Exhibit 4
Appendix Volume 2, p. 1
Report of the Examination of Bankers Reserve Life Insurance Company of Wisconsin St. Louis, Missouri As of December 31, 2017
Appendix Volume 2, p. 2
TABLE OF CONTENTS
Page I. INTRODUCTION .................................................................................................................. 1 II. HISTORY AND PLAN OF OPERATION .............................................................................. 3 III. MANAGEMENT AND CONTROL ........................................................................................ 5 IV. AFFILIATED COMPANIES .................................................................................................. 7 V. REINSURANCE ................................................................................................................. 13 VI. FINANCIAL DATA .............................................................................................................. 19 VII. SUMMARY OF EXAMINATION RESULTS ....................................................................... 28 VIII. CONCLUSION.................................................................................................................... 31 IX. SUMMARY OF COMMENTS AND RECOMMENDATIONS .............................................. 32 X. ACKNOWLEDGMENT ....................................................................................................... 33
Appendix Volume 2, p. 3
State
of
Wisconsin / OFFICE OF THE COMMISSIONER OF INSURANCE
Tony Evers, Governor Mark V. Afable, Commissioner
April 17, 2019
Wisconsin.gov
125 South Webster Street • P.O. Box 7873 Madison, Wisconsin 53707-7873 Phone: (608) 266-3585 • Fax: (608) 266-9935 E-Mail: ociinformation@wisconsin.gov Web Address: oci.wi.gov
Honorable Mark V. Afable Commissioner of Insurance State of Wisconsin 125 South Webster Street Madison, Wisconsin 53703 Commissioner: In accordance with your instructions, a compliance examination has been made of the affairs and financial condition of: Bankers Reserve Life Insurance Company of Wisconsin St. Louis, Missouri and this report is respectfully submitted.
I. INTRODUCTION The previous examination of Bankers Reserve Life Insurance Company of Wisconsin (BRLW or the company) was conducted in 2013 as of December 31, 2012. The current examination covered the intervening period ending December 31, 2017, and included a review of such 2018 and 2019 transactions as deemed necessary to complete the examination. The examination of the company was conducted concurrently with the examination of Superior HealthPlan, Inc. The Texas Department of Insurance acted in the capacity as the lead state for the coordinated examinations. Work performed by the Texas Department of Insurance was reviewed and relied on where deemed appropriate. The examination was conducted using a risk-focused approach in accordance with the National Association of Insurance Commissioners (NAIC) Financial Condition Examiners Handbook. This approach sets forth guidance for planning and performing the examination of an insurance company to evaluate the financial condition, assess corporate governance, identify current and
Appendix Volume 2, p. 4
prospective risks (including those that might materially affect the financial condition, either currently or prospectively), and evaluate system controls and procedures used to mitigate those risks. All accounts and activities of the company were considered in accordance with the riskfocused examination process. This may include assessing significant estimates made by management and evaluating management’s compliance with statutory accounting principles, annual statement instructions, and Wisconsin laws and regulations. The examination does not attest to the fair presentation of the financial statements included herein. If during the course of the examination an adjustment is identified, the impact of such adjustment will be documented separately at the end of the “Financial Data� section in the area captioned "Reconciliation of Surplus per Examination." Emphasis was placed on those areas of the company's operations accorded a high priority by the examiner-in-charge when planning the examination. The company is annually audited by an independent public accounting firm as prescribed by s. Ins 50.05, Wis. Adm. Code. An integral part of this compliance examination was the review of the independent accountant's work papers. Based on the results of the review of these work papers, alternative or additional examination steps deemed necessary for the completion of this examination were performed. The examination work papers contain documentation with respect to the alternative or additional examination steps performed during the course of the examination.
2 Appendix Volume 2, p. 5
II. HISTORY AND PLAN OF OPERATION The company was organized on January 5, 1961, as The International Casualty Insurance Corporation. Its name was changed to International General Insurance Corporation (IGIC) in November 1961. The company’s current name, Bankers Reserve Life Insurance Company of Wisconsin, was adopted on March 27, 1997. Initially, the company was licensed to write automobile and other casualty lines but delays in beginning operations resulted in the withdrawal of those lines in October 1962. In May 1964, the company was licensed to write disability insurance. In July 1964, the company’s license was amended to include life insurance. The company has had several changes in structure and business lines as summarized below. •
On August 7, 1985, American Investors Assurance Company, a Utah-domiciled insurer, purchased 100% of the outstanding common stock of IGIC’s parent company, International Inc.
•
In 1987, Robert R. Barrow acquired control of IGIC through this purchase of all outstanding common stock of International Inc.
•
Effective February 15, 1996, all outstanding shares of IGIC were sold to Atlantic Financial Company (AFC), a Florida-based corporation.
•
Effective June 30, 1996, IGIC acquired all the outstanding shares of Bankers Reserve Life Insurance Company, a Colorado-domiciled life insurer, from its parent, AFC.
•
Effective April 1, 1996, IGIC entered into a reinsurance contract in which 100% of its new and existing general account annuity business was ceded to Lincoln National Reinsurance Company and 60% was retroceded back on a funds withheld basis.
•
Effective February 28, 1997, the reinsurance contract with Lincoln National was terminated for all business.
•
BRLW sold its book of individual ordinary life insurance business to Central United Life Insurance Company through a 100% quota share coinsurance, assumption reinsurance agreement, effective April 1, 1997.
•
Effective July 1, 1999, Life and Health Insurance Company of America (LHA) acquired Bankers Reserve Life Insurance Company of Wisconsin
•
The company was sold to Centene Corporation in March 2002. Since the acquisition by Centene Corporation, BRLW has provided reinsurance to affiliated
health plans and provided multi-line managed care programs and related services to individuals
3 Appendix Volume 2, p. 6
receiving benefits under Medicaid, including Supplemental Security Income (SSI), and the Children’s Health Insurance Program (CHIP). Centene operates health plans in 29 states: Arizona Florida Indiana Maryland Minnesota Nebraska New York Oregon Tennessee Washington
Arkansas Georgia Kansas Massachusetts Mississippi Nevada North Carolina Pennsylvania Texas Wisconsin
California Illinois Louisiana Michigan Missouri New Mexico Ohio South Carolina Vermont
BRLW also entered into three agreements with the Texas Health and Human Services (THHS). The first of these three agreements, which began on September 1, 2004, was renewed in 2010, serves children enrolled in CHIP. The second agreement, which began on April 1, 2008, served children enrolled in Texas’ Foster Care Program and was terminated in 2015. A third agreement which began on March 1, 2012, serves Medicaid enrollees in rural areas and Aged, Blind, or Disabled Program (ABD) enrollees in the Hidalgo service area. As stated previously, the company assumes business from affiliated health maintenance organizations through several reinsurance agreements. In 2017, BRLW assumed reinsurance premium of $30.3 million from these health plans. Also in 2017, BRLW reported $1.7 billion of direct premium from the company’s three agreements with THHS. The growth of the company is discussed in the “Financial Data” section of this report. As of December 31, 2017, BRLW only wrote direct business in Texas but was licensed in the following 43 states and the District of Columbia: Alabama Arizona Arkansas Colorado Delaware District of Columbia Florida Georgia Idaho Illinois Indiana Iowa Kansas Kentucky Wyoming
Louisiana Maine Maryland Michigan Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico North Carolina North Dakota
Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Washington West Virginia Wisconsin
4 Appendix Volume 2, p. 7
III. MANAGEMENT AND CONTROL Board of Directors The board of directors consists of three members. All directors are elected annually to serve a one-year term. Officers are elected by the board of directors. Members of the company's board of directors may also be members of other boards of directors in the holding company group. The board members currently receive no compensation for serving on the board. Currently, the board of directors consists of the following persons: Term Expires
Name and Residence
Principal Occupation
Jeffrey A. Schwaneke St. Louis, Missouri
President and Treasurer
2018
Keith H. Williamson St. Louis, Missouri
Vice President and Secretary
2018
Darren C. Meyer St. Louis, Missouri
Vice President
2018
Officers of the Company The officers serving at the time of this examination are as follows: Name Jeffery A. Schwaneke Keith H. Williamson Michael F. Neidorff Holly A. Munin Darren C. Meyer Christopher D. Bowers
Office
Compensation*
President and Treasurer Vice President and Secretary Vice President Vice President Vice President Vice President
$ 72,409 67,387 507,645 279,533 14,070 64,555
*The officers’ salaries are paid by Centene Management Corporation, a wholly owned subsidiary of Centene Corporation, through a management agreement with BRLICW. The salaries shown above are the amounts allocated to BRLICW through the management agreement. Committees of the Board The company's bylaws allow for the formation of certain committees by the board of directors. There were no committees at the time of the examination. The company has no employees. Necessary staff is provided through a management agreement with Centene Management Company, LLC (CMC), a wholly owned subsidiary of Centene Corporation. Under the agreement, effective September 1, 2004, CMC agrees to provide the company
5 Appendix Volume 2, p. 8
with administrative and financial services necessary to manage the business operations of the company and agrees to assume responsibility for all costs associated therewith. Areas for which CMC assumes responsibility under the terms of the agreement include the following: program planning and development, management information system, financial systems and services, claims administration, provider and enrollee services and records, utilization review and quality assessment, and marketing services. CMC receives a management fee equal to actual expenses incurred. This agreement renews automatically for successive one-year renewal terms unless either party gives the other at least 90-days’ written notice of termination prior to the end of the term.
6 Appendix Volume 2, p. 9
IV. AFFILIATED COMPANIES Bankers Reserve Life Insurance Company is a member of a holding company system. The abbreviated organizational chart on the next page depicts the relationships among the affiliates in the group that have contractual agreements with BRLW. A brief description of affiliates deemed significant follows the organizational chart.
7 Appendix Volume 2, p. 10
Abbreviated Holding Company Chart As of December 31, 2017
Centene Corporation
Centene Management Company LLC
NurseWise LP
NurseWise Holdings LLC
Cenpatio Behavioral Health of TX, Inc.
Managed Health Services Insurance Corp.
OptiCare Managed Vision, Inc.
Nurtur Health, Inc.
Centene Holdings, LLC
Centene Company of Texas, LP
Superior HealthPlan, Inc.
Bankers Reserve Life Insurance Company of Wisconsin
Envolve Holdings, Inc.
Envolve PeopleCare, Inc.
8 Integrated Mental Health Mgmt, LLC
AECC Total Vision Health Plan of Texas, Inc
Envolve Pharmacy Solutions, Inc.
Envolve Vision of Texas, Inc.
Note: Not all of the subsidiaries of Centene Corporation have been included in this organizational chart as there were 235 companies in the group on December 31, 2017.
Appendix Volume 2, p. 11
Centene Corporation Centene Corporation, originally incorporated in 1993 as Coordinated Care Corporation, is a publicly held, for-profit company, headquartered in St. Louis, Missouri. It is the ultimate controlling party in the holding company system. Centene Corporation is a multi-line health care enterprise operating in two segments: Medicaid managed care and specialty services. Centene’s Medicaid managed care segment provides Medicaid and Medicaid-related health plan coverage to individuals through government subsidized and commercial programs, including Medicaid, CHIP, foster care, long-term care, Medicare special needs plans, and the Supplemental Security Income Program, also known as the Aged, Blind or Disabled Program, or collectively ABD. As of December 31, 2017, the audited financial statements of Centene Corporation reported assets of $21.9 billion, liabilities of $15.0 billion, and stockholders’ equity of $6.9 billion. Operations for 2017 produced net earnings of $828 million. Centene Management Company LLC Centene Management Company LLC (CMC), originally incorporated in 1996 as Coordinated Care Medicaid Management Corporation, was created to provide management and administrative services to Centene Corporation’s HMO subsidiaries. CMC, a wholly owned subsidiary of Centene Corporation, is a for-profit corporation that holds management agreements with Centene’s subsidiaries and employs all staff, both at corporate headquarters and at the health plans. Licenses and certifications as required by individual state regulations are current. Specifically, in Wisconsin, CMC holds a license as an Employee Benefit Plan Administrator. The unaudited financial results reported assets of $13.1 million, liabilities of $12.0 million, and stockholders’ equity of $0.8 million. Operations for 2017 resulted in net earnings of $0.1 million on revenues of $2.2 million. Managed Health Services Insurance Corp. Managed Health Services Insurance Corp. is a wholly owned subsidiary of Centene Corporation. The company was organized under the laws of Wisconsin on August 31, 1990, as a network model health maintenance organization (HMO) and provides managed care services to individuals receiving benefits under Medicaid and SSI. The company provides these services under a contract with the Wisconsin Department of Health Services (DHS) and a subcontract of another
9 Appendix Volume 2, p. 12
insurer’s contract with DHS. As of December 31, 2017, the company’s audited financial statements reported assets of $69.6 million, liabilities of $18.9 million, and capital and surplus of $50.7 million. Operations for 2017 produced a net income of $9 million on revenues of $163 million. Superior HealthPlan, Inc. Superior HealthPlan, Inc., is a wholly owned subsidiary of Centene Corporation. The company was incorporated under the laws of Texas on February 14, 2007, as a network model health maintenance organization (HMO). The company contracts with the Texas Health and Human Service to provide Medicaid, State Children’s Health Insurance Program, and Supplemental Security Income Program managed care services. The company also contracts with the Centers for Medicare and Medicaid Services (CMS) to participate in the Medicare Advantage Program. As of December 31, 2017, the company’s audited financial statements reported assets of $754 million, liabilities of $384 million, and capital and surplus of $369 million. Operations for 2017 produced a net income of $64 million on revenues of $4 billion. Agreements with Affiliates Bankers Reserve Life Insurance Company of Wisconsin entered into the following affiliated agreements as described below: • Effective December 31, 2002, the company entered into a tax-sharing agreement with Centene Corporation (Centene). Under this agreement, Centene files a consolidated tax return for member companies; member companies, in turn, agree to make quarterly payments to Centene in an amount equal to the full separate federal, state, and local income tax liability attributable to the net taxable income of each member that would have been paid if such member had filed separate federal, state, and local tax returns. •
Effective September 1, 2004, the company entered into an administrative services agreement with Centene Management Company LLC (CMC). This agreement is discussed in the caption of the report entitled "Management and Control.”
•
Effective September 1, 2004, the company entered into a delegated services agreement with Integrated Mental Health Services (IMHS). Under this Foster Care agreement, the company delegates to IMHS certain services related to behavioral health. The company agrees to
10 Appendix Volume 2, p. 13
reimburse IMHS on a per member per month basis. This agreement was terminated effective September 1, 2017. •
Effective September 1, 2004, (last amended on January 1, 2015), the company entered into an administrative services agreement with Superior HealthPlan, Inc. (SHP). SHP provides the company with the administrative services reasonably necessary to manage the business operations and affairs of the company and is responsible for all costs associated therewith. This agreement automatically renews for the successive one-year contract unless either party gives 60-days’ written notice.
•
Effective September 1, 2004 (last amended April 1, 2017), the company entered into a service agreement with NurseWise LP (NurseWise). Under this agreement, NurseWise establishes a “Care Line” for the company’s members to call with health inquiries. The company agrees to reimburse NurseWise on a per member per month basis.
•
Effective September 1, 2005 (last amended September 1, 2016), the company entered into a vision services agreement with AECC Total Vision Health Plan of Texas, Inc. (Vision Network). Vision Network serves as the company’s vision services vendor under the company’s CHIP contract with THHS, and the company compensates Vision Network for its provision of services in such capacity. The company reimburses Vision Network on a per member per month basis.
•
Effective April 1, 2008 (last amended March 1, 2016), the company entered into an administrative services agreement with Centene Management Company LLC (CMC) and Centene Company of Texas, LP (CTX). CMC contracted with the company to provide certain administrative services for the company’s STAR Health Program enrollees. CTX contracted with the company to provide certain administrative services for the company’s STAR Health Program enrollees. CMC and CTX hire, maintain, and supervise all personnel necessary to provide the administrative services for the company’s STAR Health Program. The company pays a monthly administrative fee for services of 6% of all gross revenues for the company’s STAR Health Program. This agreement automatically renews for one-year periods unless either party gives 90-days’ written notice.
11 Appendix Volume 2, p. 14
•
Effective January 1, 2009 (last amended January 29, 2018), the company entered into a disease management program services agreement with Nurtur Health, Inc. The company arranges for the provision of health care services, including disease prevention services and chronic disease management services to members enrolled in the CHIP program. Both parties agree to expand the scope to include the provision of disease management services to members enrolled in the company’s STAR Health Program effective April 1, 2008. This agreement automatically renews in one-year periods unless either party gives 90-days’ written notice.
•
Effective March 1, 2012, (last amended June 30, 2016) the company entered into a pharmacy benefit management services agreement with Envolve Pharmacy Solutions, Inc., f/k/a US Script, Inc., where the following services are provided to the company: claims processing, eligibility management, benefits and utilization management, pharmacy network management, call-center services for pharmacies and prescribers, and pharmacy complaints and appeals.
•
Effective January 1, 2009, (last amended January 01, 2018), the company entered into a disease management program services agreement with Envolve PeopleCare, Inc., where disease management services are provided for the following conditions: asthma program, COPD program, diabetes program, heart disease program, heart failure program, and puff-free pregnancy program. In addition, Envolve PeopleCare, Inc., provides services related to the EPC web portal.
12 Appendix Volume 2, p. 15
V. REINSURANCE The company's reinsurance portfolio and strategy are described below. A list of the companies that have a significant amount of reinsurance in force at the time of the examination follows. The contracts contained proper insolvency provisions. One of the company’s major functions in the holding company structure is to assume business from affiliated HMOs and then cede a portion of this business to an unaffiliated reinsurer. The amount of risk retained by BRLW from these assuming contracts varies depending on HMO, type of claims, and in some cases the region in which the claim occurred for the HMO. The strategy of having BRLW assume business from several affiliates and then cedes to a single unaffiliated reinsurer is to minimize reinsurance costs across the holding company structure. This strategy has been profitable for BRLW over the past several years. Nonaffiliated Ceding Contracts 1.
Reinsurer:
PartnerRe America Insurance Company
Type:
Specific Excess of Loss Reinsurance
Effective Date:
January 1, 2017
Expiration Date:
January 1, 2018
Covered business:
Superior HealthPlan Network, TX: Texas Medicaid recipients (STAR, STAR PLUS, CHIP, and perinatal programs)
Retention:
Specific deductible per covered person per agreement term: $1,250,000 maximum payable per covered person: $3,000,000
Coverage:
80% or 90% of covered expenses in excess of $1,250,000 dependent upon whether the expenses are referred to an audit services firm or not. Referred claims receive the higher reimbursement.
Limitations:
Hospital inpatient services: acute care services: the lesser of • the amount paid; • the contracted rate; • the applicable state Medicaid fee schedule; or • a $15,000 maximum average per diem per discharge
Limitations (cont.):
Long-term acute care hospital and sub-acute care services (extended care services, skilled nursing, rehabilitation), extended care facility/skilled nursing facility/sub-acute care facility/rehabilitation facility/hospice/home health care services: • the lesser of the amount paid; • the contracted rate; • the applicable State Medicaid fee schedule; or
13 Appendix Volume 2, p. 16
• Insolvency Coverage:
a $1,000 per diem and limited to 90 days in total for the combination of all categories
In the event of the insolvency of the reinsured, this agreement shall be payable directly to the reinsured or to its liquidator, receiver, conservator, or statutory successor on the basis of the liability of the reinsured without diminution because of the insolvency of the reinsured.
Affiliated Assuming Contracts 1.
Type:
Specific Excess of Loss Reinsurance
Reinsured:
Managed Health Services Insurance Corporation.
Covered business:
TANF and SSI Non-Dual covered persons
Retention:
Specific deductible per covered person per agreement term: $500,000
Maximum coverage: The maximum payable per covered person: $4,600,000
2.
Coverage:
90% of covered expenses excess of the specific deductible, organ transplant services, 50% if performed by a non-approved transplant provider
Limitations:
Hospital inpatient services as defined by the membership services agreement: • The lesser of the amount paid, the contracted rate • The applicable Wisconsin Medicaid fee schedule where contracted rates do not exist or • An average per diem per discharge of $10,000 for allowable expenses over $1,000,000
Effective date:
January 1, 2017
Termination:
January 1, 2018
Type:
Specific Excess of Loss Reinsurance
Reinsured:
Buckeye Community Health Plan
Covered business:
CFC (TANF), Medicaid expansion, ABD members - adults and children, MMP Opt-Out (Medicaid only), and MMP Opt-in Medicaid and Medicare.
Retention:
Specific deductible per covered person per agreement term: $200,000 Maximum payable per covered person: $4,600,000
Coverage:
90% of covered expenses in excess of the specific deductible, organ transplant services are reimbursed at 50% if performed by a non-approved transplant provider
Limitations:
Hospital inpatient services the lesser of: • The amount paid; • The contracted rate in effect at the time of admission;
14 Appendix Volume 2, p. 17
• • •
The applicable Ohio Medicaid fee schedule where contracted rates do not exist; billed charges; or A $15,000 maximum average per diem per discharge
The per diem limit is waived for an approved transplant provider case rate. Extended care facility/skilled nursing facility/sub-acute care facility/home health care rehabilitation: • The lesser of the amount paid; • The contracted rate; • The applicable Ohio Medicaid fee schedule where contracted rates do not exist; or • A $1,000 per diem Effective date:
January 1, 2017
Termination:
January 1, 2018
3. Type:
Specific Excess of Loss Reinsurance
Reinsured:
Nebraska Total Care, Inc.
Covered business:
TANF Foster Care, CHIP, SSI Dual, SSI Non-Dual, and LTC covered persons
Retention:
Specific deductible per covered person per agreement term: $200,000 Maximum payable per covered person: $4,600,000
Coverage:
90% of covered expenses excess of the specific deductible. Claims must be received by the reinsurer no later than March 1, 2019. Organ transplant services are reimbursed at 50% if performed at a non-approved transplant provider.
Limitations:
Hospital inpatient services the lesser of: • The amount paid; • The contracted rate in effect at the time of admission; • The applicable Nebraska Medicaid fee schedule where contracted rates do not exist; • Billed charges; • An average per diem per discharge of $15,000.
Effective date:
January 1, 2017
Termination:
January 1, 2018
4. Type:
Specific Excess of Loss Reinsurance
Reinsured:
Granite State Health Plan, Inc.
Covered business:
TANF and SSI Non-Dual covered persons
Retention:
Specific deductible per covered person per agreement term: $500,000
15 Appendix Volume 2, p. 18
Maximum payable per covered person: $4,600,000 Coverage:
90% of covered expenses in excess of the specific deductible. Organ transplant services are reimbursed at 50% if performed at a non-approved transplant provider.
Limitations:
Hospital inpatient services as defined by the membership services agreement the lesser of: • The amount paid; • The contracted rate in effect at the time of admission; • The applicable New Hampshire Medicaid fee schedule where contracted rates do not exist; • Billed charges; or • A maximum average per diem per discharge of $15,000 The per diem limit is waived for an approved transplant provider case rate.
Effective date:
January 1, 2017
Termination:
January 1, 2018
5. Type:
Specific Excess of Loss Reinsurance
Reinsured:
Absolute Total Care, Inc.
Covered business:
Medicaid, MMP Dual, and SSI Non-Dual members
Retention:
Specific deductible per covered person per agreement term: $500,000 Maximum payable per covered person: $4,600,000
Coverage:
90% of covered expenses in excess of the specific deductible. Organ transplant services are reimbursed at 50% if performed at a non-approved transplant provider.
Limitations:
Hospital inpatient services: the lesser of: • The amount paid. • The contracted rate in effect at the time of admission. • The applicable South Carolina Medicaid fee schedule where contracted rates do not exist. • Billed charges; or • A $15,000 maximum average per diem per discharge The per diem limit is waived for an approved transplant provider case rate.
Effective date:
February 10, 2017
Termination:
January 1, 2018
6. Type:
Specific Excess of Loss Reinsurance
Reinsured:
SilverSummit Health Plan, Inc.
Covered business:
TANF, CHIP, and Expansion covered persons
16 Appendix Volume 2, p. 19
Retention:
Specific deductible per covered person: $200,000 Maximum payable per covered person: $4,600,000
Coverage:
90% of covered expenses in excess of the specific deductible. Organ transplant services are reimbursed at 50% if performed at a non-approved transplant provider.
Limitations:
Hospital inpatient services: • The lesser of the amount paid; • The contracted rate in effect at the time of admission; • The applicable Nevada Medicaid fee schedule where contracted rates do not exist; • Billed charges or a $15,000 maximum average per diem per discharge The per diem limit is waived for an approved transplant provider case rate.
Effective date:
July 1, 2017
Termination:
January 1, 2018
7. Type:
Specific Excess of Loss Reinsurance
Reinsured:
Trillium Community Health Plan, Inc.
Covered business:
Medicaid TANF/CHIP/Foster Care, Medicaid Expansion, SSI Non-Dual, and SSI Dual.
Retention:
Specific deductible per covered person per agreement term: $500,000 Maximum payable per covered person: $4,600,000
Coverage:
90% of covered expenses excess of the specific deductible. Organ transplant services are reimbursed at 50% if performed at a non-approved transplant provider. If the agreement terminates prior to the expiration date, the complete claim must be received by the reinsurer within six months after the date of agreement termination, otherwise, the percentage payable will be reduced from 90% to 0%.
Limitations:
Hospital inpatient services: • the lesser of the amount paid; • the contracted rate in effect at the time of admission • The applicable Oregon Medicaid Fee Schedule where contracted rates do not exist; • Billed charges or a $15,000 maximum average per diem per discharge The per diem limit is waived for an approved transplant provider case rate.
Effective date:
January 1, 2017
Termination:
January 1, 2018
8. Type: Reinsured:
Specific Excess of Loss Reinsurance Peach State Health Plan, Inc.
17 Appendix Volume 2, p. 20
Covered business:
Medicaid and PeachCare for Kids recipients
Retention:
Specific deductible per covered person per agreement term: $200,000 Maximum payable per covered person: $2,000,000
Coverage:
90% of covered expenses excess of the specific deductible. Claims must be received by the reinsurer no later than November 1, 2014. Organ transplant services are reimbursed at 50% if performed at a non-approved transplant provider.
Limitations:
Hospital inpatient services: • The lesser of the amount paid; • The contracted rate; • The applicable Georgia Medicaid fee schedule where contracted rates do not exist; or • An average per diem per discharge of $10,000
Effective date:
January 1, 2016
Termination:
January 1, 2017
All assuming contracts have the following insolvency coverage with the only difference being Peach State Health Plan, Inc., has $2.0 million maximum insolvency coverage as opposed to a $4.6 million maximum for the others. Insolvency coverage:
In the event that the reinsured shall become insolvent while the agreement is in force, the reinsured or its legal representative shall notify all applicable covered persons of this provision and the following shall apply: 1. The reinsurer will continue to provide the benefits covered under the applicable membership services agreement with respect to each covered person who is confined in a hospital on the insolvency date for expenses incurred and payable by such covered person on or after such date until the earlier of a. the covered person's discharge from the hospital or b. the date the covered person becomes eligible for health insurance coverage or benefits under another group or blanket policy or plan or any federal, state, or local government plan or program. 2. The reinsurer will continue covered benefits for other covered persons for treatment or services received after the insolvency date, until the end of the period for which applicable premium was received by the reinsured, prior to the insolvency date, but not beyond the end of that period.
18 Appendix Volume 2, p. 21
VI. FINANCIAL DATA The following financial statements reflect the financial condition of the company as reported to the Commissioner of Insurance in the December 31, 2017, annual statement. Adjustments made as a result of the examination are noted at the end of this section in the area captioned "Reconciliation of Surplus per Examination." Also included in this section are schedules that reflect the growth of the company, NAIC Insurance Regulatory Information System (IRIS) ratio results for the period under examination, and the compulsory and security surplus calculation.
19 Appendix Volume 2, p. 22
Bankers Reserve Life Insurance Company of Wisconsin Assets As of December 31, 2017
Assets Bonds Common stocks Cash, cash equivalents, and short-term investments Other invested assets Investment income due and accrued Uncollected premiums and agents' balances in course of collection Amounts recoverable from reinsurers Other amounts receivable under reinsurance contracts Current federal and foreign income tax recoverable and interest thereon Net deferred tax asset Receivable from parent, subsidiaries and affiliates Health care and other amounts receivable Write-ins for other than invested assets: Prepaid expenses Separate account receivables Total assets excluding separate accounts, segregated accounts and protected cell assets From separate accounts, segregated accounts, and protected cell assets
$ 194,861,471 8,761,063
Total assets
$424,371,915
Nonadmitted Assets $
Net Admitted Assets $194,861,471 8,761,063
134,520,263 2,955,373 1,051,310
134,520,263 2,955,373 1,051,310
13,963,411 705,554
13,963,411 705,554
1,119,954
1,119,954
11,471,168 9,100,385
6,779,855
11,471,168 2,320,530
33,458,499 11,297,124
1,278,499 4,991,646
32,180,000 6,305,478
291,744 17,712
291,744
423,575,032
14,461,699
796,883
17,712 409,113,333 796,883
$14,461,699
$409,910,216
20 Appendix Volume 2, p. 23
Bankers Reserve Life Insurance Company Liabilities, Surplus, and Other Funds As of December 31, 2017 Claims unpaid Accrued medical incentive pool and bonus amounts Unpaid claims Aggregate health policy reserves General expenses due or accrued Current federal and foreign income tax Aggregate write-ins for other liabilities [including $(0) current] Total liabilities Common capital stock Aggregate write-ins for special surplus funds Gross paid in and contributed surplus Unassigned funds (surplus) Total capital and surplus Total liabilities, capital and surplus
$181,683,655 4,144,442 2,991,000 26,167,383 3,224,510 70,353 648,285 218,929,628 $
2,400,000 26,974,403 361,377,809 (199,771,624)
190,980,589 $409,910,216
21 Appendix Volume 2, p. 24
Bankers Reserve Life Insurance Company of Wisconsin Summary of Operations For the Year 2017 Net premium income Change in unearned premium reserves and reserve for rate credits Total revenues Medial and hospital: Hospital/medical benefits Other professional services Emergency room and out-of-area Prescription drugs Incentive pool, withhold adjustments, and bonus amounts Subtotal Less Net reinsurance recoveries Total hospital and medical Claims adjustment expenses General administrative expenses Increase in reserves for life and accident and health contracts Total underwriting deductions Net underwriting gain or (loss) Net investment income earned Net realized capital gains (losses) Net investment gains (losses) Net income or (loss) after capital gains tax and before all other federal income taxes Federal and foreign income taxes incurred Net loss
$1,902,175,035 1,799,211 1,903,974,246 $1,306,562,551 58,431,002 82,983,881 295,161,159 31,906,475 1,775,045,068 (14,810,342) 1,789,855,410 25,642,243 158,813,662 23,661,077 7,652,194 (4,011)
1,997,972,392 (93,998,146) 7,648,183 (86,349,963) (20,420,659) $ (65,929,304)
22 Appendix Volume 2, p. 25
Bankers Reserve Life Insurance Company of Wisconsin Cash Flow For the Year 2017 Premiums collected net of reinsurance Net investment income Total Less: Benefit- and loss-related payments Commissions, expenses paid, and aggregate write-ins for deductions Federal and foreign income taxes paid (recovered) Total deductions Net cash from operations Proceeds from investments sold, matured, or repaid: Bonds Other invested assets Total investment proceeds Cost of investments acquired (long-term only): Bonds Other invested assets Miscellaneous applications Total investments acquired Net cash from investments Cash provided (applied): Capital and paid in surplus, less treasury stock Net change in cash, cash equivalents, and shortterm investments Cash, cash equivalents, and short-term investments: Beginning of year End of year
$1,971,237,089 8,627,458 1,979,864,547 $1,802,685,847 188,111,253 (16,870,754)
$114,347,90 7 4,064,136 97,766,085 1,951,586 32,656
1,973,926,346 5,938,201
118,412,043
99,750,327
18,661,716 4,000,000 28,599,917 105,920,346 $ 134,520,263
23 Appendix Volume 2, p. 26
Bankers Reserve Life Insurance Company of Wisconsin Compulsory and Security Surplus Calculation December 31, 2017 Assets Less: Liabilities
$ 409,910,216 218,929,628
Assets available to satisfy surplus requirements Net premium earned Compulsory factor
$190,980,588
1,902,175,035 10%
Compulsory surplus
190,217,503
Compulsory surplus excess/(deficit)
$
Assets available to satisfy surplus requirements Compulsory surplus Security factor Security surplus Security surplus excess/(deficit)
$190,217,503 110%
763,085
$190,980,588
209,239,253 $ (18,258,665)
24 Appendix Volume 2, p. 27
Bankers Reserve Life Insurance Company of Wisconsin Analysis of Surplus For the Five-Year Period Ending December 31, 2017 The following schedule details items affecting the company’s total capital and surplus during the period under examination as reported by the company in its filed annual statements: Capital and surplus, beginning of year Net income or (loss) Change in net unrealized capital gains/losses Change in net deferred income tax Change in nonadmitted assets and related items Surplus adjustments: Paid in Write-ins for gains and (losses) in surplus Capital and surplus, end of year
2017
2016
2015
2014
2013
$223,692,205 (65,929,304)
$244,424,604 (20,694,945)
$268,032,065 (21,681,027)
$238,096,925 11,216,417
$198,624,084 (4,567,594)
(858,860)
881,161
(19,690)
2,938,494
(7,537,393)
(2,300,932)
1,897,518
300,000
17,200,000
49,700,000
$244,424,604
$268,032,065
$238,096,925
(255,071)
1,315,237
3,866,660
1,486,145
1,083,909
(6,388,946)
(2,838,836)
(2,451,483)
36,180,000 (184,955) $190,980,589
$223,692,205
Growth of Bankers Reserve Life Insurance Company of Wisconsin
Year
Admitted Assets
2017 2016 2015 2014 2013 2012
$409,910,216 410,427,048 425,870,628 468,762,090 434,636,315 409,443,694
Liabilities $218,929,628 186,734,848 181,446,025 200,730,026 196,539,395 210,819,610
Capital and Surplus $190,980,589 223,692,201 244,424,603 268,032,064 238,096,924 198,624,084
Medical Expenses Incurred
Premium Earned $1,903,974,246 1,958,590,637 2,102,010,933 2,363,586,865 2,322,568,276 1,719,296,459
$1,789,855,410 1,754,626,595 1,869,567,372 2,058,347,671 2,118,834,277 1,647,395,056
Net Income $ (65,929,304) (20,694,945) (21,681,027) 11,216,417 (4,567,594) (126,440,638)
Year
Profit Margin
Medical Expense Ratio
Administrative Expense Ratio
Change in Enrollment
2017 2016 2015 2014 2013 2012
-3.4% -1.1 -1.0 0.5 -0.2 -10.2
95.2% 89.6 88.9 87.1 89.7 95.8
9.7% 11.4 12.0 12.0 11.4 14.4
3.9% -1.5 -0.3 -1.0 -0.6 405.8
25 Appendix Volume 2, p. 28
Enrollment and Utilization
Year 2017 2016 2015 2014 2013
Enrollment 528,901 509,169 516,853 518,325 523,709
Hospital Days/1,000
Average Length of Stay
343.5 344.4 329.1 354.0 367.2
4.2 4.3 4.2 4.2 4.0
Per Member Per Month Information
Premiums: Commercial Medicaid Expenses: Hospital/medical benefits Other professional services Emergency room and out-of-area Prescription drugs (medical and hospital) Incentive pool and withhold adjustments Less: Net reinsurance recoveries Total medical and hospital Claims adjustment expenses General administrative expenses Increase in reserves for accident and health contracts Total underwriting deductions
2017
2016
Percentage Change
$ 179.26 324.79
$311.69 330.17
-42.5% -1.6
209.79 9.38 13.32 47.39 5.11 (2.38) 282.62
201.03 12.16 12.53 46.93 5.80 (14.73) 263.73
4.4 -22.9 6.3 1.0 -11.8 -83.9 7.2
4.12 25.50
4.16 33.14
-0.9 -23.0
3.80 $316.03
0.00 $301.02
100.0 5.0
Premium revenue decreased by 3% to $1.90 billion in 2017 from $1.96 billion in 2016. The decrease in premium revenue was mostly driven by a decrease in assumed risk through reinsurance agreements with affiliated health plans. The company’s enrollment increased by 1% from 523,709 at year-end 2013 to 528,901 at year-end 2017 and has experienced losses in four of the five years under examination. Losses of $101.7 million during the examination period were offset by capital contributions of $103.4 million. Capital and surplus was $190.9 million at year-end 2017. The company reported a security surplus deficit of $18.3 million. This is despite the capital contributions noted above. The contributions were not sufficient to meet the security surplus standard.
26 Appendix Volume 2, p. 29
The company’s per member per month general administrative expenses decreased by 23.0% from 2016 while the total underwriting deductions (including administrative expenses) increased 5.0% due to an increase in hospital and medical expenses. The company incurred a net loss of $65.9 million in 2017 primarily due to increased medical expense and the recording of a $23.7 million premium deficiency reserve. On March 1, 2012, the company began providing medical services to individuals within certain service areas enrolled in the Texas Access Reform (STAR) and STAR+PLUS programs. The STAR+PLUS program was expanded to include nursing facility benefits effective March 1, 2015. The THHS contract servicing the state’s Foster Care program was discontinued for 2015 causing an enrollment decrease. The company remains active in the CHIP, STAR, and STAR+PLUS programs through THHS in 2017 through 2019, however, company management informed OCI that the company expects to terminate these programs in 2020. The company will continue to provide reinsurance to affiliated health plans. Reconciliation of Surplus per Examination No adjustments to surplus or reclassifications were made as a result of the examination. The amount of surplus reported by the company as of December 31, 2017, is accepted.
27 Appendix Volume 2, p. 30
VII. SUMMARY OF EXAMINATION RESULTS Compliance with Prior Examination Report Recommendations There were no specific comments and recommendations in the previous examination report.
28 Appendix Volume 2, p. 31
Summary of Current Examination Results This section contains comments and elaboration on those areas where adverse findings were noted or where unusual situations existed. Comment on the remaining areas of the company’s operations is contained in the examination work papers. Executive Compensation The State of Wisconsin requires all domestic insurance companies to file a Report on Executive Compensation. According to s. 611.63 (4), Wis. Stat., the amount of all direct and indirect remuneration for services should include retirement and other deferred compensation benefits, paid or accrued each year for the benefit of each director and each officer and employee whose remuneration exceeds the specified amount. The review of the company’s executive compensation revealed that the company excluded the employer’s portion of the defined contribution plan. The company should include all remuneration paid or accrued under the defined contribution plan on behalf of each reportable employee in the Report on Executive Compensation. It is recommended that the company properly complete the Report of Executive Compensation as required by s. 611.63 (4), Wis. Stat. Reinsurance Per Statement of Statutory Accounting Principle (SSAP) No. 61R, “reinsurance is an agreement by which a reporting entity transfers all or part of its risk under a contract to another reporting entity.” Cenpatico of Arizona Inc., DBA Cenpatico Integrated Care (CIC) is not licensed as an insurer in Arizona, as such is not a reporting entity. Therefore, the agreement between the company and CIC is not a reinsurance treaty and should not be accounted for as such. The company’s agreement with CIC should have been accounted for as a direct insurance policy, not as reinsurance for BRLIC on Schedule S of the annual statement. It is recommended that the company report valid reinsurance treaties on Schedule S of future annual statements per SSAP No. 61R. Corporate Governance The review of the company’s conflict of interest statements disclosed some individuals listed on the jurat page were either not completing the conflict of interest disclosure forms during the examination period or the disclosure forms were misplaced. It is recommended that the company have
29 Appendix Volume 2, p. 32
its directors, officers, and key employees complete a conflict of interest questionnaire annually as required by a directive of the Office of the Commissioner of Insurance and maintain a record of the signed questionnaire.
30 Appendix Volume 2, p. 33
VIII. CONCLUSION The company is 100% owned subsidiary of Centene Corporation, a multi-line healthcare insurer that provides programs and related services to under-insured and uninsured individuals. BRLIC provides medical coverage primarily to the State of Texas and assumes reinsurance with affiliates. BRLIC remained active in the CHIP, STAR, and STAR+PLUS programs through the Texas Health and Human Services through 2018. An affiliate of the company will bid on the contracts for 2020. The income generated by premiums earned under the contract with THHS is the company’s main source of cash flow. Net loss increased to $65,929,304 at year-end 2017 from $20,694,945 at year-end 2016. Losses incurred of $101.7 million during the examination period were offset by capital contributions of $103.4 million. There were no adjustments made to surplus as a result of the current examination. The examination made three recommendations as listed on the following page.
31 Appendix Volume 2, p. 34
IX. SUMMARY OF COMMENTS AND RECOMMENDATIONS 1.
Page 29 - Executive Compensation—It is recommended that the company properly complete the Report of Executive Compensation as required by s. 611.63 (4), Wis. Stat.
2.
Page 29 - Reinsurance—It is recommended that the company report valid reinsurance treaties on Schedule S of future annual statements per SSAP No. 61R.
3.
Page 29 - Corporate Governance—It is recommended that the company have its directors, officers, and key employees complete a conflict of interest questionnaire annually as required by a directive of the Office of the Commissioner of Insurance and maintain a record of the signed questionnaire.
32 Appendix Volume 2, p. 35
X. ACKNOWLEDGMENT The courtesy and cooperation extended during the course of the examination by the officers and employees of the company are acknowledged. In addition to the undersigned, the following representatives of the Office of the Commissioner of Insurance, State of Wisconsin, participated in the examination: Name
Title
John Ebsen David Jensen, CFE Jerry DeArmond, CFE
Insurance Financial Examiner IT Specialist Reserve Specialist
Respectfully submitted,
Vickie Ostien Examiner-in-Charge
LIFEBLK_01-18
33
Appendix Volume 2, p. 36
Exhibit 5
Appendix Volume 2, p. 37
Illinois Department of Healthcare and Family Services Managed Care Manual for Medicaid Providers
January 2016
Appendix Volume 2, p. 38
Illinois Department of Healthcare and Family Services Managed Care Manual for Medicaid Providers
TABLE OF CONTENTS Chapter 1 1.10 1.20 1.30 1.40 1.50
Managed Care Overview Introduction Managed Care Map Populations and Programs Participant Enrollment Provider and Health Plan Participant Education at Provider Locations
Chapter 2 2.10 2.20 2.30 2.40 2.50 2.60 2.70 2.80 2.90 2.100 2.110
Provider Relations Provider Enrollment Enrollment into Medicaid Enrollment into a Health Plan Provider Contracting Provider Training Provider Billing Encounter Data Timely Payment Reimbursement Provider Complaint Resolution Non-Affiliated Providers
Chapter 3 3.10 3.20 3.30 3.40 3.50
Care Coordination Care Coordination Interdisciplinary Care Team Care Plans Service Plans as Part of the Care Plan Transition of Care
Chapter 4 4.10 4.20 4.30 4.40 4.50 4.60 4.70 4.80 4.90 4.100
Covered Services Service Package 1 Covered Services Pharmacy Hospice Services Dental Services Emergency and Non-Emergency Transportation Behavioral Health Service Package 2 Covered Services HCBS Services Nursing Facility Services Non-Covered Services
Chapter 5
Enrollee Grievance and Appeals
Page 2 of 35
Appendix Volume 2, p. 39
Illinois Department of Healthcare and Family Services Managed Care Manual for Medicaid Providers
Chapter 6 6.10 6.20 6.30 6.40 6.50 6.60 6.70 6.80
Quality Assurance Program Quality Assurance, Utilization Review and Peer Review Clinical Practice Guidelines Preventive Health Guidelines Cultural and Linguistic Services Access to Care Standards Site and Medical Record-Keeping Practice Reviews Improvement Plans Measurement of Clinical and Service Quality
Chapter 7
Definitions
Chapter 8
Links
Page 3 of 35
Appendix Volume 2, p. 40
Illinois Department of Healthcare and Family Services Managed Care Manual for Medicaid Providers
Intent of this Manual: This manual contains helpful information regarding the Medicaid managed care program for Providers enrolled in Medicaid. Please be advised that this manual is not intended to supersede, modify, or replace any policies, guidelines, or other Provider handbooks applicable to Providers in the Medical Assistance Program under the Fee-For-Service payment system. Further, this handbook does not alter or supersede any managed care contractual obligations, duties, or requirements between Providers and Health Plans or between the Illinois Department of Healthcare and Family Services and Health Plans. Further guidance regarding the Medicaid Fee-For-Service program can be found in the HFS Provider Handbooks.
Page 4 of 35
Appendix Volume 2, p. 41
Illinois Department of Healthcare and Family Services Managed Care Manual for Medicaid Providers
Chapter 1 Managed Care Overview 1.10
Introduction
In order to carry out the mission of the Department of Healthcare and Family Services to improve the health of Medicaid Participants by providing access to, and coordination of, quality health care, HFS is reforming the systems that deliver medical care to participants. This mission includes providing a Primary Care Provider (PCP) for every participant; maintaining continuity of care with that PCP; creating comprehensive networks of care around participants including primary care, specialists, hospitals and behavioral care; and offering care coordination to help participants with complex needs navigate the healthcare system pursuant to the Medicaid reform law (Public Acts 096-1501 and 97-689) and the federal Affordable Care Act (Public Law 111-148). Risk and performance is tied to reimbursement in order to transform the Medicaid healthcare delivery system to one with a focus on improved health outcomes. HFS has completed the roll-out of mandatory care coordination programs for most Medicaidonly participants in five mandatory managed care counties, and for the Dual Eligible population in two demonstration areas for the MMAI program. Through these programs HFS surpassed the 50% goal required by law, with an enrollment of over 2 million participants in care coordination programs. The five mandatory managed care regions include Rockford, Central Illinois, Metro East, Quad Cities, and Greater Chicago (Cook and Collar Counties). 1.20
Managed Care Map
Providers are able to view the current expansion map (pdf) on the HFS website. This map shows the programs and Health Plans participating in each county. 1.30
Populations and Programs
Illinois Medicaid Managed Care consists of four programs and within those programs are several Health Plans. Program definitions, populations and participating Health Plans are listed below: Integrated Care Program (ICP): The Integrated Care Program (ICP) was implemented in May of 2011. ICP is a program for Seniors and Persons with Disabilities who are eligible for the Medicaid program, but not eligible for Medicare. This care delivery system brings together an Enrollee’s Providers as an integrated care team to provide a more coordinated medical approach and keep the Enrollee healthier. Integrated care focuses on all of the factors that can affect a person’s health and well-being and puts a plan in place to manage all the Enrollee’s health needs, whether those needs are physical, behavioral or social.
Page 5 of 35
Appendix Volume 2, p. 42
Illinois Department of Healthcare and Family Services Managed Care Manual for Medicaid Providers
The ICP program operates in the following regions: •
Greater Chicago (Cook, DuPage, Kane, Kankakee, Lake and Will counties)
•
Rockford (Winnebago, Boone and McHenry counties)
•
Central Illinois (Knox, Stark, Peoria, Tazewell, McLean, Ford, Menard, Logan, Sangamon, Christian, Mason, Piatt, DeWitt, Champaign and Vermilion counties)
•
Metro East (St. Clair, Clinton and Madison counties)
•
Quad Cities (Rock Island, Henry and Mercer counties)
To achieve improvements in health, ICP coordinates care between local primary care Physicians, specialists, hospitals, nursing homes, behavioral health Providers and other Providers so that all care is organized around the needs of the enrollee. ICP was phased in as two (2) service packages. It began with the initial rollout of Service Package I for acute health services, such as Physician, hospital and pharmacy services. Service Package II covers LongTerm Services and Supports, including Home and Community Based waiver and Nursing Facility services, and became effective February 1, 2013. Medicare Medicaid Alignment Initiative (MMAI): The Medicare-Medicaid Alignment Initiative (MMAI) was implemented in March 2014. The MMAI demonstration integrates services covered in Medicare and Medicaid under one managed care program and combines financing streams to eliminate conflicting incentives between the two (2) programs. The overarching goal of MMAI is to integrate benefits to create a unified delivery system that is easier for beneficiaries eligible for both Medicare and Medicaid (Dual Eligibles) to navigate. HFS and federal Centers for Medicare and Medicaid Services (CMS) contracted with eight (8) Health Plans to assume financial risk for the care delivered to Dual Eligible participants with responsibilities for robust care coordination efforts where performance will be measured and tied to quality measurement goals. MMAI is a voluntary program with passive enrollment. The MMAI program operates in the following regions: •
Greater Chicago (Cook, DuPage, Kane, Kankakee, Lake and Will counties)
•
Central Illinois (Knox, Stark, Peoria, Tazewell, McLean, Ford, Menard, Logan, Sangamon, Christian, Mason, Piatt, DeWitt, Champaign and Vermilion counties)
Family Health Plans/ACA Adults (FHP): Family Health Plan (FHP)/Affordable Care Act (ACA) program is a mandatory managed care program for the Family Health population and the newly eligible ACA adults. HFS began mandatory enrollment in the summer of 2014. Under this expansion effort, individuals enrolled in the Illinois Health Connect program or with a Voluntary Health Plan, and newly eligible ACA adults, started the process of enrolling with a Health Plan for their health care delivery. HFS has nine (9) contracted Health Plans in the FHP/ACA program. The FHP program operates in the following regions: •
Greater Chicago (Cook, DuPage, Kane, Kankakee, Lake and Will counties)
Page 6 of 35
Appendix Volume 2, p. 43
Illinois Department of Healthcare and Family Services Managed Care Manual for Medicaid Providers
•
Rockford (Winnebago, Boone and McHenry counties)
•
Central Illinois (Knox, Stark, Peoria, Tazewell, McLean, Ford, Menard, Logan, Sangamon, Christian, Mason, Piatt, DeWitt, Champaign and Vermilion counties)
•
Metro East (St. Clair, Clinton and Madison counties)
•
Quad Cities (Rock Island, Henry and Mercer counties)
Illinois Health Connect (IHC): The Illinois Health Connect (IHC) program was the Department’s first step toward implementing managed care throughout the State. During 2014 and 2015, the majority of participants previously enrolled in IHC joined managed care Health Plans for their care coordination services. IHC remains a choice for participants in the nonmandatory managed care regions; however, it is not a choice for participants statewide. To obtain more information regarding IHC, Providers are directed to the IHC website. Health Plans and the Programs in Which They Participate: MCOs Aetna Better Health Blue Cross Blue Shield of Illinois Community Care Alliance of Illinois (CCAI) CountyCare Family Health Network (FHN) Harmony Health Plan Health Alliance Connect HealthSpring Humana IlliniCare Meridian Health Plan of Illinois Molina Healthcare NextLevel Health
ICP X X X X
MMAI X X
X X X X X X X
X X X X X X
FHP/ACA X X X X X X X X X X
1.40 Participant Enrollment The majority of Medicaid participants are required to enroll in a managed care program. The Illinois Participant Enrollment Services (ICES), Maximus, conducts all enrollment activities for the Department. Based on the eligibility data provided to the ICES by the Department, the ICES will determine which managed care program is appropriate for the participant and mail an initial enrollment packet to the participant’s address on file with the Department. The enrollment packet details the Health Plan choices available to the participant and the date by which the participant must respond with a voluntary choice. The initial enrollment packet is followed by a second enrollment packet approximately 30 days later. The second enrollment packet details the Health Plan and a Primary Care Provider (PCP) to whom the participant will be assigned if a voluntary choice is not made by the given response date. The Department encourages participants, their families, or their authorized representatives to make an active choice of a Health Plan since those individuals know the participant’s health care needs best.
Page 7 of 35
Appendix Volume 2, p. 44
Illinois Department of Healthcare and Family Services Managed Care Manual for Medicaid Providers
If a voluntary enrollment is not received by the response date, the ICES will utilize an advanced algorithm to assign the participant to a Health Plan and a PCP. The algorithm considers past Provider relationships and claims history to assign participants to a “best fit” Health Plan and PCP. As a last resort, geo-mapping is used to assign a participant to a Health Plan and PCP within certain specified travel/distance parameters. For programs that utilize a lock-in period (Family Health and Integrated Care), the ICES will conduct similar enrollment activities for participants during their annual Open Enrollment period. Participants who are required to enroll in a managed care program can do so in one of two ways. Participants (other than those enrolling in the Medicare-Medicaid Alignment Initiative) can enroll via the Internet at the ICES website. All participants may enroll by contacting the ICES at this toll-free number: 1-877-912-8880 (TTY: 1-866-565-8576). 1.50
Provider and Health Plan Participant Education at Provider Locations
If a Provider chooses to educate their patient at their Provider location(s), Providers and their staff must ensure that the patient is aware of all plan choices and use materials approved by the Department for this education. A flyer/letter template is available to Providers to use in their offices which will require the Provider to include all Health Plans with whom they are contracted. The flyer/letter template (pdf) is available on the HFS website. If a Provider chooses to prefer a Health Plan in the flyer/letter (the preference must be a benefit to the participant, not only to the Provider), Providers may add a paragraph to the flyer/letter indicating their preference. The paragraph must make no false or disparaging statements about other Health Plans and must be presented in a positive way. Any flyer/letter that has a preferred Provider paragraph must be submitted through the preferred Plan for HFS approval. The Provider template flyer/letter, including those with a preferred Health Plan paragraph must have a statement at the bottom that states, “To learn more about your Health Plan choices please contact Illinois Participant Enrollment Services (ICES) at 1-877-912-8880 or visit the ICES website”. Provider offices may provide a phone for their patients to contact the ICES directly to enroll. Online enrollment is prohibited within any Provider settings, health fairs, etc. This includes all Health Plan Primary Care Provider offices.
