
Explain what types of clinical functions, assessments and/or services may be competed during the face-to-face encounter.
Consideration: Plans need to define what qualifies as a face-to-face encounter and who is qualified to deliver the care. Most plan providers do not participate on a regular basis in the ICT meetings as of now, so engaging the member’s PCP to be part of the qualified team will require additional provider education and engagement. How will your plan meet this requirement and demonstrate that it occurred/counted (as defined in number 3)? What changes in process or systems do you need to consider if you have a vendor who is working with your provider network to conduct Annual Wellness Visits (AWV)? How is this AWV data and information going to be evidenced as a qualifying encounter when most vendors are very strict about their information inside of the provider’s EMR? Additional considerations will be required to assess your overall CM platform’s capability for documentation, tracking and reporting a very different effort outside of HRAs and care plans.
Most plan CM platforms are not equipped to share PHI with other outside members of the ICT as they may not be as involved in the member’s care plan. Careful work planning will need to be considered for successful execution these two elements
Provide a detailed description of how health concerns and/or active or potential health issues will be addressed during the face-to-face encounter.
Describe how the SNP will conduct care coordination activities through appropriate follow-up, referrals and scheduling, as necessary.
Consideration: I consider these last two to be the most difficult. How will you as the health plan through your care management staff, address the issues or needs that have now been identified through this encounter? How will the caregivers be educated for any potential issues that may arise? Identifying the issues or health concerns may be a bit easier than arranging for care coordination activities and follow up. Many plans struggle with ensuring there is follow up for any care coordination activity due to lack of response from providers, lag in claims or other data, different platforms, or overall high caseloads. All of these contribute to what started out as good intentions but what ends up as a struggle to connect the care plan dots.
If your plan’s MOC team is struggling with this new requirement, let us help you find the answers. ContactUs@RebellisGroup.com.