Page 8 of 35
Appendix Volume 2, p. 45
Illinois Department of Healthcare and Family Services Managed Care Manual for Medicaid Providers
Chapter 2 Provider Relations 2.10
Provider Enrollment
Provider enrollment in Medicaid Managed Care consists of a two part process. The first is to enroll with the Illinois Medical Assistance Program (Medicaid) and subsequently receive approval from the State to be a participating Provider in the program. The second is to contract with each Health Plan in which you want to participate. Contracting with a Health Plan does not automatically guarantee enrollment into Medicaid, as Medicaid enrollment is a separate process. 2.20
Enrollment into Medicaid
To comply with the Federal Regulations at 42 CFR Part 455 Subpart E - Provider Screening and Enrollment, Illinois has implemented an electronic Provider enrollment system. The webbased system is known as Illinois Medicaid Program Advanced Cloud Technology (IMPACT). To obtain more information and/or to enroll in IMPACT, Providers are directed to the IMPACT website. The effective date of enrollment for the eligible Provider will be established upon final approval of the application by the Department. Payment will not be made for services rendered prior to the effective date of enrollment. Change in ownership or corporate structure necessitating a new federal tax identification number terminates the participation of the enrolled Provider. Participation approval is not transferable. Claims submitted by the new owner using the prior owner’s assigned Provider number may result in recoupment of payments and other sanctions. In preparation for the enrollment process Providers should: •
Obtain a National Provider Identifier (NPI) number. The federal government requires that Providers who administer “medical and other health services” should obtain an NPI number – a unique 10-digit identification number for covered health care Providers. For more information visit the federal CMS HIPAA webpage.
•
Renew any professional certifications or licensures. Current certification or licensure is a condition of participation in the Medicaid Program. If your profession requires a certification or licensure in the State of Illinois, these qualifications must be active at the time of enrollment or revalidation. This includes the Clinical Lab Improvement Amendments Certification, administered by the Illinois Department of Public Health Office of Health Care Regulation.
•
Submit a current W9 to the Illinois State Comptroller for certification. Be sure it is current, as the comptroller does not accept copies of older versions. This W9 should have the tax number that you intend to be paid under.
•
Decide on an email address. Your email address is used for communication with the state as this will be the primary mode of communication and will be required in order to complete the enrollment process.
Page 9 of 35
Appendix Volume 2, p. 46
Illinois Department of Healthcare and Family Services Managed Care Manual for Medicaid Providers
2.30
Enrollment into a Health Plan
Enrollment into a Health Plan is a three step process: contracting, credentialing and Provider load. 1. Contracting. Contact any Health Plan you are interested in contracting with by reaching out to the Provider Network representative on the Health Plan contact list (pdf). 2. Credentialing. In addition to contracting with the Health Plan, Providers must be credentialed by the Health Plan. Credentialing takes approximately thirty (30) to ninety (90) days. It is imperative for Providers to submit clean documents with all applicable information when submitting their credentialing applications. 3. Provider Load. Once a Provider is credentialed, it takes thirty (30) to sixty (60) days to load Provider information into the Health Plan’s system. 2.40
Provider Contracting
Medicaid Providers located in or near the mandatory regions are encouraged to contract with one or more of the Health Plans (pdf) to become part of their network(s). The contract negotiated between the Medicaid Provider and the Medicaid Health Plan dictates the relationship between the two parties, including payment provisions, prior authorization requirements, utilization review requirements, Provider Complaint and resolution procedures and panel limitations. Once a Provider has contracted successfully with a Health Plan, the Provider is considered an Affiliated Provider. 2.50
Provider Training
Health Plans are required to meet with the Affiliated Provider and/or the Provider’s staff to explain their policies and procedures. Provider orientation or training will include information on the Health Plan’s utilization policies and procedures, cultural competency requirements, and billing or claims submittal information in order to be reimbursed for a service rendered. A contact person at the Health Plan will serve as the Provider’s representative. These sessions are held via phone call, webinar or in the Providers’ offices. The Health Plans and the Department developed a Provider Training Attestation form (pdf), which allows Providers to document that they have already been trained in a particular area from a specific Health Plan, so they aren’t taking the same course repeatedly for each Health Plan. The Health Plans have the Provider complete the attestation form and the Health Plan must keep the form on file for auditing purposes. In most instances Health Plans establish their own utilization and prior authorization requirements which may or may not coincide with the requirements the Department has in place under Fee-For-Service. Health Plans may also establish, via Provider subcontracts, different timely filing requirements than the Department. These are examples of processes that will be explained during a Provider’s orientation.
Page 10 of 35
Appendix Volume 2, p. 47
Illinois Department of Healthcare and Family Services Managed Care Manual for Medicaid Providers
Provider manuals are available online to all Affiliated Providers. Each Health Plan has a Provider portal where the Provider can go to learn administrative and referral requirements and to make a request for prior authorization. The Provider directory (pdf) is also available to Providers online. If a Provider has a dispute over a claim, the Health Plan will address that dispute through their Complaint and resolution system. The Department has issued several Provider notices regarding managed care and working with and coordinating care with these organizations. The Health Plans are encouraged to sign up for all Provider notices in order to remain informed of information the Department is providing to all enrolled Medicaid Providers. The Health Plans are also made aware of policy changes and rate changes through Provider notices as well. 2.60 Provider Billing Providers are responsible to bill the Health Plan directly for Health Plan Enrollees. Every Health Plan’s Enrollee ID card contains the Enrollee’s HFS RIN. Providers MUST verify coverage and Health Plan enrollment through one of the HFS automated systems using the participant’s Social Security Number or the participant’s RIN found on either the HFS Medical Card or Health Plan’s Enrollee ID card. It is critical that Providers check the Department’s electronic eligibility systems regularly to determine a participant’s enrollment in a Health Plan. The three options are: 1) Recipient Eligibility Verification Program (REV); 2) the Medical Electronic Data Interchange (MEDI) system; or 3) the Automated Voice Response System (AVRS) at 1-800-842-1461. Using REV and MEDI to Determine a Participant’s Health Plan Recipient Eligibility Verification (REV) programs and MEDI identify the name of the Health Plan for Medicaid participants enrolled in a Health Plan. Providers must bill the Health Plan for Health Plan Enrollees. Using the AVRS to Determine a Participant’s Health Plan Providers can get Participant eligibility information by calling 1-800-842-1461, the Automated Voice Response System (AVRS). To check eligibility on AVRS, Providers will need the: • • •
9-, 10- or 12-digit Medicaid Provider number; 9-digit Recipient Identification Number (RIN); and Date for which eligibility information is being sought.
The AVRS will provide all information relating to a Participant's eligibility, including Health Plan enrollment, and will permit up to 6 eligibility inquiries during each telephone call. The Department pays the Health Plans on a full-risk capitated basis to cover the cost of Medicaid services and care coordination. Providers must provide services in accordance with each Health Plan’s utilization policies and procedures, including procedures for prior Page 11 of 35
Appendix Volume 2, p. 48
Illinois Department of Healthcare and Family Services Managed Care Manual for Medicaid Providers
authorization and billing. All questions, including billing questions, should be directed to the Health Plans. 2.70
Encounter Data
If a Provider is paid on a capitated basis, it is imperative that the Provider submits Encounter Data to the Health Plan. If no claim is received, and submitted to the Department by the Health Plan, there is no record of services. Records of services help the Department monitor quality and continue to develop accurate rates for the Health Plans. 2.80
Timely Payment
Health Plans are responsible for making payments to Providers for covered services on a timely basis consistent with the Claims Payment Procedure described at 42 U.S.C. § 1396a(a)(37)(A) and 215 ILCS 5/368a. •
Health Plans must pay 90 percent (90%) of all clean claims from Providers for covered services within thirty (30) days following receipt.
•
Health Plan must pay 99 percent (99%) of all clean claims from Providers for covered services within ninety (90) days following receipt.
Note: A “clean claim” is a claim from a Provider for covered services that can be processed without obtaining additional information from the provider of the service or from a Third Party, except a claim submitted by or on behalf of a Provider who is under investigation for Fraud or Abuse, or a claim that is under review for determining whether it was Medically Necessary. For purposes of an Enrollee’s admission to a Nursing Facility, a “clean claim” means that the admission is reflected on the patient credit file that Health Plan receives from the Department. 2.90
Reimbursement
Health Plans are responsible for making payments as required under their contract with the Provider. Exclusions to this rule are listed below: •
Emergency Services. Health Plans must pay at least the Department’s rate for appropriate Emergency Services provided by a Non-Affiliated Provider.
•
Post Stabilization Services. Health Plan must pay a least the Department’s rate for all Post-Stabilization Services as a covered service in any the following situations:
Health Plan authorized such services;
Such services were administered to maintain the Enrollee’s Stabilized condition within one (1) hour after a request to the Health Plan for authorization of further Post-Stabilization Services; or
Health Plan did not respond to a request to authorize such services within one (1) hour, Health Plan could not be contacted, or, if the treating Provider is a NonAffiliated Provider, Health Plan and the treating Provider could not reach an agreement concerning the Enrollee’s care and an Affiliated Provider was unavailable for a consultation. In such case, the Health Plan must pay for services rendered by
Page 12 of 35
Appendix Volume 2, p. 49
Illinois Department of Healthcare and Family Services Managed Care Manual for Medicaid Providers
the treating Non-Affiliated Provider until an Affiliated Provider was reached and either concurred with the treating Non-Affiliated Provider’s plan of care or assumed responsibility for the Enrollee’s care. Such payment shall be made at the same rate the Department would pay for such services according to the level of services provided and exclusive of disproportionate share payments and Medicaid percentage adjustments. •
Family Planning Services. Health Plan must pay for family planning services rendered by a Non-Affiliated Provider, for which the Health Plan would pay if rendered by an Affiliated Provider, at the same rate Department would pay for such services exclusive of disproportionate share payments and Medicaid percentage adjustments, unless a different rate was agreed upon by Health Plan and the Non-Affiliated Provider.
If a Provider is having billing problems they should follow up with the managed care representative that was assigned to them for contracting. Provider Complaints must be filed with the Health Plan. 2.100 Provider Complaint Resolution Health Plans must maintain a complaint and resolution process for providers. If a provider disagrees with a policy, decision, or procedure, the provider should follow the Health Plan provider complaint process. Health Plans are required to make every effort to resolve any Provider Complaints. All disputes are handled between the Health Plan and the provider, unless the Health Plan has not fulfilled its duties under the applicable State Contract. 2.110 Non-Affiliated Providers Providers who are not contracted with a Health Plan should not provide non-emergency services to Health Plan Enrollees unless they receive a prior authorization from the Health Plan. There are some services that do not require a Non-Affiliated Provider to receive prior authorization, including: •
Emergency Services. Health Plan members may access affiliated or Non-Affiliated Providers for appropriate Emergency Services.
•
Post-Stabilization Services. Post-Stabilization Services are provided under certain situations, including:
The Health Plan authorizes such services;
Such services are administered to maintain the Enrollee’s Stabilized condition within one (1) hour after a request to the Health Plan for authorization of further PostStabilization Services; or
The Health Plan does not respond to a request to authorize further Post-Stabilization Services within one (1) hour; the Health Plan cannot be contacted, or the Health Plan and the treating Non-Affiliated Provider cannot reach an agreement concerning the Enrollee’s care and an Affiliated Provider is unavailable for a consultation. In such case, the treating Non-Affiliated Provider must be permitted to continue the
Page 13 of 35
Appendix Volume 2, p. 50
Illinois Department of Healthcare and Family Services Managed Care Manual for Medicaid Providers
care of the Enrollee until an Affiliated Provider is reached and either concurs with the treating Provider’s plan of care or assumes responsibility for the Enrollee’s care. •
Family Planning Services. Family Planning is a direct access service. Health Plans provide coverage of family planning services for all Enrollees whether the family planning services are covered by an affiliated or Non-Affiliated Provider.
•
School-Based Health Centers. Under the Family Health Plan Program, Health Plans will accept claims from Non-Affiliated Providers of school health center services outside of the Health Plan’s contracting area. Payments of such services will be according to the HFS applicable Medicaid Fee-For-Service reimbursement schedule. Health Plans may require the Non-Affiliated Providers of school health centers to follow its protocols for communication regarding services rendered in order to further care coordination.
•
School Dental Program. Under the Family Health Plan Program, Health Plans will accept claims from Non-Affiliated Providers of dental services provided in a school for Enrollees under the age of 21 outside of the Health Plans contracting area. Payments of such services will be according to the HFS applicable Medicaid Fee-For-Service reimbursement schedule. Health Plans may require the program to follow its protocols for communication regarding services rendered in order to further care coordination.
•
SASS Services. Screening, Assessment and Support Services (SASS) program is a statewide program resulting from the Children’s Mental Health Act of 2003, which requires the Department to ensure that all eligible children and adolescents receive a screening and assessment prior to any admission to a hospital for inpatient psychiatric care. With the passage of this Act, the Department joined forces with two other Illinois State departments that have been funding screening and assessment services for children and adolescents since 1992 - the Department of Human Services (DHS) and Department of Children and Family Services (DCFS) - to create a coordinated singlepoint of entry for children and adolescents in need of mental health services. This system is designed to be a family-friendly unified system that will reduce fragmentation in service delivery. Under the Family Health Plan Program, Health Plans will accept claims from a Non-Affiliated Provider of SASS services in the event that an Enrollee is screened, due to necessity, by such Non-Affiliated Provider. The Health Plan will pay for such screening at the Medicaid rate.
Health Plans will accept claims from Non-Affiliated Providers for at least six (6) months after the date the services are provided. Non-Affiliated Providers must be enrolled in the HFS Medical Program prior to receiving payment for services rendered to Illinois Medicaid participants including those enrolled in a Health Plan.
Page 14 of 35
Appendix Volume 2, p. 51
Illinois Department of Healthcare and Family Services Managed Care Manual for Medicaid Providers
Chapter 3 Care Coordination 3.10
Care Coordination
Health Plans are responsible for offering Care Management through a Care Coordinator who participates in an Interdisciplinary Care Team (ICT) for all medical, behavioral health, functional, and psychosocial needs, as appropriate, to address the needs and preferences of the Enrollee. The higher the risk of the Enrollee, the higher the level of care coordination provided by the MCO. 3.20
Interdisciplinary Care Team
Health Plan’s Care Coordinator’s may be in touch with Providers to invite them to participate in an Enrollee’s Interdisciplinary Care Team (ICT). The Care Coordinator forms an ICT with the help of the Enrollee. The ICT is person centered and is to build on each Enrollee’s specific preferences and needs. Each ICT consist of clinical and non-clinical staff whose skills and professional experience will complement and support each other in the oversight of each Enrollee’s needs. The Enrollee’s PCP is an important part of the health team involved in the coordination and direction of services for the Enrollee. The Care Coordinator provides the PCP with reports, updates, and information regarding the Enrollee’s progress through the Care Management plan. The PCP is responsible for the provision of preventive services and for the primary medical care of members. ICT meetings are not necessarily formal and face to face. Providers can participate by phone, through emails, faxes, etc. Anyway the Provider can participate in the Enrollees overall health care goals is a benefit for the Enrollee. 3.30
Care Plans
The ICT led by the Care Coordinator is responsible for developing a comprehensive personcentered Enrollee Care Plan. The Enrollee Care Plan incorporates an Enrollee’s medical, behavioral health, social, and functional needs. Providers, as part of the ICT, are welcome to participate in the development of the care plans. 3.40
Service Plans as Part of the Care Plan
Enrollees receiving Home and Community Based Waiver services have Service Plans, which include information on areas of assistance Enrollees need to keep them safe and residing in their homes. Service Plans are a component of the Care Plan. For example, a Service Plan might contain information on grooming, bathing, housework, and/or meal preparation, and the Service Plan will include how much time a service agency or assistant might need to help Enrollees complete these tasks. There are three distinct time frames for Health Plans to have a Service Plan, new or existing, in place:
Page 15 of 35
Appendix Volume 2, p. 52
Illinois Department of Healthcare and Family Services Managed Care Manual for Medicaid Providers
•
Service Plans are developed within 15 days of the Health Plan being informed from a State agency that an Enrollee is eligible for Home and Community Based Waiver services.
•
Service Plans remain in place for 180 days for an Enrollee who has an existing Service Plan but is new to the Health Plan (Enrollee came from Fee-for-Service).
•
Service Plans remain in place for 90 days for an Enrollee who is transferring from one Health Plan to another Health Plan.
The Health Plans will update the Service Plan as an Enrollee’s need changes. 3.50
Transition of Care
Health Plans are responsible for any covered services necessary to treat medical conditions that existed before the participant enrolled with the Health Plan. As long as an Enrollee is in an existing course of treatment, the service is a covered service, and the service is Medically Necessary, the Health Plan will support the continuation of that service. Health Plans are responsible for the on-going course of treatment, also called continuity of care, when a new Enrollee joins the Health Plan while in the middle of actively receiving treatment from a Provider. •
In the Integrated Care Program and the Family Health Plan Program, a Non-Affiliated Provider can continue to treat the Enrollee for an initial 90-day transition period or through the postpartum period. To do so, the Non-Affiliated Provider must agree to accept reimbursement from the Health Plan at the Health Plan’s established rates, follow the Health Plan’s Quality Assurance requirements, and agree to follow the Health Plan’s policies and procedures. This includes the Health Plan’s referral and authorization requirements.
•
In the Medicare Medicaid Alignment Initiative (MMAI), a Non-Affiliated Provider can continue to treat the Enrollee for an initial 180-day transition period. When the MMAI Enrollee switches from one Health Plan to another, the new Health Plan will offer a 90day transition period. To do so, the Non-Affiliated Provider must agree to accept reimbursement from the Health Plan at the Health Plan’s established rates, follow the Health Plan’s Quality Assurance requirements, and agree to follow the Health Plan’s policies and procedures. This includes the Health Plan’s referral and authorization requirements.
Health Plans also have special transition of care requirements for their LTSS population. LTSS Enrollees are Enrollees residing in a nursing home or receiving Home and Community Based Service waivers (HCBS). All individuals receiving HCBS have a Service Plan that addresses all identified needs for services received at home. If an Enrollee was receiving HCBS services before becoming enrolled in the Health Plan, that existing Service Plan must remain in effect for at least 180 Page 16 of 35
Appendix Volume 2, p. 53
Illinois Department of Healthcare and Family Services Managed Care Manual for Medicaid Providers
days. The Health Plan can only change the Service Plan within the 180 days if the Enrollee provides input and agrees to the change.
Page 17 of 35
Appendix Volume 2, p. 54
Illinois Department of Healthcare and Family Services Managed Care Manual for Medicaid Providers
Chapter 4 Covered Services The Health Plans are required to cover almost all services offered under Illinois Medicaid. They can also provide services beyond those covered under Medicaid, but Health Plans do so at their own expense. These additional services are approved by the Department before being offered to their members. The monthly Capitation payment the Health Plans receive from the Department for each of their members is based on Medicaid services, not the additional services they choose to offer. 4.10
Service Package I Covered Services
A list of Medicaid services can be found in 89 Ill. Adm. Code, Part 140. The list of covered services, often referred to as Service Package 1, include: •
Advanced Practice Nurse services;
•
Ambulatory Surgical Treatment Center services;
•
Assistive/Augmentative communication devices;
•
Audiology services;
•
Blood, blood components and the administration thereof;
•
Chiropractic services for Enrollees under age twenty-one (21);
•
Dental services, including oral surgeons;
•
EPSDT services for Enrollees under age twenty-one (21) pursuant to 89 Ill. Admin. Code Section 140.485, excluding shift nursing for Enrollees in the MFTD HCBS Waiver for individuals who are Medically Fragile and Technology Dependent (MFTD);
•
Family planning services and supplies;
•
FQHCs, RHCs and other Encounter rate clinic visits;
•
Home health agency visits;
•
Hospital emergency room visits;
•
Hospital inpatient services; Hospital ambulatory services;
•
Laboratory and x-ray services (Health Plan shall receive and transmit electronic lab values to support clinical management and for HEDIS® reporting);
•
Medical supplies, equipment, prostheses and orthoses, and respiratory equipment and supplies;
•
Mental health services provided under the Medicaid Clinic Option, Medicaid Rehabilitation Option, and Targeted Case Management Option;
•
Nursing care for Enrollees under age twenty-one (21) not in the HCBS Waiver for individuals who are MFTD, pursuant to 89 Ill. Admin. Code Section 140.472;
Page 18 of 35
Appendix Volume 2, p. 55
Illinois Department of Healthcare and Family Services Managed Care Manual for Medicaid Providers
•
Nursing care for the purpose of transitioning children from a hospital to home placement or other appropriate setting for Enrollees under age twenty-one (21), pursuant to 89 Ill. Admin. Code 146, Subpart D;
•
Nursing Facility services for the first ninety (90) days (NF services 91+ days included in Service Package II);
•
Optical services and supplies;
•
Optometrist services;
•
Palliative and Hospice services;
•
Pharmacy Services (drugs used in the treatment of Hepatitis C are covered only if dispensed in accordance with Health Plan’s coverage criteria approved by the Department);
•
Physical, Occupational and Speech Therapy services;
•
Physician services;
•
Podiatric services for Enrollees under age 21;
•
Podiatric services for diabetic Enrollees age 21 and over, and, effective October 1, 2014, podiatric services for all Enrollees age 21 and over;
•
Post-Stabilization Services;
•
Renal Dialysis services;
•
Respiratory Equipment and Supplies;
•
Services to prevent illness and promote health in accordance with Attachment XXI
•
Subacute alcoholism and substance abuse services pursuant to 89 Ill. Admin. Code Sections 148.340 through 148.390, 77 Ill. Admin. Code Part 2090, Day treatment (residential) and Day treatment (detox);
•
Transplants, pursuant to 89 Ill. Admin. Code Section 148.82 (using transplant Providers certified by the Department); and
•
Transportation to secure Covered Services.
4.20
Pharmacy Services
Health Plans are required to cover drugs. They must cover all drugs covered by Medicaid, but it does not have to be the exact same set of drugs. The Health Plan’s formulary cannot be any more restrictive than the Department’s list of covered drugs. The Department reviews and prior approves the Health Plan’s formularies. 4.30
Hospice Services
Health Plans are required to cover Hospice Services. Hospice Providers are required to complete a Medicaid Hospice Benefit Election Form (HFS 1592) (pdf) for hospice members. Page 19 of 35
Appendix Volume 2, p. 56
Illinois Department of Healthcare and Family Services Managed Care Manual for Medicaid Providers
Hospice Providers must submit this form to both HFS and also send a copy of the form to the Health Plan of the Enrollee. 4.40
Dental Services
Dental services are provided through the Health Plans and the dental Provider must bill the appropriate Health Plan’s dental administrator to receive payment. Some Health Plans offer additional dental benefits to their members above the basic Medicaid program benefit. 4.50
Emergency and Non-Emergency Transportation
All non-emergency transportation services for Health Plan Enrollee’s must be prior approved by the Health Plan when transport is needed for medical services covered by the Health Plan. To obtain prior approval for non-emergency transportation for Health Plan Enrollees, the Health Plan must be contacted. The phone number for the Health Plan is printed on the Participant’s Health Plan ID card. All Health Plans have medical personnel available 24 hours a day to provide prior approval. The prior approval/post approval (pdf) form the Health Plans utilize can be found on the First Transit website. Prior approval from the Health Plan is not required in the following circumstances: •
Emergency services do not require prior approval.
•
Participants are not limited to Affiliated Providers for family planning services.
Non-emergency transportation Providers may contest any decision by the Health Plan for which no denial was received prior to the time of transport that either denies a request for approval for payment of non-emergency transportation or grants a request for approval of nonemergency transportation at a level of service that entitles the ground ambulance services Provider to a lower level of compensation than requested by the ground ambulance services Provider. Health Plans require that Long Term Care Facilities and hospitals utilize a uniform certification of medical necessity for non-emergency ambulance transportation except where it is reasonable to believe a delay in transportation can be expected to negatively affect the efficient transportation. 4.60
Behavioral Health
Behavioral health services include both mental health and substance abuse. Health Plans are required to cover both services, including services provided under the Medicaid Clinic Option or Medicaid Rehabilitation Option. Some Health Plans have a subcontractor specializing in providing Behavioral Health services. Health Plans can create their own prior authorization and utilization requirements surrounding behavioral health.
Page 20 of 35
Appendix Volume 2, p. 57
Illinois Department of Healthcare and Family Services Managed Care Manual for Medicaid Providers
Health Plans require each Affiliated Provider that provides services under a DHS HCBS Waiver, under the Medicaid Clinic Option, or under the Medicaid Rehabilitation Option, or members receiving alcoholism and substance abuse treatment services to continue entering data about that Enrollee into DHS’ system. This includes the DHS Automated Reporting and Tracking System (DARTS). This is a requirement under State rules. 4.70
Service Package 2 Covered Services
Health Plans are also responsible for all Service Package 2 services, which includes Nursing Home services and Home and some Community Based Waiver Services (HCBS). These are also called Long Term Supports and Services (LTSS). 4.80
HCBS Services
Illinois has nine (9) HCBS waivers. Different State agencies operate the waivers, with HFS overseeing the operation of each waiver. Each waiver is designed for individuals with similar needs and offers a different set of services. Waiver programs are approved by Federal CMS and allow Illinois to cover a broad range of services to allow individuals to receive nontraditional services in the community or in their own homes, rather than being placed in an institutional setting. While Illinois offers nine HCBS waivers, only five of the nine are considered part of Service Package 2 and therefore the Health Plans are responsible to arrange and pay for the services under these five waivers. Waivers designed for individuals with Developmental Disabilities are excluded from managed care. Please note that for the Integrated Care Program and the Family Health Plan Program, individuals enrolled in the Developmental Disabilities waivers are enrolled in managed care for their medical coverage; it is their HCBS waiver services that are excluded and remain under Fee-For-Service. Under the Medicare Medicaid Alignment Initiative, individuals enrolled in the Developmental Disabilities waivers are excluded from managed care. Children in the Medically Fragile Technology Dependent waiver are excluded from all managed care programs. Health Plans are only allowed to use HCBS Providers that have been approved and authorized by the State agency in charge of that particular waiver. If a Provider, for example, is only approved by the Illinois Department on Aging to provide HCBS services to those on the Elderly waiver, that Provider is not allowed to provide the same services to members of the Persons with Disabilities waiver. The Provider must first be approved and authorized to provide services under the other waiver(s). The Health Plans do not credential HCBS waivers. Health Plans are required to pay HCBS Providers at least the Medicaid rate for providing HCBS services. They cannot pay less than what Medicaid offers for these services. Providers who think managed care members might benefit from HCBS services can refer those members at any time. They can contact the Enrollee’s Care Coordinator and suggest an assessment be completed to determine if the Enrollee is eligible for HCBS services. Providers can also refer their members through these websites: Page 21 of 35
Appendix Volume 2, p. 58
Illinois Department of Healthcare and Family Services Managed Care Manual for Medicaid Providers
•
Rehabilitation Services (to refer members for the Persons with Disabilities, Brain Injury, or HIV/AIDS waiver)
•
Senior HelpLine (To refer members for the Elderly waiver)
•
Supportive Living Facilities (to refer members for the Supportive Living Program)
All individuals residing in a Nursing Facility or receiving HCBS waiver services receives care coordination from their Health Plan. Care Coordinators who work with the HCBS population must meet certain educational and training criteria. Care Coordinators must also maintain frequent contact with their HCBS and Nursing Facility Enrollees. Those contact requirements are included below in the description of each waiver. Below is a brief description of the five (5) waivers that are covered by Health Plans under Service Package 2: 1. HCBS Waiver for Persons who are Elderly. The Department on Aging (DoA) is the operating agency for the HCBS waiver for persons who are elderly, which is part of the Community Care Program (CCP). The CCP offers services to persons age 60 and over who meet functional and financial eligibility criteria. Examples of services received under the Elderly waiver include Adult Day Care, Homemaker services, and/or the Personal Emergency Response System. Health Plan Care Coordinators for members enrolled in this waiver must meet with the Enrollee face-to-face at least once every 90 days. 2. HCBS Waiver for Assisted Living, Supportive Living Program. HFS is the operating agency for the Supportive Living Program. The Supportive Living Program serves persons age 65 and older or persons age 22 to 64 who have physical disabilities. A Supportive Living Facility (SLF) is a Department-approved residential setting in Illinois. Health Plan Care Coordinators for members enrolled in this waiver must meet with the Enrollee face-to-face at least once every year. 3. Persons with Disabilities Waiver. The DHS Division of Rehabilitation Services (DHSDRS) is the operating agency for this waiver, which serves individuals between the ages of birth through 59 years, unless the individual was receiving services prior to the 60th birthday and chose to remain in the waiver. The person must have a medical determination of a diagnosed, severe disability, which is expected to last for at least 12 months or for the duration of life. Examples of services received under the Persons with Disabilities waiver includes Personal Assistants, Adult Day Care, Environmental Accessibility Adaptations, additional therapy services, Home Delivered Meals, Homemaker services, and/or Personal Emergency Response System. Health Plan Care Coordinators for members enrolled in this waiver must meet with the Enrollee face-toface at least once every 90 days. 4. Persons with HIV/AIDS Waiver. DHS-DRS is the operating agency for this waiver, which serves persons with HIV/AIDS of any age who have a medical determination of HIV or AIDS with severe functional limitations, which are expected to last at least 12 months or for the duration of life. Examples of services received under the Persons with Page 22 of 35
Appendix Volume 2, p. 59
Illinois Department of Healthcare and Family Services Managed Care Manual for Medicaid Providers
Disabilities waiver includes Personal Assistants, Adult Day Care, Environmental Accessibility Adaptations, additional therapy services, Home Delivered Meals, Homemaker services, and/or Personal Emergency Response System. Health Plan Care Coordinators for Enrollees in this waiver must meet with the Enrollee face-to-face at least once every two months. 5. Persons with Brain Injury Waiver. DHS-DRS is the operating agency for this waiver, which serves persons with brain injury of any age who have an acquired brain injury. Examples of services received under the Persons with Disabilities waiver includes Personal Assistants, Adult Day Care, Environmental Accessibility Adaptations, additional therapy services, Home Delivered Meals, Homemaker services, and/or Personal Emergency Response System. Health Plan Care Coordinators for Enrollees in this waiver must meet with the Enrollee face-to-face at least once every month. Participant direction of services is an important component of HCBS services. The Department expects that the Enrollee will continue to have the authority to exercise decision-making authority over some or all services and accepts the responsibility for taking a direct role in managing them. Participant direction promotes personal choice and control over the delivery of services, including who provides services and how they are delivered. For example, the Enrollee may be afforded the opportunity and be supported to recruit, hire, and supervise individuals who provide daily supports to them. 4.90
Nursing Facilities Services
Health Plans are also responsible for Long Term Care facility services, including room and board and supervision, equipment and supplies including oxygen, laundry services, food, medications, over-the-counter drugs or items ordered by a Physician. Health Plan Care Coordinators for Enrollee residing in a Nursing Facility must meet with the Enrollee face-toface at least once every 90 days. 4.100 Non-Covered Services There are several services that Health Plans are not responsible for covering. These services remain Fee-For-Service and should be billed to the Department, not to the Health Plans. These services include: •
Services in a State Facility operated as a psychiatric hospital as a result of forensic commitment
•
Services provided through a Local Education Agency (LEA)
•
Services funded through the Juvenile Rehabilitation Services Medicaid Matching Fund
•
Any service considered cosmetic or experimental
•
Early Intervention (EI) services
Page 23 of 35
Appendix Volume 2, p. 60
Illinois Department of Healthcare and Family Services Managed Care Manual for Medicaid Providers
There are also some limitations on covered services including: •
Termination of pregnancy. This service can be provided if it meets State and federal law requirements (42 CFR Part 441, Subpart E) and the Provider completes HFS Form 2390 (pdf) after the service is completed. Termination of pregnancy is not a covered service, however, for those eligible under the State Children’s Health Insurance Program Act (215 ILCS 106).
•
Sterilization services. These services can be provided if they meet State and federal law requirements (42 CFR Part 441, Subpart F) with HFS Form 2189 (pdf)completed.
•
Hysterectomy services. HFS Form 1977 (pdf) must be completed for this service.
Page 24 of 35
Appendix Volume 2, p. 61
Illinois Department of Healthcare and Family Services Managed Care Manual for Medicaid Providers
Chapter 5 Enrollee Grievance and Appeals Each Health Plan is required to have an Enrollee Grievance and Appeals policy and procedures established to ensure that actions taken against participants are supported by policy, administrative code and law. The Department serves as a check and balance for managed care companies to make sure participants are receiving covered service to which they are entitled. Medicaid Health Plans are required to establish internal Grievance and Appeals procedures under which Medicaid Enrollees, or an authorized representative acting on their behalf, may make a Complaint, challenge the denial of coverage of, or payment for, covered services. Health Plan Enrollees receive these policies and procedures when they first enroll with the Health Plan in their Enrollee Handbook. The Grievance and Appeals procedures are also listed on each Health Plan’s website.
Page 25 of 35
Appendix Volume 2, p. 62
Illinois Department of Healthcare and Family Services Managed Care Manual for Medicaid Providers
Chapter 6 Quality Assurance Program Providers must incorporate the delivery of quality care with the primary goal of improving the health status of Enrollees and, where the Enrollee’s condition is not amenable to improvement, maintain the Enrollee’s current health status by implementing measures to prevent any further decline in condition or deterioration of health status. Providers must actively improve the quality of care provided to Enrollees, consistent with its Quality Program, its quality improvement goals, the Department’s quality strategy. 6.10
Quality Assurance, Utilization Review and Peer Review
HFS requires that Health Plans, through contacts with the Affiliated Providers, ensure participation in the Health Plans’ Quality Assurance Plan (QAP). Health Plan’s utilize their Provider services Department representatives to work closely with the Affiliated Providers to ensure they understand the expectations and requirements of participating in the Health Plan QAP. 6.20
Clinical Practice Guidelines
Clinical Practice Guidelines (CPGs) are utilized to reduce inter-practitioner/Provider variation in diagnosis and treatment. Provider CPG adherence is measured at least annually by the Health Plans. The CPGs are distributed to appropriate practitioners, Providers and Provider groups. The Health Plan determines how the CPGs are disseminated to Providers and this can be through different means including the Provider portal, web or Provider newsletters. The CPGs are available to Providers upon request. 6.30
Preventive Health Guidelines
Preventive Health Guidelines are utilized to provide coverage of diagnostic preventive procedures based on recommendations published by the US Preventive Services Task Force (USPSTF) and in accordance with Centers for Medicare & Medicaid Services (CMS) guidelines. Guidelines are updated as necessary and distributed to practitioners/Providers via the on-line Provider directory and or the Provider newsletter. 6.40
Cultural and Linguistic Services
HFS serves a diverse Medicaid population with specific cultural needs and preferences. Providers are responsible to ensure that interpreter services are made available at no cost for Medicaid participants with sensory impairment and/or who are Limited English Proficient (LEP). Providers may request interpreters for members whose primary language is other than English by calling the Health Plan Enrollee services department. If Enrollee services representatives are unable to provide the interpretation services internally, the Enrollee and Provider are immediately connected to language line telephonic interpreter service. For Health Plan’s Enrollee Service phone numbers visit the Program Information Guide website. Page 26 of 35
Appendix Volume 2, p. 63
Illinois Department of Healthcare and Family Services Managed Care Manual for Medicaid Providers
6.50
Access to Care Standards
HFS requires that Health Plans provide timely access to care for their Enrollees. Providers are required to offer hours of operation no less than hours of operation offered to commercial patients. Access standards are developed to ensure that all health care services are provided in a timely manner. The PCP or designee must be available 24 hours-a-day, seven-days-aweek to members. This access may be by telephone. Appointment and waiting-time standards are communicated to the Providers through their contract and they are also listed in the on-line Provider directory. Appointment Access No more than six scheduled appointments shall be made for each PCP per hour. Notwithstanding this limit, it is recognized that Physicians supervising other licensed healthcare Providers may routinely account for more than six appointments per hour. Office Wait Time For scheduled appointments, the wait time in offices should not exceed 60 minutes from appointment time, until the time seen by the PCP. All PCPs are required to monitor waiting times and to adhere to this standard. After Hours All practitioners must have back-up (on call) coverage after hours or during the practitioner’s absence or unavailability. Practitioners are required to maintain a 24-hour phone service, seven days a week. This access can be through an answering service. The service should instruct members with an emergency to hang-up and call 911 or go immediately to the nearest emergency room. After hours phone calls or pages must be returned within 30 minutes. At least annually, Health Plans are required to conduct an access audit of randomly selected contracted practitioner/Provider offices to determine if appointment access standards are met. One or all of the following appointment scenarios may be addressed: routine care; acute care; preventive care; and after-hours information. Results of the audit are distributed to the practitioners after its completion. A corrective action plan may be required if standards are not met. 6.60
Site and Medical Record-Keeping Practice Reviews
Providers are required to maintain compliance with certain standards for safety, confidentiality, and record keeping practices in their practices. Health Plans assess the quality, safety and accessibility of office sites where care is delivered. This includes an assessment of: •
Physical accessibility
•
Physical appearance
•
Adequacy of waiting- and examining-room space
•
Availability of appointments
Page 27 of 35
Appendix Volume 2, p. 64
Illinois Department of Healthcare and Family Services Managed Care Manual for Medicaid Providers
•
Adequacy of medical/treatment record keeping
During the Provider site-visit, Health Plans review office documentation practices with the practitioner or practitioner’s staff. This discussion includes a review of the forms and methods used to keep the medical record information in a consistent manner and include how the practice ensures confidentiality of records. 6.70
Improvement Plans
Providers are required to comply with the Health Plans Quality Improvement Plan (QIP). When compliance is not achieved, the Provider is required to submit a written improvement plan to the Health Plan. This improvement plan must include the expected time frame for completion of activities. 6.80
Measurement of Clinical and Service Quality
HFS requires the Health Plans to monitor and evaluate the quality of care and services provided to Enrollees through the following mechanisms: •
Healthcare Effectiveness Data and Information Set (HEDIS®)
•
Consumer Assessment of Healthcare Providers and Systems (CAHPS®)
•
Provider Satisfaction Survey
•
Effectiveness of Quality Improvement Initiatives
Health Plans are required to collect data to monitor performance with established standards and provide interpretation of these data to its affiliated Practitioners/Providers. Affiliated Providers must allow Health Plans to use its performance data collected in accordance with the Provider’s contract. The use of Provider performance data may include, but is not limited to, the following: (1) development of quality improvement activities; (2) public reporting to consumers. To see Health Plan’s quality measures, visit the Care Coordination website.
Page 28 of 35
Appendix Volume 2, p. 65
Illinois Department of Healthcare and Family Services Managed Care Manual for Medicaid Providers
Chapter 7 Definitions Abuse: (i) A manner of operation that results in excessive or unreasonable costs to the Federal or State health care programs; (ii) the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish (42 CFR Section 488.301). Action: (i) The denial or limitation of authorization of a requested service; (ii) the reduction, suspension, or termination of a previously authorized service; (iii) the denial of payment for a service; (iv) the failure to provide services in a timely manner; (v) the failure to respond to an Appeal in a timely manner, or (vi) solely with respect to an Health Plan that is the only Health Plan serving a rural area, the denial of an Enrollee’s request to obtain services outside of the contracting Area. Administrative Rules: The sections of the Illinois Administrative Code that govern the Medicaid Program. Adults with Disabilities: An individual who is 19 years of age or older, who meets the definition of blind or disabled under Section 1614(a) of the Social Security Act (42 U.S.C.1382), and who is eligible for Medicaid. Advanced Practice Nurse (APN): A Provider of medical and preventive services, including Certified Nurse Midwives, Certified Family Nurse Practitioners and Certified Pediatric Nurse Practitioners, who is licensed as an APN, holds a valid license in Illinois, is legally authorized under statute or rule to provide services, and is enrolled with the Department and contracted with the Health Plan. Affiliated Provider: A Provider associated as an employee or by other legally recognizable means with a Health Plan for the purpose of providing services under the Department’s contract with the Health Plan. Anniversary Date: the annual anniversary of an Enrollee’s initial enrollment in the Health Plan. For example, if an Enrollee became effective in an Health Plan on October 1, 2010, their Anniversary Date with that Health Plan would be each October 1st thereafter. Appeal: A request for review of a decision made by the Health Plan with respect to an Action. CAHPS: Consumer Assessment of Health Plans Survey is a public-private initiative to develop standardized surveys of patient’s experience with ambulatory and facility level care. Capitation: The reimbursement arrangement in which a fixed rate of payment per Enrollee per month is made to the Health Plan for the performance of all of the Health Plan’s duties and responsibilities. Care Coordinator: An employee of the Health Plan, together with an Enrollee and Providers, establishes an Enrollee Care Plan for the Enrollee and, through interaction with Affiliated Providers, ensures the Enrollee receives necessary services. Care Management: Services that assist Enrollees in gaining access to needed services, including medical, social, educational and other services, regardless of the funding source for the services. Page 29 of 35
Appendix Volume 2, p. 66
Illinois Department of Healthcare and Family Services Managed Care Manual for Medicaid Providers
Centers for Medicare & Medicaid Services (Federal CMS): The agency within DHHS that is responsible for the administration of the Medicare program and, in partnership with the states, administers Medicaid, the State Children’s Health Insurance Program (CHIP), and the Health Insurance Portability and Accountability Act (HIPAA). Complaint: A phone call, letter or personal contact from a Participant, Enrollee, family member, Enrollee representative or any other interested person expressing a concern related to the health, safety or well-being of an Enrollee. Department or HFS: The Illinois Department of Healthcare and Family Services and any successor agency. DHS: The Illinois Department of Human Services, and any successor agency. DHS-DRS: The Division of Rehabilitation Services, and any successor agency, within DHS that operates the home services programs for persons with physical disabilities, brain injury and HIV/AIDS. DoA: The Illinois Department on Aging, and any successor agency. Dual Eligible: A Participant who is eligible to receive services through both the Medicare and the Medicaid Program. Emergency Medical Condition: A medical condition manifesting itself by acute symptoms of sufficient severity (including, but not limited to, severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in (i) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, (ii) serious impairment to bodily functions, or (iii) serious dysfunction of any bodily organ or part. Emergency Services: Those inpatient and outpatient health care services that are covered services, including transportation, needed to evaluate or stabilize an Emergency Medical Condition, which are furnished by a Provider qualified to furnish Emergency Services. Encounter: An individual service or procedure provided to an Enrollee that would result in a claim if the service or procedure were to be reimbursed Fee-For-Service under the Medicaid Program. Encounter Data: The compilation of data elements, as specified by the Department in written notice, identifying an Encounter that includes information similar to that required in a claim for Fee-For-Service payment under the Department’s Medical Program. Enrollee: A Participant who is enrolled in a Health Plan. "Enrollee" shall include the caretaker relative or guardian where the Enrollee is an adult for whom a guardian has been named; provided, however, that the Health Plan is not obligated to cover services for any individual who is not enrolled as an Enrollee with the Health Plan. Enrollee Care Plan: An Enrollee-centered, goal-oriented, culturally relevant, and logical, written plan of care that assures that the Enrollee receives medical and medically-related necessary services in a supportive, effective, efficient, timely and cost-effective manner that emphasizes prevention and continuity of care. Page 30 of 35
Appendix Volume 2, p. 67
Illinois Department of Healthcare and Family Services Managed Care Manual for Medicaid Providers
Fee-For-Service: The method of charging which bills for each service or encounter rendered. Fraud: Knowing and willful deception, or a reckless disregard of the facts, with the intent to receive an unauthorized benefit. Grievance: An expression of dissatisfaction by an Enrollee, including Complaints, about any matter other than a matter that is properly the subject of an Appeal. Health Plan: A Health Maintenance Organization or a Managed Care Community Network that provides or arranges to provide covered primary, secondary, and tertiary managed health care services for Medicaid Participants under contract with the Illinois Department of Healthcare and Family Services. Health Insurance Portability and Accountability Act (HIPAA): Also known as the KennedyKassebaum Bill, the Kennedy-Kassebaum Bill, K2, or Public Law 104-191 (pdf), the federal law that makes a number of changes that have the goal of allowing persons to qualify immediately for comparable health insurance coverage when they change their employment relationships. Title II, Subtitle F, of HIPAA provides DHHS with the authority to mandate the use of standards for electronic exchange of health care data; to specify what medical and administrative code sets should be used within those standards; to require the use of national identification systems for health care patients, Providers, payers (or plans), and employers (or sponsors); and to specify the typesof measures required to protect the security and privacy of personally identifiable health care information. Home and Community-Based Services (HCBS) Waivers: Waivers under Section 1915(c) of the Social Security Act that allow Illinois to cover home and community services and provide programs that are designed to meet the unique needs of individuals with disabilities who qualify for the level of care provided in an institution but who, with special services, may remain in their homes and communities. ILCS: Illinois Compiled Statutes. Illinois Participant Enrollment Services (ICES): The entity contracted by the Department to conduct enrollment activities for Potential Enrollees, including providing impartial education on health care delivery choices, providing enrollment materials, assisting with the selection of an Health Plan and PCP, and processing requests to change Health Plans. Integrated Care Program: The program under which the Department will contract with Health Plans to provide the full spectrum of Medicaid covered services through an integrated care delivery system to Older Adults and Adults with Disabilities who are eligible for Medicaid but are not eligible for Medicare. Long-Term Care (LTC) Facility or Nursing Facility (NF): A facility that provides Skilled Nursing or intermediate long-term care services, whether public or private and whether organized for profit or not-for-profit, that is subject to licensure by the Illinois Department of Public Health under the Nursing Home Care Act, including a county nursing home directed and maintained under Section 5-1005 of the counties code; and a part of a hospital in which skilled or intermediate long-term care services within the meaning of Title XVIII or XIX of the Social Security Act are provided.
Page 31 of 35
Appendix Volume 2, p. 68
Illinois Department of Healthcare and Family Services Managed Care Manual for Medicaid Providers
Marketing: Any written or oral communication from a healthcare delivery system or its representative that can reasonably be interpreted as intended to influence a Participant to enroll, not enroll, or to dis-enroll from a health care delivery system. Medicaid Program: The program under Title XIX of the Social Security Act that provides medical benefits to groups of low-income people. Medically Necessary: A service, supply or medicine that is appropriate and meets the standards of good medical practice in the medical community, as determined by the Provider in accordance with the Health Plan’s guidelines, policies or procedures, for the diagnosis or treatment of a covered illness or injury, for the prevention of future disease, to assist in the Enrollee’s ability to attain, maintain, or regain functional capacity, or to achieve ageappropriate growth. National Committee for Quality Assurance (NCQA): A private 501(c) (3) not for profit organization dedicated to improving health care quality and has a process for providing accreditation, certification and recognition, e.g., Health Plan accreditation. Neglect: A failure to notify the appropriate health care professional, to provide or arrange necessary services to avoid physical or psychological harm to a resident or to terminate the residency of a Participant whose needs can no longer by met, causing an avoidable decline in function. Neglect may be either passive (non-malicious) or willful. Non-Affiliated Provider: A Provider who is not associated with a Health Plan for the purpose of providing health care services under a Medicaid managed care program pursuant to a written contract or agreement. Limited service agreements or contracts (e.g. single case agreements) do not constitute network participation. Nursing Facility (NF): See Long-Term Care Facility. Older Adult: An individual who is 65 years of age or older and who is eligible for the Medicaid program. Open Enrollment: The specific period of time each year in which Enrollees shall have the opportunity to change from one Health Plan to another Health Plan. Participant: Any individual determined to be eligible for the Medicaid Program. Performance Measure: A quantifiable measure to assess how well an organization carries out a specific function or process. Person: Any individual, corporation, proprietorship, firm, partnership, trust, association, governmental authority, contractor, or other legal entity whatsoever, whether acting in an individual, fiduciary, or other capacity. Personal Assistant: Individuals who provide Personal Care to a Participant when it has been determined by the Care Coordinator that the Participant has the ability to supervise the Personal Care Provider. Personal Care: Assistance with meals, dressing, movement, bathing or other personal needs or maintenance, or general supervision and oversight of the physical and mental well‑being of a Participant. Page 32 of 35
Appendix Volume 2, p. 69
Illinois Department of Healthcare and Family Services Managed Care Manual for Medicaid Providers
Personal Emergency Response System (PERS): An electronic device that enables a Participant at high risk of institutionalization to secure help in an emergency. Physician: means an individual licensed to practice medicine in all its branches in Illinois under the Medical Practice Act of 1987 or any such similar statute of the state in which the individual practices medicine. Post-Stabilization Services: Medically necessary non-emergency services furnished to an Enrollee after the enrollee is stabilized following an Emergency Medical Condition, in order to maintain such stabilization. Potential Enrollee: A Participant who is subject to mandatory enrollment in a managed care program, but is not yet an Enrollee of a Health Plan. Primary Care Provider (PCP): A Provider, including a WHCP, who within the Provider's scope of practice and in accordance with State certification requirements or State licensure requirements, is responsible for providing all preventive and primary care services to assigned Enrollees in the Health Plan. Provider: A Person enrolled with the Department to provide Covered Services to a Participant. Quality Assurance (QA): A formal set of activities to review, monitor and improve the quality of services by a Provider or Health Plan, including quality assessment, ongoing quality improvement and corrective actions to remedy any deficiencies identified in the quality of direct Enrollee, administrative and support services. Quality Assurance Plan (QAP): A written document developed by the Health Plan in consultation with its QAP committee and Medical Director that details the annual program goals and measurable objectives, utilization review activities, access and other Performance Measures that are to be monitored with ongoing Physician profiling and focus on quality improvement. Quality Program: The Health Plan’s overarching mission, vision and values, which through its goals, objectives and processes committed in writing in the QAP, are demonstrated through continuous improvement and monitoring of medical care, Enrollee safety, behavioral health services, and the delivery of services to Enrollees, including ongoing assessment of program standards to determine the quality and appropriateness of care, Case Management and coordination. It is system-wide and implemented through the integration, coordination of services, and resource allocation throughout the organization, its partners, Providers, other entities delegated to provide services to Enrollees, and extended community involved with Enrollees. Recipient Identification Number (RIN): The nine-digit identification number unique to the individual receiving coverage under one of the Department’s Medical Programs. It is vital that this number be correctly entered on billings for services rendered. Service Plan: A plan that addresses all identified needs for services received at home. Significant Change: A decline or improvement in a Participant’s status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical
Page 33 of 35
Appendix Volume 2, p. 70
Illinois Department of Healthcare and Family Services Managed Care Manual for Medicaid Providers
interventions, where the decline or improvement impacts more than one area of the Participant’s health status and requires revision of the Enrollee Care Plan. Skilled Nursing: Nursing services provided within the scope of the State's Nurse Practice Act by registered nurses, licensed practical nurses, or vocational nurses licensed to practice in the State. Skilled Nursing Facility (SNF): A group care facility that provides Skilled Nursing care, continuous Skilled Nursing observations, restorative nursing and other services under professional direction with frequent medical supervision, during the post-acute phase of illness or during reoccurrences of symptoms in long-term illness. Speech Therapy: A medically prescribed speech or language based service that is provided by a licensed speech therapist and identified in the Enrollee Care Plan that is used to evaluate or improve an Enrollee's ability to communicate. Stabilization or Stabilized: A determination with respect to an Emergency Medical Condition made by an attending emergency room Physician or other treating Provider that, within reasonable medical probability, no material deterioration of the condition is likely to result upon discharge or transfer to another facility. State: The State of Illinois, as represented through any agency, department, board, or commission. Supportive Living Facility (SLF): A residential apartment-style (assisted living) setting in Illinois that is certified by the Department that provides or coordinates flexible Personal Care services, twenty-four (24) hour supervision and assistance (scheduled and unscheduled), activities, and health related services with a service program and physical environment designed to minimize the need for residents to move within or from the setting to accommodate changing needs and references; has an organizational mission, service programs and physical environment designed to maximize residents’ dignity, autonomy, privacy and independence; and encourages family and community involvement. Third Party: Any person other than the Department, Health Plan, or any of Health Plan's affiliates. Long Term Supports and Services (LTSS): Nursing home services or Home and Community Based Service waivers (HCBS) services.
Page 34 of 35
Appendix Volume 2, p. 71
Illinois Department of Healthcare and Family Services Managed Care Manual for Medicaid Providers
Chapter 8
Links Internet Site Illinois Department of Healthcare and Family Services Administrative Rules All Kids Program Care Coordination Claims Processing System Issues Child Support Enforcement FamilyCare Family Community Resource Centers Health Benefits for Workers with Disabilities Health Information Exchange Home and Community Based Waiver Services Illinois Health Connect Illinois Veterans Care Illinois Warrior Assistance Program Maternal and Child Health Promotion Medical Electronic Data Interchange (MEDI) State Chronic Renal Disease Program Medical Forms Requests Medical Programs Forms Non-Institutional Provider Resources Pharmacy Information Provider Enrollment Information Provider Fee Schedules Provider Handbooks Provider Notices Registration for E-mail Notification Place of Service Codes Centers for Medicare and Medicaid Services (CMS)
Page 35 of 35
Appendix Volume 2, p. 72
Exhibit 6
Appendix Volume 2, p. 73
STATE OF ILLINOIS DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES and ILLINICARE HEALTH PLAN, INC. AMENDMENT NO. 6 TO THE CONTRACT FOR FURNISHING HEALTH SERVICES BY A MANAGED CARE ORGANIZATION 2018-24-401-402-KA6 WHEREAS, the Parties to the Contract for Furnishing Health Services by a Managed Care Organization (“Contract”), the Illinois Department of Healthcare and Family Services, 201 South Grand Avenue East, Springfield, Illinois 62763-0001 (“Department”), acting by and through its Director, and IlliniCare Health Plan, Inc. (“Contractor”), desire to amend the Contract; and WHEREAS, under the Managed Care Request for Proposal (RFP) 2018-24-001, HFS awarded a Contract to Contractor for the DCFS Youth in Care and Former Youth in Care populations per Section 2.6.2.1 of the RFP; and WHEREAS, Addendum #1 delineates program requirements specific to the DCFS Youth in Care and Former Youth in Care populations; and WHEREAS, the Department has a vested interest in ensuring quality outcomes that are specific to DCFS Youth in Care and Addendum #2 delineates additional quality outcomes specific to DCFS Youth in Care with penalties to be assessed by the Department, and incentives to be paid by the Department utilizing State-only funds; and WHEREAS, pursuant to Section 9.1.18, the Contract may be modified or amended by the mutual consent of the Parties; and WHEREAS, the Contract has been previously amended; NOW THEREFORE, the Parties agree to amend the Contract further, effective upon date of last signature, by deleting in their entirety the DCFS Youth Managed Care Specialty Plan Addenda and replacing with the content and provisions of these Addenda.
IN WITNESS WHEREOF, the Department and Contractor hereby execute and deliver this Amendment No. 6 to replace Addendum #1 and Addendum #2 to Contract 2018-24-401, effective as of the date of last signature. Other than the changes, modifications and additions specifically articulated in Addendum #1 and Addendum #2 to Contract 2018-24-401, the Contract shall remain in effect and binding on and against the Department and Contractor. In the event of a conflict between the provisions of these Addenda and the Contract, the provisions 2018-24-401-402-KA6 Addendum #1 (IlliniCare)
Page 1
Appendix Volume 2, p. 74
Appendix Volume 2, p. 75
STATE OF ILLINOIS AMENDMENT NO. 6 DCFS YOUTH MANAGED CARE SPECIALTY PLAN – ADDENDUM #1 To The CONTRACT between the DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES and ILLINICARE HEALTH PLAN, INC. for Furnishing Health Services by a Managed Care Organization
2018-24-401-402-KA6
2018-24-401-402-KA6 Addendum #1 (IlliniCare)
Page 3
Appendix Volume 2, p. 76
TABLE OF CONTENTS ARTICLE I: DEFINITIONS AND ACRONYMS 1.3
Additional Defined Terms Specific to the DCFS Youth Managed Care Specialty Plan
ARTICLE II: TERMS AND CONDITIONS 2.3
List of Individuals in an Administrative Capacity
ARTICLE IV: ENROLLMENT, COVERAGE & TERMINATION OF COVERAGE 4.1 4.3 4.7 4.9 4.15 4.16
Enrollment Generally Initial Program Implementation Effective Enrollment Date Enrollee Welcome Packet Capacity Identification Card
ARTICLE V: DUTIES OF CONTRACTOR 5.3 5.7 5.7.6 5.7.9 5.7.15 5.11 5.12 5.13 5.14 5.15 5.16 5.17 5.23 5.40
Pharmacy Requirements Provider Network Non-Network Providers Integrated Health Homes Interim Case Management Contracting Requirement Coordination Tools Care Management Assessments and Care Planning Interdisciplinary Care Team Individualized Plans of Care and Service Plans Individual Plan of Care Health Risk Assessment Caseload Requirements Health, Safety, and Welfare Monitoring Meetings and Committees
ARTICLE VII: PAYMENT AND FUNDING 7.22 7.23 7.24
DCFS Retained Behavioral Health Services DCFS Youth in Care Risk Corridor Interim Administrative Payment
ARTICLE VIII: TERM, RENEWAL, AND TERMINATION 8.1
Term of this Contract
ATTACHMENT XVI: QUALIFICATIONS AND TRAINING REQUIREMENTS OF CERTAIN CARE COORDINATORS AND OTHER CARE PROFESSIONALS 1.1 1.3 1.4
Qualifications of Certain Care Coordinators Training Requirements of Certain Care Coordinators Training Functions Not Otherwise Referenced
ARTICLE I: DEFINITIONS AND ACRONYMS 2018-24-401-402-KA6 Addendum #1 (IlliniCare)
Page 4
Appendix Volume 2, p. 77
1.3
Additional Defined Terms Specific to the DCFS Youth Managed Care Specialty Plan:
1.3.1 Authorized Representative means an individual, case worker, group, entity, or other person(s) approved by DCFS who is legally authorized to speak for or on behalf of the Enrollee and which has been communicated to Contractor by the Department by way of the 834 Daily File in a location agreed upon between the Department and Contractor in the 834 Daily File. 1.3.2 Comprehensive Health Evaluation means the evaluation that is conducted within twenty-one (21) days of DCFS temporary custody and includes: (i) an Early and Periodic Screening, Diagnostic and Treatment program (EPSDT) examination; (ii) vision, hearing, and dental screening, when appropriate; and (iii) mental health, developmental, and alcohol and substance abuse screenings, when appropriate. Resulting referrals for specialized services are made as needed. 1.3.3 Comprehensive Implementation Date means February 1, 2020 or a later date mutually agreed upon by the Parties documented at least sixty (60) days prior to such a later date by written notice from the Department. 1.3.4 Contract Addendum Effective Date means the date of last signature. 1.3.5 DCFS means the Illinois Department of Children and Family Services. 1.3.6 DCFS Authorized Agent means DCFS staff who have been appointed and authorized by the DCFS Guardianship Administrator to officially act in the place of the DCFS Guardianship Administrator to authorize and consent to matters concerning DCFS Youth in Care. 1.3.7 DCFS Caseworker means the representative of record who has primary responsibility for a DCFS Youth in Care’s child welfare case management, working with the youth and the youth’s family to identify services to address issues that brought the youth into the child welfare system and providing updates to and making court appearances in the youth’s Juvenile Court case. The DCFS Caseworker may be employed by DCFS or by a contracted Purchase of Service (POS) agency and may also be referred to as a “permanency worker.” 1.3.8 DCFS Guardianship Administrator means that person designated by the Director of DCFS to serve as guardian of children accepted by DCFS pursuant to the Juvenile Court Act, the Children and Family Services Act, the Abused and Neglected Child Reporting Act, and the Adoption Act. The DCFS Guardianship Administrator has the legal 2018-24-401-402-KA6 Addendum #1 (IlliniCare)
Page 5
Appendix Volume 2, p. 78
authority to consent to certain medical and behavioral health services for DCFS Youth in Care based on the specific orders entered in the Juvenile Court and on the specific ages of DCFS Youth in Care, in accordance with DCFS Rule 327. 1.3.9 DCFS Service Plan means a written plan on a form prescribed by DCFS that guides all individuals in the plan of child welfare intervention toward the permanency goals for DCFS Youth in Care. The DCFS Service Plan is developed by the DCFS Caseworker and other members of the Child and Family Team in accordance with DCFS Procedure 302, and indicates all services required for the child including services that are ordered by Juvenile Court. 1.3.10 DCFS Youth means both DCFS Youth in Care and Former Youth in Care who are Potential Enrollees, Prospective Enrollees or Enrollees in the DCFS Youth Managed Care Specialty Plan. 1.3.11 DCFS Youth in Care means a youth who is under the legal custody or guardianship of DCFS. 1.3.12 Former Youth in Care means a youth under the age of 21 who was previously under the legal custody or guardianship of DCFS but was reunified with their biological family, was adopted, was placed in subsidized guardianship, or whose Juvenile Court case was closed and is no longer under the legal custody of DCFS. 1.3.13 Health Passport means a summary of health information for each DCFS Youth in Care that contains the youth’s health history, present health care and medical conditions, if any, and available health information about the youth necessary for the youth’s proper care. 1.3.14 HealthWorks means a comprehensive system of health care developed by DCFS for all Illinois children and youth in foster care that ensures they have access to quality health care, routine health care and special health care that meets their identified health care needs and provides documentation of health needs and health care information that is readily accessible to caregivers, other healthcare providers and DCFS. HealthWorks provides access to and referral for primary health care physicians, initial health screenings, comprehensive health evaluations, well-child examinations and immunizations. 1.3.15 Initial Health Screening means the medical screening that is conducted within twentyfour (24) hours of DCFS temporary custody to identify health conditions that require prompt medical attention and to consider in making substitute care placement decisions. 2018-24-401-402-KA6 Addendum #1 (IlliniCare)
Page 6
Appendix Volume 2, p. 79
1.3.16 Interim Medical Case Management means medical case management services provided by a HealthWorks lead agency for a child within the first forty-five (45) days of being placed in DCFS temporary custody. Activities required include, at a minimum, enrollment in HealthWorks, selection of a primary care physician, gathering of child and family health information, initiation of requests for prior health records, receipt of initial health screening documentation, completion of a Comprehensive Health Evaluation, ensuring provision of the Health Passport to the caregiver of the child, providing appropriate documentation and other information to the assigned permanency worker for inclusion in the DCFS Service Plan, and supporting the completion of any appropriate screening tools as necessary. 1.3.17 Juvenile Court means a court that is presiding over matters related to petitions alleging that a child or youth is abused, neglected, dependent or delinquent under the provisions of the Juvenile Court Act, 705 ILCS 405.1 et seq. 1.3.18 Permanency Goal means the desired outcome of child welfare intervention and service that is determined to be consistent with the health, safety, well-being, and best interests of the DCFS Youth in Care as defined by the Juvenile Court Act. 1.3.19 Psychotropic Medication means any medication capable of affecting the mind, emotions and behavior. This includes medications whose use for antipsychotic, antidepressant, antimanic, antianxiety, behavioral modification or behavioral management purposes is listed in AMA Drug Evaluations, latest edition, or Physician's Desk Reference, latest edition or that are administered for any of these purposes [405 ILCS 5/1-121.1]. For the purpose of this definition, medications used to induce or sustain sleep or to treat symptoms of aggression, enuresis and psychotropic medication-induced adverse effects are also included. 1.3.20 Purchase of Service (POS) Agency means a licensed child welfare agency with whom DCFS contracts to provide child welfare services to youth and families. 1.3.21 Retained Behavioral Health Services means all behavioral health services which are potentially eligible for reimbursement under Medicaid but are being paid by DCFS, as of the Comprehensive Implementation Date. 1.3.22 Significant Events are serious, sometimes traumatic occurrences that affect children and youth served by DCFS, are subject to mandatory reporting requirements, and are described in additional detail in DCFS Procedure 331.
2018-24-401-402-KA6 Addendum #1 (IlliniCare)
Page 7
Appendix Volume 2, p. 80
ARTICLE II: TERMS AND CONDITIONS 2.3
LIST OF INDIVIDUALS IN AN ADMINISTRATIVE CAPACITY
2.3.2.10 Upon the Contract Addendum Effective Date, eight (8) full-time liaisons will be stationed on-site and hosted by DCFS Regional Offices throughout the State, as designated by the Department in consultation with DCFS, to provide administrative coordination with DCFS staff and stakeholders. Liaisons will be available during regular work hours to communicate with and to provide education and training to DCFS staff and stakeholders regarding managed care, and to engage in immediate problem resolution with Contractor’s administrative staff. Issues or barriers reported to a liaison must be addressed and the resolution communicated to the appropriate DCFS staff or stakeholder within three (3) Business Days. Beginning no sooner than six (6) months after the Comprehensive Implementation Date Contractor may, as needed, adjust the number of full-time liaisons, subject to consultation with DCFS and the Department’s Prior Approval.
ARTICLE IV: ENROLLMENT, COVERAGE AND TERMINATION OF COVERAGE 4.1
ENROLLMENT GENERALLY
4.1.1.1 For enrollments of DCFS Youth in Care effective on the Comprehensive Implementation Date, the Department shall assign the DCFS Youth in Care into Contractor’s DCFS Youth Managed Care Specialty Plan. The DCFS Guardianship Administrator will have a ninety (90)-day change period after the Effective Enrollment Date to select another Health Plan as provided in Section 4.10.1. 4.1.1.2 For enrollments of Former Youth in Care effective on the Comprehensive Implementation Date, the Department shall assign the Former Youth in Care to Contractor. The Department will mail the Prospective Enrollee notice of the enrollment assignment at least thirty (30) days prior to the Effective Enrollment Date. The notice will include the provision of all education regarding Health Plan choices, and the ninety (90)-day change period after the Effective Enrollment Date to select another Health Plan as provided in Section 4.10.1. 4.1.1.3 For enrollments of DCFS Youth in Care effective after the Comprehensive Implementation Date, the DCFS Guardianship Administrator shall select a Health Plan for the Prospective Enrollee. The Department will process the Health Plan enrollment received from the DCFS Guardianship Administrator. All Enrollees will have a ninety (90)-day change period after the Effective Enrollment Date to select another Health Plan as provided in Section 4.10.1. 2018-24-401-402-KA6 Addendum #1 (IlliniCare)
Page 8
Appendix Volume 2, p. 81
All Enrollees will have the opportunity to retain their current Medicaid Providers, including HealthWorks Providers, as long as that Medicaid Provider is within the selected Health Plan’s network. 4.1.1.4 At the time a DCFS Youth in Care Enrollee becomes a Former Youth in Care, the Enrollee will remain enrolled with Contractor. The ICES will mail an enrollment notice to the Enrollee within five (5) Business Days of the Enrollee becoming a Former Youth in Care. The mailed enrollment notice will include the notice of continued Health Plan assignment and the provision of all education regarding Health Plan choices, and the ninety (90)-day change period after the Effective Enrollment Date to select another Health Plan as provided in Section 4.10.1. 4.3
INITIAL PROGRAM IMPLEMENTATION
4.3.1 DCFS Youth Managed Care Specialty Plan Preliminary Care Coordination and Administrative Activities. Contractor shall conduct preliminary Care Coordination and administrative activities beginning on the Contract Addendum Effective Date and ending on the Comprehensive Implementation Date, at which time Contractor is responsible for all Care Management requirements and assumes full-risk for the provision of Covered Services. 4.3.1.1 Care Coordination. For each DCFS Youth in Care Prospective Enrollee identified through the Department’s 834 Daily File, Contractor shall: conduct a health risk screening; score the health risk screening to identify medical and Behavioral Health care needs; stratify based on need for Care Coordination; establish the appropriate Care Coordination team and assign a primary Care Coordinator; and complete additional assessments as needed. For Prospective Enrollees whose health risk screening or additional assessments indicate a need for Contractor to coordinate with a Provider, the Care Coordinator, or designated Contractor staff, shall identify the appropriate Provider, facilitate an introduction, and confer with the Provider as appropriate. When applicable, Contractor shall assist a Provider in becoming a Network Provider. 4.3.1.2 Communication Center. Contractor shall operate a call center staffed with trained personnel to address inquiries concerning the expansion of HealthChoice Illinois for Special Needs Children populations. The call center shall include a dedicated hotline for DCFS Youth. 4.3.1.3 Rapid Response Team. Contractor shall implement a rapid response team comprised of Contractor’s subject matter experts positioned to respond to and resolve all inquiries regarding implementation of the DCFS Youth Managed Care Specialty Plan. 4.3.1.4 Public Relations. In collaboration with the Department and DCFS, Contractor shall develop and deliver comprehensive communications, in multiple formats, 2018-24-401-402-KA6 Addendum #1 (IlliniCare)
Page 9
Appendix Volume 2, p. 82
designed to inform and educate stakeholders of the DCFS Youth Managed Care Specialty Plan. 4.3.2 For the DCFS Youth Managed Care Specialty Plan, enrollment of DCFS Youth Prospective Enrollees will begin on the Comprehensive Implementation Date. 4.7
EFFECTIVE ENROLLMENT DATE
4.7.1 For DCFS Youth in Care, coverage shall begin on the first day of the same month that the enrollment request was received by the Department. 4.7.2 For Former Youth in Care, coverage shall begin on the first day of the month following the DCFS Youth in Care coverage termination. 4.9
ENROLLEE WELCOME PACKET
4.9.1 Within five (5) Business Days after receipt of confirmation from the Department that an enrollment for a DCFS Youth was accepted, Contractor shall send an Enrollee welcome packet to the individual(s) designated by DCFS. The packet shall include all basic information as set forth in section 5.21.1. 4.15 CAPACITY 4.15.1.1 Contractor must ensure adequate physical, professional and Provider Network capacity to accept and serve all DCFS Youth Enrollees. 4.16 IDENTIFICATION CARD 4.16.1.7.1 Upon initial enrollment of DCFS Youth, the name and phone number of an Enrollee’s PCP is not required. 4.16.1.7.2 For DCFS Youth Enrollees, Contractor shall reissue an identification card to an Enrollee when a PCP is assigned or chosen.
ARTICLE V: DUTIES OF CONTRACTOR 5.3
PHARMACY REQUIREMENTS
5.3.2.20 Contractor shall comply with the requirements of DCFS Rule and Procedure 325, including all requirements for consents and the development of a system that maintains the 2018-24-401-402-KA6 Addendum #1 (IlliniCare)
Page 10
Appendix Volume 2, p. 83
requirement of prior authorization from DCFS prior to the administration of any psychotropic medication and stops prescriptions for psychotropic medications from being filled at a pharmacy if no prior authorization has been received from DCFS. 5.7
PROVIDER NETWORK
5.7.1.8 Contractor shall enter into a contract with any qualified HealthWorks Provider, HealthWorks lead agency, pediatric hospital, hospital with pediatric wings, pediatric specialist, child psychologist, and other behavioral health provider who provided Covered Services to DCFS Youth in Care prior to execution of this Contract, as verified by the Department, and as long as the Provider agrees to Contractor’s rates and adheres to Contractor’s QA requirements. In the event an existing Provider serving DCFS Youth in Care does not join the Contractor’s Provider Network, Contractor must document that they attempted to contact the Provider a minimum of five (5) times through various means, such as phone calls, e-mails and letters, and received no response, or must document the reason the Provider declined to contract with Contractor. To be considered a qualified Provider, the Provider must be in good standing with the Department’s FFS Medical Program. Contractor may establish quality standards for Providers, subject to the Department’s Prior Approval. Contractor may terminate contracts with Providers who do not meet those quality standards if the Provider is informed at the time the standards come into effect and the standards have been in effect for at minimum one (1) year. 5.7.6 Non-Network Providers 5.7.6.1 Contractor shall make reasonable efforts to negotiate single-case agreements with out-of-state Providers treating DCFS Youth in Care. In the event Contractor is not able to finalize single-case agreements with out-of-state Providers within four (4) weeks of the Comprehensive Implementation Date or within two (2) weeks of a DCFS Youth in Care being moved out-of-state, Contractor will notify DCFS. Contractor shall continue to identify alternate or other suitable care in an appropriate setting. Contractor shall assist DCFS in securing healthcare services and shall maintain responsibility for payment for all Medicaid covered services for DCFS Youth in Care who reside outside of Illinois. 5.7.9 Integrated Health Homes 5.7.9.1 Contractor shall ensure that IHHs serving DCFS Youth have previous experience coordinating services for Special Needs Children. Where requirements of the Department’s IHH program overlap with the requirements of this Contract Addendum, the IHH requirements will be prioritized. 5.7.15 Interim Medical Case Management Contracting Requirement. Contractor is responsible for the provision of Interim Medical Case Management. Contractor shall contract 2018-24-401-402-KA6 Addendum #1 (IlliniCare)
Page 11
Appendix Volume 2, p. 84
with all current qualified HealthWorks lead agencies to provide Interim Medical Case Management services to all DCFS Youth in Care through the first forty-five (45) days of DCFS custody of the youth. The Interim Medical Case Management services shall include, at a minimum, gathering of child and family health information, initiation of requests for prior health records, receipt of twenty-four (24) hour initial health screenings, selection of primary care physician, completion of the Comprehensive Health Evaluation within twenty-one (21) days of DCFS temporary custody and provision of the Health Passport to the DCFS Youth in Care’s caregivers, and supporting the completion of any appropriate screening tools as necessary. To be considered a qualified Provider, the Provider must be in good standing with the Department’s FFS Medical Program. Contractor may establish quality standards for Providers, subject to the Department’s Prior Approval. Contractor may terminate contracts with Providers who do not meet those quality standards if the Provider is informed at the time the standards come into effect and the standards have been in effect for at minimum one (1) year. Contractor shall notify the Department no less than sixty (60) days prior to the termination date of a contract with any HealthWorks lead agency. 5.11 COORDINATION TOOLS 5.11.2.1 Contractor shall have fully operational portals, which provide the DCFS Guardianship Administrator or Authorized Agents, DCFS Caseworkers, Enrollees, and Providers access to relevant information from the Care Management system. 5.12 CARE MANAGEMENT 5.12.3.3 For the DCFS Youth Managed Care Specialty Plan, Care Coordinators shall meet the qualifications and training requirements as set forth in Attachment XVI. 5.13 ASSESSMENTS AND CARE PLANNING 5.13.1.5 Contractor’s goals, benchmarks, and strategies for managing the care of DCFS Youth shall be incorporated in, and included as part of, Contractor’s Care Management program. Contractor shall use Department approved tools to determine the appropriate risk level of Care Management for DCFS Youth and will utilize additional relevant information from assessments or other evaluations, when provided by DCFS. Contractor shall determine measurable criteria to be utilized to establish each of the risk levels of Care Management. 5.13.1.5.1 Risk Level of Care Management Determination. For DCFS Youth, Contractor shall determine the appropriate risk level of Care Management in- lieu-of section 5.13.1.4 based upon an analysis of the information gathered through the process in this section. DCFS Youth Enrollees shall be assigned to one (1) of four (4) risk levels of Care Management: low risk, moderate risk, high risk or complex risk.
2018-24-401-402-KA6 Addendum #1 (IlliniCare)
Page 12
Appendix Volume 2, p. 85
5.13.1.5.1.1
Risk Level of Care Management Determination for existing DCFS Youth. For DCFS Youth enrolled on the Comprehensive Implementation Date, Contractor shall conduct a health risk screening within ninety (90) days of enrollment. Contractor shall provide health risk screenings on a prioritized basis, as determined by the Department. Any DCFS Youth Enrollee who is determined to require a health risk assessment, based on the health risk screening, shall receive the health risk assessment within one hundred and twenty (120) days of enrollment. Contractor may administer a health risk assessment in place of a health risk screening provided it is administered within ninety (90) days of enrollment. The Contractor shall utilize information included in all health risk screenings, health risk assessments and other existing health evaluations to complete an IPoC, if required, within one hundred-twenty (120) days of enrollment.
5.13.1.5.1.2
Risk Level of Care Management Determination for DCFS Youth enrolled after the Comprehensive Implementation Date. For DCFS Youth enrolled after the Comprehensive Implementation Date, Contractor shall provide a health risk screening and, if needed, a health risk assessment within sixty (60) days of enrollment. Contractor shall utilize information included in all health risk screenings, health risk assessments and other existing health evaluations to complete an IPoC, if required, within sixty (60) days of enrollment.
5.13.1.5.1.3
If DCFS is not in agreement with the risk level determination made by Contractor for a DCFS Youth in Care, Contractor will work collaboratively with the Department and DCFS to resolve the disagreement and ensure that the best interest and needs of DCFS Youth in Care are met.
5.14 INTERDISCIPLINARY CARE TEAM (ICT) 5.14.4 Contractor shall support an ICT for all DCFS Youth Enrollees categorized as moderate risk, high risk, or complex risk. 5.14.4.1 For DCFS Youth in Care Enrollees, Contractor shall make reasonable efforts to collaborate with the DCFS Caseworker to ensure that the ICT is coordinated with all DCFS team-based decision-making processes, such as Child and Family Team meetings; that the Care Coordinator is able to participate, as needed, in the DCFS team2018-24-401-402-KA6 Addendum #1 (IlliniCare)
Page 13
Appendix Volume 2, p. 86
based decision-making process; and, that the IPoC is updated as necessary with information or decisions made during a DCFS team-based decision-making process. 5.15 INDIVIDUALIZED PLANS OF CARE AND SERVICE PLANS 5.15.1.6 Include for DCFS Youth in Care Enrollees categorized as moderate risk, high risk, or complex risk, information from DCFS as available and an IPoC that is coordinated and consistent with the DCFS Service Plan as follows, given that DCFS provides this information to Contractor: 5.15.1.6.1 The IPoC shall include all goals and services that are necessary to support the Permanency Goal established in the DCFS Service Plan, given that DCFS provides this information to Contractor. 5.15.1.6.2 Information from the DCFS Service Plan will be incorporated into the IPoC as available. 5.15.1.6.3 Contractor shall not have responsibility for the payment for any nonMedicaid Services included in the DCFS Service Plan. DCFS shall retain responsibility for payment for all non-Medicaid Services. 5.15.1.6.4 Contractor shall notify the DCFS Caseworker within two (2) Business Days when the IPoC is updated. The updated IPoC shall be available for the DCFS Caseworker through the Enrollee portal. 5.15.1.7 for Former Youth in Care Enrollees categorized as moderate risk, high risk, or complex risk, reflect the requirements of Sections 5.15.1.1 through 5.15.1.4. 5.16 INDIVIDUAL PLAN OF CARE HEALTH RISK REASSESSMENT 5.16.1 Contractor shall review IPoCs of complex risk and high risk DCFS Youth Enrollees at least every thirty (30) days, and of moderate risk DCFS Youth Enrollees at least every ninety (90) days, and conduct reassessments as necessary based upon such reviews. At a minimum, Contractor shall conduct a health risk reassessment annually for each DCFS Youth Enrollee who has an IPoC. Contractor shall make available an updated IPoC through the Enrollee and Provider portals. 5.17
CASELOAD REQUIREMENTS
5.17.4 DCFS Youth caseload standards. For DCFS Youth Enrollees, caseloads of Care Coordinators shall be sufficient to ensure that contact standards are met for youth in each risk 2018-24-401-402-KA6 Addendum #1 (IlliniCare)
Page 14
Appendix Volume 2, p. 87
level of Care Management and that the health outcome targets in this Addendum and in Attachment XI are achieved. 5.17.5 DCFS Youth contact standards. Care Coordinators who provide Care Management shall maintain contact as frequently as required to meet the DCFS Youth Enrollee’s needs while adhering to the following minimum contact standards per risk level: 5.17.5.1 Complex Risk. The Care Coordinator shall contact the DCFS Youth Enrollee, and DCFS Caseworker as appropriate, and not less than one (1) time every fourteen (14) days. In-person contact shall be conducted with the DCFS Youth and the DCFS Caseworker as needed to meet the needs of the DCFS Youth. 5.17.5.2 High Risk. The Care Coordinator shall contact the DCFS Youth Enrollee, and DCFS Caseworker as appropriate, and not less than one (1) time every thirty (30) days. In-person contact may be conducted with the DCFS Youth and the DCFS Caseworker as needed to meet the needs of the DCFS Youth. 5.17.5.3 Moderate Risk. The Care Coordinator shall contact the DCFS Youth Enrollee, and DCFS Caseworker as appropriate, and not less than one (1) time every ninety (90) days. 5.17.5.4 Low Risk. The Care Coordination team shall contact the DCFS Youth Enrollee, and DCFS Caseworker as appropriate, and not less than one (1) time every one-hundred eighty (180) days. 5.17.6 Approved contacts for DCFS Youth in Care. Contractor shall ensure that contact is made only with Authorized Representative(s). 5.23 HEALTH, SAFETY, AND WELFARE MONITORING 5.23.2.3.4 Contractor shall comply with DCFS rules and procedures for reporting Significant Events. 5.40 MEETINGS AND COMMITTEES 5.40.5.1 For the DCFS Youth Managed Care Specialty Plan, Contractor shall have a DCFS Youth Enrollee advisory and stakeholder subcommittee that meets, at minimum, on a quarterly basis. Members of the committee will be geographically, culturally, and racially diverse to best reflect the profile of DCFS Youth Enrollees and must include a reasonably representative group of DCFS Youth Enrollees and stakeholders. The committee shall establish an ongoing mechanism for the community to provide Contractor with direct feedback on 2018-24-401-402-KA6 Addendum #1 (IlliniCare)
Page 15
Appendix Volume 2, p. 88
Contractor’s implementation and operations of the DCFS Youth Managed Care Specialty Plan. Contractor shall keep minutes for all meetings.
ARTICLE VII: PAYMENT AND FUNDING 7.22 DCFS RETAINED BEHAVIORAL HEALTH SERVICES The Parties acknowledge that, prior to the Comprehensive Implementation Date, DCFS has contracted with third parties and pays for certain Retained Behavioral Health Services, which were not considered in development of Capitation rates approved by the Department in connection with the Request for Proposal related to this Addendum. For the term of the Contract DCFS will continue to contract with these third parties and continue payment for all such Retained Behavioral Health Services. If at such a time a decision is made to incorporate these services into the Capitation rates, the Parties agree to negotiate in good faith during the term of the Contract as to amended rates that reflect the inclusion of amounts related to these Retained Behavioral Health Services; provided, however, that DCFS shall be obligated to continue payment for all such Retained Behavioral Health Services until such time that the Parties have agreed to amended rates. 7.23
DCFS YOUTH IN CARE RISK CORRIDOR
The Department shall utilize, for DCFS Youth in Care Enrollees, a risk corridor mechanism that allows Contractor to operate with the understanding that if there are deviations from the estimated pattern of DCFS Youth in Care Enrollees’ utilization of Covered Services used to develop the Capitation rates, the mechanism ensures that Contractor will share the risk of such deviations to a certain degree with the Department. 7.23.1 The risk corridor is based upon benefit expenses and healthcare quality improvement expenses as defined in 42 CFR 438.8, including incurred but not yet paid expenses, as reported by Contractor within a timeframe and format provided by the Department. 7.23.2 The risk corridor ratio is established as a percentage of actual expenses divided by Contractor’s target amount. The target amount is calculated by multiplying the sum of benefit expenses and quality improvement expenses by Enrollee months for the initial rating period scheduled for February 1, 2020 through December 31, 2020. 7.23.2.1 In the event Contractor’s risk corridor ratio is greater than 102.0%, the Department shall reimburse Contractor the target amount multiplied by:
2018-24-401-402-KA6 Addendum #1 (IlliniCare)
Page 16
Appendix Volume 2, p. 89
7.23.2.1.1 50.0% multiplied by [risk corridor ratio less 102.0%], if the risk corridor ratio is less than or equal to 104.0%; or 7.23.2.1.2 1.0% plus 80.0% multiplied by [risk corridor ratio less 104.0%], if the risk corridor ratio exceeds 104.0%. 7.23.2.2 In the event Contractor’s risk corridor ratio is less than 98.0%, The Department will recoup from Contractor the target amount multiplied by: 7.23.2.2.1 50.0% multiplied by [98.0% less risk corridor ratio], if the risk corridor ratio is greater than or equal to 96.0%; or 7.23.2.2.2 1.0% plus 80.0% multiplied by [96.0% less risk corridor ratio], if the risk corridor is less than 96.0%. 7.23.3 The risk corridor will be calculated using values reported consistent with the medical loss ratio (MLR) reporting. The payment or recoupment amount will be an adjustment to the numerator of the MLR for the calculation of the calendar year 2020 MLR.
7.24
INTERIM ADMINISTRATIVE PAYMENT
Department shall pay Contractor an administrative fee of $4,056,000 to support preliminary Care Coordination and other administrative activities, as described in Section 4.3.1, to prepare for the Comprehensive Implementation Date of the DCFS Youth Managed Care Specialty Plan.
ARTICLE VIII: TERM, RENEWAL, AND TERMINATION 8.1
TERM OF THIS CONTRACT
8.1.1 The DCFS Youth Managed Care Specialty Plan shall begin on the Contract Addendum Effective Date and shall terminate on March 31, 2021.
2018-24-401-402-KA6 Addendum #1 (IlliniCare)
Page 17
Appendix Volume 2, p. 90
ATTACHMENT XVI: QUALIFICATIONS AND TRAINING REQUIREMENTS OF CERTAIN CARE COORDINATORS AND OTHER CARE PROFESSIONALS QUALIFICATIONS OF CERTAIN CARE COORDINATORS 1.1.5.5 Care Coordinator qualifications for High-Needs Children apply to all Enrollees in the DCFS Youth Managed Care Specialty Plan.
TRAINING REQUIREMENTS OF CERTAIN CARE COORDINATORS 1.3.2 Care Coordinators for the DCFS Youth Managed Care Specialty Plan shall be familiar with DCFS required assessments for DCFS Youth in Care and the DCFS team-based decisionmaking process. Contractor shall train Care Coordinators in various aspects of the Illinois child welfare system to include trauma informed care, the psychotropic consent process, Illinois Medicaid Child and Adolescent Needs and Strengths (IM-CANS), motivational interviewing, and other relevant information that receives the Department’s Prior Approval.
TRAINING FUNCTIONS NOT OTHERWISE REFERENCED 1.4.1 Contractor shall make available to all Network Providers its trauma screening toolkit
within thirty (30) days of the Contract Addendum Effective Date. Contractor may periodically update or revise the contents of the trauma screening toolkit. As of the Contract Addendum Effective Date, the trauma screening toolkit includes, but is not limited to: • Trauma Events Screening Inventory Child Report Form Revised (TESI-CRF-R); • Child PTSD Symptom Scale for DSM 5 (CPSS5); • Mood and Feeling Questionnaire (MFQ); • Center for Epidemiological Studies Depression Scale for Children (CES-DC); • Screening for Anxiety and Related Emotional Disorders (SCARED); and • NCTSN Child Welfare Referral Tool (CWRT). 1.4.2 On an annual basis, Contractor shall offer training in trauma informed care to all Network Providers. Training material content and format must receive Prior Approval from the Department.
2018-24-401-402-KA6 Addendum #1 (IlliniCare)
Page 18
Appendix Volume 2, p. 91
STATE OF ILLINOIS AMENDMENT NO. 6 DCFS YOUTH MANAGED CARE SPECIALTY PLAN – ADDENDUM #2 To The CONTRACT between the DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES and ILLINICARE HEALTH PLAN, INC. for Furnishing Health Services by a Managed Care Organization
2018-24-401-402-KA6
2018-24-401-402-KA6 Addendum #2 (IlliniCare)
Page 19
Appendix Volume 2, p. 92
TABLE OF CONTENTS ARTICLE I: DEFINITIONS AND ACRONYMS 1.3
Additional Defined Terms Specific to the DCFS Youth Managed Care Specialty Plan
ATTACHMENT XI: QUALITY ASSURANCE 1.2
Additional Outcomes for DCFS Youth in Care
ARTICLE I: DEFINITIONS AND ACRONYMS 1.3
Additional Defined Terms Specific to the DCFS Youth Managed Care Specialty Plan:
1.3.23 Baseline Period means the period of time beginning February 1, 2020, to December 31, 2020. 1.3.24 Beyond Medical Necessity means a hospitalization that continues after a DCFS Youth in Care has been medically cleared for discharge. The hospital is reimbursed for the Beyond Medical Necessity stay by DCFS.
2018-24-401-402-KA6 Addendum #2 (IlliniCare)
Page 20
Appendix Volume 2, p. 93
ATTACHMENT XI: QUALITY ASSURANCE 1.2
Additional Outcomes for DCFS Youth in Care
1.2.1 Contractor shall prioritize meeting additional outcomes and performance measures for DCFS Youth in Care as required by the Department as follows: 1.2.1.1
Preventable inpatient hospitalizations for physical health will be reduced;
1.2.1.2 Discharge planning and identification of Medicaid community-based services available after discharge will be completed for 100% of DCFS Youth in Care admitted to an inpatient psychiatric hospital; 1.2.1.3 For DCFS Youth in Care who are identified as hospitalized Beyond Medical Necessity (BMN), specialized care conferences with the DCFS case worker will be convened within 20 days of reaching BMN status for at least eighty percent (80%) of BMN Youth in Care; 1.2.1.4 HEDIS/CHIPRA measures (to include EPSDT measures) for DCFS Youth in Care will remain consistent or will improve in relation to the HEDIS/CHIPRA measures reported by DCFS at the time of the Contract Addendum execution, provided that the data collection process utilized by DCFS is consistent with HEDIS/CHIPRA data requirements. 1.2.1.5 Equal or increased percentage of DCFS Youth in Care with Behavioral Health issues shall be engaged in Behavioral Health treatment excluding Retained Behavioral Health Services; 1.2.1.6 Equal or increased percentage of DCFS Youth in Care who receive screening for trauma symptoms and are referred for further trauma assessment and trauma oriented Behavioral Health services; and 1.2.1.7 Other outcomes agreed to by Contractor and the Department, in consultation with DCFS.
2018-24-401-402-KA6 Addendum #2 (IlliniCare)
Page 21
Appendix Volume 2, p. 94
1.2.2 Target Outcomes Penalties and Incentives. After the Baseline Period, Contractor must meet the outcomes identified in this Addendum as well as any quality outcomes required in Attachment XI of the Contract. The Baseline Period will be utilized as the baseline for outcome measures, except for outcome measure referenced at 1.2.1.5. Six (6) months after the Baseline Period, outcome measures will be evaluated by the Department. In the event that fifty percent (50%) of the outcome measure targets are not achieved, Contractor must develop a corrective action plan detailing the strategy to achieve required outcome targets. The corrective action plan will be submitted for the Department’s review and approval within thirty (30) days of the completion of the outcome measure evaluation, if required. Outcome measures will be reevaluated six (6) months after the submission of the corrective action plan and at intervals of six (6) months thereafter. The Department may assess Contractor penalties or may pay Contractor a separate State-funded only incentive payment at this point in time and every six (6) months thereafter as follows: • • • • •
$100,000 for not meeting at least 50% of the outcome measure targets; $50,000 for not meeting at least 60% of the outcome measure targets; $40,000 for not meeting at least 70% of the outcome measure targets; $90,000 for meeting at least 90% of outcome measure targets; and $100,000 for meeting 100% of outcome measure targets.
1.2.3 Information Required from DCFS. The Department shall support and facilitate monthly data exchanges with DCFS to ensure Contractor receives accurate Enrollee level information regarding Behavioral Health treatment and diagnoses for DCFS Youth in Care and the POS Agencies for which they are accessing care in a format developed and provided by Contractor.
2018-24-401-402-KA6 Addendum #2 (IlliniCare)
Page 22
Appendix Volume 2, p. 95
Exhibit 7
Appendix Volume 2, p. 96
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 2 of 173 Statewide Scheduling * Legal Video * Internet Repository 1 THE UNITED STATES DISTRICT COURT FOR THE WESTERN DISTRICT OF TEXAS AUSTIN DIVISION KATHY CLARK, AMY ENDSLEY, SUSAN GRIMMETT, MARGUERIETTE SCHMOLL, AND KEVIN ULRICH, ON BEHALF OF THEMSELVES AND ALL OTHERS SIMILARLY SITUATED, Plaintiffs, vs. CENTENE CORPORATION, CENTENE COMPANY OF TEXAS, L.C., AND SUPERIOR HEALTHPLAN, INC., Defendants.
* * * * * * * * * Civil Action No. * 1:12-CV-00174-SS * * * * * *
*************************************** ORAL DEPOSITION OF CORPORATE REPRESENTATIVE ESMERALDA CAZARES-BAIG OCTOBER 23, 2012 ***************************************
AcuScribe Court Reporters, Inc. (800) 497-0277
Appendix Volume 2, p. 97
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 3 of 173 Statewide Scheduling * Legal Video * Internet Repository 18 1 2
question. Q.
Well, I guess I don't really understand the
3
corporate structure, that's why I'm kind of struggling
4
with it.
What does Centene Texas do?
5
A.
It manages Superior Health Plan.
6
Q.
Okay.
7
And then there's a separate entity
called Centene Management Company.
Correct?
8
A.
Correct.
9
Q.
What does it do?
10
A.
It is -- its role is as a consultant to
11 12 13 14
Centene Company Texas. Q.
Is there a contract between Centene Management
Company and Centene Texas? A.
I believe there's a -- Centene Company of
15
Texas pays a percentage of its profits to it for
16
consulting fees, but I'm not -- I don't know the depths
17
of it.
18
Q.
19
And you told me that Mr. Adams works for
Centene Management Company.
20
A.
Cindy Adams.
21
Q.
I'm sorry, it's Ms. Adams works for Centene
22
Management Company?
23
A.
24
Texas.
25
Q.
Cindy Adams works for Centene Company of
And she answers to somebody at --
AcuScribe Court Reporters, Inc. (800) 497-0277
Appendix Volume 2, p. 98
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 4 of 173 Statewide Scheduling * Legal Video * Internet Repository 19 1 2
A.
To Tom Wise, who is also in Austin, and
he's -- Tom Wise answers to Chris Bowers.
3
Q.
4
sorry.
5
A.
Correct.
6
Q.
And works for Centene Management Company?
7
A.
Yes.
8
Q.
Do you know who Chris Bowers answers to?
9
A.
I do not.
10
Q.
What does Centene Texas do?
11 12
That's the person I was thinking of, I'm And Chris Bowers is in St. Louis?
It's somebody new. What's the
business function of Centene Texas? A.
To -- how do I say it?
To meet the contract
13
requirements of the state of Texas in managing Superior
14
Health Plan.
15
Q.
What is Superior Health Plan?
16
A.
It's a managed care -- managed care
17
organization.
18
Q.
Is it like an insurance company?
19
A.
Yes.
20 21 22 23
For Medicaid and CHIP members.
Medicaid, Medicare and CHIP members. Q.
And tell me again, what is Centene Texas's
business function with relation to Superior? A.
They are responsible for managing the contract
24
that -- with the state for the Superior Health Plan
25
insurance company.
AcuScribe Court Reporters, Inc. (800) 497-0277
Appendix Volume 2, p. 99
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 5 of 173 Statewide Scheduling * Legal Video * Internet Repository 20 1 2 3
Q.
What does it mean to manage that?
What does
that entail? A.
To hire all the -- all the individuals
4
necessary to ensure that we're meeting our contract
5
requirements, make sure that we have the appropriate
6
structure in place.
7
Q.
What are the contract requirements?
8
A.
Oh, my.
9
There are two big notebooks worth.
just know the utilization part of it.
10
Q.
Let's talk about the utilization part of it.
11
A.
Okay.
To review services and ensure that they
12
meet medical necessity and they are appropriate
13
services.
14
Q.
And if it's determined that they aren't
15
appropriate, then somebody pays somebody for those
16
services?
17
A.
Yes.
A nurse will approve those services and
18
send an approval letter to the provider, who will then
19
submit a claim for those services.
20
Q.
To whom?
21
A.
To our claims department.
22
I
I don't know the
details of that side of it.
23
Q.
And then who makes the payment?
24
A.
I --
25
Q.
Is it Superior or is it --
AcuScribe Court Reporters, Inc. (800) 497-0277
Appendix Volume 2, p. 100
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 6 of 173 Statewide Scheduling * Legal Video * Internet Repository 22 1
A.
Yes.
2
Q.
Where does that money come from?
3
A.
The state.
4
Q.
So the state pays Centene Texas to provide the
5
utilization review process for Superior?
6 7 8 9
A.
To manage the care of the Medicaid members,
Q.
What -- tell me again exactly what your job
yes.
title is right now.
10
A.
Vice President of Utilization Management.
11
Q.
And tell me what your job is.
12
A.
I am responsible for overseeing the concurrent
13 14 15
review and pre-authorization team. Q.
Okay.
Where is Centene of Texas located?
In
other words, where is its main office?
16
A.
Austin.
17
Q.
Its main office is in Austin, Texas?
18
A.
Yes.
19
Q.
It's not in St. Louis?
20
A.
Did you say Centene -- I'm sorry, I may have
21
misunderstood you.
22
Q.
Centene of Texas.
23
A.
In Austin.
24
Q.
Do you have any idea why with the secretary of
25
the state of Texas their office is listed as being in
AcuScribe Court Reporters, Inc. (800) 497-0277
Appendix Volume 2, p. 101
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 7 of 173 Statewide Scheduling * Legal Video * Internet Repository 33 1
A.
If they work under my current role,
2
pre-certification nurses or concurrent review nurses.
3
Those would be the only two terms.
4
Q.
Pre-certification nurses?
5
A.
Or concurrent review nurses.
6
Q.
The plaintiffs in this case, were they all
7
either pre-certification nurses or concurrent review
8
nurses?
9 10 11 12 13
A.
None were concurrent review, they are all
pre-certification nurses. Q.
What's the difference between
pre-certification nurses and concurrent review nurses? A.
Pre-certification nurses are responsible for
14
reviewing medical services and determining medical
15
necessity for those medical services.
16
typically out-patient services.
17
nurses are responsible for reviewing and determining
18
medical necessity for levels of care of in-patient
19
admissions.
20
Q.
They're
Concurrent review
When I use the term nurse, I'm just going to
21
use it generally referring to either pre-certification
22
or concurrent review nurses.
Okay?
23
A.
Okay.
24
Q.
And you're in charge of both of those
25
categories?
AcuScribe Court Reporters, Inc. (800) 497-0277
Appendix Volume 2, p. 102
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 8 of 173 Statewide Scheduling * Legal Video * Internet Repository 53 1
dates.
2
Q.
3
equipment?
4
A.
Yes.
5
Q.
Computers, office furniture, they may lease
6
Equipment.
Does Centene Texas purchase
that, but do they own equipment, as far as you know?
7
A.
As far as I know, yes.
8
Q.
Is that equipment purchased by Centene Texas
9
or by some other entity?
10
A.
Centene Texas.
11
Q.
Have you ever seen --
12
MR. LANGENFELD:
13
MR. BLEICH:
14
Q.
These.
Let me go ahead and --
15
MR. LANGENFELD:
16
MR. KAISER:
17
We're up to 9?
I don't think we have that.
I only have -- this is 7, I think, isn't it?
18 19
Do we have other copies?
MR. LANGENFELD:
This is -- the Systems
Policy For End Users was No. 8, Bob.
20
MR. BLEICH:
Yeah, I just didn't have a
22
MR. KAISER:
So what is 7?
23
didn't have that either.
24
talking about this?
21
25
copy for you. Because I
Where was I when we were
Okay.
MR. LANGENFELD:
And then 8 we're on? We're up to 9.
AcuScribe Court Reporters, Inc. (800) 497-0277
Appendix Volume 2, p. 103
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 9 of 173 Statewide Scheduling * Legal Video * Internet Repository 60 1
searching for.
2
Q.
And then you use that?
3
A.
Yes.
4
Q.
How did the SHP only come on that document?
5 6
Do you know? A.
I would say it was somebody in our H.R.
7
department in Austin had that put in there.
8
one we preferred to use.
It was the
9
Q.
Okay.
10
A.
I believe H.R. works with compensation to
11
Who formulated these job descriptions?
create them.
12
Q.
H.R. of Centene Texas?
13
A.
Local H.R., yes.
14
Q.
Works with compensation?
15
A.
I believe.
For the job gradings and the
16
exempt status.
17
works with us to develop the -- the responsibilities
18
that are written in here.
19 20
Q.
And then H.R., local H.R. helps --
So these -- obviously at the top of the job
description there's a logo.
And whose logo is that?
21
A.
Centene Corporation.
22
Q.
Are these job descriptions established by
23
Centene Corporation or are they established on a local
24
level?
25
A.
On a local level, in collaboration with the
AcuScribe Court Reporters, Inc. (800) 497-0277
Appendix Volume 2, p. 104
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 10 of 173 Statewide Scheduling * Legal Video * Internet Repository 64 MR. LANGENFELD:
1
It goes on, though, to
2
say in Centene -- employed at Centene Texas and Centene
3
Corporation's role, if any, in determining, creating,
4
documenting, publishing, reviewing, maintaining,
5
updating exemption status. MR. KAISER:
6
And you've not asked about
7
Centene Corporation's role, you've asked about Centene
8
Management Company's role. MR. LANGENFELD:
9 10
No, actually I'm asking
specifically about Centene Texas, their role.
11
MR. KAISER:
Right.
12
MR. LANGENFELD:
And she's here as the
13
corporate rep of Centene Texas.
14
her is simply --
15 16
Q.
Does Centene Texas, as far as you know, have
authority to change the exempt status?
17
A.
I do not know.
18
Q.
Okay.
19
And so my question to
Does Centene Texas, as far as you know,
have the authority to change job descriptions?
20
A.
Yes.
21
Q.
Without input from anybody else?
22
A.
They get -- they go to Centene management H.R.
23
team to get -- and consult with them on whether it's
24
appropriate changes to it, whether it's going to impact
25
the exempt status or the pay grade.
AcuScribe Court Reporters, Inc. (800) 497-0277
Appendix Volume 2, p. 105
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 11 of 173 Statewide Scheduling * Legal Video * Internet Repository 65 Q.
1
And so that's not something Centene Texas does
2
unilaterally on its own, it has to go through another
3
organization to do that?
4
A.
Yes.
5
Q.
And the compensation team is with Centene
6
It goes to the compensation team.
Management Company?
7
A.
Yes.
8
Q.
Let's talk about 1474.
9 10
That's the job
description for the positions that were filled by Cathy Clark and Kevin Ulrich?
11
A.
Yes.
12
Q.
Of course, that job description at the top of
13
it has Centene Corporation's logo.
Correct?
14
A.
Correct.
15
Q.
What do you consider to be the primary duty of
16
a pre-certification nurse as established by this job
17
description? MR. KAISER:
18
I'm going to object insofar
19
as it's calling for a legal conclusion.
When you use
20
primary duty, of course, that's a term that is used out
21
of the regulations.
22
ordinary duty means, then I don't have any objection to
23
it.
24
primary duty means what it means in the regulation,
25
then that's a legal conclusion.
If you mean in a generic way what
But to the extent that you're going to then say
AcuScribe Court Reporters, Inc. (800) 497-0277
Appendix Volume 2, p. 106
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 12 of 173 Statewide Scheduling * Legal Video * Internet Repository 66 MR. LANGENFELD:
1 2
she's a nurse. MR. KAISER:
3 4
MR. LANGENFELD:
MR. KAISER:
Not a
And you can answer it subject
to that. THE WITNESS:
9 10
I got you, Bob.
problem.
7 8
I just want to make sure that
that's on the record.
5 6
No, she's not a lawyer,
A.
Okay
They're responsible for reviewing medical
11
services and determining whether these services meet
12
medical necessity.
13 14
Q.
Okay.
Now let's go to 1476.
description you identified for Grimmett and Endsley.
15
A.
Yes.
16
Q.
The same question, then.
17
MR. KAISER:
19
objection.
20
A.
22 23 24 25
What's the primary
duty for this position?
18
21
That's the job
Subject to the same
But go ahead.
The primary duty is for them to review medical
services and to determine medical necessity. Q.
So substantively, what's the difference
between these two jobs? A.
The only difference is that on the pre-cert we
added that they were responsible for identifying
AcuScribe Court Reporters, Inc. (800) 497-0277
Appendix Volume 2, p. 107
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 13 of 173 Statewide Scheduling * Legal Video * Internet Repository 74 1 2
A.
No.
It was just strictly who -- what their --
what product they were, what insurance plan they had.
3
Q.
What other insurance plans were there?
4
A.
So there's foster care and then there's Star,
5 6
Star Plus, CHIP, CHIP perinate. Q.
Okay.
And so the different groups
7
depending -- depended on the insurance plan, not on the
8
job duties performed by the employees?
9
A.
Correct.
10
Q.
And each of those groups probably had both
11
pre-authorization nurses and prior -- pre-certification
12
nurses within those groups?
13 14 15 16
A.
Depending on when they got hired and who their
manager was at the time, probably. Q.
But their job duties would be essentially the
same?
17
A.
Yes.
18
Q.
Let's talk about the process of the
19
authorization.
20
happens is a request from a provider comes in.
21
right?
22
A.
Correct.
23
Q.
And that's faxed in or e-mailed in, or how
24 25
As I understand, the first thing that Is that
does that work? A.
It's faxed.
It's fax, phone or web.
AcuScribe Court Reporters, Inc. (800) 497-0277
Appendix Volume 2, p. 108
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 14 of 173 Statewide Scheduling * Legal Video * Internet Repository 75 1
Q.
Nowadays it's probably mostly web.
2
A.
You would think, but no.
3
Q.
No?
4
A.
No.
5
Q.
Those doctors are dinosaurs.
6
to change?
7
A.
They do not want to do that.
8 9 10
They don't want
MR. KAISER:
If you could help me
understand which paragraph we're under, that would be helpful to me.
11
MR. LANGENFELD:
It's under the first
12
one.
We're talking about job duties, and in order to
13
understand the job duties, I need to understand the
14
process.
15
MR. KAISER:
Okay.
I just wanted to keep
16
track and make sure we're not turning this into --
17
we're taking Esmey's deposition.
18
MR. LANGENFELD:
19
MR. KAISER:
Oh, no, no, no.
Okay.
20
Q.
I'm still talking about the work at Centene
21
Texas.
22
assigned -- who is it -- how is it determined who it's
23
assigned to?
So the request comes in.
And how is it
24
A.
It goes to the referral specialist team.
25
Q.
And who are the referral specialists?
AcuScribe Court Reporters, Inc. (800) 497-0277
Appendix Volume 2, p. 109
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 15 of 173 Statewide Scheduling * Legal Video * Internet Repository 76 1
A.
They are nonclinical individuals that are
2
responsible for entering what is on the request form
3
into our care management system.
4
Q.
What do they enter?
5
A.
The member's name.
Do you know? Well, they find the member
6
and then they enter the member's information.
They'll
7
enter the physician's information and then basic what
8
type of service is being requested.
9
Q.
And then where does that request go to?
10
A.
It then goes to an in box where a manager or
11
supervisor will filter that work to the
12
pre-certification nurses.
13
Q.
Now, in looking at some of the documents
14
provided, it appears there are some instances where the
15
referral specialist might completely bypass the initial
16
review process.
17
process, I'm speaking about the job performed by the
18
plaintiffs in this case, as opposed to the secondary
19
review, which is performed by the medical director.
And when I say the initial review
20
A.
Okay.
21
Q.
Or are there other terms that you're more
22
comfortable with?
23
A.
No, that's fine.
24
Q.
Okay.
25
So I understand there are some
instances where the referral specialist might
AcuScribe Court Reporters, Inc. (800) 497-0277
Appendix Volume 2, p. 110
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 16 of 173 Statewide Scheduling * Legal Video * Internet Repository 77 1
completely bypass the initial review and send it
2
directly to medical, to the secondary review?
3 4 5 6 7
A.
The referral specialist never sends
anything to the medical director. Q.
Even in situations, for example, for
experimental procedures or -A.
No. MR. KAISER:
8 9
No.
Again, same objection,
because now we're talking about the job descriptions of
10
the referral specialist and not the plaintiffs or
11
anybody who holds a job like the plaintiffs.
12
Q.
And then so how is it determined whether the
13
request ends up in Amy Endsley's stack or Kevin
14
Ulrich's or somebody else's?
15 16 17 18 19 20 21 22 23
A.
The supervisor or manager just randomly
assigns a set amount of cases to them. Q.
Is it just based on numbers, who's busier and
who needs more work to do? A.
Everyone is supposed to get an even amount of
cases to work. Q.
So it's mostly on volume as opposed to a
particular type of request? A.
Correct.
In some -- in most -- during the
24
time that these individuals were there, yes.
25
then the process has changed.
Since
With the exception of
AcuScribe Court Reporters, Inc. (800) 497-0277
Appendix Volume 2, p. 111
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 17 of 173 Statewide Scheduling * Legal Video * Internet Repository 79 1
Q.
"Designee reviews all relevant information to
2
determine if a Level I or a Level II review is
3
indicated."
4
Is that what they're referring to?
I took that to mean referral specialist.
5
A.
No.
6
Q.
Who is that?
7
A.
A pre-certification nurse.
8
Q.
So a pre-certification nurse looks at it to
9 10 11
determine whether it should go to a Level I review or a Level II review first? A.
Right.
Whether they should go ahead and
12
review it for medical necessity or whether they send it
13
to Level II, being the medical director.
14
Q.
And so then the -- the request ends up in like
15
a -- is it a physical piece of paper that the nurse
16
receives or is it sent to them electronically?
17
A.
Electronically.
18
Q.
So they open up their e-mail box and there are
19
the requests?
20
A.
Yes.
21
Q.
And do they just typically start with the one
22
that's been there the longest or the first one on the
23
list or ...
24 25
A.
They have been told that they are to start
with the oldest first to ensure that we meet our
AcuScribe Court Reporters, Inc. (800) 497-0277
Appendix Volume 2, p. 112
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 18 of 173 Statewide Scheduling * Legal Video * Internet Repository 80 1
turnaround expectations for the state.
2
Q.
What is the turnaround expectation time?
3
A.
For none-CHIP products it is three days.
4
CHIP products it's two days. Q.
5 6
For
And so what's the first thing that the nurse
does once they open up and see the request? A.
7
They are to look at the clinical that was --
8
well, they open the case, they go and look to see if
9
clinical was received or came with the request.
If it
10
was, then they go ahead and review the clinical and
11
determine whether it meets medical necessity. Q.
12
So when they open it up and start reviewing
13
the clinical, how do they know what they're looking
14
for? A.
15
Because they're nurses, and if the request
16
says it's for home health skilled nursing visits, then
17
as nurses they know what to look in the clinical for,
18
to be able to approve by review and for medical
19
necessity.
20
Q.
21
So the only thing they rely on to determine
medical necessity is their nursing experience? A.
22
No.
That's how they know what they're looking
23
for.
That was the question.
But they use the
24
guidelines that we provide them, which are either our
25
policies, the Interqal or TMHP.
AcuScribe Court Reporters, Inc. (800) 497-0277
Appendix Volume 2, p. 113
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 19 of 173 Statewide Scheduling * Legal Video * Internet Repository 87 1
Okay?
2
A.
Yes.
3
Q.
We both -- both health care providers submit
4
both of our requests for authorization.
Wouldn't you
5
agree that the system is set up so that if everything
6
else is the same, they both get approved?
7
A.
Yes.
8
Q.
So the system is designed to be an objective
9
system.
10
A.
Yes.
11
Q.
Just so that we're talking about the same
12
thing, can you give me your -- your definition of what
13
objective means?
14
A.
That there are clear guidelines to making a
15
determination.
16
looking at something, it's factual.
17 18
Q.
There's no personal feeling involved in
It's strictly applying the facts to the
guidelines?
19
A.
Right.
20
Q.
And in fact -MR. KAISER:
21 22
questions, can I take a break? MR. LANGENFELD:
23 24 25
When you finish the line of Whenever you're -We can just go ahead and
take one now. (Recess from 11:06 to 11:18)
AcuScribe Court Reporters, Inc. (800) 497-0277
Appendix Volume 2, p. 114
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 20 of 173 Statewide Scheduling * Legal Video * Internet Repository 88 1
Q.
I think we were talking about whether the
2
utilization review process is set up to be an objective
3
process.
4
A.
I think we agreed that it is. Well, with some nursing judgment involved in
5
it, which isn't always objective.
6
thought we just defined objective.
7
Q.
We did.
Is that what we -- I
And I thought the definition you gave
8
was it's based on the facts and the guidelines without
9
personal influence.
10 11 12
A.
Without personal opinion, but the nursing
judgment plays into it. Q.
Well, the way the system is set up, wouldn't
13
you agree that -- and we kind of talked about this as
14
an example with you and me, that if two people have the
15
same coverage and the same clinical --
16
A.
Correct.
17
Q.
-- and the same guidelines are applied, then
18
the result should be the same.
19
A.
If they were done by the same nurse.
20
Q.
So --
21
A.
But if two different nurses get it, how they
22
use their nursing judgment to apply the clinical
23
guidelines may differ.
24 25
Q.
Okay.
The way it's intended to work, wouldn't
you agree that if two people have the same ailment, the
AcuScribe Court Reporters, Inc. (800) 497-0277
Appendix Volume 2, p. 115
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 21 of 173 Statewide Scheduling * Legal Video * Internet Repository 89 1
same procedure is requested and they have the same
2
clinical, then they should be treated the same?
3
results should be the same.
4
that?
5 6
A.
Should be.
Wouldn't you agree with
But yes, it is all depending on
the nurses.
7
Q.
But it is designed so that it should be?
8
A.
Uh-huh.
9
Q.
And the object -- is that a yes?
10
A.
Yes.
11
Q.
And the objectivity of the process is
12 13
The
extremely important. A.
Wouldn't you agree?
Well, there's a lot of -- when you look at our
14
policies, there's a lot of nursing judgment that plays
15
into it.
16
will describe progress.
17
be different from what another nurse thinks is
18
progress.
19 20
Q.
It's not -- everything isn't objective, so it What I think is progress may
And we'll come back to that. MR. KAISER:
Just when we do come back to
21
it, I want us to be cognizant of the fact that what
22
this witness is being asked to testify is in general
23
terms the job duties.
24
MR. LANGENFELD:
25
MR. KAISER:
Job duties.
In general terms.
AcuScribe Court Reporters, Inc. (800) 497-0277
That's the
Appendix Volume 2, p. 116
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 22 of 173 Statewide Scheduling * Legal Video * Internet Repository 94 1 2
approve it, should there be that situation? A.
A nurse cannot not approve something.
A
3
medical director is the one that makes the ultimate
4
decision.
5
Q.
No, I didn't say denial.
6
A.
Okay.
7
You said not approved.
So to me that
equals --
8
Q.
So you think nurses can --
9
A.
No, I do not.
10
Q.
Well, there are circumstances where nurses
11
That's why I'm saying that.
don't approve procedures.
12
A.
And they send it to the medical director.
13
Q.
Right.
14
A.
Yes.
15
Q.
So my question is, should there be a situation
Right.
16
where one nurse might look at a situation, a procedure,
17
the same clinical, the same guidelines, should there be
18
a situation where one nurse who looks at it and
19
approves it and the next nurse looks at it and doesn't
20
approve it?
Should that happen?
21
A.
I -- no.
22
Q.
And you mentioned that nurses don't have
23
authority to deny.
24
A.
Right.
25
Q.
That goes to whom?
AcuScribe Court Reporters, Inc. (800) 497-0277
Appendix Volume 2, p. 117
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 23 of 173 Statewide Scheduling * Legal Video * Internet Repository 103 1
it, is she?
2
A.
3
different.
4
Q.
5
Well, they may both -- their judgment may be
Well, but if they both agree that it meets the
guidelines, then they both approve it.
6
A.
Right.
7
Q.
What guidelines are used?
8 9 10 11
Right?
I mean, what's the
hierarchy of the guidelines? A.
Our policy is first and then the Interqal
criteria and then TMHP. Q.
And so how does that work if the request comes
12
in and they look and it doesn't meet the policies, they
13
then go to the next --
14
A.
No.
They --
15
Q.
Explain that.
16
A.
So the request comes in and they look at the
17
policy for this treatment, then they use the policy to
18
make -- to determine medical necessity, if within the
19
policy it says you can refer to -- which I believe the
20
therapy policy does say if you're not finding something
21
specific to meet the criteria within this policy, you
22
can go to Interqal.
23
if it does not say that, then they use the policy to
24
make the ultimate decision on whether it meets or does
25
not meet criteria.
Then they can go to Interqal, and
AcuScribe Court Reporters, Inc. (800) 497-0277
Appendix Volume 2, p. 118
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 24 of 173 Esmeralda Cazares-Baig 5/28/2014 1
UNITED STATES DISTRICT COURT WESTERN DISTRICT OF TEXAS AUSTIN DIVISION
2 3 4 5
KATHY CLARK, AMY ENDSLEY, SUSAN GRIMMETT, MARGUERIETTE SCHMOLL, AND KEVIN ULRICH, ON BEHALF OF THEMSELVES AND ALL OTHERS SIMILARLY SITUATED,
6
Plaintiffs, 7
V. 8 9 10
Page: 1
CENTENE CORPORATION, CENTENE COMPANY OF TEXAS, L.P., AND SUPERIOR HEALTHPLAN, INC.,
11
Defendants.
§ § § § § § § § § § § § § § § § §
Civil Action No. 1:12-CV-00174-SS JURY DEMANDED
12 13 14
**************************************************
15
ORAL DEPOSITION OF
16
ESMERALDA CAZARES-BAIG
17
MAY 28, 2014
18
**************************************************
19 20 21 22 23 24 25
ORAL DEPOSITION OF ESMERALDA CAZARES-BAIG, produced as a witness at the instance of the Plaintiffs, and duly sworn, was taken in the above-styled and numbered cause on the 28th day of May, 2014, from 9:22 a.m. to 12:51 p.m., before Cynthia Warren, Certified Shorthand Reporter in and for the State of Texas, reported by machine shorthand, at the offices of Boulette & Golden, LLP, 2801 Via Fortuna, Suite 350, Austin, Texas 78746, pursuant to the Federal Rules of Civil Procedure and the provisions stated on the record.
800-545-9668 612-339-0545
Paradigm Reporting & Captioning www.paradigmreporting.com
Appendix Volume 2, p. 119
#79138
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 25 of 173 Esmeralda Cazares-Baig 5/28/2014
Page: 12
1
A.
Who?
2
Q.
Oh, the statewide function ones.
3
A.
They get faxes.
4
Q.
So do they have like an office at the hospital
5
and then the clinical information is faxed to them?
6
A.
They work from home.
7
Q.
Oh, I was talking about the on-site folks.
8
A.
They go to the hospital and they go to the
9
floors the members are on and review the clinical there.
10 11
Q.
And then you had a director of medical
management operations?
12
A.
Yes.
13
Q.
And who is that individual?
14
A.
Lev Grodzinskiy.
15
Q.
How do you spell the first name?
16
A.
Lev, L-E-V.
17
Q.
Okay.
18
And then for the director of concurrent
review statewide functions, who is that individual?
19
A.
Gloria Rios.
20
Q.
R-I-O-S?
21
A.
Yes.
22
Q.
And then the director of shared services?
23
A.
Michelle Staley.
24
Q.
Could you spell the last name, please?
25
A.
S-T-A-L-E-Y.
800-545-9668 612-339-0545
Paradigm Reporting & Captioning www.paradigmreporting.com
Appendix Volume 2, p. 120
#79138
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 26 of 173 Esmeralda Cazares-Baig 5/28/2014
Page: 14
1
Q.
Two.
2
A.
San Antonio and Austin.
3
Q.
And then the concurrent review nurses that work
4
And which offices are those?
from home, do they report to a certain office?
5
A.
San Antonio.
6
Q.
And then how about the on-site concurrent
7
review nurses, do they report to a certain office?
8
A.
Some to San Antonio and some statewide.
9
Q.
What does that mean, to report statewide?
10
A.
So we have offices throughout Texas, so based
11
on what office they got hired in, that's the office they
12
report to.
13
Q.
14
How many offices do you have in the state of
Texas, Centene Company of Texas?
15
A.
Eight.
16
Q.
So besides San Antonio and Austin, where are
17
your other offices?
18
A.
El Paso.
19
Q.
Do you have any on-site concurrent review
20
nurses that report out of the El Paso office?
21
A.
Yes.
22
Q.
And then what other office?
23
A.
Amarillo.
24
Q.
Amarillo?
25
A.
Uh-huh.
800-545-9668 612-339-0545
Paradigm Reporting & Captioning www.paradigmreporting.com
Appendix Volume 2, p. 121
#79138
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 27 of 173 Esmeralda Cazares-Baig 5/28/2014 1
Q.
Page: 17
Is there a department within the medical
2
management department that's responsible for
3
reviewing -- for sort of detecting the fraud and abuse
4
that you're talking about?
5
A.
Medical management operations is mainly
6
responsible, but all of the directors are responsible
7
for keeping an eye on that.
8 9
Q.
Gotcha.
And are you familiar with the term
utilization review agent?
10
A.
Yes.
11
Q.
And what does that mean?
12
A.
To me or. . .
13
Q.
Sure, yes, if you know the definition of it.
14
A.
To review medical services and determine
15
whether services meet medical necessity.
16 17
Q.
Is Centene Company of Texas a utilization
review agent?
18
A.
Yes.
19
Q.
And it provides the -- Centene Company of Texas
20
provides the utilization services for Superior
21
HealthPlan's members?
22
A.
Yes.
23
Q.
Do you know how many members there are that
24
have Superior HealthPlan coverage?
25 800-545-9668 612-339-0545
A.
Over 900,000. Paradigm Reporting & Captioning www.paradigmreporting.com
Appendix Volume 2, p. 122
#79138
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 28 of 173 Esmeralda Cazares-Baig 5/28/2014 1 2
Q.
And it's my understanding that's Superior's
Medicaid health plan?
3
A.
We do Medicaid along with other products.
4
Q.
Along with what?
5
A.
Other products.
6
Q.
What other products?
7
A.
So all Medicaid, Medicare, and Ambetter.
8
Q.
I missed that last word.
9
A.
Ambetter.
10
Q.
Could you spell that, please?
11
A.
A-M-B-E-T-E-R -- T-T-E-R.
12
Q.
What's Ambetter?
13
A.
It's private insurance.
14
Q.
Oh, not state-funded, you mean?
15
A.
No.
16
Q.
Is that a new line of business?
17
A.
Yes.
18
Q.
And when did that start?
19
A.
It was through Obamacare.
20
Page: 18
So January of this
year.
21
Q.
Of the 900 [sic] members, do you know what the
22
division is between Medicaid members, Medicare members,
23
and Ambetter members?
24 25
A.
The majority are Medicaid members.
Medicare is
about 3,000 members and Ambetter is about 2,000 members.
800-545-9668 612-339-0545
Paradigm Reporting & Captioning www.paradigmreporting.com
Appendix Volume 2, p. 123
#79138
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 29 of 173 Esmeralda Cazares-Baig 5/28/2014 1
Q.
Anything else that you can describe as your
2
general responsibilities as the vice president of
3
medical management?
4
A.
Page: 19
I would just add coordinating services with our
5
case management team to ensure our members are getting
6
their services met.
7 8
Q.
Is case management team, is that a different
department?
9
A.
Yes.
10
Q.
And who oversees the case management
11
department?
12
A.
Brian Travers.
13
Q.
Brian or Ryan?
14
A.
Brian.
15
Q.
Brian.
16
A.
Yes, Austin.
17
Q.
-- Austin.
18
I was in Knoxville, Tennessee last
week so I'm like where am I.
19 20
And he offices here in --
Okay.
Now, the nurses in this case, do
any of them work in the case management department?
21
A.
No.
22
Q.
Do the case management department nurses also
23
have the job title of case manager?
24
A.
Yes, Case Manager II.
25
Q.
In terms of the chain of command from the
800-545-9668 612-339-0545
Paradigm Reporting & Captioning www.paradigmreporting.com
Appendix Volume 2, p. 124
#79138
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 30 of 173 Esmeralda Cazares-Baig 5/28/2014 1
director prior authorization down, what's that look
2
like?
Page: 20
3
A.
They have managers that report to them.
4
Q.
Okay.
5
A.
Manager of prior authorization.
6
Q.
And is that the same sort of hierarchy or chain
And what's their job titles?
7
of command for the concurrent review nurses?
8
manager of concurrent review?
Is there a
9
A.
Yes.
10
Q.
And do you know how many managers there are for
11
prior authorization currently?
12
A.
Six.
13
Q.
And has that number fluctuated over the last
14
few years?
15
A.
Yes.
16
Q.
And from what to what?
17
A.
Probably one to six.
18
Q.
Okay.
19
And then is that one to six between the
DME group and then the therapy home health aide group?
20
A.
They each currently have three and three.
21
Q.
Oh, gotcha.
22
And then for concurrent review,
how many managers have you had over the last few years?
23
A.
For concurrent review it has varied.
So
24
concurrent review did not report to me prior to -- the
25
entire team started reporting to me in 2012, so prior to
800-545-9668 612-339-0545
Paradigm Reporting & Captioning www.paradigmreporting.com
Appendix Volume 2, p. 125
#79138
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 31 of 173 Esmeralda Cazares-Baig 5/28/2014 1
Page: 21
2012 I don't know those numbers.
2
Q.
3
there?
4
A.
Approximately ten.
5
Q.
Who did the team report to prior to 2012?
6
A.
To the operations team.
7
Q.
The director -- what's the operations team?
8
A.
So our vice president of operations, not the --
9
Okay.
So back in 2012 how many managers were
they're not the director of medical management offices.
10
Q.
Got it.
So there's an operations team that's a
11
separate department from the medical management
12
department?
13
A.
Yes.
14
Q.
And who -- is there currently an operations
15
team?
16
A.
Yes.
17
Q.
And back in 2012 who was the head of the
18
operations team?
19
A.
Jason McBride.
20
Q.
And could you spell his last name, please?
21
A.
M-C-B-R-I-D-E.
22
Q.
And is he currently the vice president of the
23
operations team?
24
A.
No.
25
Q.
What does shared services mean?
800-545-9668 612-339-0545
He's our chief of shared services.
Paradigm Reporting & Captioning www.paradigmreporting.com
Appendix Volume 2, p. 126
#79138
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 32 of 173 Esmeralda Cazares-Baig 5/28/2014 1
A.
Page: 22
So under medical management, shared services is
2
the team that does a mix of services for medical
3
management operations.
4
auditing, they have our workforce management analyst
5
reporting to them.
6
shares their services.
So they do the training, the
So the medical management team
7
Q.
8
what else?
9
A.
Workforce management.
10
Q.
What's that?
11
A.
That's the individuals that monitor our call
12
queue.
13
Q.
Okay.
So they do auditing, training, and then
Is there a title for individuals -- a job title
14
for those individuals who manage the -- or monitor the
15
call queue?
16
A.
Workforce management analyst.
17
Q.
So when you talked about chief of shared
18
services that Mr. McBride currently holds the title, is
19
that something different than the shared services within
20
the medical management department?
21
A.
Yes.
22
Q.
And what is the shared services that he
23
oversees?
24 25
A.
He oversees -- so he is currently my boss.
So
he oversees medical management, he oversees
800-545-9668 612-339-0545
Paradigm Reporting & Captioning www.paradigmreporting.com
Appendix Volume 2, p. 127
#79138
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 33 of 173 Esmeralda Cazares-Baig 5/28/2014
Page: 33
1
that manages or administers the Medicaid program through
2
Centene Company of Texas.
3
Q.
So is Centene Company a managed care company?
4
A.
Centene Company of Texas, yes.
5
Q.
Sorry.
6
Centene Company of Texas, is it a
managed care company?
7
A.
Yes.
8
Q.
Is that the same thing as a utilization review
9
agent or is that two different things?
10 11
A.
I don't know enough about it to say the
differences.
12
Q.
Okay.
If you go back to Exhibit No. 6, what
13
are the various folders underneath Centene or underneath
14
Texas dash SHP?
15
A.
So those folders are the folders of those
16
departments and what policies they hold within those --
17
what policies those departments have.
18
Q.
Okay.
So if we go to page 3 of the document,
19
which is Bates number 906, there's a folder called
20
Utilization Management.
Do you see that?
21
A.
Yes.
22
Q.
And are those the policies that apply to the
23
prior authorization and concurrent review nurses in this
24
case?
25 800-545-9668 612-339-0545
A.
Yes. Paradigm Reporting & Captioning www.paradigmreporting.com
Appendix Volume 2, p. 128
#79138
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 34 of 173 Esmeralda Cazares-Baig 5/28/2014 1 2
Q.
Page: 34
And you had mentioned that policies will
sometimes change; is that right?
3
A.
Correct.
4
Q.
And how often does that happen?
5
A.
We add new policies depending on reviewing the
6
utilization.
7
we didn't require authorization for but now we will
8
because we're seeing over-utilization, we'll create a
9
policy on how to apply medical necessity criteria; and
So we determine there's some services that
10
sometimes we'll also, with that in mind, say we no
11
longer need a policy because things are good with that
12
service.
13 14
Q. service?
15 16
What do you mean, things are good with that
A.
So we're not seeing over-utilization or abuse
of a service.
17
Q.
So do the revisions happen only with
18
over-utilization or do they happen
19
with under-utilization?
20 21
A.
They have to happen once a year.
Updates and a
review of the policy happen yearly.
22
Q.
And who is responsible for updating or annually
23
reviewing the policies that the prior authorization
24
nurses and concurrent review nurses have to follow?
25 800-545-9668 612-339-0545
A.
So the utilization -- the directors of prior Paradigm Reporting & Captioning www.paradigmreporting.com
Appendix Volume 2, p. 129
#79138
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 35 of 173 Esmeralda Cazares-Baig 5/28/2014
Page: 35
1
auth are responsible for reviewing along with the
2
medical director, the CMO, and myself; and depending on
3
what year it was, there may have been other individuals
4
that reviewed the policies as well.
5
Q.
I just want to make sure to get all the people
6
who are involved in reviewing the policies and updating
7
them.
You've got the directors of prior authorization?
8
A.
Uh-huh.
9
Q.
What about the director of concurrent review,
10
are they involved in the review process?
11
A.
For the concurrent review policies, yes.
So it
12
is dependent on whether those policies apply to what the
13
team that reports to them does.
14
Q.
And if you looked at the list of policies on
15
Exhibit 6, how would we be able to tell which policies
16
apply to the prior authorization nurses versus the
17
policies that apply to the concurrent review nurses?
18
A.
So it may vary.
It depends on what kind of
19
services the prior authorization nurses are reviewing.
20
Some of them specifically say concurrent review or DRG,
21
which is only for concurrent review nurses.
22
majority of anything titled TX.UM.10 point something is
23
typically what the prior authorization nurses would use.
24 25
Q.
Gotcha.
The
Just so I follow you, if you take a
look at 907, which is page 4, where it says TX.UM.02.16
800-545-9668 612-339-0545
Paradigm Reporting & Captioning www.paradigmreporting.com
Appendix Volume 2, p. 130
#79138
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 36 of 173 Esmeralda Cazares-Baig 5/28/2014 1 2
Q.
Okay.
So every time I see a "see linked"
followed by a reference number to CC.UM --
3
A.
Yes.
4
Q.
-- does that mean that there's a corporate
5
Page: 38
policy that basically says the same thing?
6
A.
Yes.
7
Q.
Okay.
So then what's the difference between
8
Centene Texas's policy on interrater reliability versus
9
the corporate policy on interrater reliability?
10
A.
What's the difference?
11
Q.
Yeah, is there a difference?
12
A.
No.
13
Q.
Oh, gotcha.
14
And what is inter -- I can't even
say it -- interrater reliability?
15
A.
It is InterQual.
So McKesson has a program
16
called InterQual that basically has clinical criteria
17
embedded in it to help the nurses make the appropriate
18
medical necessity decisions.
19 20
Q.
So what does interrater reliability measure or
track or is it a score?
21
A.
Yes.
22
Q.
Is it a report?
23
A.
So the nurses have to take a test once a year
24
on the areas that they process, areas of responsibility,
25
and they have to score greater than 80 percent on it.
800-545-9668 612-339-0545
Paradigm Reporting & Captioning www.paradigmreporting.com
Appendix Volume 2, p. 131
#79138
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 37 of 173 Esmeralda Cazares-Baig 5/28/2014 1 2
Q.
And what does a score of 80 percent demonstrate
or show?
3 4
Page: 39
A.
That they know how to apply the medical
necessity criteria.
5
Q.
So are they evaluated based on their ability or
6
their skills in being able to apply the medical
7
necessity criteria to the clinical information that they
8
review?
9
A.
Is that what the test is?
10
Q.
Yes.
11
A.
Is that your question?
12
Q.
Is this a written test?
13
A.
It's a computerized.
14
Q.
And if they don't score 80 percent or greater,
15
Yes.
what's the consequence of that?
16
A.
They have to just go through retraining.
17
Q.
And what kind of retraining -- I'm sorry.
18
ahead.
19
A.
And then -- sorry.
On the InterQual testing,
20
like the -- retraining on what InterQual is, how to
21
apply InterQual, review of the books or there's a
22
computerized version as well.
23
test.
And then they retake the
24
Q.
There's a computerized version of what?
25
A.
Of InterQual.
800-545-9668 612-339-0545
Go
Paradigm Reporting & Captioning www.paradigmreporting.com
Appendix Volume 2, p. 132
#79138
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 38 of 173 Esmeralda Cazares-Baig 5/28/2014
Page: 52
1
Q.
(By Ms. Srey)
Do you know what it stands for?
2
A.
Oh, my gosh.
I can't recall off the top of my
3
head.
They're the DME codes.
4
Q.
Oh, okay.
5
A.
They are for procedures.
6
Q.
Inpatient and outpatient procedures?
7
A.
Yes.
8
Q.
And are there standard CPT codes in the managed
9
What are the CPT codes for then?
care industry?
10
A.
Yes.
11
Q.
So besides CCMS, Amisys, any other computer
12
systems that the nurses use in the performance of their
13
jobs?
14
A.
Intranet to get to their policies.
15
Q.
And how much training is provided at the
16
beginning of one's employment on these systems?
17
A.
So I can only speak to the time frame in which
18
I have overseen the team, and during that time frame
19
it's been approximately two to three weeks.
20 21
Q.
And just so we're clear on the time frame, do
you mean post December 2010?
22
A.
Post July 2010.
23
Q.
Okay.
24
So there's two to three weeks of
training on the systems?
25 800-545-9668 612-339-0545
A.
Yes. Paradigm Reporting & Captioning www.paradigmreporting.com
Appendix Volume 2, p. 133
#79138
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 39 of 173 Esmeralda Cazares-Baig 5/28/2014 1
review?
2
A.
Yes.
3
Q.
Can only a medical director do a level 2
4
Page: 57
review?
5
A.
Yes.
6
Q.
What else does the quality audits entail
7
besides the regulatory requirements and what I'm going
8
to characterize as appropriate documentation to the
9
medical director?
10
A.
Yes.
11
Q.
Anything else?
12
A.
How medical necessity was applied and how
13
the -- was the authorization set up correctly.
14 15
Q.
How do you measure how the medical necessity
was applied from a quality perspective?
16
A.
We look to see that they use the -- how do I
17
say this?
18
They have to write a clinical note, so we make sure that
19
the clinical note entails all the details of the
20
member's clinical picture.
Like we review the clinical that they wrote.
21
Q.
Okay.
22
A.
And applying the policy, yes.
23
Q.
Applying the -- for example, the InterQual
24
Anything else?
guidelines to the clinical notes that they put together?
25 800-545-9668 612-339-0545
A.
Right. Paradigm Reporting & Captioning www.paradigmreporting.com
Appendix Volume 2, p. 134
#79138
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 40 of 173 Esmeralda Cazares-Baig 5/28/2014 1
monthly.
2 3
Q.
Okay.
So this Exhibit 7 does relate to the
quality audits that you were testifying to earlier?
4
A.
Yes.
5
Q.
Okay.
6
And in terms of TAT, what does that
stand for, the metric?
7
A.
Turnaround time.
8
Q.
And is there a specific turnaround time that
9
they are required to review their cases by?
10
A.
Yes.
11
Q.
Okay.
12
Page: 61
Zero to 1.
It's in parentheses.
And that's for both prior authorization
and concurrent or is it different between the two?
13
A.
It's different.
14
Q.
And what's the -- what's zero to 1, who is that
15
for?
16
A.
Concurrent.
17
Q.
And then for prior authorization, do they get a
18
little bit more time?
19
A.
For -- it depends on what type of request it
20
is.
21
day as well.
22
service, then they get two days.
23
product, then they get three days.
24 25
So if it is an urgent request they get one business
Q.
If it is a by-product, CHIP-related If it is a Medicaid
And do the turnaround times sometimes cause a
backlog in the number of authorizations that are sitting
800-545-9668 612-339-0545
Paradigm Reporting & Captioning www.paradigmreporting.com
Appendix Volume 2, p. 135
#79138
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 41 of 173 Esmeralda Cazares-Baig 5/28/2014 1
in the pend queue?
2 3
Page: 62
A.
Repeat the question.
I think -- just clarify
the question.
4
Q.
Thinking about sort of a backlog and the number
5
of authorizations that are sitting in the queue that
6
need to be reviewed, is it -- is the backlog a result of
7
the fact that there are all these turnaround time
8
expectations and having to review certain types of
9
services by one day, other types of services by a couple
10
of days?
11
A.
Yes.
12
Q.
What about productivity, what does that
13
measure?
14 15
A.
review per day.
16 17
Q.
Okay.
How many authorizations are typically
assigned to a nurse per day?
18 19
It measures how many authorizations you should
A.
It varies as well by what type of nurse they
are and what type of service they're doing.
20
Q.
So the concurrent review nurse, which is what
21
we're looking at on Exhibit 7, the productivity goal is
22
15 cases per day; is that right?
23
A.
So they carry on average, depending on whether
24
they're on-site or telephonic, anywhere from 20 to 30
25
authorizations.
800-545-9668 612-339-0545
They just don't review them every day. Paradigm Reporting & Captioning www.paradigmreporting.com
Appendix Volume 2, p. 136
#79138
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 42 of 173 Esmeralda Cazares-Baig 5/28/2014
Page: 63
1
So for them it's more of how many reviews they did per
2
day, not how many auths they worked.
3
Q.
Gotcha.
And then for the preauthorization,
4
because they're not carrying X -- 20 and 30 cases, it's
5
about how many authorization codes that they're able to
6
give out per day?
7
A.
Correct.
8
Q.
For quality of clinical decisions, there's a
9
parentheses focused audits.
10
A.
What does that mean?
So if you look at the parentheses under the
11
goal, every month they did a focus -- they changed up
12
what the focus audit was, whether it was specific to IQ
13
or the medical director reviews or target length-of-stay
14
management.
15
Q.
What's IQ stand for?
16
A.
InterQual.
17
Q.
What's HEDIS -- HEDIS?
18
A.
HEDIS, it's a quality measures.
19
Q.
What does that mean?
20
A.
So there are standard quality measures that we
21
are to monitor on members, whether they -- if they're
22
diabetic, if they're getting their A1C test completed
23
every year, those kind of measures.
24
is done through the quality team, but since this team
25
goes on-site, we ask that they look at the documentation
800-545-9668 612-339-0545
Paradigm Reporting & Captioning www.paradigmreporting.com
So typically that
Appendix Volume 2, p. 137
#79138
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 43 of 173 Esmeralda Cazares-Baig 5/28/2014
Page: 64
1
and see if any of those measures were captured during
2
that on-site.
3
Q.
4
measuring?
5
A.
If there were any issues with the individual.
6
Q.
Can members complain about an individual?
7
What about issues and complaints, what is that
Is
it the healthcare provider complaining?
8
A.
It's usually the healthcare provider.
9
Q.
Okay.
Any other ways of monitoring job
10
performance besides quality audits, what you can look at
11
through the Avaya phone system, that you can think of?
12 13
A.
No.
Like productivity, anything that's on this
list is pretty much how we monitor the nurses.
14
Q.
If a nurse doesn't meet the productivity
15
standards, is there consequences in terms of corrective
16
actions or disciplinary warnings, that type of thing?
17
A.
Yes.
So if they don't meet their goals the
18
first month, we do coaching with them.
19
meet them a second month, it depends.
20
nurse that works from home, we'll bring them back in to
21
make sure there's not something going on at home that's
22
distracting them from the day-to-day job.
23
we'll do various performance measures.
If they don't
24
Q.
Performance improvement plans?
25
A.
Performance improvement, yes.
If they're a
800-545-9668 612-339-0545
Paradigm Reporting & Captioning www.paradigmreporting.com
In addition
Appendix Volume 2, p. 138
#79138
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 44 of 173 Esmeralda Cazares-Baig 5/28/2014 1
Q.
Page: 65
And then you said there -- after 30 days there
2
would be coaching.
3
their productivity goals two months in a row, 60 days?
4
A.
Is there -- what if they don't meet
We follow our policy on performance
5
improvement -- I'm drawing a blank on the word --
6
measures, that's not right either.
7
moment.
8
verbal, those kind of things.
Sorry, give me a
Whether it's like a verbal or a documented
9
Q.
The disciplinary steps?
10
A.
Yes.
11
Q.
At some point is there -- is there a certain
12
threshold where if they don't meet their productivity
13
goals then they face termination?
14
A.
It takes time so we do -- we spend a lot of
15
time with our employees trying to coach them into
16
getting to where they need to be.
17
of how long they must be in each step of the
18
disciplinary steps.
19
Q.
So there's guidelines
And how was it -- who determined the
20
productivity goals, whether it was concurrent review for
21
15 reviews or prior authorization having X amount of
22
cases that they needed to authorize?
23
those productivity goals?
Who determined
24
A.
The directors and I.
25
Q.
Do those productivity goals change year from
800-545-9668 612-339-0545
Paradigm Reporting & Captioning www.paradigmreporting.com
Appendix Volume 2, p. 139
#79138
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 45 of 173 Esmeralda Cazares-Baig 5/28/2014 1 2
Page: 70
Is this just a document for internal use purposes?
3
A.
We do have to turn it in to -- when we submit
4
to our URA, they ask to see our program description for
5
the Texas Department of Insurance.
6
Q.
When you submit for your URA license you need
7
to provide a copy of your program description to the
8
Texas Department of Insurance?
9
A.
Yes.
10
Q.
Anything else that you need to provide to them?
11
A.
We provide a lot of information, but it comes
12
through our compliance department so they would have the
13
full list of what goes to them.
14 15
Q.
And is that the compliance department within
Centene Company of Texas?
16
A.
Yes.
17
Q.
And who's in charge of that?
18
A.
Cheryl Cizler.
19
Q.
Could you spell her last name, please?
20
A.
C-I-Z-L-E-R.
21
Q.
Do you know what the responsibility of the
22
compliance department is other than complying with Texas
23
insurance codes on utilization review?
24 25
A.
To ensure the company is complying with any and
all state and regulatory responsibilities.
800-545-9668 612-339-0545
Paradigm Reporting & Captioning www.paradigmreporting.com
Appendix Volume 2, p. 140
#79138
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 46 of 173 Esmeralda Cazares-Baig 5/28/2014 1
Q.
Page: 71
Do you know if that -- the compliance
2
department is also responsible for compliance with the
3
Fair Labor Standards Act wage and hour laws?
4
A.
I do not know.
5
Q.
Is that something that the medical management
6
department is responsible for, your group?
7
A.
No.
8
Q.
Do you also submit -- besides the Texas
9
Department of Insurance, do you submit this utilization
10
management program description to any other types of
11
entities or third-party companies?
12
A.
Any of our -- like HHSC, since they have the --
13
we have the state contract with HHSC, they will request
14
it at times.
15
Q.
I'm missing the acronym, H --
16
A.
Health and Human Services.
17
Q.
HHS?
18
A.
Health and Human Services Commission.
19
Q.
Okay.
Is that something that Ms. Cizler's
20
department is also responsible for, providing
21
information to HHSC?
22
A.
Yes.
23
Q.
What about NCQA?
24
A.
We would submit it to them, too, if that was
25
part of their request for their annual audit.
800-545-9668 612-339-0545
Paradigm Reporting & Captioning www.paradigmreporting.com
Appendix Volume 2, p. 141
#79138
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 47 of 173
00082 1 appears to be a job description for Case Manager I 2 (Pre-certification Nurse), Bates labeled 1475 at the 3 bottom. Would this be a job -- first of all, do you 4 recognize this document? 5
A. Yes.
6
Q. And would this be a job description that would
7 be used today if you were hiring for a concurrent review 8 nurse or a prior authorization nurse? 9 10
A. Could be, yes. Q. Did you have any role in putting these job
11 descriptions together that are in Exhibits 10 and 11? 12
A. I was not a part of creating these, no.
13
Q. Is there somebody within your local management
14 group who is -- who was a part of creating these, do you 15 know? 16
A. Not that I'm aware of, no.
17
Q. What's your understanding of how these job
18 descriptions are created, if you have one? 19
A. I don't.
20
Q. Okay. In Exhibit 10, what about 1478, would
21 that be a job description that would be used for hiring 22 either a concurrent review nurse or a prior 23 authorization nurse? 24
A. Yes.
25
Q. Do prior authorization nurses develop care
Cazares-Baig, Esmeralda_5-28-14
Page 82
Appendix Volume 2, p. 142
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 48 of 173
00083 1 plans? 2
A. No.
3
Q. Do the concurrent review nurses develop care
4 plans? 5
A. No.
6
Q. Do you see under the second bullet point it
7 says, "Position Responsibilities. Develop, assess and 8 adjust as necessary the care plan and promote desired 9 outcome"? 10
A. Yes.
11
Q. Based on that does that -- would this job
12 description apply to concurrent review nurses and prior 13 authorization nurses? 14
A. They'll assess care plans, not necessarily
15 develop them. 16
Q. Okay. Do they coordinate services between the
17 primary care physician and other medical/non-medical 18 providers as necessary, the next bullet point? 19
A. Yes.
20
Q. And then are we talking about the concurrent
21 review nurses or prior authorization nurses doing that? 22
A. Both.
23
Q. And has that changed during the past few years
24 or have the prior authorization nurses since July 25 of 2010, have they been responsible for coordinating
Cazares-Baig, Esmeralda_5-28-14
Page 83
Appendix Volume 2, p. 143
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 49 of 173 Esmeralda Cazares-Baig 5/28/2014
Page: 113
1
A.
Aside from the --
2
Q.
Aside from the discharge planning one.
3
A.
Yes.
4
Q.
And what's that?
5
A.
So I'm talking recent because there's a lot of
6
policies.
7
illness, if they -- they had some recommendations about
8
the way the policy or the work processes were written so
9
we went back and we've actually tweaked that one like
So aside from discharge planning, spell of
10
four or five times because of their feedback on how we
11
laid out the policy.
12
Q.
What -- I'm sorry, go ahead.
13
A.
The DRG policy.
So it talks about how often
14
they are to review the member's criteria.
15
give some feedback on what their feeling was, their
16
thoughts were on how often they were supposed to review
17
that criteria or review those members inpatient.
18
Q.
So they did
In terms of this feedback that you're
19
testifying about, that's not their primary job purpose,
20
is it?
21
A.
No.
22
Q.
Because their primary purpose is to review
23
inpatient admissions to assure appropriate level of care
24
and medical necessity, correct?
25 800-545-9668 612-339-0545
A.
Correct. Paradigm Reporting & Captioning www.paradigmreporting.com
Appendix Volume 2, p. 144
#79138
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 50 of 173 Esmeralda Cazares-Baig 5/28/2014 1
Page: 115
that Centene Company of Texas puts together?
2
A.
I know Sunshine Hartnagel did have a lot of
3
feedback.
4
things that she thought was missing and what she thought
5
we should do, and she actually asked me if she could
6
make that her special project and went through
7
everything and everything that existed.
8
did in particular.
She actually had created a whole list of
So I know she
9
It's been a few years since I -- the ones
10
that directly reported to me since I've had them, but I
11
do know in like meetings and I may have e-mails too, but
12
Kevin Ulrich, he did recommend -- we'd have meetings and
13
I'd say here -- especially when I first started with
14
this team, here's the policies that exist, what do
15
you-all recommend, and we'd have a meeting and they'd
16
all give feedback on that; and Kevin was definitely one
17
that was always vocal.
18
So at this point all I can say is those
19
two that I'm aware of.
20
they didn't all report to me, so it may not have been
21
recommendations directly to me but to their management
22
team.
23
Q.
I don't know the full list and
But for people like Mr. Ulrich or Sunshine
24
Hartnagel, that was not their primary purpose was to
25
provide feedback to management about how the policy was
800-545-9668 612-339-0545
Paradigm Reporting & Captioning www.paradigmreporting.com
Appendix Volume 2, p. 145
#79138
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 51 of 173 Esmeralda Cazares-Baig 5/28/2014 1
Page: 116
working or not?
2
A.
No, but we do in our meetings say we -- it's a
3
collaborative effort so we do want their input.
4
the job day-to-day so they know sometimes better than we
5
do where the gaps are on where policies need to be
6
created.
7
Q.
They do
They're the ones that are doing the day-to-day
8
ongoing utilization management services that Centene
9
Company of Texas provides to the members of Superior
10
HealthPlan?
11
A.
Correct.
12
Q.
So based on their day-to-day experience and
13
them doing the actual services that Centene Company of
14
Texas provides, they're able to know this policy doesn't
15
flow quite right, here's a change that you might want to
16
make to it?
17
A.
Correct, or there's gaps, why don't we have a
18
policy for this procedure.
19
directly that it was Kevin, but we have a podiatry
20
policy.
21
we continuously have, there's no clinical guidelines for
22
this, can we create a policy for podiatry, and we did.
23
Q.
Like -- and I can't say
It was developed because one of the nurses that
So for that situation that you're describing
24
where the nurse noticed there was no guideline for
25
podiatry, is she actually putting the guidelines
800-545-9668 612-339-0545
Paradigm Reporting & Captioning www.paradigmreporting.com
Appendix Volume 2, p. 146
#79138
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 52 of 173 Page 1
·1· · · · · · IN THE UNITED STATES DISTRICT COURT · · · · · · · ·FOR THE WESTERN DISTRICT OF TEXAS ·2· · · · · · · · · · · AUSTIN DIVISION ·3· · · ·4· · · ·5· · · ·6· · · ·7· · · ·8· · · ·9· · · 10·
KATHY CLARK, AMY ENDSLEY,· · ) SUSAN GRIMMETT, MARGUERIETTE ) SCHMOLL AND KEVIN ULRICH, ON ) BEHALF OF THEMSELVES AND ALL ) OTHERS SIMILARLY SITUATED,· ·) · · · · · · · · · · · · · · ·) · · · · ·Plaintiffs,· · · · ·) · · · · · · · · · · · · · · ·) VS.· · · · · · · · · · · · · )· · ·Civil Action · · · · · · · · · · · · · · ·) No. 1:12-CV-00174-SS CENTENE CORPORATION, CENTENE ) COMPANY OF TEXAS, L.P., AND· ) SUPERIOR HEALTHPLAN, INC.,· ·) · · · · · · · · · · · · · · ·) · · · · ·Defendants.· · · · ·)
11· ***************************************************** 12· · · · · · · · · · ORAL DEPOSITION OF 13· · · · · · · · · · · KAREN CALABRESE 14· · · · · · · · · · · ·June 18, 2014 15· ***************************************************** 16· · · ORAL DEPOSITION OF KAREN CALABRESE, produced as a 17· witness at the instance of the Defendants, and duly 18· sworn, was taken in the above-styled and numbered 19· cause on June 18, 2014, from 9:03 a.m. to 12:27 p.m., 20· before WILLIAM M. FREDERICKS, CSR in and for the State 21· of Texas, reported by machine shorthand at the offices 22· of Boulette & Golden LLP, 2801 Via Fortuna, Suite 530, 23· Austin, Texas, pursuant to the Federal Rules of Civil 24· Procedure. 25 FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 147
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 53 of 173 Page· 34..37 Page 34
Page 35
·1· day.· Sometimes more.
·1· time you left your desk?
·2· · · Q.· ·And the difference -- the increase in the
·2· · · A.· ·I would not log off.
·3· number of requests you were processing from when you
·3· · · Q.· ·Okay.
·4· started to when you ended, would you say that that was
·4· · · A.· ·I would just stand by.
·5· a result of a change in workload or just a change in
·5· · · Q.· ·Okay.· What about the phone, would you log
·6· your ability to process cases?
·6· off the phone when you left your desk?
·7· · · A.· ·I think being more comfortable with the
·7· · · A.· ·Yes.
·8· process of how to complete the requests, becoming more
·8· · · Q.· ·Okay.· And what was the reason for doing
·9· proficient.
·9· that?
10· · · Q.· ·Sure.· Just the longer you did it the better
10· · · A.· ·Logging off the phone?
11· you got at it?
11· · · Q.· ·Yes, ma'am.
12· · · A.· ·Sure.
12· · · A.· ·If I had stepped away from my desk, I would
13· · · Q.· ·Okay.· All right.· So you've come into the
13· not want to receive a call.
14· office; you've badged in; you've logged on to your
14· · · Q.· ·Right.· Because you're not there to answer
15· computer; you've logged on to your phone.
15· it?
16· · · · · · · · Did you typically do those -- logging on
16· · · A.· ·Right.
17· to your phone versus logging on to your computer, did
17· · · Q.· ·Okay.· And that's the way the phone system
18· you typically do one first versus the other?
18· works, right?· When you log on, the phone system is
19· · · A.· ·I don't remember.
19· automatically routing calls to people who are logged
20· · · Q.· ·Okay.· It doesn't take very long to do either
20· in?
21· one of those things, right?
21· · · A.· ·In the queue, yes.
22· · · A.· ·Right.
22· · · Q.· ·Okay.· People aren't calling you directly at
23· · · Q.· ·Okay.· And when did you log off of your --
23· a direct line?· They're actually calling in to some
24· let me ask a different question.
24· main number and getting routed to you?
25· · · · · · · · Did you log off of your computer every
25· · · A.· ·Correct.
Page 36
Page 37
·1· · · Q.· ·Okay.· And so if you were not at your desk
·1· · · A.· ·There was an assigned person, a non-nurse
·2· and you logged off the phone, the phone would just
·2· that would assign to all the nurses.
·3· ring and you wouldn't be there to answer it?
·3· · · Q.· ·And was that person called a referral
·4· · · A.· ·Correct.
·4· specialist?
·5· · · Q.· ·Okay.· Were there particular hours during the
·5· · · A.· ·Yes.
·6· day that phone calls came in?
·6· · · Q.· ·Okay.· And do you know what the referral
·7· · · A.· ·Phone calls would come in between 8:00 and
·7· specialist was -- how the referral specialist was
·8· 5:00.
·8· deciding which nurse to assign particular cases to?
·9· · · Q.· ·Okay.· And the phone calls that were coming
·9· · · A.· ·No.
10· in, what were they?
10· · · Q.· ·Okay.· Do you know whether it was random
11· · · · · · · · MR. BAGGIO:· Objection, vague.
11· versus whether there was an actual -- some kind of
12· · · Q.· ·(BY MR. GOLDEN)· Let me ask a different
12· plan that the referral specialist was using?
13· question.
13· · · A.· ·I don't know how they assigned them.
14· · · · · · · · You said when you -- when you would come
14· · · Q.· ·Okay.· Do you have any sense as to whether
15· in, you'd log into your computer and your phone and
15· your workload was larger or smaller than other
16· then you'd check your, I guess you called it an inbox,
16· pre-authorization nurses?
17· is that right?
17· · · A.· ·I don't --
18· · · A.· ·Yes.
18· · · · · · · · MR. BAGGIO:· Objection, calls for
19· · · Q.· ·And when you call it an inbox, that's an
19· speculation.
20· electronic collection of requests that are pending
20· · · Q.· ·(BY MR. GOLDEN)· You can still answer the
21· that somebody wants you to review?
21· question.
22· · · A.· ·Yes.
22· · · A.· ·I don't know.
23· · · Q.· ·Do you know how those requests get assigned
23· · · Q.· ·Okay.· All right.· So you come in and you log
24· to you versus to some other nurse who works at
24· into the system and there are requests waiting in your
25· Centene?
25· inbox, right?
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 148 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 54 of 173 Page· 38..41 Page 38
Page 39
·1· · · A.· ·Uh-huh.
·1· give verbal clinical.
·2· · · Q.· ·Is that a "yes"?
·2· · · Q.· ·(BY MR. GOLDEN)· Okay.· So a provider or a
·3· · · A.· ·Yes.
·3· facility, whoever is making the request, has the
·4· · · Q.· ·And was there a rule or a law or regulation
·4· option to submit those requests different ways?
·5· that required you to turn around requests within a
·5· · · A.· ·Yes.
·6· certain amount of time?
·6· · · Q.· ·If you got a request in your inbox versus a
·7· · · A.· ·Yes.
·7· request on the phone -- how can I ask this question.
·8· · · Q.· ·How long was that?
·8· · · · · · · · Did you get the same types of requests
·9· · · A.· ·I'm estimating it was a 24-hour turnaround
·9· in the inbox versus on the phone or did they tend to
10· time.
10· be different types of folks who would call in versus
11· · · Q.· ·So it was your goal -- when you walked in in
11· folks who would submit it in writing?
12· the morning and you saw those cases sitting in your
12· · · A.· ·It would vary.· It would just depend.
13· inbox, it was your goal to get rid of all of them
13· · · Q.· ·Okay.
14· before the end of the day?
14· · · A.· ·Because I would do all types of requests.
15· · · A.· ·Yes.
15· · · Q.· ·And when you say "all types of requests,"
16· · · Q.· ·Okay.· The phone calls that come in, are
16· what do you mean by that?
17· those additional requests?
17· · · A.· ·Inpatient, outpatient.
18· · · A.· ·Yes.
18· · · Q.· ·And so the requests that you handled, for
19· · · Q.· ·Why is it that some requests would come in
19· example, didn't happen to be tailored to any of your
20· electronically and some requests would come in by
20· specific prior expertise as a nurse, is that right?
21· phone?· How does that happen?
21· · · A.· ·Can you repeat that question.
22· · · · · · · · MR. BAGGIO:· Objection, calls for
22· · · Q.· ·Sure.· Let me ask it a different way.
23· speculation.
23· · · · · · · · For example, one of your prior jobs was
24· · · A.· ·Some providers or facilities would fax in the
24· working in a neonatal ICU.· It wasn't like all the
25· requests and some would rather call for the request to
25· neonatal ICU requests were coming to you?
Page 40
Page 41
·1· · · A.· ·Correct.
·1· the cases that came in on the phone queue?
·2· · · Q.· ·Okay.· You worked a wide variety of cases?
·2· · · A.· ·Yes.· There was an assigned referral
·3· · · A.· ·Yes.
·3· specialist that would assign the nurses work in their
·4· · · Q.· ·All right.· And do you have any reason to
·4· box each day.
·5· believe that the types of cases you got were different
·5· · · Q.· ·Okay.· So let's talk a little bit about that.
·6· than the types of cases that other prior authorization
·6· · · · · · · · How much do you know about what the
·7· nurses were getting?
·7· referral specialist was doing who was assigning the
·8· · · A.· ·No.
·8· cases to the nurses in their boxes?
·9· · · Q.· ·Okay.· So in terms of handling cases, was
·9· · · A.· ·I just know that she would assign requests to
10· there a difference in the way that you handled cases
10· the nurses.
11· that came in in your inbox versus those that came in
11· · · Q.· ·Was the referral specialist doing anything
12· on the phone?
12· else like entering data or categorizing cases or
13· · · A.· ·No.
13· anything like that?
14· · · Q.· ·Is it fair to assume that what you would do
14· · · A.· ·I don't know.
15· is you would start working on the cases in your inbox
15· · · Q.· ·All right.· Well, when you open up one of
16· and then you'd stop if the phone ring?
16· these cases in your inbox, what kind of information do
17· · · A.· ·Yes.
17· you have when you go to one of these cases?
18· · · Q.· ·Can you estimate a percentage of how many of
18· · · A.· ·You would have a faxed clinical for review
19· the cases you worked were ones that you got
19· for whatever request they were asking for.
20· electronically versus ones that you got on the phone?
20· · · Q.· ·Okay.· And what is a -- you say a "faxed
21· · · A.· ·I don't know.
21· clinical."· What is a faxed clinical?
22· · · Q.· ·Okay.· I'm going to talk about the referral
22· · · A.· ·For an inpatient admission, it would be
23· specialist in a second.· The referral specialist
23· history and physical.· It could be M.D. notes,
24· divvied up the cases that came in in writing.
24· progress notes; labs; radiology reports.· It could
25· · · · · · · · Did the referral specialists also route
25· also include a discharge summary.
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 149 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 55 of 173 Page· 54..57 Page 54
Page 55
·1· and whatnot, but then the last sentence is -- this is
·1· procedures, InterQual and TMHP, these are the
·2· your conclusion from having reviewed this file and
·2· different types of guidelines that you might go to to
·3· spoken to somebody at Professional Imaging, is that
·3· review whether a request should be approved or not?
·4· right?
·4· · · A.· ·Yes.
·5· · · A.· ·Yes.
·5· · · Q.· ·When you say no criteria found using three of
·6· · · Q.· ·So you said "No criteria found using P&P."
·6· these, does that mean that you looked in all three and
·7· · · · · · · · What is "P&P"?
·7· didn't find any relevant criteria?
·8· · · A.· ·Policy and procedure.
·8· · · A.· ·Yes.
·9· · · Q.· ·Okay.· What do you mean when you say "no
·9· · · Q.· ·Okay.· And so then the last note is "Send to
10· criteria found"?· What does that mean?
10· medical director for review"?
11· · · A.· ·There's no criteria to approve this request
11· · · A.· ·Yes.
12· for medical necessity.
12· · · Q.· ·Okay.· So let's talk about that for a second.
13· · · Q.· ·So you couldn't find a criteria that related
13· · · · · · · · The general rule was when you received
14· to a request for the kinds of procedures that the
14· requests, if you were able to approve a request, you
15· doctor is asking for here?
15· could do that without the medical director review,
16· · · A.· ·Correct.
16· correct?
17· · · Q.· ·Okay.· And so you've got "No criteria found
17· · · A.· ·Correct.
18· using P&P" comma and then "IQ Review."
18· · · Q.· ·But you never actually deny a request.· If
19· · · · · · · · "IQ" stands for InterQual, is that
19· you aren't able to approve a request, you always send
20· correct?
20· it to the medical director, correct?
21· · · A.· ·Yes.
21· · · A.· ·Correct.
22· · · Q.· ·And then "TMHP" stands for what?
22· · · Q.· ·Okay.· In this particular case, you couldn't
23· · · A.· ·Texas Medicaid Healthcare Partnership, if I'm
23· find criteria.· Are there some cases that are -- are
24· not mistaken.
24· there some requests that are by default always
25· · · Q.· ·And so these three things, P&P, policies and
25· approved?· Was there a list of cases or requests that
Page 56
Page 57
·1· if these requests come in, we always say yes?
·1· recall if it was generated automatically, the fax. I
·2· · · A.· ·I'm sorry.· I didn't understand that last --
·2· don't recall.
·3· · · Q.· ·Sure.· Was there a -- when you're reviewing
·3· · · Q.· ·Okay.· All right.· So let's talk about --
·4· these requests as they come in, is there an initial
·4· we're going to talk more about some of these other
·5· list that says the following procedures always receive
·5· cases on Exhibit 2 at some point, but I want to talk
·6· automoatic approval?
·6· more specifically about how these three things, the
·7· · · A.· ·Not that I'm aware of.
·7· policies and procedures, InterQual and the TMHP, work.
·8· · · Q.· ·Okay.· Do you know, is the referral
·8· So let's just use this case here, this first page of
·9· specialist able to approve any kinds of cases at all?
·9· Exhibit 2 as an example.
10· · · A.· ·I don't know.
10· · · · · · · · When you get this kind of a case, how do
11· · · Q.· ·Okay.· If you approve a case, do you also
11· you go about looking for where to find criteria?
12· fill out one of these reports through Care Manager?
12· · · A.· ·I remember the way I was trained, you would
13· · · A.· ·Yes.
13· always look at policy and procedure first.· If you
14· · · Q.· ·So every request that you get you generate
14· couldn't find criteria there, you would move to
15· one of these reports?
15· InterQual, and then you would go to TMHP.· If you
16· · · A.· ·Yes.
16· still could not find criteria to meet, then you would
17· · · Q.· ·When you approve a case, what else -- do you
17· send it to medical director for review.
18· actually contact the provider and let them know that a
18· · · Q.· ·Okay.· So it sounds like there's two
19· procedure is approved or does somebody else do that?
19· different instances in which you would send a case to
20· · · A.· ·Typically a letter would be faxed out to the
20· medical director for review.· One is if you couldn't
21· provider.
21· find any criteria, is that right?
22· · · Q.· ·And do you fax the letter yourself or do you
22· · · A.· ·Correct.
23· have -- is there someone else who does that for you?
23· · · Q.· ·And then another one is if you found what you
24· · · A.· ·Again, it's been a couple of years since I've
24· thought were relevant criteria, and then you decided
25· worked with this company.· I want to -- I'm trying to
25· that the criteria didn't warrant approval of the case?
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 150 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 56 of 173 Page· 58..61 Page 58
Page 59
·1· · · · · · · · MR. BAGGIO:· Objection, mischaracterizes
·1· · · Q.· ·(BY MR. GOLDEN)· I'm handing you what the
·2· prior testimony.
·2· court reporter has marked as Exhibit 3.
·3· · · Q.· ·(BY MR. GOLDEN)· All right.· What would be
·3· · · · · · · · (Document tendered.)
·4· the other reason that you would have to contact the
·4· · · Q.· ·(BY MR. GOLDEN)· Do you recognize this
·5· medical director?
·5· document?
·6· · · A.· ·If a provider was out of network.
·6· · · A.· ·I recognize this is one of the policy and
·7· · · Q.· ·Okay.· So now we've got at least two.· You
·7· procedures.
·8· would forward it on to the medical director -- if
·8· · · Q.· ·Okay.· So when we were talking a minute ago
·9· there's no guidelines, you'd forward it on to the
·9· and you said that the things that you would look at to
10· medical director if it's out of network.
10· make these determinations is you'd start with policies
11· · · · · · · · In what other situations would you
11· and procedures and then go to InterQual, this is the
12· forward it on to the medical director?
12· kind of policy and procedure you were talking about?
13· · · A.· ·That's all that I can recall.
13· · · A.· ·Yes.
14· · · Q.· ·Okay.· What do you do if you think you can't
14· · · Q.· ·Okay.· I want to talk about the way that you
15· approve the case?
15· apply these policies and procedures, so if you would
16· · · A.· ·Well, it would go to medical director.
16· turn to the second page of Exhibit 3, which is marked
17· · · Q.· ·Okay.· So there is -- that you can think of,
17· at the bottom 01443.· The criteria start there under
18· there's three reasons why you would send it on to the
18· the heading "Policy/Criteria," right?
19· medical director:· There's no criteria, it's out of
19· · · A.· ·Yes.
20· network or you don't think that the guidelines support
20· · · Q.· ·Okay.· And so I want to make sure I
21· approval of the case?
21· understand this.· You get a request -- so this happens
22· · · A.· ·Yes.
22· to be the policy for physical, occupational and speech
23· · · Q.· ·Okay.· Let's talk about these policies and
23· therapy services, right?
24· procedures, InterQual and TMHP for a second.
24· · · A.· ·Yes.
25· · · · · · · · (Deposition Exhibit 3 marked.)
25· · · Q.· ·Okay.· So if you got a case that related to a Page 60
Page 61
·1· request for physical therapy, for example, you would
·1· · · A.· ·Yes.
·2· start with this policy?
·2· · · Q.· ·"The member exhibits signs and symptoms of
·3· · · A.· ·Yes.
·3· physical deterioration or impairment in one or more of
·4· · · Q.· ·Okay.· So if you go down under the heading
·4· the following areas," and then it lists several.
·5· "Policy/Criteria," the first thing that is listed
·5· · · · · · · · Do you see that?
·6· there is "Outpatient Speech Therapy, Occupational
·6· · · A.· ·Yes.
·7· Therapy, and/or Physical Therapy evaluation and
·7· · · Q.· ·Okay.· Let's just use, for example, the first
·8· treatment services are considered medically necessary
·8· one, "Sensory/Motor Ability."
·9· when all the following criteria are met."
·9· · · · · · · · So when you get a case that comes in,
10· · · · · · · · Do you see that?
10· how are you figuring out whether this criteria is met,
11· · · A.· ·Yes.
11· whether the member exhibits signs and symptoms of
12· · · Q.· ·Okay.· Now, when it says "all the following
12· physical deterioration in sensory or motor ability?
13· criteria," that means -- there are criteria a, b and
13· · · A.· ·The clinical that was submitted to me would
14· all the way through j, is that correct?
14· have to tell me that the member exhibited signs and
15· · · A.· ·Yes.
15· symptoms of physical deterioration.
16· · · Q.· ·And are you reading that to mean -- when they
16· · · Q.· ·Okay.· And when you say the clinical would
17· say "all the following criteria are met," that means
17· have to tell you that, are you literally looking for
18· you have to meet every single one of those, a, b, c,
18· the words "sensory/motor ability" or are you reading
19· d, all the way to j?
19· the record and saying, This clinical says things that
20· · · A.· ·Yes.
20· are deterioration of sensory/motor ability?
21· · · Q.· ·Okay.· So let's just talk about some of these
21· · · A.· ·There would have to be additional clinical
22· criteria.· Let's just start with the first one.
22· that would tell me signs and symptoms of the patient.
23· · · · · · · · The first criteria says "The member" --
23· · · Q.· ·Okay.· And that's what I'm getting at, is
24· and that's the -- the member is the patient, is that
24· it's not always the case that the physician, for
25· correct?
25· example, is literally writing in the record "The
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 151 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 57 of 173 Page· 70..73 Page 70
Page 71
·1· · · Q.· ·Okay.· All right.
·1· basis you don't get to see what he does at Centene?
·2· · · · · · · · THE REPORTER:· Can we take a quick break
·2· · · A.· ·Correct.
·3· when you get to a good point?
·3· · · Q.· ·Okay.· And is that basically true for the
·4· · · · · · · · MR. GOLDEN:· Yeah, why don't we take a
·4· rest of the nurses too?
·5· break.· That would be great.
·5· · · A.· ·Yes.
·6· · · · · · · · (Recess.)
·6· · · Q.· ·You all don't work in teams; you actually
·7· · · Q.· ·(BY MR. GOLDEN)· All right.· Ms. Calabrese,
·7· work individually on these requests?
·8· we've taken a short break.· I want to change gears for
·8· · · A.· ·Correct.
·9· just a second and talk for a moment about your
·9· · · Q.· ·Okay.· Now, you all sometimes have meetings
10· interaction with other nurses who worked at Centene
10· and trainings and stuff together, right?
11· while you were at work.
11· · · A.· ·We didn't really have meetings, no.
12· · · · · · · · Did you actually work together with
12· · · Q.· ·Okay.· But in terms of if I asked you what
13· anybody -- any other nurses while you were working at
13· any other prior authorization nurse was doing on a
14· Centene?
14· daily basis, you wouldn't really know, right?
15· · · A.· ·Can you explain "together"?
15· · · A.· ·Not specifically, no.
16· · · Q.· ·Sure.· Let's just use some of the folks who
16· · · Q.· ·I wanted to ask you just two follow-up
17· are involved in this case, for example.· Kevin Ulrich
17· questions from earlier.· Number one was you mentioned
18· is one of the named Plaintiffs.
18· earlier that the phone queue was open from 8:00 to
19· · · · · · · · Do you have an opinion about
19· 5:00.
20· Mr. Ulrich's skill as a nurse?
20· · · · · · · · Were there other people who were on the
21· · · A.· ·No.
21· phone queue from 9:00 to 6:00?
22· · · Q.· ·Okay.· Do you even have the information to
22· · · A.· ·As far as I can recall, yes.
23· have an opinion about his skill as a nurse?
23· · · Q.· ·Was it your understanding that the health
24· · · A.· ·No.
24· insurance that you all were dealing with covered
25· · · Q.· ·Okay.· And is that because on a day-to-day
25· people in the State of Texas and nowhere else?· Is
Page 72
Page 73
·1· that right?
·1· home health case got assigned to your queue and you
·2· · · A.· ·I'm trying to keep this company separate from
·2· had to call someone and say, Hey, I don't do home
·3· where I'm at now.
·3· health?
·4· · · Q.· ·Sure.
·4· · · A.· ·I don't remember.
·5· · · A.· ·I want to -- I want to say that as far as I
·5· · · Q.· ·Okay.
·6· remember the phone queue was 8:00 to 5:00.· I don't
·6· · · · · · · · (Deposition Exhibit 4 marked.)
·7· recall the 9:00 to 6:00.
·7· · · Q.· ·(BY MR. GOLDEN)· I'm showing you what the
·8· · · Q.· ·Okay.· Do you ever remember anyone mentioning
·8· court reporter has marked as Exhibit 4.
·9· there being some folks who were on the phone until
·9· · · · · · · · (Document tendered.)
10· 6:00 because a very small part of Texas over on the
10· · · Q.· ·(BY MR. GOLDEN)· Do you recognize this
11· west side is in a different time zone?
11· document?
12· · · A.· ·I don't know.
12· · · A.· ·No.
13· · · Q.· ·Okay.· All right.· Oh, and the other question
13· · · Q.· ·Okay.· Earlier when we were talking about the
14· was did there ever come a time where a case would get
14· ways that you would evaluate cases, you talked about
15· assigned to you and you would need to ask that it be
15· policies and procedures, TMHP and InterQual.
16· assigned to somebody else?
16· · · · · · · · When you used InterQual, was it online?
17· · · A.· ·Not that I recall.
17· · · A.· ·Yes.
18· · · Q.· ·Okay.· You were dealing mostly with inpatient
18· · · Q.· ·Okay.· Did you ever use the InterQual -- the
19· and outpatient stuff, is that right?
19· actual paper books for InterQual?
20· · · A.· ·Yes.
20· · · A.· ·No.
21· · · Q.· ·Were there types of cases that you simply
21· · · Q.· ·Okay.· We're just going to skip this
22· didn't handle that you're aware of?
22· Exhibit 4 then.
23· · · A.· ·I don't recall doing home health.
23· · · · · · · · Talk to me a little bit about
24· · · Q.· ·Okay.· So that's an easy enough example.
24· mechanically how the online InterQual guidelines work.
25· · · · · · · · Do you ever remember a situation where a
25· I've heard someone describe it as like a red
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 152 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 58 of 173 Page· 74..77 Page 74
Page 75
·1· light/green light system.· Is that --
·1· because it's a six-year-old, right?
·2· · · A.· ·That's correct.
·2· · · A.· ·Yes.
·3· · · Q.· ·Okay.· So literally how does it work?· Leave
·3· · · Q.· ·Okay.· So you start off and this is a
·4· out the medical stuff, but, I mean, if you're just
·4· pediatric case.· Okay.· How do you go about trying to
·5· going through it, how do you use InterQual?
·5· figure out whether InterQual specifically has relevant
·6· · · · · · · · MR. BAGGIO:· Objection, vague.
·6· criteria for this kind of case?
·7· · · Q.· ·(BY MR. GOLDEN)· Okay.· Let me try that a
·7· · · A.· ·You would have to plug in the CPT code.
·8· different way.
·8· · · Q.· ·Okay.· And what happens when you plug in the
·9· · · · · · · · You get a case that comes in and --
·9· CPT code?
10· first, how do you figure out whether InterQual has
10· · · A.· ·It would pull up the criteria, and you would
11· guidelines that cover the procedure that you need?
11· just basically click what options applied with the
12· · · A.· ·You would have to know first if it was adult
12· clinical that you received.
13· or pediatric.
13· · · Q.· ·Okay.· And so let's talk about that.· So you
14· · · Q.· ·Okay.· So let's just assume that it's an
14· put in the CPT code, and then what happens is -- if
15· adult case for starters.· How would you go -- so,
15· you look just for a second back at Exhibit 3, we
16· again, to use -- this may be a pediatric case.· I'm
16· talked on the second page of Exhibit 3 about these
17· not actually sure.
17· criteria, right?
18· · · · · · · · But to go back to Exhibit 2 for a
18· · · A.· ·Yes.
19· second, you know, the end result of Exhibit 2, that
19· · · Q.· ·InterQual has a similar system except it's
20· first page, was you didn't find any relevant criteria
20· sort of automated as you go through it online, right?
21· using the policies and procedures, InterQual and TMHP.
21· · · A.· ·Yes.
22· · · · · · · · Do you remember that?
22· · · Q.· ·Instead of a list, it's literally like a --
23· · · A.· ·Yes.
23· you enter the CPT code, and then it gives you the
24· · · Q.· ·Okay.· I'm not sure you can tell -- can you
24· first question and then you answer it, right?
25· tell if this is a pediatric -- oh, it's a pediatric
25· · · A.· ·Correct.
Page 76
Page 77
·1· · · Q.· ·Okay.· And then based on the answer to that
·1· · · A.· ·There's no other options to click.
·2· question, it either gives you the next question or it
·2· · · Q.· ·Okay.· There you go.
·3· tells you that you're done, right?
·3· · · · · · · · And so is there a like a final screen in
·4· · · A.· ·Correct.
·4· InterQual that says, you know, these criteria met,
·5· · · Q.· ·And so how does that work?· So start with you
·5· these criteria not met, or --
·6· answer one of the questions in the negative.· What
·6· · · A.· ·If the criteria is not met, you're not
·7· does InterQual tell you then?· How do you know that
·7· clicking on that option.
·8· you're finished?
·8· · · Q.· ·Right.· So that's what I'm getting at.· So
·9· · · A.· ·If criteria were met, the green light would
·9· you get a criteria that comes up, and you determine
10· come up.
10· that it's not met and you click on it.· Literally what
11· · · Q.· ·Okay.· And so when you tell InterQual that
11· happens next?
12· one of the criteria is not met, does the system tell
12· · · · · · · · MR. BAGGIO:· Objection, mischaracterizes
13· you then you're done, or do you go all the way through
13· prior testimony.
14· all the criteria no matter what?
14· · · Q.· ·(BY MR. GOLDEN)· All right.· So let's just
15· · · A.· ·I will go through the criteria as far as it
15· walk me through this.· So you put in your CPT code.
16· will let me go --
16· What happens next?
17· · · Q.· ·That's what I'm getting at, is when you --
17· · · A.· ·It will pull up that procedure if it has that
18· · · A.· ·-- to see if it will give me the green light
18· procedure.· A lot of times you put in that code and
19· or if it says criteria is not met.
19· that code is not available, so you're not able to do
20· · · Q.· ·And that's what I mean, is from just a
20· the review.
21· mechanical standpoint, when you say "as far as it will
21· · · Q.· ·And that's like what happened on this first
22· let me go," how do you know when it's not going to let
22· page of Exhibit 2?
23· you go any farther?· Like what happens?· Do you get a
23· · · A.· ·Exactly, yes.
24· screen that says "Criteria not met," you know, you're
24· · · Q.· ·Okay.· So assume that it does call up
25· finished now or like how does --
25· something, that you put in the code, the CPT code and
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 153 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 59 of 173 Page· 94..97 Page 94
Page 95
·1· · · A.· ·They did not hire LVNs for the NICU.
·1· to Centene's written interrogatories to you?
·2· · · Q.· ·What about at Centene, do you know if Centene
·2· · · A.· ·Yes.
·3· hires LVNs to do pre-authorization nursing jobs?
·3· · · Q.· ·And I think you mentioned earlier that you
·4· · · A.· ·Yes.
·4· had a chance to review these, is that correct?
·5· · · Q.· ·Do you think it would be harder to do this
·5· · · A.· ·Briefly, yes.
·6· job if you were just an LVN and not an RN?
·6· · · Q.· ·And if you go to the very, very last page
·7· · · A.· ·I don't think so.
·7· there is a signed and notarized Verification that
·8· · · Q.· ·Okay.· I mean, to kind of back up from what
·8· you've signed, is that right?
·9· you said earlier, in a clinical setting, there's
·9· · · A.· ·Yes.
10· literally a legal difference between what an RN is
10· · · Q.· ·And it says that you signed it on
11· allowed to do and what an LVN is allowed to do, right?
11· November 22nd, 2013.
12· · · A.· ·Hands on patient, yes.
12· · · · · · · · Does that seem about right?
13· · · Q.· ·Okay.· In terms of the kind of
13· · · A.· ·Yes.
14· pre-authorization review that you were doing -- let me
14· · · Q.· ·And did you understand that you -- when you
15· ask a different question.
15· were signing that, that you were essentially swearing
16· · · · · · · · Does an RN have to go to more school
16· an oath that these answers were true and accurate?
17· than an LVN?
17· · · A.· ·Yes.
18· · · A.· ·I don't know.
18· · · Q.· ·Okay.· In Answer No. 4, which appears on the
19· · · Q.· ·Okay.
19· third page, it asks you about nursing licenses.
20· · · · · · · · (Deposition Exhibit 5 marked.)
20· · · · · · · · Do you see that?
21· · · · · · · · THE REPORTER:· Exhibit 5.
21· · · A.· ·Yes.
22· · · · · · · · (Document tendered.)
22· · · Q.· ·And you say that you were an RN in Texas from
23· · · Q.· ·(BY MR. GOLDEN)· I'm handing you what the
23· 2007 to present, right?
24· court reporter has marked as Exhibit 5.
24· · · A.· ·Yes.
25· · · · · · · · Do you recognize these as your answers
25· · · Q.· ·And then in Ohio from 2013 to present?
Page 96
Page 97
·1· · · A.· ·Yes.
·1· night, yes.
·2· · · Q.· ·Just to be clear, you became an RN licensed
·2· · · Q.· ·Okay.· And then sometimes you would work from
·3· in Ohio after you were no longer working for Centene,
·3· home?
·4· is that right?
·4· · · A.· ·Yes.
·5· · · A.· ·Yes.
·5· · · Q.· ·What would determine when you would work from
·6· · · Q.· ·Okay.· All right.· Back up to Page 2, please.
·6· home and when you would not work from home?
·7· I want to talk about Question No. 1.· Specifically I
·7· · · A.· ·If my task list for the day was not complete,
·8· want to talk about Answer (c) to Question No. 1.
·8· I would occasionally log on at home during the week,
·9· · · · · · · · So Question (c) was "the average amount
·9· and then occasionally on the weekends with mandatory
10· of time you devoted to each duty or responsibility on
10· work hours as well.
11· a daily basis," and your answer was "11 to 12 hours
11· · · Q.· ·All right.· What do you mean when you say
12· per day in office plus often finish work from home."
12· "with mandatory work hours as well"?
13· · · · · · · · Did I read that right?
13· · · A.· ·We were required to work mandatory Saturdays.
14· · · A.· ·Yes.
14· · · Q.· ·Okay.· And who told you that you were
15· · · Q.· ·And is that accurate?
15· required to work mandatory Saturdays?
16· · · A.· ·Yes.
16· · · A.· ·Lorie DeSalvo.
17· · · Q.· ·All right.· So you mentioned the -- you
17· · · Q.· ·Do you know whether all of the pre-cert
18· mentioned earlier today that you typically came in
18· nurses were working mandatory Saturdays when you were
19· sometime between 7:30 and 8:00, right?
19· or was it just the folks who were working for Lorie?
20· · · A.· ·Yes.
20· · · A.· ·I don't know.
21· · · Q.· ·And so if you said you were working 11 to 12
21· · · Q.· ·So the phone queue was open from -- you think
22· hours a day in the office, that's going home somewhere
22· the phone queue was open from 8:00 to 5:00, right?
23· between 7:00 and 8:00 o'clock at night?
23· · · A.· ·To the best of my knowledge, yes.
24· · · A.· ·I would work through lunch.· So it would
24· · · Q.· ·And so was it your regular practice to log
25· usually be 6:30 to 7:00, sometimes 8:00 o'clock at
25· off of the phone at 5:00 o'clock?
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 154 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 60 of 173 Page· 130..133 Page 130
Page 131
·1· want to know that badly that I'm going to ask you
·1· · · A.· ·"Acanthosis" -- I don't even know if I can
·2· about --
·2· pronounce that.
·3· · · A.· ·Right.
·3· · · Q.· ·Okay.· And --
·4· · · Q.· ·-- what you did somewhere else.· I was just
·4· · · A.· ·"Nigricans."
·5· making sure.
·5· · · Q.· ·And does "Acq" stand for acquired?
·6· · · · · · · · All right.· If you could turn to
·6· · · A.· ·Yes.
·7· Exhibit -- still on Exhibit 2, now the third page of
·7· · · Q.· ·Okay.· Then there's a Vitamin D deficiency,
·8· Exhibit 2, which is marked at the bottom 02161.· This
·8· and then something else that I don't know what that
·9· appears to be a pediatric referral for a
·9· is.
10· nine-year-old.
10· · · · · · · · Those four diagnoses, are you -- when
11· · · · · · · · Do you see that?
11· you write down what the diagnosis is in this chart,
12· · · A.· ·Yes.
12· are you literally lifting those words from the
13· · · Q.· ·And then you have a note here.· In the kind
13· clinical itself?
14· of first section there you say "No response from
14· · · A.· ·Yes.
15· provider to retrieve additional clinical."
15· · · Q.· ·Okay.· So the doctor is using -- whatever
16· · · · · · · · Do you see that?
16· acanthosis is -- I don't know what it is -- the doctor
17· · · A.· ·Yes.
17· is the one who is writing on the chart "it's
18· · · Q.· ·Does that mean that you tried to contact the
18· acquired," is that right?
19· provider and didn't get a call back?
19· · · A.· ·That's correct.
20· · · A.· ·That's correct.
20· · · Q.· ·Okay.· And then going down to the -- below
21· · · Q.· ·Okay.· The diagnosis, which is the third
21· the CPT code, what does -- I mean, I can guess, but
22· section under the "Note Text," the diagnosis says
22· what does "WEB AUTH" stand for?
23· "Abnormal weight gain," and then I'm not even going to
23· · · A.· ·That is a request that came in via the web,
24· try to pronounce -- what's the thing that comes after
24· the computer.
25· "Abnormal weight gain"?
25· · · Q.· ·And then the stuff that is written there Page 132
Page 133
·1· after "WEB AUTH," where does that information come
·1· do this job?
·2· from?
·2· · · A.· ·Yes.
·3· · · · · · · · Let me ask that a different way.· Don't
·3· · · Q.· ·Why?
·4· answer that question.· Let me ask it a different way.
·4· · · A.· ·To review medical clinical --
·5· · · · · · · · It says the "patient is obese." I
·5· · · Q.· ·Uh-huh.
·6· assume that means the doctor actually used the word
·6· · · A.· ·-- you have to know the terminology.
·7· "obese" --
·7· · · Q.· ·I mean, that's why it's not all just done by
·8· · · A.· ·Yes.
·8· a computer, right?· I mean, you actually have to have
·9· · · Q.· ·-- in the chart?
·9· someone who can understand it and interpret it?
10· · · A.· ·Yes.
10· · · A.· ·Yes.
11· · · Q.· ·That's not you looking at the height and
11· · · Q.· ·I think I asked this earlier, but in case I
12· weight of the patient and concluding that the patient
12· did not, is there a basic list of procedures that are
13· is obese?
13· always approvable to your knowledge?
14· · · A.· ·Correct.
14· · · A.· ·I don't recall.
15· · · Q.· ·What about the words "abnormal weight gain,"
15· · · Q.· ·Okay.
16· is it the doctor who is concluding that it's abnormal?
16· · · · · · · · (Deposition Exhibit 12 marked.)
17· · · A.· ·The doctor is stating that.
17· · · · · · · · THE REPORTER:· Exhibit 12.
18· · · Q.· ·And what about the lab values?· The same
18· · · · · · · · (Document tendered.)
19· thing?
19· · · Q.· ·(BY MR. GOLDEN)· The court reporter is
20· · · A.· ·Correct.
20· handing you what has been marked as Exhibit 12.· I'll
21· · · Q.· ·Okay.· And then the conclusion that you came
21· ask you first if you've ever seen this?
22· to on this one is you couldn't find criteria and so
22· · · A.· ·I believe I've seen this before online.
23· you sent it to the medical director, correct?
23· · · Q.· ·Okay.· Right.· You applied for this job --
24· · · A.· ·Correct.
24· you think anyway that you applied for this job through
25· · · Q.· ·In your opinion, do you have to be a nurse to
25· Centene's website, right?
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 155 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 61 of 173
00001 1 2
IN THE UNITED STATES DISTRICT COURT FOR THE WESTERN DISTRICT OF TEXAS AUSTIN DIVISION
3 4 KATHY CLARK, AMY ENDSLEY, SUSAN ) GRIMMETT, MARGUERIETTE SCHMOLL, ) 5 AND KEVIN ULRICH, ON BEHALF OF ) THEMSELVES AND ALL OTHERS ) 6 SIMILARLY SITUATED, ) ) 7 Plaintiffs, ) No. 1:12-CV-00174-SS ) 8 ) vs. ) 9 ) CENTENE CORPORATION, CENTENE ) 10 COMPANY OF TEXAS, L.P., AND ) SUPERIOR HEALTHPLAN, INC., ) 11 ) Defendants. ) 12 13 14 15
DISCOVERY DEPOSITION OF SHELLY CATTOOR
16 17 18
Taken on behalf of the Plaintiffs May 14, 2014
19 20 21 22 23
Christopher C. Wiegers, CCR Missouri CCR 848
24 25
Cattoor, Shelly 5/14/2014
Page 1
Appendix Volume 2, p. 156
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 62 of 173
00006 1 that if you answer a question that you understood the 2 question. 3
A. Okay.
4
Q. What did you do to prepare for your deposition?
5
A. I reviewed a handful of job descriptions.
6
Q. Anything else that you did to prepare for your
7 deposition? 8
A. I met with Bob Kaiser a couple of days ago. We
9 chatted briefly. 10
Q. Okay. I don't need to get into what you guys
11 talked about. Have you had any other conversations with 12 anyone other than your attorney? 13
A. Nothing more than me telling my boss that I'm going
14 to be here. 15
Q. Who do you report to?
16
A. Bob Sanders. His full name is H. Robert Sanders.
17
Q. What is Mr. Sanders' job position?
18
A. Senior vice president compensation and employee
19 benefits. 20
Q. Is he an employee of Centene Management Company?
21
A. Correct.
22
Q. You said senior vice president --
23
A. Compensation and employee benefits.
24
Q. Okay. And what is your official job title?
25
A. Director of compensation.
Cattoor, Shelly 5/14/2014
Page 6
Appendix Volume 2, p. 157
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 63 of 173
00021 1 recently. I'm not 100 percent certain at this time. I 2 believe it's Ezme Baig. It was Christine Brzycki recently, 3 but her role changed. 4
Q. Okay. Do you know what it changed from to what it
5 changed to? 6
A. Christine Brzycki was the senior vice president --
7 I believe that was her title -- of medical management. And 8 within the last six or twelve months she became the plan 9 product president -- tongue twister title. I think that's 10 right. She's still at Superior HealthPlan. 11
Q. Okay. And you mentioned there was a small medical
12 management department at CMC? 13
A. Yes.
14
Q. Does it employ the same type of nurses that the
15 medical management department at Superior HealthPlan 16 employees? 17
A. No.
18
Q. In terms of job descriptions, what is your role
19 with respect to the job descriptions for Superior -- that 20 are used at Superior? 21
A. Can you kind of explain a little bit more?
22
Q. Sure. As the director of compensation -- or in
23 your compensation department do you guys have a role in 24 either creating job descriptions that are used at CTX or 25 Superior for their employees?
Cattoor, Shelly 5/14/2014
Page 21
Appendix Volume 2, p. 158
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 64 of 173
00022 1 A. Well, most of the health plan job descriptions have 2 been around for a long time. But as, you know, needed, we 3 review them or the need for a new job description might 4 arise. And as I mentioned before -- I can't remember which 5 question it was when we were talking about how the human 6 resources generalist local representative will work with the 7 local operational management if they need either a new job 8 description or a current job description revised. So 9 they'll work together with the human resources 10 representative before they bring that forward towards my 11 department, and then someone on my team will review the job 12 description, you know, ask questions if needed, and then 13 they will benchmark the job using third-party provided 14 salaries surveys. Because we use a market pricing approach 15 to determine salaries and salary grades -- or I should say 16 salary grades and therefore salaries. 17
Q. So someone in your department at CMC would
18 benchmark the job in terms of the appropriate salary. What 19 else would they do if there was a new job created or a 20 revision that needed to be made? 21
A. Yes.
22
Q. Anything else besides benchmarking the job?
23
A. Well, they would also -- if it was a brand new job
24 and they filled out a job description questionnaire, they 25 would obviously review that entire document, which mainly
Cattoor, Shelly 5/14/2014
Page 22
Appendix Volume 2, p. 159
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 65 of 173
00023 1 lists responsibilities of the job, the primary purpose, if 2 the job has direct reports, how many -- you know, kind of 3 what the job's financial impact is from a budget 4 perspective. And then they'll also review some questions 5 about, you know, what kind of supervisory responsibility the 6 role has, what kind of decision making authority they have 7 to determine what level the job is. 8
Q. By level do you mean the job grade?
9
A. I mean the titling, making sure the titling is
10 correct, making sure the FLSA status is correct. 11
Q. So who within your department would determine the
12 job title -13
A. The job title?
14
Q. -- for a brand new job?
15
A. Typically the local management will recommend a
16 title. 17
Q. Okay.
18
A. And then as long as it's not totally misaligned
19 with the rest of the organization, which is not unheard of, 20 it would stick. But then we would make a recommendation for 21 a revised title if they were, for example, saying that some 22 job should be a vice president and clearly it wasn't that 23 big of a scope of responsibility. 24
Q. So within your compensation department who would be
25 doing that?
Cattoor, Shelly 5/14/2014
Page 23
Appendix Volume 2, p. 160
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 66 of 173
00024 1 A. Well, it would be one of the people reporting to 2 me. But if there were, you know, conflict between what they 3 were recommending and what the human resources 4 representative or the local management was recommending, 5 they would come to me or even my boss to make sure that it's 6 appropriately decided what the title or level should be. 7
Q. So would that be either the compensation analyst,
8 the manager of compensation, or both? 9
A. It could be either. Typically the compensation
10 analysts will work on jobs at the manager level and below, 11 and typically the manager of compensation will evaluate jobs 12 at the director level and above. Clearly if somebody comes 13 to us and says this job is a vice president level and then 14 it's not, there's a little bit of a gray area. But that's 15 how we try to stratify the work. 16
Q. Sure. So the compensation analyst -- you said that
17 they would work with supervisors or managers and below, and 18 then the compensation manager would work for people above 19 that in terms of hierarchy? 20
A. For job descriptions for those new or revised jobs.
21 I just want to make sure I'm being clear about the job being 22 evaluated and the person they're working with to make the 23 job evaluation. 24
Q. Sure.
25
A. Okay.
Cattoor, Shelly 5/14/2014
Page 24
Appendix Volume 2, p. 161
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 67 of 173
00025 1 Q. And you had mentioned a couple of times a 2 questionnaire, a job description questionnaire? 3
A. Yes.
4
Q. What is that?
5
A. It's just a form if they don't have a job
6 description that they say this job is very similar to this 7 job. If they're totally coming up with something from 8 scratch, we offer them this job description questionnaire to 9 kind of, you know, put them into our format -- standard 10 format to kind of glean out the main essential job 11 functions, job responsibilities, the primary purpose, the 12 skills and knowledge and certifications that might be 13 required. 14
Q. How often is it that the company is -- or that
15 these -- for example, Superior is coming up with new jobs, 16 or is it more common that they are asking for a revision to 17 a job description? 18
A. It's much more common that Superior is specifically
19 asking for revisions. Because we've been in the managed 20 care business now for some time, so it's rare that they come 21 forward with a brand new job. Typically, if they do, they 22 might think it's brand new, and then my department might be 23 a little more familiar with similar jobs across the 24 organization and they might say -- you know, either the 25 manager or the compensation analyst might say well, did you
Cattoor, Shelly 5/14/2014
Page 25
Appendix Volume 2, p. 162
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 68 of 173
00026 1 consider maybe this job description being appropriate. 2 Sometimes that works or we create a new one if that doesn't. 3
Q. Can you describe for me sort of the process for
4 revising an existing job description? We've talked about 5 sort of the creation of a new job, but for a revision to a 6 job description, how does that work? 7
A. Well, similar in the start of the process to what I
8 explained. You know, the local management will work with 9 the local HR representative to come up with the revisions 10 that they feel are needed, and then they'll bring it to my 11 department for someone on my team to evaluate. And then 12 typically we'll say either okay, this is a significant 13 evaluation or if it affects, you know, a de minimus part of 14 the role -- if it's just kind of, you know, wordsmithing or 15 adding a bullet to be more specific to that particular 16 department saying it might be a job description that's used 17 across multiple departments, you know, we might suggest to 18 them this really isn't a job description modification. You 19 know, feel free to include this information in the job 20 posting to be more specific, but it's really not changing 21 the minimum requirements or essential job function of the 22 job. But if it is, then we would go through that similar 23 process I had described to you before. They would benchmark 24 the job, re-examine the information either on the revised 25 job description or the job description questionnaire to make
Cattoor, Shelly 5/14/2014
Page 26
Appendix Volume 2, p. 163
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 69 of 173
00027 1 sure that it's leveled properly from a title perspective and 2 then also from an FLSA status perspective. 3
Q. So is it your -- is the compensation department at
4 CMC deciding FLSA exemption status? 5
A. Typically what happens is they say they feel,
6 according to these general job responsibilities, that the 7 FLSA status is either exempt or non-exempt. 8
Q. Who is they?
9
A. The local management.
10
Q. Okay.
11
A. And obviously they're running that by the human
12 resources local representative as well. But we rely on the 13 local management to tell us what the job duties and 14 responsibilities are, what the essential job functions are, 15 and what the minimum requirements for the job are. So they 16 have almost always an opinion -- strong opinion on what that 17 should be. But we obviously are familiar with 18 characteristics of non-exempt and exempt jobs, and we'll 19 tell them if we agree or disagree and work it out if we need 20 to. 21
Q. So does it ultimately have to get approval from
22 your team at the CMC corporate level as opposed to the 23 localized level in terms of the FLSA exemption status? 24
A. Well, we always provide our recommendation. Whose
25 recommendation, you know, it ends up being -- typically we
Cattoor, Shelly 5/14/2014
Page 27
Appendix Volume 2, p. 164
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 70 of 173
00028 1 rely on local management because they're the ones that are 2 actually interfacing. We make sure they have the same tools 3 we have, you know, these simple checklists about the 4 characteristics of exempt jobs, and we make sure they fill 5 that out. If it's kind of a little bit of a struggle in 6 determining whether it should be non-exempt or exempt, we 7 say okay, local management, then please complete this 8 administrative exempt questionnaire, and we'll go over that 9 and we'll determine from the way you've completed this 10 questionnaire if the job should be non-exempt or exempt. 11
Q. So is this checklist that you mentioned different
12 than the questionnaire? 13
A. It is a little more thorough, because typically we
14 find ourselves, you know, stuck trying to figure out if it 15 should be exempt under the administrative test. And that 16 one tends to stump our local management more than others. 17 So that one is a little more thorough. 18
Q. And that's -- this checklist that you have, that's
19 something that's maintained in your department? 20
A. It's not maintained. It's just a checklist. I
21 mean, we have it, yes, but -22
Q. You have a copy of it?
23
A. -- we didn't create it.
24
Q. Okay. Do you know who created it?
25
A. I believe it came from WorldatWork. I'm not 100
Cattoor, Shelly 5/14/2014
Page 28
Appendix Volume 2, p. 165
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 71 of 173
00037 1 function or that role. 2
A. I could tell you by title. I don't know if
3 Ezmerelda Baig is in a management level in medical 4 management. I think she is. And it was Christine Brzycki, 5 but as I mentioned before, her roles changed somewhat 6 recently. 7
Q. Ms. Cattoor, do you recall reviewing the
8 classification decision for pre-certification and prior 9 authorization and concurrent review nurses for CTX any time 10 within the last three years? 11
A. No. It was never brought to my attention by
12 management, so no. 13
Q. Do you know -- as you sit here today do you know
14 one way or another whether anyone on your compensation team 15 reviewed the classification decisions for those positions 16 within the last three years for CTX? 17
A. The revision date tells me obviously that someone
18 on my team revised the job description, but it's my 19 recollection that the job description didn't substantively 20 change. There was just some wordsmithing additional 21 verbiage on the position responsibilities. It was nothing 22 changing the essential job functions or minimum 23 qualifications I believe. 24
Q. Is your department responsible for compliance with
25 the FLSA or state wage and hour laws?
Cattoor, Shelly 5/14/2014
Page 37
Appendix Volume 2, p. 166
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 72 of 173
00038 1 A. I suppose, yes. 2
Q. And are you familiar with the company's efforts in
3 terms of compliance with the FLSA? 4
A. Yes.
5
Q. And are you responsible for the compliance efforts
6 for the -- for CTX as well? 7
A. We are not responsible for knowing daily activities
8 of individuals within job descriptions and making sure the 9 right people are in the right role. That would be local 10 management's responsibility. But we are responsible for 11 taking job descriptions that local management provides us 12 and providing our recommendation on what the FLSA status 13 should be. 14
Q. Besides providing recommendations about what the
15 FLSA status should be for when you review a job description, 16 anything else that you can think of in terms of your 17 department's role in FLSA compliance? 18
A. I'm not sure I understand your question.
19
Q. Sure. Do you guys do any sort of internal audits
20 or external audits or hire any third-party companies to come 21 look at exemption status? 22
A. No.
23
Q. Have you -- are you aware of whether CMC or CTX or
24 CMC on behalf of CTX has requested the Department of Labor 25 to do any type of audit of the classification decisions?
Cattoor, Shelly 5/14/2014
Page 38
Appendix Volume 2, p. 167
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 73 of 173
00042 1 2
(A short break was taken.) Q. (By Ms. Srey) Ms. Cattoor, are you familiar with
3 the job duties and responsibilities of a CTX 4 pre-certification nurse? 5
A. I'm familiar with this document and what's listed
6 as their responsibilities on this document, yes. 7
Q. So beyond the document, do you have any knowledge
8 about their job duties and responsibilities? 9 10
A. Not really, no. Q. Okay. Do you know if these nurses have a job
11 responsibility of working in a department that runs CTX's 12 business? 13
A. I would agree that yes, their operation
14 significantly impacts their business. 15
Q. So what department do they work in that is part of
16 running CTX's business? 17
A. Medical management.
18
Q. Is that considered a back office department?
19
A. No. That's considered operations.
20
Q. Is there an operations department?
21
A. I believe so.
22
Q. So are they -- these nurses, are they the ones
23 providing the day-to-day utilization management services 24 that CTX provides to SHP members? 25
A. That's my understanding.
Cattoor, Shelly 5/14/2014
Page 42
Appendix Volume 2, p. 168
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 74 of 173 Page 1
·1· · · · · · · · THE IN UNITED STATES DISTRICT COURT · · · · · · · · · ·FOR THE WESTERN DISTRICT OF TEXAS ·2· · · · · · · · · · · · · AUSTIN DIVISION ·3· · · ·4· · · ·5· · · ·6· · · ·7· · · ·8· · · ·9· · · 10·
KATHY CLARK, AMY ENDSLEY,· · · · ·) SUSAN GRIMMETT, MARGUERIETTE· · · ) SCHMOLL AND KEVIN ULRICH, ON· · · ) BEHALF OF THEMSELVES AND ALL· · · ) OTHERS SIMILARLY SITUATED,· · · · ) · · · · · · · · · · · · · · · · · ) · · · · ·PLAINTIFFS,· · · · · · · ) · · · · · · · · · · · · · · · · · ) VS.· · · · · · · · · · · · · · · ·)· · · Civil Action · · · · · · · · · · · · · · · · · )· No. 1:12-CV-00174-SS CENTENE CORPORATION, CENTENE· · · ) COMPANY OF TEXAS, L.P., AND· · · ·) SUPERIOR HEALTHPLAN, INC.,· · · · ) · · · · · · · · · · · · · · · · · ) · · · · ·DEFENDANTS.· · · · · · · )
11· ********************************************************** 12· · · · · · · · · · · ORAL DEPOSITION OF 13· · · · · · · · · · · ANGELITA CERVANTEZ 14· · · · · · · · · · · · ·JUNE 26, 2014 15· ********************************************************** 16· · · ·ORAL DEPOSITION OF ANGELITA CERVANTEZ, produced as a 17· witness at the instance of the Defendants, and duly sworn, 18· was taken in the above-styled and numbered cause on the 19· 26th day of June, 2014, from 1:24 p.m. to 4:13 p.m., 20· before Karen Morris, CSR in and for the State of Texas, 21· reported by machine shorthand at the La Quinta Inn, 5006 22· Auburn Street, Lubbock, Texas, pursuant to the Federal 23· Rules of Civil Procedure. 24 25 FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 169
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 75 of 173 Page· 11
·1· · · ·Q.· -- and then another hospital? ·2· · · ·A.· Yes. ·3· · · ·Q.· Got it.· Okay.· So tell me, what does -- well, ·4· tell me what a concurrent review nurse does. ·5· · · ·A.· We have a caseload we did.· I'm not a review ·6· nurse anymore.· We had a census or a caseload that we ·7· carried, and we reviewed those charts to determine if they ·8· were eligible to remain in-patient. ·9· · · ·Q.· Okay. 10· · · ·A.· Or if they met the criteria to be approved for 11· the hospital to be paid for their stay. 12· · · ·Q.· Okay.· So if I look at your resume -13· · · ·A.· Uh-huh. 14· · · ·Q.· -- that would be the concurrent onsite review of 15· medical record to determine admission eligibility.· Right? 16· · · ·A.· Yes. 17· · · ·Q.· Now, when you say review of medical record, what 18· medical record -19· · · ·A.· The chart. 20· · · ·Q.· -- would you review? 21· · · ·A.· One of the hospitals still had charts.· Another 22· hospital had an electronic medical record.· You have to go 23· onsite to review it, because it didn't have -24· · · ·Q.· Regardless of which hospital you went to? 25· · · ·A.· Regardless. FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 170 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 76 of 173 Page· 12
·1· · · ·Q.· Yes.· So -- so in the case of a physical chart, a ·2· paper chart, right -·3· · · ·A.· Yes. ·4· · · ·Q.· -- where would you get that chart? ·5· · · ·A.· At the nurses' station in the hospital. ·6· · · ·Q.· Okay. ·7· · · ·A.· On the unit. ·8· · · ·Q.· Okay.· And what is typically included in that -·9· in the chart? 10· · · ·A.· Everything.· I would say everything.· For that 11· patient's stay that time, for that admission. 12· · · ·Q.· Uh-huh. 13· · · ·A.· Or from their first day there.· Their history and 14· physical.· Labs.· Nurses' notes.· Progress notes. 15· · · ·Q.· Okay.· Were there -16· · · ·A.· Radiology, I guess. 17· · · ·Q.· I don't remember if you said this, did you say 18· medications? 19· · · ·A.· Yeah.· No, I didn't say that.· But, yes, there 20· was a medication -- an MAR, medication administration 21· record on there as well, in the chart. 22· · · ·Q.· Okay.· And you said it was for -- for this stay? 23· · · ·A.· For that admission. 24· · · ·Q.· Were there prior medical records for prior 25· admissions? FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 171 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 77 of 173 Page· 100
·1· · · ·Q.· Maybe this will help. ·2· · · ·A.· Yes. ·3· · · ·Q.· If you go above where it says -- you see at the ·4· top of the page -·5· · · ·A.· Yeah. ·6· · · ·Q.· -- page 79, where it says note text? ·7· · · ·A.· Note text. ·8· · · ·Q.· And it says, (reading) Not meeting IQ for ·9· antepartum IS? 10· · · ·A.· IS?· Not receiving IV fluid and IS. 11· · · ·Q.· So -12· · · ·A.· I can't remember what all that means.· We also 13· had this book. 14· · · ·Q.· Yeah. 15· · · ·A.· There was an InterQual computer program that you 16· did a checklist pretty much quick, quick, quick.· They met 17· all of this criteria -18· · · ·Q.· Right. 19· · · ·A.· -- and it would light up green that they had met 20· criteria, or red that they had not.· But I cannot -- what 21· does IS mean?· Let me find it. 22· · · ·Q.· Does IS mean something? 23· · · ·A.· I can't remember if it does. 24· · · ·Q.· Oh.· Is that intensity of service? 25· · · ·A.· Probably.· I'm not sure completely, but probably. FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 172 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 78 of 173
Page 1
IN THE UNITED STATES DISTRICT COURT FOR THE WESTERN DISTRICT OF TEXAS AUSTIN DIVISION KATHY CLARK, AMY ENDSLEY, ) SUSAN GRIMMETT, MARGUERIETTE ) SCHMOLL AND KEVIN ULRICH, ON ) BEHALF OF THEMSELVES AND ALL ) OTHERS SIMILARLY SITUATED, ) ) Plaintiffs, ) ) VS. ) Civil Action ) No. 1:12-CV-00174-SS CENTENE CORPORATION, CENTENE ) COMPANY OF TEXAS, L.P., AND ) SUPERIOR HEALTHPLAN, INC., ) ) Defendants. ) ORAL DEPOSITION OF KATHY CLARK On October 22, 2012, between the hours of 8:57 a.m. and 3:39 p.m., in the offices of Dunham & Jones, 1800 Guadalupe Street, Austin, Texas, before me, WILLIAM M. FREDERICKS, a Certified Shorthand Reporter for the State of Texas, appeared KATHY CLARK, who, being by me first duly sworn, gave an oral deposition at the instance of the Defendants in said cause, pursuant to the Federal Rules of Civil Procedure.
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM
Appendix Volume 2, p. 173
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 79 of 173
Page 123
1 2
Q.
Roughly how long did it take you to complete
the login process?
3
A.
A minute, two minutes.
4
Q.
Okay.
5
And then what did you have to do to
log into your phone?
6
A.
Apply a code.
7
Q.
You punched a code into the phone?
8
A.
Yes.
9
Q.
How long did that take you?
10
A.
Seconds.
11
Q.
And you followed this process every day?
12
A.
Yes.
13
Q.
What was your job title when you worked for
14
Centene?
15
A.
Pre-certification nurse.
16
Q.
What is a pre-certification nurse?
17
A.
Reviewing requests from providers, various
18
providers for Medicaid services for authorization.
19
Q.
What types of providers?
20
A.
Physicians; nurse practitioners; therapists;
21
home health.
22
Q.
Had you ever done that sort of work before?
23
A.
Only in an auditing capacity.
24
Q.
This was the job you referred to before where
25
you were --
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM
Appendix Volume 2, p. 174
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 80 of 173
Page 127
1
Q.
2
you mean?
3
A.
4
When you say "clinical information," what do
Nursing notes; lab results; progress notes
from physicians.
5
Q.
All of those things?
6
A.
Yes.
7
Q.
Anything else?
8
A.
That's all I can remember.
9
Q.
And how often would you say that the clinical
10
information was missing altogether?
11
A.
It varied.
12
Q.
A lot of the time; some of the time; none of
13
the time?
14
A.
Given a percentage, 30 percent of the time.
15
Q.
And if you got a request that had no clinical
16 17 18
information, what would you do? A.
Phone the provider and ask them to submit
information within a certain period of time.
19
Q.
Just a message that said --
20
A.
Yes.
21
Q.
-- send in the info?
22
A.
Yes.
23
Q.
You wouldn't ask any questions?
24
A.
No.
25
Q.
Okay.
So the request comes to you by what
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM
Appendix Volume 2, p. 175
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 81 of 173
Page 128
1
method?
2
A.
Through the computer.
3
Q.
And how does that work?
When you see it, how
4
would you -- how would it come to you?
5
MR. BLEICH:
6 7
Q.
(BY MR. BRENNER)
Objection, form. Is it by e-mail; is there a
software program you're using?
8
A.
It was a software program for the mailbox.
9
Q.
What was that called?
10
A.
I don't -- I don't recall.
11
Q.
And would that automatically open when you
12
logged on to your computer in the morning?
13
A.
I think you had to access it.
14
Q.
Was there some other password required?
15
A.
I don't recall.
16
Q.
You don't recall how you accessed it, but it
17
didn't automatically show up?
18
A.
No.
19
Q.
So these requests came to you -- did you have
20
some sort of an in-box or was there some accumulation
21
of requests?
22
A.
How did it -- how was it passed to you?
It was in a different program in a -- in a
23
mailbox, in-box.
24
it.
25
Q.
I don't recall the specific name of
So you'd open this program, and what would it
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM
Appendix Volume 2, p. 176
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 82 of 173
Page 133
1
A.
I'm --
2
Q.
What types of information would be presented
3 4
to you when you opened a request? A.
The request form of what they wanted, the
5
provider, what they wanted.
6
member's name; the member's ID.
7 8
Q.
Who it was from; the
So you didn't input any of that
information into --
9
A.
No.
10
Q.
-- the system; it was already there?
11
A.
Yes.
12
Q.
Do you have any idea how it got there?
13
A.
It was faxed to the -- to -- to Centene.
14
Q.
So are you looking at a fax?
15
A.
Yes.
16
Q.
It's actually an image of the fax itself?
17
A.
Yes.
18
Q.
And it has all that information on it
19
already?
20
A.
Yes, sir.
21
Q.
So let's talk about the service being
22
requested.
23
is there a code involved?
24
want?
25
A.
Is that listed by the type of service or How do you know what they
It's usually spelled out.
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM
Appendix Volume 2, p. 177
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 83 of 173
Page 134
1
Q.
So it would say, for example, "physical
2
therapy"?
3
A.
If -- yes.
4
Q.
Anything else?
5
A.
Related to physical therapy?
6
Q.
Yeah.
Would it say anything else besides the
7
words "physical therapy" in the service requested
8
category?
9
A.
There would be documen- --
10
MR. BLEICH:
11
Go ahead.
Object to the form.
12
A.
-- documentation to support that request.
13
Q.
(BY MR. BRENNER)
I understand that, but
14
would it identify the service being requested by
15
anything else other than the words "physical therapy"?
16
Would there be a code, a billing code, anything like
17
that?
18
A.
There might be a CPT code; there might not
20
Q.
What's a CPT code?
21
A.
I don't remember what "CPT" stands for.
19
be.
It
22
is a billing code that is used to identify certain
23
procedures.
24
stands for.
25
Q.
I'm sorry.
I don't remember what it
What did that code mean when you saw it?
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM
Appendix Volume 2, p. 178
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 84 of 173
Page 135
1
What did it mean to you?
2
A.
That a certain procedure was being requested.
3
Q.
Okay.
So would it always include a CPT code
4
and the name of the service or could it be one or the
5
other?
6
A.
7
10
It could be
both.
8 9
It could be one or the other.
Q.
So in the instance that it was just a CPT
code listed and there was no service, how did you know what was being requested?
11
A.
I would research that CPT code.
12
Q.
Research it how?
13
A.
I would go up to the online request for CPT
14
codes and look that code up.
15
Q.
So you used some online function --
16
A.
Yes.
17
Q.
-- to figure out what they were asking for?
18
A.
Yes.
19
Q.
Can you estimate how often you had to do
20
that?
21
A.
I can't remember.
22
Q.
So you're looking at a request.
23
do?
24
you do with it?
25
What do you
You have this request in front of you.
A.
What do
I would read the entire submission request.
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM
Appendix Volume 2, p. 179
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 85 of 173
Page 139
1
Q.
And they used "Centene" as the company name?
2
A.
Yes.
3
Q.
So you start with the internal guidelines?
4
A.
Yes.
5
Q.
Do you have any idea who developed those
6
guidelines?
7
A.
8
committee.
9
Q.
Whose quality committee?
10
A.
Centene.
11
Q.
Was that an Austin-based committee?
12
A.
I don't know where that committee sits.
13
Q.
You didn't know those people?
14
A.
No.
15
Q.
Were you involved in that process at all?
16
A.
No.
17
Q.
You never had any input --
18
A.
No.
19
Q.
-- into the development of those guidelines?
20
A.
No.
21
Q.
Did you ever make any suggestions about
22
I am assuming it would be their quality
guidelines that needed to be improved or changed --
23
A.
No.
24
Q.
-- or were missing?
25
You never had any input in that at all?
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM
Appendix Volume 2, p. 180
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 86 of 173
Page 140
1
A.
No.
2
Q.
Now, I started to ask you before whether
3
these guidelines were comprehensive.
4
Did all guidelines cover all services?
5
A.
Not all.
6
Q.
Okay.
7 8
Let's take it one at a time.
The Centene guidelines, those internal guidelines, did they cover all services or not?
9
A.
No.
10
Q.
What types of things were not covered?
11
A.
I can't recall any specific, but not
12 13 14
everything was covered. Q.
The InterQual guidelines, would they cover
all types of services?
15
A.
No.
16
Q.
Can you remember what they didn't cover?
17
A.
No, I can't.
18
Q.
And the third one, TMHP, was that
19
comprehensive or not?
20
A.
No.
21
Q.
Can you remember what it didn't cover?
22
A.
No, I can't remember.
23
Q.
Was there overlap between the three?
24
A.
Yes.
25
Q.
There was?
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM
Appendix Volume 2, p. 181
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 87 of 173 Page 1
·1· · · · · · IN THE UNITED STATES DISTRICT COURT · · · · · · · ·FOR THE WESTERN DISTRICT OF TEXAS ·2· · · · · · · · · · · AUSTIN DIVISION ·3· · · ·4· · · ·5· · · ·6· · · ·7· · · ·8· · · ·9· · · 10·
KATHY CLARK, AMY ENDSLEY,· · ) SUSAN GRIMMETT, MARGUERIETTE ) SCHMOLL AND KEVIN ULRICH, ON ) BEHALF OF THEMSELVES AND ALL ) OTHERS SIMILARLY SITUATED,· ·) · · · · · · · · · · · · · · ·) · · · · ·Plaintiffs,· · · · ·) · · · · · · · · · · · · · · ·) VS.· · · · · · · · · · · · · )· · ·Civil Action · · · · · · · · · · · · · · ·) No. 1:12-CV-00174-SS CENTENE CORPORATION, CENTENE ) COMPANY OF TEXAS, L.P., AND· ) SUPERIOR HEALTHPLAN, INC.,· ·) · · · · · · · · · · · · · · ·) · · · · ·Defendants.· · · · ·)
11· ***************************************************** 12· · · · · · · · · ·ORAL DEPOSITION OF 13· · · · · · · · · ·JULIA ANA DE LEON 14· · · · · · · · · · ·June 23, 2014 15· ***************************************************** 16· · · ORAL DEPOSITION OF JULIA ANA DE LEON, produced as 17· a witness at the instance of the Defendants, and duly 18· sworn, was taken in the above-styled and numbered 19· cause on June 23, 2014, from 8:42 a.m. to 12:03 p.m. 20· before WILLIAM M. FREDERICKS, CSR in and for the State 21· of Texas, reported by machine shorthand at the 22· Crockett Hotel, 320 Bonham Street, Room 703, 23· San Antonio, Texas, pursuant to the Federal Rules of 24· Civil Procedure. 25 FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 182 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 88 of 173 Page· 22..25 Page 22
Page 23
·1· · · A.· ·For the Research Nurse/Charge Nurse, and then
·1· · · A.· ·Yes.
·2· I transitioned into the coordinator.
·2· · · Q.· ·Is there a reason you made them so detailed?
·3· · · Q.· ·Okay.· So roughly three years and then two
·3· · · A.· ·No, no reason.
·4· years or so, or three-and-a-half years and
·4· · · Q.· ·Okay.· Would you use this résumé to send to
·5· one-and-a-half years?
·5· prospective employers?
·6· · · A.· ·I did one -- yeah, about one in Clinical
·6· · · A.· ·Yes.
·7· Research Coordinator, and then I went back to the
·7· · · Q.· ·And would the purpose be so that the
·8· floor.
·8· prospective employers would know what experience you
·9· · · Q.· ·Okay.
·9· had?
10· · · A.· ·Yeah.
10· · · A.· ·Yes.
11· · · Q.· ·You went back to the floor as?
11· · · Q.· ·Okay.· Let's move to Page 2, and it says that
12· · · A.· ·As a research nurse.
12· the next -- well, on Page 3 it says that the next
13· · · Q.· ·Okay.· Is Cetero Research a hospital?
13· position you had after working for Cetero was
14· · · A.· ·No.· It was a clinical research facility.
14· Superior Health Plan?
15· · · Q.· ·So when you say you went back to the -- do
15· · · A.· ·Yes.
16· they have patients?
16· · · Q.· ·And you've already said that that was around
17· · · A.· ·We have -- they're called subjects, yes.
17· April of 2011?
18· · · Q.· ·Okay.· So when you went back to the floor --
18· · · A.· ·Yes.
19· I mean, but they were people, right?· I mean --
19· · · Q.· ·And then that was as a Case Manager II?
20· · · A.· ·Right.
20· · · A.· ·Yes.
21· · · Q.· ·So when you said you went back to the floor,
21· · · Q.· ·Okay.· So if I go down to Page 2 where it
22· there were people who were in beds?
22· says "Case Manager II" --
23· · · A.· ·Yes, pretty much.· It depends on the study.
23· · · A.· ·Yes.
24· · · Q.· ·Okay.· This is a fair amount of detail on
24· · · Q.· ·-- does that list the job duties that you
25· these.· These are fairly detailed.
25· had? Page 24
Page 25
·1· · · A.· ·Yes, sir.
·1· · · Q.· ·It's probably "promote" I assume, right?
·2· · · Q.· ·Okay.· Is it truthful and accurate?
·2· · · A.· ·I believe so.
·3· · · A.· ·Yes, sir, from what I remember.
·3· · · Q.· ·Yeah.· So can you tell me what does that
·4· · · Q.· ·Okay.· Can you just give it to me in a
·4· mean?· What did you mean when you wrote that?
·5· summary fashion kind of what it is that a Case
·5· · · A.· ·We would contact patients.· I contacted a
·6· Manager II does?
·6· couple of them just to check on them.· I would get a
·7· · · A.· ·For this particular position, I mostly did
·7· request to call a certain patient that -- I don't
·8· DME requests.
·8· know -- their sugars were high.· So I would just call
·9· · · Q.· ·Uh-huh.
·9· and follow up and see if they went ahead and called
10· · · A.· ·It was for over 21, and to see if they
10· their doctor or if they needed anything.
11· qualified for medical equipment.
11· · · Q.· ·So what is "collaborative duties"?· What does
12· · · Q.· ·Okay.· Well, let's walk through, if you don't
12· that mean?
13· mind, some of the items where you have listed "Case
13· · · A.· ·I'm not sure.
14· Manager II."
14· · · Q.· ·Okay.· I mean, that's something you wrote,
15· · · A.· ·Okay.
15· right?
16· · · Q.· ·The second bullet point, do you see that?
16· · · A.· ·Right.
17· · · A.· ·Yes.
17· · · Q.· ·Okay.· Is there somebody else who told you
18· · · Q.· ·Can you read that?
18· what to write there?
19· · · A.· ·"Perform collaborative duties to assess, plan
19· · · A.· ·No.· I know that was part of my job
20· and coordinate continuum of care for select members at
20· description.
21· high risk in order to pro note quality, cost effective
21· · · Q.· ·Okay.· What does it mean when it says "to
22· programs."
22· assess, plan and coordinate continuum of care"?
23· · · Q.· ·Okay.· I think it's probably -- maybe it's a
23· · · A.· ·As I mentioned earlier, I would -- this
24· typo or maybe it's --
24· particular -- I only did a couple of calls to be
25· · · A.· ·Yes.
25· honest.· I would call the patient and see, you know,
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 183 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 89 of 173 Page· 26..29 Page 26
Page 27
·1· if their sugars had gone down; see if I needed to
·1· a staff nurse and you would visit a patient in the
·2· assist with a doctor's appointment.· If they needed
·2· morning and you --
·3· anything that I can help them with.
·3· · · A.· ·Yes.
·4· · · Q.· ·And how would you know that?
·4· · · Q.· ·-- you assess how they feel?
·5· · · A.· ·I would speak to the -- to the patient.
·5· · · A.· ·Yes.
·6· · · Q.· ·But how -- when you speak to them, what would
·6· · · Q.· ·It was the same set of skills?
·7· you speak to them about?
·7· · · A.· ·Yes.
·8· · · A.· ·I would call them -- like I said, this
·8· · · Q.· ·Okay.· So you would have a discussion with a
·9· particular one that I remember, you know, her sugar
·9· patient?
10· was high the day before, so they asked me to call and
10· · · A.· ·Yes.
11· follow up.
11· · · Q.· ·And then what would you do?
12· · · Q.· ·Who is "they"?
12· · · A.· ·If they say they were fine or if they say
13· · · A.· ·I don't remember.· I would get an e-mail or a
13· yes, they did follow up, then I would maybe give them
14· message.· So I'd call and see how they were doing; see
14· another -- call the next day or maybe a day after. I
15· if they checked their sugar this morning; did they
15· would just follow up until they were okay.
16· take their medication.
16· · · Q.· ·So what does the "assess" part mean?· When
17· · · Q.· ·Did you have a list of questions that you had
17· you say "assess," what does that mean?
18· to ask them?
18· · · A.· ·Right.· Again, I would ask them questions to
19· · · A.· ·No.
19· see how they were doing.
20· · · Q.· ·How did you know what to ask them?
20· · · Q.· ·Okay.
21· · · A.· ·I don't know.
21· · · A.· ·That would be my assessment.
22· · · Q.· ·I mean, was that something you would have
22· · · Q.· ·Okay.· The next word in there is "plan."· So
23· learned in nursing school?
23· what does that -- what did you mean when you wrote
24· · · A.· ·That -- yes.
24· that?
25· · · Q.· ·Okay.· Is that similar to like when you were
25· · · A.· ·Again, if they needed something -- I don't
Page 28
Page 29
·1· know -- they needed DME, I would just see how I can
·1· · · Q.· ·So what would be examples of durable medical
·2· help them get it.
·2· equipment?
·3· · · Q.· ·Now, that's obviously a different example,
·3· · · A.· ·Wheelchairs, oxygen, hospital beds, walkers.
·4· because when you're low on blood sugar would you need
·4· · · Q.· ·Okay.· Would it include people who had to
·5· DME?
·5· wear like vests for respiratory problems?
·6· · · A.· ·No.
·6· · · A.· ·Yes.
·7· · · Q.· ·Okay.· So that would be --
·7· · · Q.· ·Okay.· Does that have a better name than a
·8· · · A.· ·Well, they might need a meter.
·8· vest?
·9· · · Q.· ·Okay.· A blood meter?
·9· · · A.· ·I don't remember.
10· · · A.· ·Yes.· But I don't know if that would be
10· · · Q.· ·Okay.· And so when it says -- when you say
11· considered DME.
11· "plan continuum of care," what does that mean?
12· · · Q.· ·Okay.· Well, in the example that you just
12· · · · · · · · MR. BAGGIO:· Objection, asked and
13· gave where you said it might -- you plan and see
13· answered.
14· whether they need DME, can you give me an example of
14· · · Q.· ·(BY MR. KAISER)· So specifically referring to
15· that?
15· DME, how would you plan a continuum of care for
16· · · A.· ·I don't remember.
16· somebody who had a DME need?· If you can give me an
17· · · Q.· ·Okay.· Just for the record, "DME" is durable
17· example that would be --
18· medical equipment?
18· · · A.· ·I don't know.
19· · · A.· ·Yes.
19· · · Q.· ·Okay.· And then the last -- or the next word
20· · · Q.· ·Okay.
20· other than "and" is "coordinate," and that's
21· · · A.· ·I'm sorry.
21· "coordinate continuum of care."· What does that mean?
22· · · Q.· ·Well, there's a lot of terms that you know
22· What did you mean when you wrote that?
23· that we probably don't know.· Just assume I don't know
23· · · A.· ·I don't know.· I don't remember.
24· anything.
24· · · Q.· ·Okay.· If we keep on marching forward --
25· · · A.· ·Okay.
25· well, do you know generally what "continuum of care"
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 184 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 90 of 173 Page· 42..45 Page 42
Page 43
·1· · · Q.· ·So were there times when you would suggest
·1· problems that people were having?
·2· alternatives?
·2· · · A.· ·Yes.· As a case manager, yes.
·3· · · A.· ·No.
·3· · · Q.· ·Okay.· So the next bullet point, do you mind
·4· · · Q.· ·Okay.· That it may not meet the criteria
·4· reading that one.
·5· for -- let's say, for example, it may not meet the
·5· · · A.· ·"Identify related risk management quality
·6· criteria for a nurse but might meet one for a home
·6· concerns and report these scenarios to appropriate
·7· healthcare worker?
·7· resources."
·8· · · A.· ·Not that I recall.
·8· · · Q.· ·Okay.· What does that mean?
·9· · · Q.· ·Okay.· And with DME, there's different levels
·9· · · A.· ·Again, I would say it means talking to the
10· of help that people can get from -- so, for example --
10· subject -- the patient -- I'm sorry -- and if they
11· let me make it concrete -- you may have an individual
11· needed something, I would try to get it for them.
12· who may not qualify for a wheelchair but might qualify
12· · · Q.· ·Okay.· What is a risk management quality
13· for a walker.· Is that --
13· concern?
14· · · A.· ·I would say so.
14· · · A.· ·I would say a patient living in a home
15· · · Q.· ·Okay.· So would there be a time when you
15· without any fans, any -- you know, any
16· would say to the -- either the DME company or the
16· air-conditioning, and then we would try to provide
17· patient, I can't approve you for a wheelchair, but I
17· that for them.
18· think you might be suitable for a walker?
18· · · Q.· ·And how would you know that?
19· · · A.· ·I don't remember.
19· · · A.· ·Again, talking to the patient.
20· · · Q.· ·Okay.· Would that be the kind of thing that
20· · · Q.· ·Okay.· Was that a typical question that you
21· you would look for?
21· would ask people, what kind of air-conditioning or
22· · · A.· ·Yeah, if it was there, then yes, but I don't
22· heating you have?
23· remember myself doing it.
23· · · A.· ·Not typical.
24· · · Q.· ·Okay.· Was it part of your -- but was it part
24· · · Q.· ·I mean, how would that come up?
25· of your job to look for those kinds of solutions to
25· · · A.· ·From my experience, just if they would
Page 44
Page 45
·1· request an air-conditioner.
·1· that's something that you did when you were with --
·2· · · Q.· ·Was it normal for people to request
·2· · · A.· ·Coventry.
·3· air-conditioners?
·3· · · Q.· ·-- Coventry.
·4· · · A.· ·Yes, in the summer.
·4· · · · · · · · What is Coventry?
·5· · · Q.· ·Okay.· And then how would you make a
·5· · · A.· ·It's another health -- health insurance plan.
·6· determination as to whether air-conditioner is
·6· · · Q.· ·Is it also Medicaid?
·7· appropriate or not?
·7· · · A.· ·No.
·8· · · A.· ·The -- I can't remember if it's the Texas
·8· · · Q.· ·It's private pay?
·9· Medicaid or -- one of our policies we had.
·9· · · A.· ·Yes.· Federal I believe.
10· · · Q.· ·Okay.· And it says "report these scenarios to
10· · · Q.· ·I'm sorry?
11· the appropriate resources."
11· · · A.· ·I think it was federal if I remember
12· · · · · · · · What does that mean?
12· correctly.
13· · · A.· ·I wouldn't know.· I'm sorry.
13· · · Q.· ·Okay.· While you were at Superior, you did
14· · · Q.· ·Okay.· Now, the next job title that you've
14· not serve in a concurrent review position?
15· listed is Concurrent Review -- is there anything else
15· · · A.· ·No.
16· that you did other than what's listed under "Case
16· · · Q.· ·Okay.· Would you know what a concurrent
17· Manager II"?
17· review nurse does at Superior?
18· · · A.· ·No, other than the request and those couple
18· · · A.· ·No.
19· of cases that I had.
19· · · Q.· ·Okay.· Now, you were always stationed in
20· · · Q.· ·As I look through all the bullet points that
20· San Antonio?
21· you've listed under "Case Manager II," are all of
21· · · A.· ·Yes.
22· these the principal job duties that you performed as a
22· · · Q.· ·Did you have an office?
23· Case Manager II or am I missing something?
23· · · A.· ·A cubicle.
24· · · A.· ·Yeah.· No, I think this is it.
24· · · Q.· ·Okay.· But there was an office?· You didn't
25· · · Q.· ·Okay.· The Concurrent Review Coordinator,
25· work out of your home?
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 185 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 91 of 173 Page· 46..49 Page 46
Page 47
·1· · · A.· ·Right.
·1· · · A.· ·Oh, my work?· I would get it from a list. I
·2· · · Q.· ·Okay.· And I have not seen the offices.· Are
·2· guess it was called a queue.· I can't remember.· And
·3· there a lot of people in the office or is the
·3· we would just -- I'd just take it from there.
·4· San Antonio office relatively small?
·4· · · Q.· ·Well, maybe you can help me walk through your
·5· · · A.· ·With the first position, it was a large
·5· day.
·6· office.
·6· · · · · · · · So typically what time did you get to
·7· · · Q.· ·Okay.· That's with the Case Manager II?
·7· work?
·8· · · A.· ·Yes.
·8· · · A.· ·About 7:00.
·9· · · Q.· ·Okay.· And were there other Case Manager
·9· · · Q.· ·And in order to start your work, did you have
10· II's?
10· to do anything, log on or anything like that?
11· · · A.· ·There was maybe one that I remember.
11· · · A.· ·Yes, log into the computer.
12· · · Q.· ·Okay.· Were there pre-authorization nurses?
12· · · Q.· ·Okay.· Would you also log on to phones?
13· · · A.· ·In that office, no.
13· · · A.· ·No, I wouldn't.
14· · · Q.· ·So who else was populating that large office
14· · · Q.· ·Okay.· The kind of work that you were doing
15· while you were a Case Manager II?· Not by name but by
15· was not -- you wouldn't describe it as a call center?
16· job duties.
16· · · A.· ·Not what I was doing.
17· · · A.· ·Right.· No, I -- again, I don't remember
17· · · Q.· ·Okay.· Other people did?
18· their title, but they were I guess member
18· · · A.· ·Yes.
19· coordinators.· I don't remember their title, but they
19· · · Q.· ·Okay.· Would you be on the phone as part of
20· would assist the members.
20· your job?
21· · · Q.· ·Okay.· How would a case get to you?
21· · · A.· ·I would when I'd have to call if somebody has
22· · · A.· ·Again, those two that I worked with, by
22· been denied.
23· e-mail.
23· · · Q.· ·Any other time?
24· · · Q.· ·No.· But just generally speaking, how would a
24· · · A.· ·No.· And, again, when I had to just -- those
25· case get -- how would you get your work?
25· couple of cases that I spoke to the person. Page 48
Page 49
·1· · · Q.· ·Okay.· Was there a medical -- if you didn't
·1· average a day?
·2· approve somebody for care, what would happen to their
·2· · · A.· ·No, I don't remember.· A lot, but I don't
·3· request?
·3· remember.
·4· · · A.· ·I would write -- send it to medical director
·4· · · Q.· ·Okay.· And would they be in any particular
·5· review.
·5· order?
·6· · · Q.· ·And when you say you send it, what is it that
·6· · · A.· ·I don't remember.
·7· you are sending?
·7· · · Q.· ·Okay.· Would you pick from them in any
·8· · · A.· ·I would type up the information and then why
·8· particular order?
·9· they didn't meet, you know, per whatever I was using,
·9· · · A.· ·I would just go down my list just from top to
10· InterQual or Medicaid, and then send it to them.
10· bottom.
11· · · Q.· ·And you'd write it up where?
11· · · Q.· ·Okay.· And then what would come -- besides
12· · · A.· ·On the computer.
12· the name, what would come with that?
13· · · Q.· ·And are you writing up information that you
13· · · A.· ·An attachment with their request, their
14· would have gotten from the patient or from some place
14· information.
15· else?
15· · · Q.· ·And where was that coming from?
16· · · A.· ·From the request that was sent to me.
16· · · A.· ·The people who would receive the fax, and
17· Typically a fax.
17· then they would disburse it out.
18· · · Q.· ·Okay.· So if we could start right from the
18· · · Q.· ·Does that person have a particular job title?
19· beginning so I can understand how this process worked.
19· · · A.· ·I don't remember their job titles.
20· · · · · · · · So you would have -- when you would come
20· · · Q.· ·Is there such a -- are you familiar with the
21· in in the morning, you would have a list of cases --
21· job title of referral specialist?
22· · · A.· ·Yes.
22· · · A.· ·I don't know.
23· · · Q.· ·-- that you would have to deal with?
23· · · Q.· ·Okay.· So you would get an attachment which
24· · · A.· ·Yes.
24· included the request from some other person within
25· · · Q.· ·Do you know about how many there would be on
25· Superior?
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 186 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 92 of 173 Page· 46..49 Page 46
Page 47
·1· · · A.· ·Right.
·1· · · A.· ·Oh, my work?· I would get it from a list. I
·2· · · Q.· ·Okay.· And I have not seen the offices.· Are
·2· guess it was called a queue.· I can't remember.· And
·3· there a lot of people in the office or is the
·3· we would just -- I'd just take it from there.
·4· San Antonio office relatively small?
·4· · · Q.· ·Well, maybe you can help me walk through your
·5· · · A.· ·With the first position, it was a large
·5· day.
·6· office.
·6· · · · · · · · So typically what time did you get to
·7· · · Q.· ·Okay.· That's with the Case Manager II?
·7· work?
·8· · · A.· ·Yes.
·8· · · A.· ·About 7:00.
·9· · · Q.· ·Okay.· And were there other Case Manager
·9· · · Q.· ·And in order to start your work, did you have
10· II's?
10· to do anything, log on or anything like that?
11· · · A.· ·There was maybe one that I remember.
11· · · A.· ·Yes, log into the computer.
12· · · Q.· ·Okay.· Were there pre-authorization nurses?
12· · · Q.· ·Okay.· Would you also log on to phones?
13· · · A.· ·In that office, no.
13· · · A.· ·No, I wouldn't.
14· · · Q.· ·So who else was populating that large office
14· · · Q.· ·Okay.· The kind of work that you were doing
15· while you were a Case Manager II?· Not by name but by
15· was not -- you wouldn't describe it as a call center?
16· job duties.
16· · · A.· ·Not what I was doing.
17· · · A.· ·Right.· No, I -- again, I don't remember
17· · · Q.· ·Okay.· Other people did?
18· their title, but they were I guess member
18· · · A.· ·Yes.
19· coordinators.· I don't remember their title, but they
19· · · Q.· ·Okay.· Would you be on the phone as part of
20· would assist the members.
20· your job?
21· · · Q.· ·Okay.· How would a case get to you?
21· · · A.· ·I would when I'd have to call if somebody has
22· · · A.· ·Again, those two that I worked with, by
22· been denied.
23· e-mail.
23· · · Q.· ·Any other time?
24· · · Q.· ·No.· But just generally speaking, how would a
24· · · A.· ·No.· And, again, when I had to just -- those
25· case get -- how would you get your work?
25· couple of cases that I spoke to the person. Page 48
Page 49
·1· · · Q.· ·Okay.· Was there a medical -- if you didn't
·1· average a day?
·2· approve somebody for care, what would happen to their
·2· · · A.· ·No, I don't remember.· A lot, but I don't
·3· request?
·3· remember.
·4· · · A.· ·I would write -- send it to medical director
·4· · · Q.· ·Okay.· And would they be in any particular
·5· review.
·5· order?
·6· · · Q.· ·And when you say you send it, what is it that
·6· · · A.· ·I don't remember.
·7· you are sending?
·7· · · Q.· ·Okay.· Would you pick from them in any
·8· · · A.· ·I would type up the information and then why
·8· particular order?
·9· they didn't meet, you know, per whatever I was using,
·9· · · A.· ·I would just go down my list just from top to
10· InterQual or Medicaid, and then send it to them.
10· bottom.
11· · · Q.· ·And you'd write it up where?
11· · · Q.· ·Okay.· And then what would come -- besides
12· · · A.· ·On the computer.
12· the name, what would come with that?
13· · · Q.· ·And are you writing up information that you
13· · · A.· ·An attachment with their request, their
14· would have gotten from the patient or from some place
14· information.
15· else?
15· · · Q.· ·And where was that coming from?
16· · · A.· ·From the request that was sent to me.
16· · · A.· ·The people who would receive the fax, and
17· Typically a fax.
17· then they would disburse it out.
18· · · Q.· ·Okay.· So if we could start right from the
18· · · Q.· ·Does that person have a particular job title?
19· beginning so I can understand how this process worked.
19· · · A.· ·I don't remember their job titles.
20· · · · · · · · So you would have -- when you would come
20· · · Q.· ·Is there such a -- are you familiar with the
21· in in the morning, you would have a list of cases --
21· job title of referral specialist?
22· · · A.· ·Yes.
22· · · A.· ·I don't know.
23· · · Q.· ·-- that you would have to deal with?
23· · · Q.· ·Okay.· So you would get an attachment which
24· · · A.· ·Yes.
24· included the request from some other person within
25· · · Q.· ·Do you know about how many there would be on
25· Superior?
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 187 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 93 of 173 Page· 50..53 Page 50
Page 51
·1· · · A.· ·Yes.
·1· · · A.· ·Yes.
·2· · · Q.· ·Would it include clinical information?
·2· · · Q.· ·Okay.· Because otherwise you're just taking
·3· · · A.· ·Yes.
·3· for granted that the DME company is telling you the
·4· · · Q.· ·Okay.· And would it include a doctor's
·4· truth?
·5· records, medical records?
·5· · · A.· ·Right.
·6· · · A.· ·I don't remember for the cases that I did.
·6· · · Q.· ·Okay.· So you would have to have some kind of
·7· · · Q.· ·Well, tell me what you remember that it did
·7· verification that it was -- that there was a medical
·8· include.
·8· basis for the request?
·9· · · A.· ·Yeah, it would include, again, a request from
·9· · · A.· ·Yes.· Yes.
10· the company saying, you know, the patient's name,
10· · · Q.· ·Okay.· And as you sit here today, you don't
11· other information, and then what they're requesting,
11· remember whether that was just the doctor's sign-off
12· the cost; and then they would have like their own
12· on what the DME company sent or whether the doctor had
13· sheet saying whatever, you know, subject can't walk
13· also sent you?
14· or -- I mean, patient can't walk or -- you know, just
14· · · A.· ·Right, I don't remember.
15· their information for requesting stuff.
15· · · Q.· ·Okay.
16· · · Q.· ·Would this be from a -- like a doctor or was
16· · · A.· ·It's so long ago.
17· it just from a rental company?
17· · · Q.· ·And typically how long was this attachment?
18· · · A.· ·The company, the --
18· · · A.· ·It can be anywhere from one page to 20,
19· · · Q.· ·The DME company?
19· 20-something pages.
20· · · A.· ·-- medical equipment company.
20· · · Q.· ·Okay.· And what would you review it for?
21· · · Q.· ·Okay.· So was there medical information?· Was
21· · · A.· ·To see if they qualified for the equipment.
22· there information from a medical provider?
22· · · Q.· ·Okay.· And how would you decide that?
23· · · A.· ·I don't remember.
23· · · A.· ·I would use the procedures, policies, the
24· · · Q.· ·Would the medical provider, a doctor, have to
24· InterQual or the Texas Medicaid book.
25· sign off on it?
25· · · Q.· ·And how would you decide which one to use? Page 52
Page 53
·1· · · A.· ·We would just go through it.· I would just
·1· · · Q.· ·Okay.· That's all you remember?
·2· know, okay, I know this one is not -- or, you know,
·2· · · A.· ·That's all I remember.
·3· they'll tell me this is not in InterQual; it's in this
·3· · · Q.· ·Okay.· I assume you knew more back then?
·4· one.· But we will go through all of them and look for
·4· · · A.· ·Yes.
·5· it, or I would.
·5· · · Q.· ·Okay.
·6· · · Q.· ·Okay.· So can you give me some -- an example
·6· · · A.· ·I'm sorry.
·7· of one that was not in InterQual but would have been
·7· · · Q.· ·And then you said you would review this, and
·8· in some other policy?
·8· if it was something that you couldn't approve that you
·9· · · A.· ·No.· The only one I can think of is maybe a
·9· would send it to a medical director?
10· knee brace.
10· · · A.· ·Yes.
11· · · Q.· ·Okay.· So I assume you -- do you remember --
11· · · Q.· ·And was the medical director present in
12· well, do you remember what policy was used for a knee
12· San Antonio?
13· brace?
13· · · A.· ·No.
14· · · A.· ·I believe it was the Texas Medicaid book.
14· · · Q.· ·Was there a particular medical director that
15· · · Q.· ·Okay.· And who put that out?
15· you would work with?
16· · · A.· ·I don't know.· The state.
16· · · A.· ·No.
17· · · Q.· ·Is that from the State of Texas?
17· · · Q.· ·Do you remember the names of the medical
18· · · A.· ·I believe so.
18· directors that you would work with?
19· · · Q.· ·Okay.· And would that list criteria?
19· · · A.· ·Dr. Layland; Dr. Rodriguez.
20· · · A.· ·Yes.
20· · · Q.· ·Okay.· And so how would you work with them?
21· · · Q.· ·Okay.· Do you remember what those criteria
21· · · A.· ·Again, I would type up the -- their request
22· were?
22· and then would tell them, you know, per the Texas
23· · · A.· ·I don't remember.· All I know is that if it
23· handbook it did not meet criteria, and then just send
24· was used for sports they didn't qualify.· That's all I
24· it to them and they would decide.
25· knew.
25· · · Q.· ·Would you ever have telephone conversations
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 188 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 94 of 173 Page· 54..57 Page 54
Page 55
·1· with the medical directors?
·1· was on there.· I mean, it would be 20 pages because it
·2· · · A.· ·No, I don't -- I don't recall.
·2· was a whole bunch of questions and stuff like that,
·3· · · Q.· ·You don't remember ever talking to any of
·3· and, you know, like that would make it bigger.
·4· them?
·4· · · Q.· ·So the 20 pages -- where I'm getting the
·5· · · A.· ·I don't remember.
·5· 20 pages was you said that sometimes you could get an
·6· · · Q.· ·Okay.· This report -- I think it's like a
·6· attachment that could be anyplace from one to 20
·7· narrative, is that right?
·7· pages.
·8· · · A.· ·Yes.
·8· · · A.· ·Right.
·9· · · Q.· ·Okay.· And so how long was that typically?
·9· · · Q.· ·And so let's say that it was -- was there a
10· · · A.· ·I don't know.
10· typical number of pages?
11· · · Q.· ·Was it relatively short?
11· · · A.· ·No, I don't know.· I don't remember.
12· · · A.· ·It just depends on what they were requesting.
12· · · Q.· ·Okay.· So if you had an attachment that was
13· · · Q.· ·Okay.· And what would you include in your
13· 20 pages, then how much of that 20 pages showed up in
14· narrative?
14· your narrative?
15· · · A.· ·Everything that was sent to me, the
15· · · A.· ·Well, it would be -- my narrative obviously
16· information that was sent to me.
16· would be longer, but I can't give you a precise --
17· · · Q.· ·So if they sent you 20 pages of
17· · · Q.· ·I mean, was it 20 -- was your narrative
18· documentation, would you just repeat the 20 pages of
18· 20 pages long?
19· documentation to the doctor?
19· · · A.· ·No.
20· · · A.· ·20 pages?· Well, I would put everything that
20· · · Q.· ·Okay.· So would you distill the information
21· was pertaining to the wheelchair or whatever it was
21· in the medical record down for the doctor?
22· they're asking.
22· · · A.· ·Yes, I would say.
23· · · Q.· ·And how would you figure out what was
23· · · Q.· ·Okay.· I suspect, and tell me if I'm wrong,
24· pertaining to the wheelchair?
24· that if you get 20 pages of documentation, that
25· · · A.· ·Well, pretty much all the information that
25· there's things in there that are not pertinent?
Page 56
Page 57
·1· · · A.· ·I guess.· I don't know.· I don't remember.
·1· · · A.· ·Well, a case manager, again, that is
·2· · · Q.· ·Okay.· Well, I mean, did you do any more than
·2· different because I am assessing the patient.
·3· just repeat verbatim word for word what was in the --
·3· · · Q.· ·Okay.· So would you use your clinical
·4· · · A.· ·Well, no, not verbatim.
·4· judgment as a case manager?
·5· · · Q.· ·Okay.· So what would you do?· How would you
·5· · · A.· ·As a case manager, yes.
·6· figure out what to tell the doctor?
·6· · · Q.· ·Okay.· Under the pre-cert nurse -- well,
·7· · · A.· ·I would just -- I don't know.· I would just
·7· could you give me some examples of how you would use
·8· get all the information that it had and just write it
·8· your judgment as a case manager, not as a
·9· down, type it down for the doctor.· I mean, I wouldn't
·9· preauthorization nurse, so I could understand this
10· put like every everything.
10· better.· Maybe I could understand the difference
11· · · Q.· ·Right.· How would you decide what to include
11· better.
12· and not to include?
12· · · A.· ·Again, I would go back to diabetes, you know.
13· · · A.· ·Well, everything pertaining to the wheelchair
13· The patient would tell me whether their sugars are
14· or whatever they were asking for.
14· high or -- you know, just give me something, and I
15· · · Q.· ·Right.· So how would you decide what
15· would just say, No, you know, maybe you should go see
16· pertained to the wheelchair?
16· your doctor or -- you know, just make suggestions to
17· · · A.· ·I would look by the guidelines and see --
17· the patient.
18· kind of like match them up.
18· · · Q.· ·Okay.· So under the "Pre Certification
19· · · Q.· ·Were there times when you would have to use
19· Nurse," under the bullet points, I think we've talked
20· your judgment?
20· about the durable medical equipment.· The second
21· · · A.· ·No.
21· bullet point is a skilled nursing request.
22· · · Q.· ·Never?
22· · · · · · · · Do you see that?
23· · · A.· ·Not for the DME because we had to go by the
23· · · A.· ·Yes.
24· book.
24· · · Q.· ·So what is a skilled nursing request?
25· · · Q.· ·How about as a case manager, would you use --
25· · · A.· ·That's if a patient needs -- I don't know --
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 189 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 95 of 173 Page· 58..61 Page 58
Page 59
·1· tube feedings or they need some kind of trach care,
·1· · · A.· ·I don't remember.· I honestly don't remember.
·2· and they would ask for a nurse to go out and assist.
·2· · · Q.· ·Okay.· The third bullet point, it says "Act
·3· · · Q.· ·Okay.· Is this similar to what we talked
·3· as clinical resources to referral staff."
·4· about with the case manager where you would have to
·4· · · · · · · · So who is the referral staff?
·5· decide do you need a nurse or do you need a home
·5· · · A.· ·I don't remember.
·6· health --
·6· · · Q.· ·So when you say act as -- what does it mean
·7· · · A.· ·No.
·7· to act as a clinical resource?
·8· · · Q.· ·Okay.· So tell me -- give me a sense of how
·8· · · A.· ·I don't know.· I can't answer that.
·9· that process played itself out.
·9· · · Q.· ·The end of the sentence, it says "make
10· · · A.· ·They would send a request for the skilled
10· appropriate referrals."
11· nurse.
11· · · · · · · · Do you know what you mean when you said
12· · · Q.· ·And who is "they"?
12· "make appropriate referrals"?
13· · · A.· ·The provider, the one that --
13· · · A.· ·No.
14· · · Q.· ·A doctor?
14· · · Q.· ·Other than what you've written here, is
15· · · A.· ·Yeah, or the home health agency.
15· this -- were there any other duties that you had as
16· · · Q.· ·Okay.· And then what would you do?
16· a -- principal duties that you had as a
17· · · A.· ·Again, I can't remember what -- what we used,
17· pre-certification nurse?
18· if it was our policies and procedures, I believe, or
18· · · A.· ·No.
19· the InterQual; and, again, they would send the medical
19· · · Q.· ·So these include the principal duties of a
20· information and you kind of plug that into that,
20· pre-certification nurse?
21· whatever I was using.· And then, again, if they didn't
21· · · A.· ·Yes.
22· meet, we would send it for medical director review.
22· · · Q.· ·Okay.· The next job you have is "Clinical
23· · · Q.· ·Okay.· And again, and I think you may have
23· Research Nurse," and I assume that was with Worldwide
24· answered this more broadly, but did you ever have any
24· Clinical Trials?
25· conversation with doctors about skilled nursing?
25· · · A.· ·Yes, sir. Page 60
Page 61
·1· · · Q.· ·Okay.· So that would not be with Superior?
·1· You said you would typically get in around 8:00?
·2· · · A.· ·No.
·2· · · A.· ·No.· 7:00.
·3· · · Q.· ·Okay.· Oh, I skipped one.· Under "Pre
·3· · · Q.· ·7:00.· I'm sorry.
·4· Certification Nurse," it says "Provide provider
·4· · · · · · · · Did your hours change when you were --
·5· education."
·5· let's talk about first your time as a case manager,
·6· · · · · · · · What does that mean?
·6· and then we'll move to when you were a
·7· · · A.· ·Again, as I mentioned earlier, if somebody
·7· pre-certification nurse.
·8· didn't qualify, you know, just tell them maybe send
·8· · · A.· ·Okay.
·9· more information.
·9· · · Q.· ·Did you -- was the term also used, a
10· · · Q.· ·Would you suggest what kind of information to
10· "pre-auth nurse"?
11· send?
11· · · A.· ·I believe so.
12· · · A.· ·No.· I would just say if you get more
12· · · Q.· ·Okay.· Are they the same thing, pre-auth and
13· information, just send it in and we can review it
13· pre-certification?
14· again.
14· · · A.· ·I would think so.
15· · · Q.· ·In what way is that providing education?
15· · · Q.· ·Okay.· Because honestly, I've heard both
16· · · A.· ·I guess just letting them know you have
16· terms, and I may call it one from time to time, but I
17· another option.· I mean, you know, you have -- it's
17· mean them to be the same thing, as long as you
18· not the end.· You can try again.
18· understand --
19· · · Q.· ·Would they ask why didn't it pass?
19· · · A.· ·Yes.
20· · · A.· ·They would ask, but I would say the medical
20· · · Q.· ·-- them to be the same thing.
21· director reviewed it.· You will be getting a letter in
21· · · · · · · · Okay.· So let's first talk about the
22· the mail, because they would get one, and then they
22· time that you were a Case Manager II.
23· had a choice to call, and I can't remember what
23· · · A.· ·Yes, sir.
24· department to speak to.
24· · · Q.· ·So that was from April 2011 --
25· · · Q.· ·Okay.· Now, I jumped around a little bit.
25· · · A.· ·To about February of 2012.
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 190 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 96 of 173 Page· 78..81 Page 78
Page 79
·1· · · Q.· ·Okay.· And you also described and said "we.
·1· · · · · · · · (Recess.)
·2· · · A.· ·Oh, I was just saying other coworkers that
·2· · · Q.· ·(BY MR. KAISER)· Okay.· Ms. De Leon, I did
·3· started with me.
·3· have a follow-up question.· It's the risk of taking
·4· · · Q.· ·Okay.· Because when you were the Case Manager
·4· breaks.
·5· II, it was really just you?
·5· · · · · · · · As a Case Manager II, would you develop
·6· · · A.· ·Right.
·6· case -- care plans?
·7· · · Q.· ·But when you were a pre-auth, or
·7· · · A.· ·As I said earlier, I honestly didn't work a
·8· pre-certification nurse, were you the only
·8· lot as a case manager.· From day one, they had me
·9· pre-certification nurse in San Antonio?
·9· doing DME.· Like I said, maybe it was one or two cases
10· · · A.· ·No.· It was a team.
10· that there was just a follow-up call.
11· · · Q.· ·And how many were there?
11· · · Q.· ·Okay.· We were describing the time frame --
12· · · A.· ·That were doing the under 21, I think it was
12· so when you were a case manager, you were really just
13· just two other ones.
13· a pre-auth nurse?
14· · · Q.· ·And who were they?
14· · · A.· ·I would say yes.
15· · · A.· ·Maria and Gina.
15· · · Q.· ·Okay.
16· · · Q.· ·Do you know Maria's last name?
16· · · A.· ·Yeah.· And I did bring it up to my supervisor
17· · · A.· ·Batista I believe.
17· that I wanted to do -- learn more case management, but
18· · · Q.· ·Okay.· Can you spell that?
18· all I did was pretty much DME.
19· · · A.· ·No.
19· · · Q.· ·Okay.· When you were a pre-certification
20· · · Q.· ·Okay.
20· nurse, you said at some point two or three weeks after
21· · · A.· ·Sorry.
21· you finished training -- I assume when you were in
22· · · · · · · · THE REPORTER:· When you get a chance,
22· training you had regular hours, right?
23· let's take a break.
23· · · A.· ·I would say so, yes.
24· · · · · · · · MR. KAISER:· Okay.· We can take a break
24· · · Q.· ·Okay.· Was the training conducted here or
25· now.· Sure.
25· elsewhere? Page 80
Page 81
·1· · · A.· ·In Austin.
·1· · · Q.· ·Okay.· And then you came back to San Antonio
·2· · · Q.· ·In Austin?
·2· as a pre-certification nurse?
·3· · · A.· ·Yes.
·3· · · A.· ·Yes.
·4· · · Q.· ·Okay.· So were you in a hotel?
·4· · · Q.· ·And did you office in the same office that
·5· · · A.· ·Yes.
·5· you had when you had been a case manager?
·6· · · Q.· ·You didn't travel back and forth every day?
·6· · · A.· ·No.
·7· · · A.· ·Just on the weekend.
·7· · · Q.· ·A different office?
·8· · · Q.· ·Okay.· Do you remember where it is that you
·8· · · A.· ·It was a different location.
·9· stayed?
·9· · · Q.· ·Okay.· And you had earlier described the
10· · · A.· ·No.
10· other location as having a fair number of people
11· · · Q.· ·Okay.· And that was all -- the training was
11· there?
12· all provided by --
12· · · A.· ·Yes.
13· · · A.· ·Yes.
13· · · Q.· ·Did this office have a fair number of people
14· · · Q.· ·-- Thea?
14· as well?
15· · · A.· ·Thea, yes.
15· · · A.· ·Initially it did, and then they opened
16· · · Q.· ·Okay.· And do you remember what the hours
16· another location, and I think everybody else left
17· were when you were in training?
17· except -- we stayed behind, and I want to say
18· · · A.· ·No.· I don't remember if it was 8:00 to --
18· concurrent review.
19· 8:00 or 9:00 to maybe 4:00 or 5:00.· I don't remember.
19· · · Q.· ·How many Superior Health Plan offices were
20· · · Q.· ·Okay.· And would you get a lunch when you
20· there in San Antonio while you were a
21· were in training?
21· pre-certification nurse?
22· · · A.· ·Yes.
22· · · A.· ·It was just two.
23· · · Q.· ·Okay.· So you didn't work any more than eight
23· · · Q.· ·Okay.· And was it -- but it was a different
24· hours in a day?
24· office than when you had been a case manager?
25· · · A.· ·Not in training.
25· · · A.· ·Yes.
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 191 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 97 of 173 Page· 86..89 Page 86
Page 87
·1· · · A.· ·To make an assessment?
·1· · · Q.· ·Okay.· Were you getting it from the person
·2· · · Q.· ·Yeah.
·2· who had entered that data?
·3· · · A.· ·Well, there was really nothing to assess
·3· · · A.· ·I don't know.· I don't know who would put it
·4· except the information that was sent to us to review.
·4· into our boxes.
·5· · · Q.· ·Okay.
·5· · · Q.· ·Okay.· Could a referral specialist do your
·6· · · A.· ·But I don't remember what those
·6· job as a pre-authorization nurse?
·7· qualifications were.
·7· · · A.· ·As a pre-authorization nurse?· I would say
·8· · · Q.· ·Okay.· You've had a little bit of time to
·8· yes.
·9· think about it.· Does the title "referral specialist"
·9· · · Q.· ·How come?
10· sound familiar to you?
10· · · A.· ·Because you have all the criteria you need in
11· · · A.· ·Referral specialist?· No.
11· front of you --
12· · · Q.· ·So when a request first came in, there would
12· · · Q.· ·Okay.
13· be some kind of data entry that would be listing like
13· · · A.· ·-- and you have to go by that criteria.· You
14· the person's name --
14· can't deviate.
15· · · A.· ·Right.
15· · · Q.· ·Okay.· Could they have done your job as a
16· · · Q.· ·-- and their address and then kind of
16· case manager?
17· administrative or clerical work?
17· · · A.· ·As a case manager, I would say no.
18· · · A.· ·Yes.
18· · · Q.· ·Okay.· Could they have done your job as a
19· · · Q.· ·Who did that?
19· case manager?
20· · · A.· ·I don't remember.
20· · · A.· ·As the case manager there, probably so,
21· · · Q.· ·Okay.· It wasn't you?
21· again, because all I did was DME for the most part.
22· · · A.· ·No.
22· · · Q.· ·Okay.· Have you ever seen your job
23· · · Q.· ·Okay.· By the time you got it, that had
23· description as a pre-authorization nurse?
24· already been done?
24· · · A.· ·I'm sure I have.· I just don't remember it.
25· · · A.· ·Yes.
25· · · Q.· ·Okay. Page 88
Page 89
·1· · · · · · · · (Deposition Exhibit 5 marked.)
·1· · · A.· ·Well, because I don't remember really talking
·2· · · · · · · · THE REPORTER:· Exhibit 5.
·2· to referral specialists.
·3· · · · · · · · (Document tendered.)
·3· · · Q.· ·I don't understand what you mean by "for this
·4· · · Q.· ·(BY MR. KAISER)· You've been handed what's
·4· case.
·5· been marked as Exhibit 5.
·5· · · A.· ·I meant for this job right here (indicating.
·6· · · · · · · · Have you seen that before?
·6· · · Q.· ·Well, how about for your résumé, is your
·7· · · A.· ·I don't remember.· I may have.
·7· résumé truthful?
·8· · · Q.· ·Okay.· So does this accurately reflect your
·8· · · · · · · · MR. BAGGIO:· Objection, asked and
·9· job description as a pre-certification nurse?
·9· answered.
10· · · A.· ·From my experience, I pretty much just did
10· · · Q.· ·(BY MR. KAISER)· Is that untruthful -- when
11· review the requests, the pre-authorizations and sent
11· you send this out, are you lying to prospective
12· them for review.
12· employers when you say that you act as a clinical
13· · · Q.· ·Did you also act as a clinical resource to
13· resource for referral staff?
14· referral specialists?
14· · · A.· ·I honestly don't know because I don't
15· · · A.· ·Not that I recall.
15· remember if I did it or not.
16· · · Q.· ·So why would you include that on your résumé?
16· · · Q.· ·Okay.· You don't remember when you wrote this
17· · · A.· ·Maybe because it was on here.
17· Exhibit 1?
18· · · Q.· ·Well, is it truthful that you did that?
18· · · A.· ·I don't remember the date --
19· · · A.· ·Looking back, probably not, no.
19· · · Q.· ·Okay.
20· · · Q.· ·So then is your résumé not truthful?
20· · · A.· ·-- of when I wrote it.
21· · · A.· ·I would say for the most part, yes.
21· · · Q.· ·Are you still at -- are you still at
22· · · Q.· ·Well, does that mean that in some parts it's
22· Worldwide Clinical Trials?
23· untruthful?
23· · · A.· ·Yes.
24· · · A.· ·Well, probably for this case I would say yes.
24· · · Q.· ·Okay.· Are you still a clinical research
25· · · Q.· ·What do you mean "for this case"?
25· nurse?
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 192 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 98 of 173 Page· 94..97 Page 94
Page 95
·1· · · A.· ·Yes.
·1· · · Q.· ·-- "As Julia's role and duties continue to
·2· · · Q.· ·And then you have "Employee Comments"?
·2· expand she will be communicating with more members
·3· · · A.· ·Okay.
·3· ensuring their needs are being identified and concerns
·4· · · Q.· ·It refers to educating your team members.
·4· are addressed."
·5· · · · · · · · Who were your team members?
·5· · · · · · · · Do you see that?
·6· · · A.· ·That would be like my other under 21 that may
·6· · · A.· ·Yes.
·7· have questions.
·7· · · Q.· ·Was there a time when you did that?
·8· · · Q.· ·Were you -- you were -- thisis -- is this
·8· · · A.· ·No, sir.
·9· evaluation for while you were a pre-auth nurse?
·9· · · · · · · · MR. KAISER:· This is Exhibit 7, right?
10· · · A.· ·Yes.
10· · · · · · · · THE REPORTER:· Yes.
11· · · Q.· ·Okay.
11· · · · · · · · (Deposition Exhibit 7 marked.)
12· · · A.· ·I believe so because that's the only -- well,
12· · · · · · · · (Document tendered.)
13· I would say yes, because that's when Valerie was my
13· · · Q.· ·(BY MR. KAISER)· So I've handed you what has
14· supervisor.
14· been marked as Exhibit 7, which I believe might be
15· · · Q.· ·Okay.· It said -- I'm following it again for
15· notes that you maintained on particular cases.
16· "Employee Comments."· "By educating the team on DME
16· · · A.· ·Okay.
17· they are better able to make sure our members are
17· · · Q.· ·I mean, but my first question is going to be,
18· receiving the proper equipment."
18· are these notes that you would have maintained on
19· · · · · · · · What do you mean by that?
19· cases?
20· · · A.· ·Since I had experience with the Texas
20· · · A.· ·Yes.
21· handbook, they would ask me questions like where is
21· · · Q.· ·Okay.· Now, they talk about "Event review
22· this at or -- so I would just help them find sections.
22· created for Layland, David."
23· · · Q.· ·So do you see under the "Manager Comments" on
23· · · · · · · · Do you see that?
24· that same section at the very bottom --
24· · · A.· ·Yes.
25· · · A.· ·Yes.
25· · · Q.· ·Is that Dr. Layland you referred to earlier? Page 96
Page 97
·1· · · A.· ·Yes.
·1· · · A.· ·They would send me that information.
·2· · · Q.· ·Okay.· So under -- it says "Requestor's
·2· · · Q.· ·What is it that they would send you?
·3· Comments."
·3· · · A.· ·The patient's -- like their diagnosis and
·4· · · · · · · · What are those?
·4· information that --
·5· · · A.· ·That would be what was sent to me.
·5· · · Q.· ·So give me an example, for example, of what
·6· · · Q.· ·Okay.· And you would just summarize the basic
·6· would be -- what would tell you that the person had --
·7· information that they requested or you included
·7· I lost track -- developmental delay.
·8· everything that they've sent?
·8· · · A.· ·I mean, it would state on their request.
·9· · · A.· ·I don't know.· I don't remember if they would
·9· · · Q.· ·It would say the words "developmental delay"?
10· do everything or not.
10· · · A.· ·I would say yes.
11· · · Q.· ·Okay.· I mean, this is pretty short.
11· · · Q.· ·It wouldn't say -- if it said, for example,
12· · · A.· ·Right.
12· Down Syndrome --
13· · · Q.· ·In fact, all of them are pretty short.
13· · · A.· ·Then I would put Down Syndrome.
14· · · · · · · · Are these typical, the length of these?
14· · · Q.· ·You wouldn't say "developmental delay"?
15· · · A.· ·It just depends what they were asking for.
15· · · A.· ·No.
16· · · Q.· ·Right.· But on average, are these generally
16· · · Q.· ·And it says "ANT process."· What's "ANT"?
17· the size of the event notes that would -- that you
17· · · A.· ·I don't remember.· Albertal (phonetic) in --
18· would enter?
18· I can't remember what the "T" stands for.
19· · · A.· ·I would say yes.
19· · · Q.· ·That would be your process, though, right?
20· · · Q.· ·Okay.· So it says "Per request patient with
20· That wouldn't be the request -- the requestor wouldn't
21· developmental delay and incontinence."
21· talk about the ANT process?
22· · · · · · · · Do you see that?
22· · · A.· ·No.
23· · · A.· ·Yes.
23· · · Q.· ·That would be your -- would that describe
24· · · Q.· ·And how would you decide whether the patient
24· where your process started?
25· had developmental delay?
25· · · A.· ·Yeah, that's my department.
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 193 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 99 of 173 Page· 98..101 Page 98
Page 99
·1· · · Q.· ·Okay.· So when it says "ANT process
·1· · · Q.· ·Is that something that you would have learned
·2· initiated," that was by you?
·2· in nursing school?
·3· · · A.· ·Right.
·3· · · A.· ·Something that I would learn in nursing
·4· · · Q.· ·Okay.· And then it says "requesting provider
·4· school?
·5· submit," and then there is stuff that you wanted
·5· · · Q.· ·Or through your experience as a nurse.
·6· submitted.· That request would have come from you?
·6· · · A.· ·Probably not.· I don't -- I don't remember
·7· · · A.· ·Right, if we're missing information.
·7· what it's pertaining to.
·8· · · Q.· ·Not "we."· You?
·8· · · Q.· ·Would you expect that, for example, a
·9· · · A.· ·Me.· Sorry.
·9· referral specialist would be able to understand what
10· · · Q.· ·Right.· Okay.· So when it says "accurate
10· accurate diagnostic information was?
11· diagnostic information," what do you mean by "accurate
11· · · A.· ·I would just say depending on their
12· diagnostic information"?
12· background.
13· · · A.· ·I don't know.· I don't remember what it would
13· · · Q.· ·So what kind of background would they need to
14· tell you.
14· make -- make it so that they were skilled enough to do
15· · · Q.· ·What would be inaccurate diagnostic
15· that?
16· information?
16· · · A.· ·I don't know.
17· · · A.· ·I don't know.
17· · · Q.· ·I mean, they'd need a medical background,
18· · · Q.· ·Is there a difference between accurate
18· right?
19· diagnostic information and inaccurate diagnostic
19· · · · · · · · MR. BAGGIO:· Objection, mischaracterizes
20· information?
20· prior testimony.
21· · · A.· ·I guess accurate is correct and inaccurate
21· · · Q.· ·(BY MR. KAISER)· You don't know?
22· would be wrong.
22· · · A.· ·No.
23· · · Q.· ·Right.· So how would you decide whether it's
23· · · Q.· ·I mean, could I pull somebody off the street
24· correct or not correct?
24· and have them do that?
25· · · A.· ·I don't remember.
25· · · A.· ·Maybe. Page 100
Page 101
·1· · · Q.· ·What would it depend on?
·1· · · A.· ·I don't remember.
·2· · · A.· ·Well, if they know how to read.
·2· · · Q.· ·Okay.· Is the glossary attached to InterQual
·3· · · Q.· ·So all they have to do is be able to speak
·3· or all of them?
·4· English?
·4· · · A.· ·I don't remember.
·5· · · A.· ·Well, they would have to know how to read to
·5· · · Q.· ·Okay.· So let's mark -- well, let me --
·6· read protocols and what their -- I mean, not
·6· let's -- if you don't mind, take a look at Page 75.
·7· protocols.· Read the information they have in front of
·7· It's the second-to-last page.· And I'm looking at a
·8· them.
·8· request, and it looks like -- it says "Encounter Date
·9· · · Q.· ·Okay.· What kind of things would they have to
·9· 12/1/12."
10· read?
10· · · · · · · · Do you see that?
11· · · A.· ·What kind of things they would have to read?
11· · · A.· ·Yes.
12· · · Q.· ·Yeah.
12· · · Q.· ·And it's for Cranial Technologies.· That's
13· · · A.· ·First of all, the request.
13· the requestor I guess?
14· · · Q.· ·Okay.
14· · · A.· ·Yes.
15· · · A.· ·InterQual; the handbook; the policies.
15· · · Q.· ·Okay.· I just want to make sure we're on the
16· · · Q.· ·And they'd have to understand what the terms
16· same one.
17· meant, right?
17· · · · · · · · So what is this for?
18· · · A.· ·Yes.
18· · · A.· ·Oh, for a helmet.
19· · · Q.· ·Okay.· I mean, there are some terms that are
19· · · Q.· ·And what's the medical condition?
20· used that are really -- even in the policies that are
20· · · A.· ·It's congenital skull deformity.
21· very technical, aren't there?
21· · · Q.· ·What does it mean to have a congenital skull
22· · · A.· ·Right, but there is a glossary, because there
22· deformity?
23· is some terms I didn't understand.
23· · · A.· ·If they're born with their skull not formed
24· · · Q.· ·Okay.· So let me hand you -- where is the
24· properly.
25· glossary?
25· · · Q.· ·And how would you know what a congenital
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 194 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 100 of 173 Page· 102..105 Page 102
Page 103
·1· skull deformity is?
·1· · · A.· ·How would I know?
·2· · · A.· ·You can look it up I would say.
·2· · · Q.· ·Yeah.· How would you know that somebody's
·3· · · Q.· ·Did you have to look that up in order to do
·3· skull is not formed properly?
·4· this?
·4· · · A.· ·By looking at the person.
·5· · · A.· ·I didn't have to look it up.
·5· · · Q.· ·Okay.· Well, you're not looking at a person
·6· · · Q.· ·Okay.· Why not?
·6· when you --
·7· · · A.· ·Because I've had a lot of experience working
·7· · · A.· ·Right.
·8· with these.
·8· · · Q.· ·-- look at these, right?
·9· · · Q.· ·And what kind of experience?
·9· · · · · · · · Okay.· What were you looking at to
10· · · A.· ·Or I -- I was used to doing the requests.
10· determine whether the person had a congenital skull
11· · · Q.· ·So before you ever walked into Superior
11· deformity?
12· Health Plan, did you understand what the word
12· · · A.· ·The information that was sent to me.
13· "congenital" meant?
13· · · Q.· ·Okay.· So it says -- if you go down a couple
14· · · A.· ·Yes.
14· lines, it says "Per request patient with" -- I don't
15· · · Q.· ·Okay.· Where did you learn that?
15· even know how to say it.
16· · · A.· ·In nursing school.
16· · · · · · · · Do you see where I'm referring to?
17· · · Q.· ·Okay.· And it means what?
17· · · A.· ·Yes.
18· · · A.· ·It's just the -- I don't remember at this
18· · · Q.· ·Can you tell me what that is because there's
19· time.· I'm sorry.
19· no way I'm going to pronounce it.
20· · · Q.· ·You don't remember what you learned the term
20· · · A.· ·Plagiocephaly.
21· "congenital" meant?
21· · · Q.· ·P-l-a-g-i-o-c-e-f -- or c-e-p-h-a-l-y. I
22· · · A.· ·The "congenital," no.
22· can't even spell it.
23· · · Q.· ·Okay.· And what is a skull deformity?
23· · · · · · · · What is that?
24· · · A.· ·When the skull is not formed properly.
24· · · A.· ·I wouldn't be able to tell you off the top of
25· · · Q.· ·Okay.· And how would you know that?
25· my head. Page 104
Page 105
·1· · · Q.· ·Okay.· At the time you wrote this did you
·1· · · Q.· ·Would it include blood type?
·2· know what it meant?
·2· · · A.· ·No.
·3· · · A.· ·I guess.· I don't remember.
·3· · · Q.· ·Would you get medical records to review for a
·4· · · Q.· ·And then the next sentence says "Relevant
·4· request like this?
·5· medical history."
·5· · · A.· ·Again, I don't remember.· I know they would
·6· · · · · · · · Do you see that?
·6· send -- I can't remember what type of information they
·7· · · A.· ·Yes.
·7· would send me, but it was...
·8· · · Q.· ·How do you decide what's relevant for a
·8· · · Q.· ·When it says "etiology positional," what does
·9· person with plagiocephaly?
·9· that mean?
10· · · A.· ·I don't know.· I just put whatever they sent
10· · · A.· ·The cause of it, the cause of the congenital
11· me.
11· defect.
12· · · Q.· ·Well, you sent a hundred percent of whatever
12· · · Q.· ·So in this case, what was the cause of the
13· they sent you?
13· congenital defect?
14· · · A.· ·I'm sorry?
14· · · A.· ·Positional, which means I guess they only had
15· · · Q.· ·You sent a hundred percent of whatever they
15· him only on one side more often than others.
16· sent you or --
16· · · Q.· ·So how is that congenital?
17· · · A.· ·No.· I said I wrote -- I typed whatever they
17· · · A.· ·It's not.
18· sent me.
18· · · Q.· ·Where it says "DOC band treatment
19· · · Q.· ·Well, how would you decide what's relevant
19· recommended," what does that mean?
20· and not relevant?
20· · · A.· ·I don't remember what that means.
21· · · A.· ·I don't know.· I'd say whatever the --
21· · · Q.· ·Do you remember what "band treatment" is?
22· whatever information they sent me.
22· · · A.· ·No.
23· · · Q.· ·Well, would the information typically
23· · · Q.· ·Okay.· It does refer to "Did not meet
24· include, for example, the weight of the baby?
24· criteria per TX.UM.10.16," right?
25· · · A.· ·I don't remember.· Not for these, no.
25· · · A.· ·Yes.
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 195 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 101 of 173 Page· 134..137 Page 134
Page 135
·1· · · A.· ·Four or five criteria?
·1· · · Q.· ·Okay.· And so what goes into parts of a
·2· · · Q.· ·Yeah.
·2· wheelchair?
·3· · · A.· ·I would say some a little more, but...
·3· · · · · · · · I mean, I assume you don't have to
·4· · · Q.· ·So you've got 20 pages of medical
·4· separately cost out wheels and handles, right?
·5· documentation, and you've got, say, 10 criteria.· So
·5· · · A.· ·Yes, you would.
·6· why would it take three hours?
·6· · · Q.· ·You have to --
·7· · · A.· ·Because then you have to type up the report
·7· · · A.· ·It would depend.· Like the -- I don't know.
·8· and send it in.
·8· Say those -- not the manual wheelchairs.· The ones
·9· · · Q.· ·How long would it take to type up the report?
·9· with the battery would have casters, wheels, the back
10· · · A.· ·I don't know.
10· rest.· Everything was pretty much itemized.
11· · · Q.· ·So these would -- these exhibits --
11· · · Q.· ·There's a basic model, though, right?
12· Exhibit 7, those would be like examples of the reports
12· · · A.· ·Yes.
13· that you would type up, right?
13· · · Q.· ·Okay.· And so would you have to make an
14· · · A.· ·Right.· No, these wouldn't take three hours.
14· assessment for each component of that wheelchair as to
15· · · Q.· ·Okay.· Were some of them much longer?
15· whether it was medically necessary?
16· · · A.· ·Typically like the wheelchairs.
16· · · · · · · · MR. BAGGIO:· Objection, mischaracterizes
17· · · Q.· ·They were what?· They were much longer than
17· prior testimony.
18· what we've seen?
18· · · A.· ·No.· I mean, I would just write everything
19· · · A.· ·Yes, because we'd have to type up the cost of
19· down.
20· each and every part that they were asking for.
20· · · Q.· ·(BY MR. KAISER)· Right.· But would you have
21· · · Q.· ·You don't get a wheelchair just as -- it
21· to decide whether casters were necessary?
22· doesn't come as a unit?
22· · · A.· ·I wouldn't decide.
23· · · A.· ·No.
23· · · · · · · · MR. BAGGIO:· Objection, mischaracterizes
24· · · Q.· ·You've got to buy the parts?
24· prior testimony.· I'm sorry.
25· · · A.· ·The more complex wheelchairs, yes.
25· · · A.· ·I wouldn't do that.· I would just type it up Page 136
Page 137
·1· for the doctor.
·1· · · Q.· ·Okay.
·2· · · Q.· ·(BY MR. KAISER)· Well, what if you approved
·2· · · A.· ·I can't tell you the exact number.
·3· it?
·3· · · Q.· ·What were your most common requests for
·4· · · A.· ·I don't think I was allowed to approve
·4· durable medical equipment?
·5· anything over a certain amount.
·5· · · A.· ·The most common requests were like diapers.
·6· · · Q.· ·How much?
·6· · · Q.· ·Okay.
·7· · · A.· ·I don't remember.· I don't remember if it was
·7· · · A.· ·Ensure.
·8· like over 1,500.
·8· · · Q.· ·Was there a predetermined amount of time that
·9· · · Q.· ·Can you get a motorized wheelchair for that
·9· you could approve diapers for?
10· little?
10· · · A.· ·I don't remember.
11· · · A.· ·I don't know.· I don't remember.
11· · · Q.· ·Was it an up-to number, you can do it up to
12· · · Q.· ·Did you ever approve requests for motorized
12· 30 days or up to 60 days or up to 90 days?
13· wheelchairs?
13· · · A.· ·I don't remember.
14· · · A.· ·I don't remember approving any.
14· · · Q.· ·Okay.· Could you approve it for less than the
15· · · Q.· ·Okay.· So let's talk about the ones you would
15· amount of time that they asked for?
16· have approved.· Would those have been just the manual
16· · · A.· ·I don't remember.
17· wheelchairs?
17· · · Q.· ·Will you look at Exhibit 7 again, the very
18· · · A.· ·Yes.
18· last page.
19· · · Q.· ·Okay.· And do those have like individual
19· · · · · · · · This is for CF Medical Supplies?
20· component parts also?
20· · · A.· ·Yes.
21· · · A.· ·No.
21· · · Q.· ·Right?· Okay.
22· · · Q.· ·Okay.· So for a manual -- how many requests
22· · · · · · · · So it says "Coverage: Waiver."· What
23· for a motorized wheelchair would you get?· Would you
23· does that mean?
24· get a lot of them or not a lot of them?
24· · · A.· ·I know that was for the over 21 side. I
25· · · A.· ·I remember getting a few.
25· can't remember.· I think the waiver was an additional
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 196 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 102 of 173 Robin Lorie Desalvo 5/28/2014 1
UNITED STATES DISTRICT COURT WESTERN DISTRICT OF TEXAS AUSTIN DIVISION
2 3 4 5
KATHY CLARK, AMY ENDSLEY, SUSAN GRIMMETT, MARGUERIETTE SCHMOLL, AND KEVIN ULRICH, ON BEHALF OF THEMSELVES AND ALL OTHERS SIMILARLY SITUATED,
6
Plaintiffs, 7
V. 8 9 10
Page: 1
CENTENE CORPORATION, CENTENE COMPANY OF TEXAS, L.P., AND SUPERIOR HEALTHPLAN, INC.,
11
Defendants.
§ § § § § § § § § § § § § § § § §
Civil Action No. 1:12-CV-00174-SS JURY DEMANDED
12 13 14
**************************************************
15
ORAL DEPOSITION OF
16
ROBIN LORIE DESALVO
17
MAY 28, 2014
18
**************************************************
19 20 21 22 23 24 25
ORAL DEPOSITION OF ROBIN LORIE DESALVO, produced as a witness at the instance of the Plaintiffs, and duly sworn, was taken in the above-styled and numbered cause on the 28th day of May, 2014, from 1:48 p.m. to 4:22 p.m., before Cynthia Warren, Certified Shorthand Reporter in and for the State of Texas, reported by machine shorthand, at the offices of Boulette & Golden, LLP, 2801 Via Fortuna, Suite 350, Austin, Texas 78746, pursuant to the Federal Rules of Civil Procedure and the provisions stated on the record.
800-545-9668 612-339-0545
Paradigm Reporting & Captioning www.paradigmreporting.com
Appendix Volume 2, p. 197
#79138
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 103 of 173 Robin Lorie Desalvo 5/28/2014 1 2
Q.
Page: 30
And do you recall ever during that time frame
requiring mandatory overtime?
3
A.
I don't recall mandatory, no, ma'am.
4
Q.
If you required the nurses to work extra hours
5
above 40, did you need to get approval from your
6
supervisor to do so?
7
A.
I'm not sure how to answer that question.
8
Q.
Do you know the names of the plaintiffs in this
9
Yes.
case?
10
A.
I know a few of them.
11
Q.
Who do you know is involved in this case?
12
A.
Margueriette Schmoll.
13
Q.
And how do you know Ms. Schmoll?
14
A.
She was a prior authorization nurse.
15
Q.
And do you supervise her work?
16
A.
Yes, ma'am.
17
Q.
Do you remember if she's a Case Manager I or
19
A.
I believe she was a Case Manager I.
20
Q.
Did you hire her?
21
A.
Yes, ma'am.
22
Q.
Did you set her schedule?
23
A.
Yes, it was agreed upon.
24
Q.
What do you mean, it was agreed upon?
25
A.
That she would work her schedule 8:00 to 5:00.
18
II?
800-545-9668 612-339-0545
Paradigm Reporting & Captioning www.paradigmreporting.com
Appendix Volume 2, p. 198
#79138
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 104 of 173 Robin Lorie Desalvo 5/28/2014 1
Page: 40
termination?
2
A.
Did I?
3
Q.
Did you?
4
A.
No.
5
Q.
Could you?
6
A.
No.
7
Q.
You didn't have any authority to recommend her
8
for termination if she weren't meeting productivity
9
standards or had some performance issues?
10
A.
What time frame are you talking about?
11
Q.
When you were her supervisor.
12
A.
Yes.
13
Q.
Yes what?
14
A.
I could make determinations on her performance.
15
Q.
When you were her supervisor who was your
16
employer?
17 18
A.
At that time I believe my checks were from
Bankers.
19
Q.
Did you -- besides supervising Ms. Schmoll,
20
were you supervising other nurses who were not a part of
21
the foster care section?
22
A.
It would -- time frame.
23
Q.
During the time that you were a supervisor.
24
From January of 2011 to October of 2012 when you were
25
the supervisor of utilization management prior
800-545-9668 612-339-0545
Paradigm Reporting & Captioning www.paradigmreporting.com
Appendix Volume 2, p. 199
#79138
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 105 of 173 Robin Lorie Desalvo 5/28/2014 1
5:00?
2
A.
8:00 to 5:00.
3
Q.
Was that the standard within your group in
4
terms of the schedule?
5
A.
We had nurses that worked 8:00 to 5:00 and
6
those that worked 9:00 to 6:00 because we cover the
7
whole state of Texas.
8 9
Page: 43
Q.
So is it sort of like a staggered shift
starting an hour earlier and ending an hour later?
10
A.
Yes, ma'am.
11
Q.
Were the nurses that you supervised assigned to
12
specific parts of the state of Texas depending on what
13
shift they worked on?
14
A.
No, ma'am.
15
Q.
Earlier when you were describing sort of the
16
layout of the office and the fact that you could -- you
17
would walk around and you could see them working at
18
their desk, was that -- could you do that for the time
19
period when you were a supervisor of utilization
20
management prior authorization?
21
A.
Yes, ma'am.
22
Q.
Did you have any meetings that you required the
23
nurses that you supervised to attend outside of their
24
scheduled shift?
25 800-545-9668 612-339-0545
A.
Yes. Paradigm Reporting & Captioning www.paradigmreporting.com
Appendix Volume 2, p. 200
#79138
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 106 of 173 Robin Lorie Desalvo 5/28/2014 1
MR. KAISER:
So, for example, you see the
2
word -- let me find one in here.
3
here where it says --
4
Q.
(By Ms. Srey)
5 6
THE WITNESS: A.
Right.
I'm not sure because that's an internal --
that's an internal e-mail address, so I'm not really sure why.
11 12
Or any of them, see the word
"external" shows up.
8
10
So you see right up in
Deedra Coker?
MR. KAISER:
7
9
Page: 69
Q.
(By Ms. Srey)
And so the meeting that you set
up was from 4:00 p.m. to 5:30 p.m.
Do you see that?
13
A.
Yes, ma'am.
14
Q.
So if someone's scheduled shift ended at 5:00,
15
were they required to stay late until the meeting ended?
16
A.
Yes, ma'am.
17
(Exhibit No. 19 marked.)
18
Q.
I handed you Exhibit 19.
It appears to be an
19
e-mail chain.
20
the chain and let me know when you've completed it.
If you want to take a moment to look at
21
A.
Yes, ma'am.
22
Q.
For the nurses that you supervised could they
23
work from home?
24
A.
Yes, ma'am.
25
Q.
And they could -- they worked from home after
800-545-9668 612-339-0545
Paradigm Reporting & Captioning www.paradigmreporting.com
Appendix Volume 2, p. 201
#79138
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 107 of 173 Page 1
·1· · · · · · ·IN THE UNITED STATES DISTRICT COURT · · · · · · · · FOR THE WESTERN DISTRICT OF TEXAS ·2· · · · · · · · · · · ·AUSTIN DIVISION ·3· · · ·4· · · ·5· · · ·6· · · ·7· · · ·8· · · ·9· · · 10·
·KATHY CLARK, AMY ENDSLEY,· · ) ·SUSAN GRIMMETT, MARGUERITE· ·) ·SCHMOLL, and KEVIN ULRICH, ON) ·BEHALF OF THEMSELVES AND ALL ) ·OTHERS SIMILARLY SITUATED,· ·) · · · · · · · · · · · · · · · ) · · · · · ·Plaintiffs,· · · · ) ·vs.· · · · · · · · · · · · · ) CASE NO. 1:12-CV-00174-SS · · · · · · · · · · · · · · · ) ·CENTENE CORPORATION, CENTENE ) ·COMPANY OF TEXAS, L.P., and· ) ·SUPERIOR HEALTHPLAN, INC.,· ·) · · · · · · · · · · · · · · · ) · · · · · ·Defendants.· · · · ) ·---------------------------------------------------------
11· · · · · · · · · · · ·ORAL DEPOSITION 12· · · · · · · · · · · ·CORDELIA GARCIA 13· · · · · · · · · · · · ·JULY 1, 2014 14· ·--------------------------------------------------------15· · · ·ORAL DEPOSITION OF CORDELIA GARCIA, produced as a 16· ·witness at the instance of the Defendants and duly 17· ·sworn, was taken in the above-styled and numbered cause 18· ·on the 1st day of July, 2014, from 1:57 p.m. to 19· ·4:36 p.m., before Jean Thomas Fraunhofer, Certified 20· ·Shorthand Reporter in and for the State of Texas, 21· ·reported by computerized stenotype machine at the 22· ·offices of BOULETTE & GOLDEN, LLP, 2801 Via Fortuna, 23· ·Suite 530, Austin, Texas 78746, pursuant to the Federal 24· ·Rules of Civil Procedure and the provisions stated on 25· ·the record or attached hereto. FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 202
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 108 of 173 Page· 33
·1· ·Centene entering data into a computer system to -- you ·2· ·know, for reporting in terms of what cases had been ·3· ·approved and what cases needed medical director review? ·4· · · ·A.· ·I'm sorry.· Can you repeat that again? ·5· · · ·Q.· ·Sure.· When you were working at Centene, do you ·6· ·remember entering data into a system to report the ·7· ·result of the work that you had done at the end of the ·8· ·day? ·9· · · ·A.· ·Yes. 10· · · ·Q.· ·And it was called case manager or Care Manager? 11· · · ·A.· ·CareEnhance Care Manager. 12· · · ·Q.· ·Have you ever seen these kinds of reports from 13· ·CareEnhance Care Manager? 14· · · ·A.· ·I normally did not print them out, so this 15· ·looks a little bit different to me, but it seems 16· ·familiar. 17· · · ·Q.· ·Okay.· And you mentioned a second ago when I 18· ·asked you about it that these had your name on it, if 19· ·you look -- as you see on the top kind of on the right 20· ·it's got your name and the date.· Do you see that? 21· · · ·A.· ·Yes.· I saw the name on it. 22· · · ·Q.· ·Okay.· After you applied InterQual guidelines, 23· ·you were typing this information to the computer; is 24· ·that right? 25· · · ·A.· ·Yes. FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 203 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 109 of 173 Page· 34
·1· · · ·Q.· ·Okay.· Were you doing that at the hospital, at ·2· ·your home, in the office? ·3· · · ·A.· ·I had my InterQual handbook at the hospital ·4· ·bedside, met, met, check mark, move onto the next one, ·5· ·do the same thing for all of my reviews, collect the ·6· ·information and then once I completed all of the on-site ·7· ·data collection and utilizing that criteria, if they ·8· ·met, they didn't meet, getting all of that, coming back ·9· ·home and then entering them into the computer system. 10· · · ·Q.· ·Okay.· Were you taking notes at the hospital? 11· · · ·A.· ·Yes. 12· · · ·Q.· ·Okay.· You were actually applying -- When you 13· ·were applying the InterQual guidelines, you were 14· ·actually doing that before you even left the hospital; 15· ·is that right? 16· · · ·A.· ·Yes. 17· · · ·Q.· ·Okay.· So you get up, you go to the hospital, 18· ·you run the census, you review patients' charts.· At 19· ·that time you were applying the InterQual criteria; is 20· ·that right? 21· · · ·A.· ·Yes. 22· · · ·Q.· ·And when you are done with that hospital, you 23· ·go to the other hospital if you have cases there? 24· · · ·A.· ·Yes. 25· · · ·Q.· ·And you do the same thing there? FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 204 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 110 of 173
Case: Kathy Clark, et al v. Centene Corporation, et al
Transcript of Stephanie Hall Date: October 24, 2012
This transcript is printed on 100% recycled paper
515 Olive Street, Suite 300 St. Louis, MO 63101 Phone:314-241-6750 1-800-878-6750 Fax:314-241-5070 Email:schedule@goreperry.com Internet: www.goreperry.com
Appendix Volume 2, p. 205
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 111 of 173 Stephanie Hall 10/24/2012
Kathy Clark, et al v. Centene Corporation, et al
13 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
A Michael Neidorff would be one, but I don't know any of the others. Q Okay. What -- what relationship is there between Centene Corporation and Centene Company of Texas with regard to management of Centene Company of Texas? A Centene Corporation is just a holding company. Q What does that mean? A That it's on the New York Stock Exchange. Q What do they do? A Stock is traded. CNC stock is traded. Q Does it manage its subsidiary? A No. Q Does it have any influence in the employment practices of its subsidiary, in particular, Centene Company of Texas? A No. Q Does it have any employees? A No. Q It doesn't have a single employee? A Centene Corporation? Q Yes, Ma'am. A No. Q Where is it located? Is it in this
15 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
Q And specifically, what types of management do you provide for Centene Company of Texas in the area of employment? Do you set the exempt status of nurse employees? A The compensation department does, yes. Q And that's the compensation of Centene Management Company? A Centene Management Company. MR. LANGENFELD: All right. Can we go off the record for just a minute? (Off-the-record discussion.) QUESTIONS BY MR. LANGENFELD: Q Miss Hall, how long have you been with Centene Management Company? A Nine years. Q And tell me your job title. A Vice President of Human Resources For Health Plans. Q Who do you answer to? A Carol Goldman. Q I'm sorry? A Carol Goldman. Q And who is Carol Goldman? A Chief administrative officer. Q Of?
14 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
building? A It's in Delaware. Q Its corporate office? A It's where the -- it resides in Delaware. Q And I may have asked you, but Superior Health Plan, Inc., is that a subsidiary? A No. Q It's just a completely independent entity? A It's a contract with the State of Texas. Q Are you personally involved with -- who are you employed by? A Centene Management Company. Q Is Centene Management Company involved in the employment practices and policies of Centene Company of Texas? A We do provide consultative services to Centene Company of Texas. Q What does that mean? A That means we provide policies, procedures, guidelines. Q And who establishes those policies, procedures and guidelines? A In what area? Q In the employment area. A Centene Management Company.
16 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
A Centene Management Company. Q And who does she answer to? A Michael Neidorff. Q And who is Mr. Neidorff? A CEO and chairman. Q Of? A Centene Management Company. Q Is he also CEO of Centene Corporation? A It's a holding company. Q Well, let me ask it again. Is it -- is he CEO of Centene Corporation? A I don't know. Q When was Centene Management Company formed? A 2001, I believe. Q Do you know when Centene Company of Texas was formed? A I don't. Q Did Centene administer health plans before 2001? A I don't know. I wasn't here then. Q What's the business purpose of Centene Management Company? A To provide consultative services to our subsidiaries. Q Well, does Centene Management Company employ
4 (Pages 13 to 16) FAX 314-241-5070
Gore Perry Reporting and Video 314-241-6750
www.goreperry.com
Appendix Volume 2, p. 206
d38a7086-e477-401b-926b-f024d004b6ec
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 112 of 173 Stephanie Hall 10/24/2012
Kathy Clark, et al v. Centene Corporation, et al
17 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
nurses? When I talk in terms of nurses, I'm talking about utilization review nurses. Does Centene Management Company employ utilization review nurses? A Yes, Sir. Q And are those utilization review nurses assigned to other subsidiaries or other locations to administer various health plans? A Yes, Sir. Q Do you know which health plans they're assigned to? There's a lot of them. A There are. Q Okay. I don't mean to ask you an unfair question. Let me ask you whether Centene Management Company's nurses provide utilization review services for Centene Company of Texas, or does Centene Company of Texas employ its own nurses? A Centene Management Company provides UM nurses for their subsidiary. Centene Company of Texas has there own UM nurses. Q And those nurses service Superior Health Plan? A Those who -- those being who? Q The nurses employed by Centene Company of Texas. A Repeat your question.
19 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
employed by Bankers Trust. Q They're employed by Bankers Trust? A Yes. MR. KAISER: Why don't we ask the question again, and just listen to the question. He's asking you a global question about all other nurses. QUESTIONS BY MR. LANGENFELD: Q Within the Centene organization, utilization review nurses are employed; correct? A Could you repeat that, please? Q Within the Centene organization, utilization review nurses are employed; correct? A Centene -- yes. Q What subsidiaries or what entities within the Centene organization actually employ utilization review nurses? MR. KAISER: If you know. THE WITNESS: Centene Management Company, Centene Company of Texas, and Bankers Reserve. QUESTIONS BY MR. LANGENFELD: Q And are the job duties of the utilization review nurses at all three of those entities essentially the same? A The job duties are essentially the same, however, there are differences based off the state
18 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
Q The nurses employed by Centene Company of Texas help to administer the Superior Health Plan? A Superior Health Plan is just a contract with the state. Centene Company of Texas nurses provide services to the Medicaid members. Q Okay. Let's do this. MR. KAISER: I don't know if this'll make things go faster. The -- we'll stipulate that the nurses at Centene Company of Texas are carrying out the provisions of the contract for Superior Health Plan. MR. LANGENFELD: Okay. MR. KAISER: Does that -MR. LANGENFELD: That helps. That does help. QUESTIONS BY MR. LANGENFELD: Q There are other health plans, though, besides Superior. A Yes. Q Okay. And all of the other nurses that deal with all those other health plans are employed by Centene Management Company? A That is correct. Q Let me show you -A So, I'm sorry, I need to clarify. They're
20 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
contract, and based off of -MR. KAISER: I'm going to object to the question insofar as it's going beyond the scope of what this witness is being asked to testify. She's being asked to testify about the relationship between Superior Health Plan, Centene Management Company, Centene Company of Texas, and Centene Corporation, and whether Centene Management Company is involved in and controls the employment practices and business operations of Superior Health Plan; and if so, the extent of the involvement of control. She's not being asked to testify here today about the job duties of any particular employee employed in any subsidiary other than these, or for that matter, for any subsidiaries at all. And I would caution you to not provide testimony about things other than those things, and those things that you have personal knowledge of. MR. LANGENFELD: Give me just a minute, would you? MR. KAISER: Sure. (Short recess taken.) QUESTIONS BY MR. LANGENFELD: Q Okay. So Centene Management Company provides management services for Centene Company of
5 (Pages 17 to 20) FAX 314-241-5070
Gore Perry Reporting and Video 314-241-6750
www.goreperry.com
Appendix Volume 2, p. 207
d38a7086-e477-401b-926b-f024d004b6ec
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 113 of 173 Page 1
·1· · · · · · IN THE UNITED STATES DISTRICT COURT · · · · · · · ·FOR THE WESTERN DISTRICT OF TEXAS ·2· · · · · · · · · · · AUSTIN DIVISION ·3· · · ·4· · · ·5· · · ·6· · · ·7· · · ·8· · · ·9· · · 10·
KATHY CLARK, AMY ENDSLEY,· · ) SUSAN GRIMMETT, MARGUERIETTE ) SCHMOLL AND KEVIN ULRICH, ON ) BEHALF OF THEMSELVES AND ALL ) OTHERS SIMILARLY SITUATED,· ·) · · · · · · · · · · · · · · ·) · · · · ·Plaintiffs,· · · · ·) · · · · · · · · · · · · · · ·) VS.· · · · · · · · · · · · · )· · ·Civil Action · · · · · · · · · · · · · · ·) No. 1:12-CV-00174-SS CENTENE CORPORATION, CENTENE ) COMPANY OF TEXAS, L.P., AND· ) SUPERIOR HEALTHPLAN, INC.,· ·) · · · · · · · · · · · · · · ·) · · · · ·Defendants.· · · · ·)
11· ***************************************************** 12· · · · · · · · · ·ORAL DEPOSITION OF 13· · · · · · · · · · ·YASIRA HUNTER 14· · · · · · · · · · ·June 24, 2014 15· ***************************************************** 16· · · ORAL DEPOSITION OF YASIRA HUNTER, produced as a 17· witness at the instance of the Defendants, and duly 18· sworn, was taken in the above-styled and numbered 19· cause on June 24, 2014, from 8:54 a.m. to 12:15 p.m., 20· before WILLIAM M. FREDERICKS, CSR in and for the State 21· of Texas, reported by machine shorthand at the 22· Crockett Hotel, 320 Bonham Street, Room 703, 23· San Antonio, Texas, pursuant to the Federal Rules of 24· Civil Procedure. 25 FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 208
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 114 of 173 Page· 101
·1· · · Q.· ·Okay.· If you look at Page 45, this one is a ·2· little harder to read only because they've got that ·3· thing on the side, but I think what it says is "It's ·4· in the details," and you can see the word "details" is ·5· written down there. ·6· · · · · · · · Are each of these items things that you ·7· would have collected details on? ·8· · · A.· ·Yes. ·9· · · Q.· ·I think we've already been through Page 46. 10· · · · · · · · If you look at Page 47, does this 11· accurately reflect the way that information is 12· processed by a concurrent review nurse? 13· · · A.· ·Yes. 14· · · Q.· ·Okay.· On Page 48, there's an item on here 15· that I saw that is -- we hadn't talked about before, 16· and that is checking with family member. 17· · · · · · · · Would you from time to time have -18· well, you know what?· I didn't even ask this.· Would 19· you have conversations with the patients themselves? 20· · · A.· ·Sometimes. 21· · · Q.· ·Okay. 22· · · A.· ·Yes. 23· · · Q.· ·And for what purpose? 24· · · A.· ·Benefits maybe.· Sometimes they just need to 25· know, Hey, is -- can I go to the skilled nursing FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 209 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 115 of 173 Page· 150
·1· · · A.· ·No, I wouldn't run down the list, because the ·2· chest pain was kind of a regular thing that you would ·3· always see, so you kind of remember what to look for ·4· as far as the lab is concerned. ·5· · · Q.· ·Uh-huh. ·6· · · A.· ·So I would gather information of what I can ·7· remember, you know, the signs and symptoms of it. ·8· · · Q.· ·I see.· So at some point you had used these ·9· so often that you really -- it just became a part of 10· your thinking matter? 11· · · A.· ·Yes. 12· · · Q.· ·Okay. 13· · · A.· ·Yes. 14· · · Q.· ·And you would be able to -- even without 15· looking at the book or the computer, you'd be able to 16· say, Okay, they've got this, they've got this, they've 17· got this, you'd be able to look at the clinical record 18· and see whether those things were present, and then 19· that was enough to make a determination as to whether 20· they met the criteria or not? 21· · · A.· ·Yes. 22· · · Q.· ·Got it. 23· · · A.· ·And just keep in mind when I learned the 24· InterQual, that's when I took the book with me. 25· · · Q.· ·Yeah. FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 210 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 116 of 173 Page· 164
·1· would you send it to someone or was it already just in ·2· the network? ·3· · · A.· ·Send it -- I don't -- clarify that. ·4· · · Q.· ·I mean, so you would -- let's say you ·5· approved a matter.· So how would Superior know that ·6· you approved it? ·7· · · A.· ·Because of the -- my narrative, and the ·8· InterQual will be green. ·9· · · Q.· ·Okay.· So you don't send it to a person; it's 10· just automatically in the system? 11· · · A.· ·It's automatically in the system. 12· · · Q.· ·And then you're done with it other than to 13· follow up and see that the person's treatment plan is 14· being -- you're done with the initial admission? 15· · · A.· ·Yes. 16· · · Q.· ·And then in the follow-up days, you have 17· follow-up -- you may have a follow-up visit where 18· you're following the person -19· · · A.· ·Yes. 20· · · Q.· ·-- the patient, and then you would come home, 21· add more narrative to the work -- to the InterQual -22· to the CCMS notes and continue to follow the progress, 23· right? 24· · · A.· ·Right. 25· · · Q.· ·And then at some point the person gets FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 211 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 117 of 173 Page· 175
·1· where you can actually look up and see what is -- what ·2· are they talking about, positive cardio biomarkers. ·3· · · Q.· ·Okay.· So if you didn't know what positive ·4· cardiac biomarkers were, you could look at No. 4 and ·5· that would tell you what they are? ·6· · · A.· ·Yes. ·7· · · Q.· ·Okay.· And if you would actually turn to ·8· Note 4.· It's on Page ADLT-11 in Exhibit 3. ·9· · · A.· ·Yes. 10· · · Q.· ·And that is actually -- that would help you 11· determine what positive cardiac -- positive cardiac 12· biomarkers are if you don't know what that term means? 13· · · A.· ·Yes. 14· · · Q.· ·Okay.· In that definition, it references 15· "troponins."· I believe you mentioned those earlier, 16· is that right? 17· · · A.· ·Yes. 18· · · Q.· ·Okay.· And if you didn't know what troponins 19· were, could you just look that word up? 20· · · A.· ·Yes. 21· · · Q.· ·And on the -- where would you find troponins 22· in any medical -- or in the information received from 23· the hospital? 24· · · A.· ·In the lab section on the chart. 25· · · Q.· ·And would it actually say "troponins"? FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 212 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 118 of 173 Thea Palima 5/29/2014 1
UNITED STATES DISTRICT COURT WESTERN DISTRICT OF TEXAS AUSTIN DIVISION
2 3 4 5
KATHY CLARK, AMY ENDSLEY, SUSAN GRIMMETT, MARGUERIETTE SCHMOLL, AND KEVIN ULRICH, ON BEHALF OF THEMSELVES AND ALL OTHERS SIMILARLY SITUATED,
6
Plaintiffs, 7
V. 8 9 10
Page: 1
CENTENE CORPORATION, CENTENE COMPANY OF TEXAS, L.P., AND SUPERIOR HEALTHPLAN, INC.,
11
Defendants.
§ § § § § § § § § § § § § § § § §
Civil Action No. 1:12-CV-00174-SS JURY DEMANDED
12 13 14
**************************************************
15
ORAL DEPOSITION OF
16
THEA PALIMA
17
MAY 29, 2014
18
**************************************************
19 20 21 22 23 24 25
ORAL DEPOSITION OF THEA PALIMA, produced as a witness at the instance of the Plaintiffs, and duly sworn, was taken in the above-styled and numbered cause on the 29th day of May, 2014, from 9:02 a.m. to 10:55 a.m., before Cynthia Warren, Certified Shorthand Reporter in and for the State of Texas, reported by machine shorthand, at the offices of Boulette & Golden, LLP, 2801 Via Fortuna, Suite 350, Austin, Texas 78746, pursuant to the Federal Rules of Civil Procedure and the provisions stated on the record.
800-545-9668 612-339-0545
Paradigm Reporting & Captioning www.paradigmreporting.com
Appendix Volume 2, p. 213
#79139
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 119 of 173 Thea Palima 5/29/2014 1
outside the presence of counsel?
2
A.
No.
3
Q.
Tell me a little bit about your employment at
4
Centene.
5 6
A.
When did you first start there? I started as a temp in August of 2009, and I
became a permanent employee on March 2010.
7
Q.
So you worked as a temp for about six months?
8
A.
That is correct.
9
Q.
Who did you temp through?
10
A.
Maxim.
11
Q.
Maxim Healthcare?
12
A.
Yes.
13
Q.
And how did you find out about the job?
14
A.
Actually through Craigslist.
15
Q.
Okay.
16
And when you started as a temp, what
position were you working in?
17 18
Page: 7
A.
I was a case manager prior authorization nurse.
That was the official title.
19
Q.
And when you were hired on in March of 2010 did
20
you then become a permanent employee and work as a case
21
manager prior authorization nurse?
22
A.
I started as a case manager prior auth nurse in
23
August of 2009, and I didn't change my job title or job
24
duties.
25 800-545-9668 612-339-0545
Q.
Okay.
And how long did you hold the case Paradigm Reporting & Captioning www.paradigmreporting.com
Appendix Volume 2, p. 214
#79139
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 120 of 173 Thea Palima 5/29/2014 1
manager prior authorization nurse position?
2 3
A.
Can you clarify that question?
Q.
Oh, sure.
I'm wondering, is that the position
that you currently hold?
6
A.
No, no.
7
Q.
Okay.
8
I thought I
just answered it.
4 5
Page: 8
I'm wondering how long you worked in
that position, period.
9
A.
How long.
I believe -- it's so hard for me to
10
remember right now the specific dates.
11
now is 2014.
12
trainer, so that would entail from the time that I
13
became a trainer, that's when my position ended as case
14
manager prior auth nurse.
15 16
Q.
Okay.
November 2013 I believe I became a
So in November of 2013 you became a
trainer?
17
A.
I think that was 2012.
18
up the years.
19
reviewed my resume --
20
I apologize.
MR. KAISER:
I'm sorry, I'm mixing
Maybe I should have
No, you're fine.
21
A.
-- before I came here.
22
Q.
(By Ms. Srey)
23
Let's see, right
Just so for the clear record,
sometime in November of 2012 you became a trainer?
24
A.
That is correct.
25
Q.
And what was your official job title when you
800-545-9668 612-339-0545
Paradigm Reporting & Captioning www.paradigmreporting.com
Appendix Volume 2, p. 215
#79139
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 121 of 173 Thea Palima 5/29/2014 1
became a trainer?
2 3
A.
I was the clinical trainer for the prior
authorization department.
I also did auditing as well.
4
Q.
Auditing of cases --
5
A.
That is correct.
6
Q.
-- or authorizations?
7 8
And is that the position that you currently hold --
9
A.
That is not correct.
10
Q.
-- clinical trainer?
11 12
Okay.
If you can just wait till I finish
my question.
13
A.
I'm sorry.
14
Q.
That's okay.
15
We're talking over each other a
little bit.
16 17
Page: 9
How long did you work as a clinical trainer?
18
A.
I was roughly employed as a clinical trainer
19
until roughly about 11 months after I took the position.
20
I did become a service manager in a different department
21
under foster care.
22 23
Q.
Okay.
And then do you currently work as a
service manager under foster care?
24
A.
That is not correct.
25
Q.
How long did you hold the service manager
800-545-9668 612-339-0545
Paradigm Reporting & Captioning www.paradigmreporting.com
Appendix Volume 2, p. 216
#79139
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 122 of 173 Thea Palima 5/29/2014 1
Page: 10
foster care position?
2
A.
I held it until July of last year, 2013.
3
Q.
Okay.
Let me just go back a little bit.
You
4
said that you worked as a clinical trainer for about 11
5
months, correct?
6
A.
That is correct.
7
Q.
So 11 months would take us to about October of
8
2013; is that correct?
9 10
A.
Let me rephrase my time frame as I was
confused.
11
Q.
Oh, sure.
12
A.
Okay.
No problem.
No problem.
So I started in the company in
13
August 2009 as a temporary employee, case manager prior
14
auth nurse.
15
was the fact that I became a permanent employee and not
16
a temporary employee.
The only thing that changed on March 2010
17
Q.
Gotcha, okay.
18
A.
Then after that I could recall it was around
19
November, and unfortunately I don't recall the specific
20
dates from that time, but I did become the clinical
21
trainer during my tenure there at the prior auth
22
department.
23
prior auth nurse.
24
as a service manager July -- not July, I believe it was
25
2013, and I started back at prior auth on July 2013.
800-545-9668 612-339-0545
It was shortly after I was a case manager From there I did leave to foster care
Paradigm Reporting & Captioning www.paradigmreporting.com
Appendix Volume 2, p. 217
#79139
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 123 of 173 Thea Palima 5/29/2014 1 2
Q.
Page: 11
When you started back at prior auth in July
of 2013 what were you doing?
3
A.
2013 I became the manager for the home health
4
department or side.
5
would more be a division, home health and basically for
6
private duty nursing, skilled nursing visits.
There would not be a department; it
7
Q.
Okay.
8
A.
I apologize for the time frame and I should
9 10
have reviewed my resume, but roughly that's what I could recall at this moment.
11
Q.
Okay.
And then going back, approximately how
12
long did you hold the clinical trainer position?
13
think we haven't established what year that was, but how
14
long did you hold that position for?
15
A.
It was less than a year.
16
Q.
Okay.
17
A.
It was approximately about 11 months.
18
Q.
And when you held the clinical trainer
19
position, were you also working authorizations?
20
also do reviews or just do training?
21 22
A.
And I
Did you
I actually did training and auditing of the
clinical reviews that the nurses did.
23
Q.
So to be clear, you did not do any of your own
24
authorizations or have authorizations assigned to you to
25
review during the time that you were clinical trainer?
800-545-9668 612-339-0545
Paradigm Reporting & Captioning www.paradigmreporting.com
Appendix Volume 2, p. 218
#79139
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 124 of 173
00014 1 came to what is the prior authorization department. 2
Q. So tell me more about this coursework. Are we
3 talking about like books and in-classroom training, that 4 type of thing? 5
A. That is correct. I actually created a manual
6 that entailed what our work processes were. 7
Q. Is that the prior authorization manual?
8
A. When you say prior authorization manual,
9 there's so many types of differences in manuals. What I 10 had was a training manual that I created to guide the 11 clinicians on how to do our work process. 12
Q. Tell me -- I don't think I've seen the training
13 manual. I've seen a prior authorization manual. It's 14 like 500-and-some pages long. I didn't print it. Tell 15 me a little bit more about this training manual, what's 16 in it. 17
A. Sure. The training manual is basically a guide
18 from start to finish on how we process our 19 authorizations. So the beginning would be information 20 regarding what is the prior auth department, what do we 21 do, as well -22
Q. As a general -- I'm sorry, go ahead.
23
A. -- as well as information on how to process
24 each authorization based on the service type. 25
Q. So part of the training manual describes the
Palima,Thea_5-29-14
Page 14
Appendix Volume 2, p. 219
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 125 of 173 Thea Palima 5/29/2014 1
Page: 15
general purpose of the department?
2
A.
That is correct, there is a portion that I've
3
included that details what the prior auth department is
4
and also what we do and how we do our work process.
5
Q.
About how thick is this training manual?
6
A.
It differs in pages.
If I was to say, to
7
include all service types, I would say it would be
8
definitely more than 100 pages, but I can't give you an
9
approximate amount of the pages until I actually do go
10
over the previous manual I put together.
11
Q.
You lost me in the last part.
Was there a
12
training manual that existed before you put this
13
training manual together that you've been testifying to?
14
A.
There is.
There was a training manual that
15
existed.
16
understand so I started from scratch and compiled
17
documentation.
18 19
Q.
And where did you get the documentation from
that you included in the training manual?
20 21
However, I felt that it was very difficult to
A.
The actual resources that the previous manual
had, I just expanded on them.
22
Q.
So can you give me an example of what you're
23
talking about in terms of the actual resources that the
24
previous manual had that you expanded upon?
25 800-545-9668 612-339-0545
A.
Yes.
For example, the previous manual would Paradigm Reporting & Captioning www.paradigmreporting.com
Appendix Volume 2, p. 220
#79139
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 126 of 173 Thea Palima 5/29/2014
Page: 16
1
list reference sources of where to locate on how to
2
process a specific procedure.
3
was all there; however, it was in different pages, some
4
only reference go here.
5
apart and, for example, you're going to process a
6
request for home health services.
7
hierarchy of review, which is policy and procedures,
8
InterQual, TMHP, then no criteria.
9
It was all clustered.
It
What I did was I broke that
I had then listed the
With that, for example, for policy and
10
procedures, if there was a policy and procedure
11
available for home health services, I would then put
12
that in another section of that specific service type
13
manual and indicate this is what the policy is and this
14
is what it looks like.
15
already on the previous manual, but the previous manual
16
was a stack of references where it didn't guide you to
17
what reference source you need to use before you process
18
a request.
19
Q.
20
And that would -- that is
So was it sort of like a flow chart or a work
process chart that said if this, go here?
21
A.
That is correct.
22
Q.
And did you do that for every service type?
23
A.
Yes.
24
Q.
So for example, did you have a -- in the
25
training manual a flow chart or a work process for
800-545-9668 612-339-0545
Paradigm Reporting & Captioning www.paradigmreporting.com
Appendix Volume 2, p. 221
#79139
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 127 of 173 Thea Palima 5/29/2014 1 2
Q.
Page: 35
And another example of other universal
processes might be the documentation of a case?
3
A.
Documentation is included in each service type,
4
so the documentation would vary on what information that
5
we need to include.
6
types.
7
presentation.
8 9
Q.
So that would be on the service
However, it would be included in that
Gotcha.
Let me show you something else.
Again
I only have one page.
10
(Exhibit No. 21 marked.)
11
Q.
I'm showing you what's been marked as
12
Deposition Exhibit No. 21.
13
that it was a document produced to us by your counsel,
14
and at the top it reads Request Comes In For DME.
15
my only question to you is, did you put this sort of
16
decision tree together?
17
A.
And again, I'll represent
I put the flow chart together.
I didn't make
18
any decisions on how we changed a work process.
19
However, I created this work flow, that's correct.
20
Q.
21
processes?
22
A.
And
Who makes the decisions on changing work
Usually it's reviewed by upper management at
23
the time I was a trainer, so I went through the work
24
processes that were already set forth.
25 800-545-9668 612-339-0545
Q.
Do the prior authorization nurses make the Paradigm Reporting & Captioning www.paradigmreporting.com
Appendix Volume 2, p. 222
#79139
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 128 of 173 Thea Palima 5/29/2014 1
decisions on changing work processes?
2
A.
No, no staff.
A worker bee would not be able
3
to change policies and procedures.
4
case, but no.
5
Q.
(Exhibit No. 22 marked.)
7
Q.
Similar question.
I'm handing you what's been
marked as Exhibit 22.
9 10
I wish that was the
Gotcha.
6
8
Page: 36
MR. KAISER:
So we're not marking the
second -- the back page of it; is that --
11
MS. SREY:
That is correct.
For the
12
record, the only the front page of the document is being
13
marked, not the -- if there is information on the back
14
half that's not being marked, I ran out of paper so I
15
had to print on already-printed-on paper.
16
Q.
(By Ms. Srey)
Thea, I'm handing you what's
17
been marked as Deposition Exhibit No. 22, and it is
18
another flow chart.
19
SNV, which I take to mean home health skilled nursing
20
visit?
21
A.
That is correct.
22
Q.
Is this a document that you put together?
23
A.
Yes, that is a flow chart that I put together
It says Request Comes In For HHS
24
for information regarding how to process a home health
25
SNV case.
800-545-9668 612-339-0545
Paradigm Reporting & Captioning www.paradigmreporting.com
Appendix Volume 2, p. 223
#79139
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 129 of 173
00065 1 take longer to do their job and so they wouldn't get all 2 their work done for the week but still had to meet the 3 requirements for the turnaround time expectations and 4 would have to work extra overtime hours; is that true? 5
A. They would -- basically for them, if they
6 didn't get up to speed with their skills to make sure 7 that you do process your work, then I see that they 8 could be working extra hours. But for me, I don't think 9 it's fair if I get 40 cases -- and she has to get 40 10 cases too. If I'm able to time manage well and produce 11 my work, then I should be done with work. And that's 12 how I feel about that. If they're not capable of doing 13 the job appropriately with the skills and knowledge that 14 they attain throughout the whole course of working in 15 our department, then I feel they may need to consider a 16 different line. 17
Q. Sure. You had mentioned the skills and
18 knowledge they had attained by doing the job. So in 19 your opinion, if after some time had passed and they 20 weren't getting it, then perhaps they should be let go, 21 find something else? 22
A. Not necessarily let go. I think the supervisor
23 should try to hone in on those skills of what they're 24 lacking and kind of really try to help them grow and 25 help them establish those set of skill sets, but it's
Palima,Thea_5-29-14
Page 65
Appendix Volume 2, p. 224
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 130 of 173
00066 1 also up to the employee if they're willing and driven to 2 do that. 3
Q. Was it important to the job to have good
4 computer skills? It sounds like that was a big aspect 5 of the job. 6
A. Yes.
7
Q. Let me show you a couple of other e-mails.
8 Actually let's do this. 9 10
(Exhibit No. 24 marked.) Q. Ms. Palima, I've handed you what's been marked
11 as Exhibit 24. Do you recognize this document? 12
A. Yes.
13
Q. And what is it?
14
A. It is the job specific orientation, prior auth
15 nurse. Basically it's a list of items that we reviewed. 16
Q. During that two-week training course?
17
A. Yes. And if they were not completed, they
18 would be marked as not complete and I would instruct the 19 supervisor that we weren't able to finish up and they 20 need to either make sure that they go through the 21 materials depending on which factor it is. 22
Q. And I think I forgot to ask you about this.
23 Was there -- after the two-week training course was 24 there job shadowing where a nurse, a new hire, would sit 25 with another nurse that had already been doing the job
Palima,Thea_5-29-14
Page 66
Appendix Volume 2, p. 225
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 131 of 173
00068 1 Q. So the nurses are trained on how to have proper 2 telephone etiquette when they're calling the provider? 3
A. Yes, in general nurses should have good
4 etiquette, but this would be a good entertaining video 5 and also educational just to remind them that these are 6 the types of situations you might find yourself and this 7 would be a good response for those situations. 8
Q. What about if you go midpoint down, it says SHP
9 UM Workplan, what's that? 10
A. Where is that?
11
Q. It's --
12
MR. KAISER: I think it's TX.UM.01b.
13
MS. SREY: Yes. I can't read upside down.
14
MR. KAISER: Almost dead center.
15
A. Oh, Workplan. Superior HealthPlan UM Workplan.
16 I should know this, but I don't recall exactly what's in 17 that policy. But I essentially expect it to be some 18 sort of work plan for each department. 19
Q. (By Ms. Srey) Okay. Going one, two -- three
20 down from there, TX.UM.02.05, Interrater Reliability, 21 what's that? 22
A. That is InterQual.
23
Q. What do you mean that's InterQual? That's the
24 InterQual guidelines? 25
A. No, this would be guidelines regarding the
Palima,Thea_5-29-14
Page 68
Appendix Volume 2, p. 226
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 132 of 173
00069 1 Interrater Reliability, Non Physician Staff. And to be 2 very honest, I'm very familiar with these policies as 3 soon as I open them up and I see it. 4
Q. Sure.
5
A. But to quote what is exactly in that policy, I
6 can't give you verbatim what's in there. There are so 7 many policies. 8
Q. Do you know what the purpose of that policy is?
9
A. I'd say it's regarding interrater reliability.
10
Q. What does that mean? What does interrater
11 reliability mean? 12
A. I don't have a definition for you. I'm sorry.
13
Q. That's okay. So this is a document --
14 Exhibit 24, a document that you would use when you're 15 training new employees to keep track to make sure that 16 you've covered all of the information that needs to be 17 covered or someone else is going to cover all the 18 information? 19
A. This would be an example of some policies and
20 procedures that I have them take a look at. And again, 21 I would tell the supervisor if we didn't have enough 22 time to go over any policy and procedures. Keep in mind 23 I give them a good foundation of how to do their job 24 from start to finish, but it's also their job to make 25 sure that they do further research in what these
Palima,Thea_5-29-14
Page 69
Appendix Volume 2, p. 227
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 133 of 173
00070 1 policies and procedures are. 2
Q. Sure. And all of the policies and procedures
3 that dictate their work, they're inside a system called 4 Compliance 360? 5
A. That is correct.
6
Q. And the nurses don't play any part in modifying
7 or updating those policies and procedures, correct? 8
A. No.
9
Q. Let me show you another exhibit.
10
MR. KAISER: Before we move there, my
11 third page is a blank page. 12
MS. SREY: Oh. Well, I could have had an
13 extra piece of paper. 14
MR. KAISER: So this is the two-page
15 thing, right? 16
MS. SREY: Yes.
17
MR. KAISER: Okay. Got it.
18
THE WITNESS: Oh, no, there's the last
19 one. 20
MR. KAISER: She has a last page, but I
21 don't have a last page. 22
MS. SREY: Can we go off the record for
23 one second? 24
MR. KAISER: Sure.
25
(Brief interruption.)
Palima,Thea_5-29-14
Page 70
Appendix Volume 2, p. 228
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 134 of 173 Thea Palima 5/29/2014 1
A.
She was a prior authorization nurse that
2
reviewed for medical necessity for requests for home
3
health and also for therapies.
4
Q.
And in that role was she required to follow the
5
hierarchy of guidelines that you've testified about
6
earlier today?
7
A.
Yes.
8
Q.
Could she make any decisions to deny
9
authorization requests?
10
A.
Nobody necessarily has a right to deny a
11
clinical aspect for review because only the medical
12
director would deny that.
13
for administrative reasons such as due to no prior
14
authorization.
15 16
Q.
However, we do deny requests
Such as the request isn't listed on the prior
authorization list?
17 18
Page: 78
A.
No.
For example, provider submitted the
request a week after a procedure happened.
19
Q.
Okay.
20
A.
And we have to tell them what the word "prior"
21
means.
22
Q.
23
Prior means before. Right.
So other than that circumstance -- and
I think you called it an administrative denial?
24
A.
Yes.
25
Q.
Can the nurses make any other type of denial
800-545-9668 612-339-0545
Paradigm Reporting & Captioning www.paradigmreporting.com
Appendix Volume 2, p. 229
#79139
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 135 of 173
Page 1
IN THE UNITED STATES DISTRICT COURT FOR THE WESTERN DISTRICT OF TEXAS AUSTIN DIVISION KATHY CLARK, AMY ENDSLEY, SUSAN GRIMMETT, MARGUERIETTE SCHMOLL AND KEVIN ULRICH, ON BEHALF OF THEMSELVES AND ALL OTHERS SIMILARLY SITUATED,
) ) ) ) ) ) Plaintiffs, ) ) VS. ) Civil Action ) No. 1:12-CV-00174-SS CENTENE CORPORATION, CENTENE ) COMPANY OF TEXAS, L.P., AND ) SUPERIOR HEALTHPLAN, INC., ) ) Defendants. ) ORAL DEPOSITION OF MARGUERIETTE SCHMOLL On October 15, 2012, between the hours of 9:06 a.m. and 2:26 p.m., in the offices of Dunham & Jones, 1800 Guadalupe Street, Austin, Texas, before me, WILLIAM M. FREDERICKS, a Certified Shorthand Reporter for the State of Texas, appeared MARGUERIETTE SCHMOLL, who, being by me first duly sworn, gave an oral deposition at the instance of the Defendants in said cause, pursuant to the Federal Rules of Civil Procedure.
Appendix Volume 2, p. 230
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 136 of 173
Page 92
1
application (indicating)?
2
A.
Right.
3
Q.
Okay.
4
Do you recall who it was that
interviewed you?
5
A.
I know Lorie did.
6
Q.
And how did you know Lorie?
7
A.
I had worked with her at the University of
8
Texas.
9
Q.
In the student health?
10
A.
Yes.
11
Q.
And do you recall what job she had there?
12
A.
Staff nurse.
13
Q.
And was she going to be your supervisor?
14
A.
Yes.
15
Q.
Do you recall if you interviewed with anybody
16 17
Office nurse.
else? A.
I think I did a phone interview with -- her
18
name is Naomi -- I don't remember what her last name
19
is -- that was the supervisor above Lorie at that
20
time.
21
Q.
Was that somebody who was here in Texas?
22
A.
Yes.
23
Q.
Okay.
24
A.
I may have met her later on, but I never
25
Did you ever meet Naomi?
actually worked with her.
Appendix Volume 2, p. 231
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 137 of 173
Page 93
1
Q.
Okay.
2
A.
No.
3
Q.
Okay.
4
And you don't remember her last name?
It wasn't somebody who you regularly
worked with?
5
A.
No.
6
Q.
Was it somebody who was in the Austin office?
7
A.
I don't think so.
8 9 10
I think she was in
San Antonio. Q.
Okay.
Anybody else that you interviewed
with?
11
A.
I don't think so.
12
Q.
Okay.
13
A.
Eventually I did talk to Karen Pelletier.
14
Q.
And where was she?
15
A.
She was in Austin.
16
Q.
Okay.
17 18 19 20
Anybody from human resources?
When you say "eventually," was that
before or after you were hired? A.
That was as I was hired.
She called me to
make the offer. Q.
I see.
Okay.
And would she have been the
21
one who would have described your pay and those kinds
22
of things?
23
A.
Yes.
24
Q.
Okay.
25
A.
Austin.
And do you know where she was located?
Appendix Volume 2, p. 232
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 138 of 173
Page 94
1
Q.
Okay.
2
A.
Yes.
3
Q.
You worked -- did you always work out of the
4
In the same office that you were in?
same office?
5
A.
Yes.
6
Q.
And where was that?
7
A.
Austin.
8
Q.
Where?
9
A.
Location-wise?
10
Q.
Uh-huh.
11
A.
South Interstate 35 near Oltorf.
12
Q.
Okay.
13
A.
It was prior authorization nurse.
14
Q.
Were the terms "utilization review nurse"
15
Now, what was your job?
used or no?
16
A.
They may have been.
17
Q.
No.
18
A.
With me?
19
Q.
Yeah.
20
A.
At times, because it's an interchangeable
21 22 23
With you was it used?
term everywhere. Q.
Okay.
Were you the only nurse doing foster
care?
24
A.
No.
25
Q.
Who else was doing it?
Appendix Volume 2, p. 233
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 139 of 173
Page 95
1
A.
When I first started there, Lorie was the
2
supervisor but was also doing cases, and there was
3
another nurse that did foster care all the time and a
4
third nurse who did foster care part of the time.
5
Q.
Now, what is -- was there a particular plan
6
that you were working for?
7
why you did just foster care kids.
8 9
A.
I'm trying to figure out
They had just obtained the contract for Texas
foster care --
10
Q.
Uh-huh.
11
A.
-- and all of the foster care was under the
12
same plan.
13
Q.
Okay.
14
A.
Yes.
15
Q.
Was foster care somehow separate from the
16
Is that also part of Medicaid?
other Medicaid provisions?
17
A.
Yes.
18
Q.
Okay.
19
A.
No.
20
Q.
Had you ever worked in foster care before?
21
A.
No.
22
Q.
Did you -- what kind of training did you get?
23
A.
It was mostly on-the-job training.
Do you know why it was separate?
There was
24
some computer training in the computer training room
25
as far as how to access the software and that sort of
Appendix Volume 2, p. 234
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 140 of 173
Page 134
1 2 3
Q.
Is there an "other"?
Is there a category for
"other"? A.
I don't think there's an "other."
There's
4
not -- there's not something that you can type in
5
or --
6
Q.
Or something that wasn't on the list?
7
A.
I don't think there was -- that there was
8
something on the list.
If it didn't -- if it wasn't
9
on that list, then it didn't apply --
10
Q.
Okay.
11
A.
-- I think is the -- is what it amounted to.
12
There was no place that you could add something if it
13
wasn't on the list.
14
Q.
Okay.
So when -- as a person in foster
15
care -- now, you said there was another person who was
16
doing foster care, and then you had even a third
17
person who was in foster care sometime, right?
18
A.
At first.
19
Q.
At first.
20
A.
When they put us under a different
And then how did that change?
21
supervisor, they changed -- Lorie was no longer our
22
supervisor, and at that time there was only two of us
23
doing foster care with Lorie doing it part of the
24
time.
25
Q.
And who was the new supervisor?
Appendix Volume 2, p. 235
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 141 of 173
Page 135
1
A.
2
name was.
3
Q.
4
Cheryl, and I don't remember what her last
Okay.
And how long did that last where
Cheryl was your supervisor?
5
A.
I don't remember.
6
Q.
Okay.
Several months.
The people in -- the nurses in foster
7
care, did you all have specialties or was it just
8
whatever came in just got assigned, as long it was
9
foster care, to one of you?
10
A.
It was everything most of the time.
11
Q.
Okay.
So there was no sorting out by
12
specialties or anything like that between you and the
13
other foster care nurses?
14
A.
Only for a short time where the home health
15
all went to one person.
16
whatever.
17
Q.
Okay.
Otherwise, we all got just
And was there a case load that you had
18
or a number of authorizations that you were handling
19
at any given time?
Would that number track?
20
A.
Yes, it was supposed to have been tracked.
21
Q.
Okay.
22 23
Do you have a sense of how many you
were handling at any given period of time? A.
24
day.
25
doing.
I think we were supposed to be doing 30 a
I believe that's how many we were supposed to be
Appendix Volume 2, p. 236
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 142 of 173
Page 166
1 2 3 4
Q.
Okay.
Do you remember how you learned that
you were moving to a half-hour lunch? A.
The supervisor told us in our -- in our nurse
meeting.
5
Q.
6
been who?
7
A.
Beth England.
8
Q.
Okay.
9
And the supervisor at that time would have
Now, that's a new name, because I
remember Lorie and I remember Cheryl.
10
A.
Correct.
11
Q.
So when did Beth come into the picture?
12
A.
I don't know.
13 14
left. Q.
Probably six months before I
Possibly less than that. Okay.
So then within those six months before
15
you left is when you -- if I do this -- if I read into
16
this correctly, then the half-hour lunch started then
17
within six months of you leaving?
18
A.
Correct.
19
Q.
Okay.
20 21
THE WITNESS:
Would this be a good time
for us to take a break?
22
MR. KAISER:
If you want to take a
23
break, it's a good time to take a break.
24
THE WITNESS:
25
(Lunch recess.)
Okay.
Appendix Volume 2, p. 237
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 143 of 173
Page 169
1 2 3
were told you had to do overtime? A.
About the same time the lunch break was
changed.
4
Q.
Okay.
5
A.
Some.
6
Q.
How much?
7
A.
It was sporadic, but a few hours a week.
8
Q.
Did you keep any records of that?
9
A.
No.
10
Q.
Okay.
11
14
And I understand how overtime works
when you bring in an extra Saturday.
12 13
Had you worked overtime prior to then?
How did you work overtime prior to working -- other than working Saturdays? A.
They told us we had to work at least an hour
15
a day overtime, the supervisor did, Beth did, and we
16
had to stay when there was a nurse meeting, which the
17
nurse meeting always started an hour after I got off,
18
plus the amount of time for the nurse meeting; and
19
then if the -- if the number of cases needed to be
20
decreased, we had to work however much overtime to get
21
the number of cases down.
22
Q.
If I can, what I'd like to do is to break
23
this into kind of components, because I get the sense,
24
and tell me if I'm wrong, that there was kind of a
25
schedule that you followed prior to Ms. England coming
Appendix Volume 2, p. 238
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 144 of 173
Page 175
1 2 3
hired us into a particular -Q.
Okay.
So you were hired in the 8:00 to 5:00
slot?
4
A.
Correct.
5
Q.
And then when Ms. England came in, at some
6
point she mandated that you work an extra hour during
7
the weekday?
8
A.
At least.
9
Q.
And did your schedule then change?
10
A.
They never changed the actual schedule of who
11
worked what hours.
12
Q.
So when did you work?
13
A.
I usually worked through lunch or a half
14
hour -- they changed the lunch so you were only
15
getting a half-hour lunch.
16
half hour somewhere, and I usually put it on the end
17
of the day til 5:30.
18 19
Q.
Okay.
So you had to put an extra
So you would work -- you yourself
would generally work from 8:00 til 5:30?
20
A.
Or later.
21
Q.
Okay.
22
A.
Sometimes later.
23
Q.
And how often did you work later?
24
A.
I don't know how often.
25
Probably at least
twice a week that I would work later than that.
Appendix Volume 2, p. 239
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 145 of 173
Page 176
1 2
Q.
Okay.
time with Ms. England.
3 4
Now I'm going to focus just on the
Was she the one that said that you needed to work Saturdays?
5
A.
She was the one that told us that, yes.
6
Q.
Prior to Ms. England, had you worked
7
Saturdays?
8
A.
No.
9
Q.
Okay.
10
Saturdays?
11
A.
Every other Saturday.
12
Q.
Was that a scheduled thing?
13
A.
Not at first.
14
Q.
Okay.
15
A.
It was -- it progressed from half a day to
And so how often did you work
16
until you finished all that were in your box to all
17
day --
18
Q.
Okay.
19
A.
-- every other week.
20
Q.
So if we could work and you could help me
21
So --
understand how it progressed.
22
A.
Okay.
23
Q.
So at first it was a half a day?
24
A.
The first week that we did it, it was a half
25
a day.
Appendix Volume 2, p. 240
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 146 of 173
Page 190
1
resources outside of Austin?
2
A.
No.
3
Q.
When you would approve items, did you have
4
any sense of what the cost of the item was?
5
A.
Sometimes.
6
Q.
And how would you get that understanding?
7
A.
Sometimes the providers had it on their
8
forms.
9
don't remember anything in our software at work that
I don't remember that we had anything -- I
10
gave prices, but the -- there were items that the
11
providers did have the prices on their request.
12 13
Q.
Was your authorization to approve something
limited by dollars?
14
A.
In some cases.
15
Q.
Okay.
16
A.
DME if it was over a certain price.
17
Q.
And what would be -- for example, what would
18 19 20
And what would those cases be?
be the price? A.
I think it was $3,000.
I believe it was --
it couldn't be over $3,000 and us approve it.
21
Q.
For any DME or for a particular type of DME?
22
A.
Any.
23
Q.
Any other limitations that are related to
24 25
dollars? A.
I don't remember any other than that.
Appendix Volume 2, p. 241
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 147 of 173 Page 1
·1· · · · · · IN THE UNITED STATES DISTRICT COURT · · · · · · · ·FOR THE WESTERN DISTRICT OF TEXAS ·2· · · · · · · · · · · AUSTIN DIVISION ·3· · · ·4· · · ·5· · · ·6· · · ·7· · · ·8· · · ·9· · · 10·
KATHY CLARK, AMY ENDSLEY,· · ) SUSAN GRIMMETT, MARGUERIETTE ) SCHMOLL AND KEVIN ULRICH, ON ) BEHALF OF THEMSELVES AND ALL ) OTHERS SIMILARLY SITUATED,· ·) · · · · · · · · · · · · · · ·) · · · · ·Plaintiffs,· · · · ·) · · · · · · · · · · · · · · ·) VS.· · · · · · · · · · · · · )· · ·Civil Action · · · · · · · · · · · · · · ·) No. 1:12-CV-00174-SS CENTENE CORPORATION, CENTENE ) COMPANY OF TEXAS, L.P., AND· ) SUPERIOR HEALTHPLAN, INC.,· ·) · · · · · · · · · · · · · · ·) · · · · ·Defendants.· · · · ·)
11· ***************************************************** 12· · · · · · · · · ·ORAL DEPOSITION OF 13· · · · · · · · · · ·JANE TOWNSEND 14· · · · · · · · · · ·June 18, 2014 15· ***************************************************** 16· · · ORAL DEPOSITION OF JANE TOWNSEND, produced as a 17· witness at the instance of the Defendants, and duly 18· sworn, was taken in the above-styled and numbered 19· cause on June 18, 2014, from 1:18 p.m. to 4:49 p.m., 20· before WILLIAM M. FREDERICKS, CSR in and for the State 21· of Texas, reported by machine shorthand at the offices 22· of Boulette & Golden LLP, 2801 Via Fortuna, Suite 530, 23· Austin, Texas, pursuant to the Federal Rules of Civil 24· Procedure. 25 FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 242
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 148 of 173 Page· 18..21 Page 18
Page 19
·1· into a database, and if it didn't meet, then it was
·1· about it?
·2· sent to a physician.
·2· · · A.· ·Well, I had to go to California a couple
·3· · · Q.· ·Were you -- so were you administering claims
·3· times and, you know, work out there, and it just took
·4· for these payers, is that the idea?
·4· me away from the family.· So...
·5· · · A.· ·No.· Authorization for a claim.
·5· · · Q.· ·All right.· And so your next job was for
·6· · · Q.· ·Okay.· So a payer, an insurance company,
·6· Comprehensive Health Services?
·7· would call in and would say, We have the following
·7· · · A.· ·Yes.
·8· need; is it covered under our policy?
·8· · · Q.· ·And what did you do for them?
·9· · · A.· ·Well, would it be authorized.
·9· · · A.· ·Actually, that was at Dell.· Comprehensive
10· · · Q.· ·And is that -- I mean, is that a medical
10· Health Services had the contract for Dell.· They won
11· necessity review?· Is that what you all were doing?
11· the contract from Concentra.· So I worked for them
12· · · A.· ·Yes.
12· very infrequently because I had a legal nurse
13· · · Q.· ·You mentioned the word "guidelines."· Did you
13· consulting business, and I needed to have ongoing
14· all at Beech Street use a particular set of
14· exposure to clinical work.· So maybe once a month I'd
15· guidelines?
15· work for them.
16· · · A.· ·I think they used Milliman.
16· · · Q.· ·You said you had a legal nurse consulting
17· · · Q.· ·All right.· So how long were you working for
17· business.· What were you doing?
18· either Beech Street or Concentra?
18· · · A.· ·I would review documents for lawyers and
19· · · A.· ·Only like four months.
19· provide reference material that would support the
20· · · Q.· ·And why did you leave that job?
20· documentation or not.
21· · · A.· ·I didn't like it.
21· · · Q.· ·I mean, were you providing like expert
22· · · Q.· ·That's fair.
22· witness consulting services?
23· · · A.· ·Sorry.
23· · · A.· ·Well, I wasn't the expert witness.
24· · · Q.· ·No, that's fair.
24· · · Q.· ·You were just providing consulting to help
25· · · · · · · · Anything in particular you didn't like
25· the lawyers understand the documents?
Page 20
Page 21
·1· · · A.· ·Yes.· Yes.
·1· three months.
·2· · · Q.· ·You're going to get to do some of that today
·2· · · Q.· ·And then you became an employee?
·3· with me.
·3· · · A.· ·Yes.
·4· · · A.· ·Oh.
·4· · · Q.· ·Why did you apply at Centene?
·5· · · Q.· ·I don't understand a lot of these documents,
·5· · · A.· ·I wanted to do case management.
·6· so we'll be doing the same thing.· It's okay.
·6· · · Q.· ·Okay.· Can you briefly describe your job
·7· · · A.· ·All right.
·7· duties for Centene?· What were you doing there?
·8· · · Q.· ·All right.· And then according to the résumé,
·8· · · A.· ·Well, we would get a census from a hospital.
·9· it looks like you started at Superior Health Plan in
·9· We usually covered most of them up and down 35.· We
10· 2009.· Is that correct?
10· would go to the hospitals.· We would obtain
11· · · A.· ·Yes.
11· information from the records, and we would take that
12· · · Q.· ·And for purposes of today, is it fair for --
12· information and enter it into a database, which was
13· I would like you to just assume that if I say Superior
13· InterQual.
14· Health Plan or Centene I mean the same thing.· Okay?
14· · · · · · · · And InterQual had two sections.· There
15· · · A.· ·Yes.
15· was medical necessity and intensity.· And if the
16· · · Q.· ·So you started working for them when in 2009?
16· people qualified or that case qualified, then there
17· Do you remember?
17· would be like a green sign that said it was approved.
18· · · A.· ·February.
18· If not, then you'd get a red sign, and those had to go
19· · · Q.· ·And how did you get from doing this
19· to the doctors.
20· consulting work and also working on the side for CHS,
20· · · Q.· ·So on a day-to-day basis are you mostly
21· how did you get from that job to working for --
21· working onsite in the hospitals?
22· · · A.· ·For Centene?
22· · · A.· ·A good portion of the day, because we had
23· · · Q.· ·Yes, ma'am.
23· several hospitals.
24· · · A.· ·I had applied, but I was a contractor for
24· · · Q.· ·And so I can understand this, the reason that
25· Centene.· I did not work for Centene for the first
25· you're doing this is physicians in the hospital are
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 243 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 149 of 173 Page· 22..25 Page 22
Page 23
·1· requesting to perform services for these patients, and
·1· · · Q.· ·Okay.· What do you call them?
·2· then Centene is performing the analysis of whether
·2· · · A.· ·These are inpatient admissions.
·3· those procedures are medically necessary?
·3· · · Q.· ·Admissions.· Okay.
·4· · · A.· ·Yes.· Or the actual admission.
·4· · · A.· ·Uh-huh.
·5· · · Q.· ·And I guess in addition to the admission, do
·5· · · Q.· ·But what do you call the thing that you're
·6· you all also do medical necessity reviews on whether
·6· doing?· When someone asks you to conduct the medical
·7· or not someone should stay versus being discharged?
·7· necessity review, what do you call that?· Do you call
·8· · · A.· ·Well, we would -- if the documentation in the
·8· it a case; do you call it an inquiry?· I mean --
·9· records indicated according to InterQual guidelines
·9· · · A.· ·You can call it case.
10· that they were ready to be discharged or they needed
10· · · Q.· ·Okay.· When you get one of these cases, how
11· more time, then the patient could stay.· We nurses
11· does it come to you initially?
12· didn't make any determinations.
12· · · A.· ·It will come in your work list.
13· · · Q.· ·All right.· So most of my exposure in this
13· · · Q.· ·And that's like an electronic inbox?
14· case has been with pre-authorization nurses, so I want
14· · · A.· ·Yes.
15· to ask you a question.
15· · · Q.· ·So on a typical day, you wake up in the
16· · · · · · · · Do you know -- from your job at Centene,
16· morning and you get ready for work, what do you do
17· do you know what the basic differences are between a
17· next?· Do you go to the office; do you log on to your
18· concurrent review nurse and a pre-authorization nurse?
18· computer; do you go to a hospital?
19· · · A.· ·I don't believe they go to hospitals and
19· · · A.· ·I first log on to the computer and print a
20· collect clinical information.· I believe -- I don't
20· census for the hospital or hospitals, and that will
21· really know.
21· tell you who and how many you need to see.
22· · · Q.· ·That's okay.· When you get a request, when
22· · · Q.· ·And that's how you know where you need to go?
23· you're working on processing or -- is that what you
23· · · A.· ·Yes.
24· call them, by the way, requests?
24· · · Q.· ·So what was one of the hospitals that you
25· · · A.· ·No.
25· worked at? Page 24
Page 25
·1· · · A.· ·I did them all.· Dell was one.· St. David's,
·1· into the InterQual database.· If it's approved, then
·2· North Austin.
·2· we send a notice to the hospital that it's been
·3· · · Q.· ·Let's go with St. David's --
·3· approved.· If it is not, it goes to the physician.· If
·4· · · A.· ·Seton.
·4· he approves it, we also send a letter of approval.· If
·5· · · Q.· ·-- just for --
·5· he denies it, then we notify them that we're sending
·6· · · A.· ·Yeah.
·6· it to the doctor, and we notify them that it has not
·7· · · Q.· ·-- just for ease.
·7· been approved, and then we also send a letter that it
·8· · · · · · · · So let's say you get a census and it
·8· was not approved.
·9· says that one of the places you need to go to today is
·9· · · Q.· ·Do you actually send those letters or is
10· St. David's.· Are you also getting medical records
10· there somebody else that sends --
11· through that work list or do you go get those at the
11· · · A.· ·They're all electronic.
12· hospital?
12· · · Q.· ·Okay.
13· · · A.· ·No.· You go to the hospital.
13· · · A.· ·Yeah.· And administrative would send those
14· · · Q.· ·And do you have a desk or an office or a cube
14· letters out.
15· at the hospital?
15· · · Q.· ·Where is the doctor physically located?· Back
16· · · A.· ·No.
16· at the Centene office, in the hospital with you or --
17· · · Q.· ·All right.· So how do you get ahold of the
17· · · A.· ·No.· At one time we had one doctor on site,
18· records?
18· but he retired, and I don't know -- one was in
19· · · A.· ·Well, you go to the rooms, and they have a
19· San Antonio.· They were rarely on site.· But this was
20· little a fold-down table and the chart is in there.
20· all electronic.
21· · · Q.· ·All right.· So then you review the chart and
21· · · Q.· ·Were there situations where you would review
22· whatever records are available?
22· the chart and recognize that you needed more
23· · · A.· ·Yes.
23· information before you could use InterQual?
24· · · Q.· ·Okay.· And then what do you do next?
24· · · A.· ·You might.
25· · · A.· ·Then we take that information and we put it
25· · · Q.· ·I mean, did you make a practice out of -- did
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 244 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 150 of 173 Page· 30..33 Page 30
Page 31
·1· a signature.
·1· · · Q.· ·The first one is on Page 2.· Interrogatory
·2· · · Q.· ·It may just not be attached.· That's okay.
·2· No. 1 asks you to state each position you held while
·3· · · A.· ·Yeah.
·3· working for the company, and then it gives some
·4· · · Q.· ·All right.· I want to walk through -- well,
·4· subsidiary questions.
·5· let me stop for a second.
·5· · · A.· ·Uh-huh.
·6· · · · · · · · Other than talking to your lawyer or
·6· · · Q.· ·The title that you gave was "Onsite Case
·7· anybody who works with or for your lawyer, did you
·7· Manager."
·8· talk to anybody for the purposes of preparing for
·8· · · · · · · · Do you see that?
·9· today's deposition?
·9· · · A.· ·Uh-huh.
10· · · A.· ·No.
10· · · Q.· ·Is that what -- is that a "yes"?
11· · · Q.· ·Did you review any documents for the purpose
11· · · A.· ·Yes.
12· of preparing yourself for today's deposition?
12· · · Q.· ·Is that what the folks called you at Centene,
13· · · A.· ·No.
13· was onsite case manager?
14· · · Q.· ·Okay.· Did you look at these -- do you
14· · · A.· ·No.· We were nurse case managers.· The
15· remember when the last time you looked at these
15· "onsite" signified that you went to the various
16· interrogatory responses was?
16· hospitals.
17· · · A.· ·It was a while ago.
17· · · Q.· ·I have also heard the title "concurrent
18· · · Q.· ·Okay.· I think they were written in
18· review nurse" used.
19· December of 2013 or January of 2014.· Does that seem
19· · · · · · · · Did people ever use that title to
20· like --
20· describe you?
21· · · A.· ·That seems correct.
21· · · A.· ·Yes.
22· · · Q.· ·Okay.· I want to talk to you a little bit
22· · · Q.· ·Okay.· Then in Part (b) of your answer, you
23· about some of the answers that you gave to these
23· gave a brief description of your duties and
24· interrogatories.
24· responsibilities.· If you would read that, please, to
25· · · A.· ·Uh-huh.
25· yourself and let me know when you're done. Page 32
Page 33
·1· · · A.· ·Uh-huh.
·1· left from home as opposed to the office?
·2· · · · · · · · Okay.· Yes.
·2· · · A.· ·I would say five.
·3· · · Q.· ·Would you say that's accurate?
·3· · · Q.· ·You were leaving directly from home almost
·4· · · A.· ·Yes.
·4· every day?
·5· · · Q.· ·All right.· And then it asks you how many
·5· · · A.· ·Yes.
·6· hours that you devoted to each duty or responsibility
·6· · · Q.· ·Did you work a regular schedule, and by
·7· on a daily basis, and you've said -- I guess that's
·7· "regular schedule" I mean the same days of every week?
·8· one to three hours driving?· Is that what that says?
·8· · · A.· ·Yes.
·9· It says "3 hours to an hour."
·9· · · Q.· ·What were those days?
10· · · A.· ·Three hours.
10· · · A.· ·Monday through Friday and some weekends.
11· · · Q.· ·What does that mean, "3 hours to an hour"?
11· · · Q.· ·How often did you work weekends?
12· · · A.· ·It probably should have been one to three
12· · · A.· ·Hmm.· When they became NCQA certified, there
13· hours.
13· had to be a one-day turnaround.· So if cases came in
14· · · Q.· ·Okay.· So you spent one to three hours
14· on Fridays and we had no clinical information to
15· driving to or from hospitals after reporting to the
15· determine the medical necessity for them, we would
16· office, is that right?
16· work on Saturdays because you had to have a one-day
17· · · A.· ·Yes.
17· turnaround time.
18· · · Q.· ·When you got up in the morning, was it your
18· · · Q.· ·And was that one business day or just
19· regular practice to go to the office first?
19· 24 hours no matter what?
20· · · A.· ·On occasion.
20· · · A.· ·It's a -- 24 hours.
21· · · Q.· ·Was it more regular for you to go to the
21· · · Q.· ·Did folks have to work Sundays in case cases
22· office or more regular for you to leave directly from
22· came in on Saturdays?
23· home?
23· · · A.· ·No, they wouldn't come on Saturday.
24· · · A.· ·More directly from home.
24· · · Q.· ·Why don't cases come in on Saturdays?
25· · · Q.· ·How many days a week would you say that you
25· · · A.· ·Well, because most of the insurance offices
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 245 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 151 of 173 Page· 34..37 Page 34
Page 35
·1· are closed.
·1· who are informed by the facilities of an admission.
·2· · · Q.· ·Okay.· So if you know, walk me through how
·2· · · Q.· ·And when you say "a case is built by the
·3· the information -- the initial -- the information that
·3· administrative people," you mean the administrative
·4· gets in the census, how it gets into the census.
·4· people at Centene?
·5· · · · · · · · So a patient is at the hospital and
·5· · · A.· ·Yes.
·6· needs a procedure, right?
·6· · · Q.· ·And they base -- the administrative people
·7· · · A.· ·Well, not necessarily a procedure.· They
·7· who build those cases, they base that information --
·8· could be just ill.
·8· they base those case openings on information provided
·9· · · Q.· ·Okay.
·9· by the hospital --
10· · · A.· ·And they're admitted to a hospital --
10· · · A.· ·Yes.
11· · · Q.· ·All right.
11· · · Q.· ·-- or the insurance company?
12· · · A.· ·-- by their physician.
12· · · A.· ·The hospitals.
13· · · Q.· ·Right.
13· · · Q.· ·Okay.· So if a patient is, for example,
14· · · A.· ·Okay?· So they would appear on your census.
14· admitted on Sunday, does the hospital wait until
15· · · Q.· ·Okay.· And that's what I'm getting at.· So
15· Monday to send that information to Centene?
16· the physician admits the patient to the hospital.· Who
16· · · · · · · · MR. BAGGIO:· Objection, calls for
17· puts the data into the census, the hospital or the
17· speculation.
18· insurance company?
18· · · A.· ·I don't know.
19· · · A.· ·The hospital.
19· · · Q.· ·(BY MR. GOLDEN)· Okay.· Well, I'm trying to
20· · · Q.· ·Okay.
20· understand what you mean when you say that a case can
21· · · A.· ·The census -- the hospital census belongs to
21· come in on Friday but not on Saturday or Sunday.· How
22· the hospital.
22· does that happen?
23· · · Q.· ·Okay.· And then how do things get into your
23· · · A.· ·Well, hospitals are open, and their case
24· work flow or your work list?
24· managers or their workers I would think work on
25· · · A.· ·A case is built by the administrative people
25· Fridays.
Page 36
Page 37
·1· · · Q.· ·Sure.· Okay.· Let me try and ask this another
·1· referral specialists personally?
·2· way.
·2· · · A.· ·Those that we worked with.
·3· · · · · · · · The 24-hour turnaround is from when
·3· · · Q.· ·Do you know whether they have medical
·4· Centene gets the request?
·4· backgrounds?
·5· · · A.· ·Yes.
·5· · · A.· ·No, I don't know.
·6· · · Q.· ·Do you know if a patient comes in on
·6· · · Q.· ·Okay.· And then the referral specialist does
·7· Saturday, does the hospital wait until Monday to
·7· some data entry, puts in some basic details to build
·8· submit that information to Centene?
·8· the case, is that correct?
·9· · · A.· ·I don't know.
·9· · · A.· ·Yes.
10· · · Q.· ·All right.· So the information is submitted
10· · · Q.· ·Okay.· And then it gets put into your
11· to Centene, and then you say the case is built by the
11· workflow?
12· administrative staff.
12· · · A.· ·Yes.
13· · · · · · · · Do you all call those referral
13· · · Q.· ·And you have been told that you have a
14· specialists or is that something else?
14· 24-hour turnaround, correct?
15· · · A.· ·Yes.
15· · · A.· ·Yes.
16· · · Q.· ·Okay.
16· · · Q.· ·So when you wake up in the morning and you
17· · · A.· ·Uh-huh.
17· have this list of cases, you're trying to get those
18· · · Q.· ·And is a referral specialist a nurse?
18· all done by the end of the day?
19· · · A.· ·No.
19· · · A.· ·Yes.· But the list grows too.
20· · · Q.· ·Does a referral specialist need to have a
20· · · Q.· ·Over the course of the day?
21· medical background to do their job?
21· · · A.· ·Yes.
22· · · · · · · · MR. BAGGIO:· Objection, calls for
22· · · Q.· ·Because new requests are made?
23· speculation.
23· · · A.· ·Yes.
24· · · A.· ·I don't know.
24· · · Q.· ·How do you check your list during the course
25· · · Q.· ·(BY MR. GOLDEN)· Do you know any of the
25· of the day?
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 246 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 152 of 173 Page· 38..41 Page 38
Page 39
·1· · · A.· ·Electronically.
·1· · · Q.· ·Okay.· And then you go either to your home
·2· · · Q.· ·Do you have a laptop that you carry with you?
·2· office or to the office and then enter that data into
·3· · · A.· ·We have a laptop that we work with, but we
·3· InterQual?
·4· don't carry it to the hospitals with us.
·4· · · A.· ·Yes.
·5· · · Q.· ·Okay.· So if you're at the hospital, how are
·5· · · Q.· ·And then that's how the cases get processed,
·6· you using InterQual when you're at the hospital?
·6· either denied or passed on to the physician, correct?
·7· · · A.· ·We don't.
·7· · · A.· ·If they're denied, they go to the physician.
·8· · · Q.· ·Okay.· Where do you use InterQual?
·8· · · Q.· ·I'm sorry.· I apologize.· Either approved or
·9· · · A.· ·When we get back to either the office or our
·9· passed on to the physician?
10· home office.
10· · · A.· ·Correct.
11· · · Q.· ·Okay.· So then let's go back to this
11· · · Q.· ·Okay.· How detailed are the InterQual
12· Answer (c) to Interrogatory 1 here.
12· guidelines?
13· · · A.· ·Uh-huh.
13· · · A.· ·Very.
14· · · Q.· ·So you're spending somewhere between one and
14· · · · · · · · MR. BAGGIO:· Objection, vague.
15· three hours a day driving, right?
15· · · Q.· ·(BY MR. GOLDEN)· Did you ever have a
16· · · A.· ·Yes.
16· situation where you would review a file in the
17· · · Q.· ·And then it sounds like according to this
17· hospital, make some notes, go back to your house or
18· you're spending one to two hours a day in the hospital
18· the office and log into InterQual and realize that you
19· actually reviewing medical records?
19· did not -- you do not have sufficient information to
20· · · A.· ·Yes.
20· answer all the InterQual questions?
21· · · Q.· ·Do you make copies of those medical records
21· · · A.· ·It's possible.
22· and bring them with you?
22· · · Q.· ·Do you ever remember it happening?
23· · · A.· ·No.
23· · · A.· ·I don't remember it happening.
24· · · Q.· ·Do you take notes?
24· · · Q.· ·Okay.· I mean, when you're taking notes, are
25· · · A.· ·Yes.
25· you literally copying down every single thing that is Page 40
Page 41
·1· written in the medical record to bring back to your
·1· · · A.· ·Correct.
·2· place?
·2· · · Q.· ·Okay.· Let's just look at one of these and
·3· · · A.· ·Well, we had a little worksheet that we used.
·3· see if this helps.
·4· · · Q.· ·And what does the worksheet do?
·4· · · · · · · · (Deposition Exhibit 4 marked.)
·5· · · A.· ·It has some items that InterQual would need.
·5· · · · · · · · THE REPORTER:· Exhibit 4.
·6· · · Q.· ·Okay.· It's my understanding that one of the
·6· · · · · · · · (Document tendered.)
·7· ways that InterQual is organized is you can, for
·7· · · Q.· ·(BY MR. GOLDEN)· All right.· We're going to
·8· example, enter a procedure code and it will --
·8· step away from Exhibit 3 for a second and talk about
·9· InterQual will take you to the right set of criteria.
·9· Exhibit 4 for a little bit.
10· · · · · · · · Is that your understanding?
10· · · · · · · · First of all, do you recognize
11· · · A.· ·It could.
11· Exhibit 4?
12· · · Q.· ·Okay.
12· · · A.· ·I've never seen it before.
13· · · A.· ·The updated version does.
13· · · Q.· ·Okay.· If you look at the top of
14· · · Q.· ·Okay.· Is the same thing true when you're
14· Exhibit 4, on the top left-hand side, there's a title
15· doing concurrent review, is it -- are you logging on
15· that says "CareEnhance Care Manager."
16· to InterQual and trying to find the right set of
16· · · · · · · · Do you see that?
17· criteria or are you regularly using the same set of
17· · · A.· ·Uh-huh.
18· criteria?
18· · · Q.· ·Is that a "yes"?
19· · · A.· ·No.· InterQual has many different categories.
19· · · A.· ·Yes.· I'm sorry.
20· So if there was a cardiac patient, you would go to the
20· · · Q.· ·That's okay.· Does that name mean anything to
21· cardiac section.
21· you?
22· · · Q.· ·And if it was a cardiac patient, the
22· · · A.· ·No.
23· InterQual guidelines related to cardiac events, which
23· · · Q.· ·Okay.· What did you all call the system that
24· we assume would focus on things that relate to cardiac
24· you were using to enter -- so once you run the
25· procedures or health, right?
25· InterQual guidelines, what do you call the system
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 247 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 153 of 173 Page· 42..45 Page 42
Page 43
·1· you're using to enter data to report the results?
·1· number, and then it says "North Austin Medical Center:
·2· · · A.· ·They changed the name.· It's Compass.
·2· Emergent."
·3· · · Q.· ·All right.· Well, I'm going to represent to
·3· · · · · · · · Do you see that?
·4· you, and we're going to walk through this a little
·4· · · A.· ·Yes.
·5· bit, that these are printouts of some of the cases
·5· · · Q.· ·First of all, do you know what that number
·6· that you handled while you were working at Centene.
·6· is, what that number stands for?
·7· Okay?
·7· · · A.· ·That's the authorization for the case from
·8· · · A.· ·Uh-huh.
·8· Centene.
·9· · · Q.· ·And so if you look on the first page of
·9· · · Q.· ·So it's like a case tracking number?
10· Exhibit 4 -- and every page of Exhibit 4 is a separate
10· · · A.· ·Yes.
11· case.· All right?· So I'm just going to start with the
11· · · Q.· ·Okay.· And then the next thing that's entered
12· first one, and we'll talk about some of the other ones
12· there is "North Austin Medical Center: Emergent."
13· later.
13· · · · · · · · Does that mean that the facility we're
14· · · · · · · · The first page of Exhibit 4, which is
14· talking about is the emergency room at North Austin
15· numbered at the bottom 081196, if you look at the top,
15· Medical Center?
16· there's an "Encounter Date" of September 6, 2012, at
16· · · A.· ·I have no idea.
17· 11:45 a.m.
17· · · Q.· ·Okay.· All right.· If you go below that,
18· · · · · · · · Do you see that?
18· there's "Note Text," and it says "Event review created
19· · · A.· ·Yes.
19· for Edwards, Bill by Jane Townsend."
20· · · Q.· ·And then just to the right of that it says
20· · · · · · · · Do you see that?
21· "Entered Townsend, Jane"?
21· · · A.· ·Yes.
22· · · A.· ·Yes.
22· · · Q.· ·Who is Bill Edwards?
23· · · Q.· ·Okay.· If you go down a couple lines, then it
23· · · A.· ·He was the physician.
24· actually describes the event, and it says "Event
24· · · Q.· ·Did you all sometimes call these physicians
25· August 1st, 2012, Admission," and then there's a
25· medical directors? Page 44
Page 45
·1· · · A.· ·Yes.
·1· · · A.· ·Stop what?· I guess I don't understand.
·2· · · Q.· ·Okay.· All right.· Then below that line
·2· · · Q.· ·So you do the review and she doesn't meet the
·3· there's a new line called "Requester's Comments."
·3· criteria, why aren't you just finished?· Why are you
·4· · · · · · · · Do you see that?
·4· going to do five more reviews?· I don't get it.
·5· · · A.· ·Uh-huh.
·5· · · A.· ·Well, this is a case where this lady had to
·6· · · Q.· ·There's that same number again, and then it
·6· stay in the hospital, so -- let me see what he did.
·7· says "CCR Line 6."
·7· Okay.· "Criteria Status" of didn't meet, and he must
·8· · · · · · · · Do you know what that means?
·8· have approved it.
·9· · · A.· ·Concurrent review line.· She had five above
·9· · · Q.· ·When you say "he must have approved it" --
10· that.
10· · · A.· ·Dr. Edwards.
11· · · Q.· ·What do you mean she --
11· · · Q.· ·Okay.
12· · · A.· ·That the concurrent -- this is the sixth
12· · · A.· ·When you get a patient, and we did all --
13· concurrent review that we're sending to the physician.
13· everybody -- anybody on our census, whether they were
14· · · Q.· ·So is it six different procedures or is this
14· male, female, children, NICU, whatever, if they were
15· the sixth review of the same thing?
15· on our census, we reviewed them.· Many women come
16· · · A.· ·No.· No.· It's an inpatient admission.
16· antepartum.· That's before they're going to deliver.
17· · · Q.· ·So when you say this is the sixth one, does
17· Okay.· But they don't meet criteria; however, it is
18· that mean she's been admitted five times before?
18· more safe to keep them in the hospital.
19· · · A.· ·No.· She's been reviewed six times by us, or
19· · · · · · · · And so "Concurrent Review Line 6" is my
20· by me.
20· way of saying to Dr. Edwards, Look at Concurrent
21· · · Q.· ·Okay.· Why are we doing more than one review?
21· Review Line 6, not 5, 4, 3 or 1; and "Previously
22· · · A.· ·Because she does not meet criteria according
22· reviewed" says to him we've reviewed this case before.
23· to InterQual.
23· · · Q.· ·I got you.· Okay.· And so actually, if you'll
24· · · Q.· ·Okay.· So if she doesn't meet the criteria,
24· just for a second page through with me, the next
25· why don't we just stop?
25· couple of pages -- so this page says we're talking
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 248 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 154 of 173 Page· 46..49 Page 46
Page 47
·1· about a 24-year-old female at 25 weeks.
·1· · · A.· ·There is -- there was criteria that depending
·2· · · A.· ·Uh-huh.· Yes.
·2· on the age, like babies, if they were less than
·3· · · Q.· ·The next one actually says -- the second page
·3· 33 weeks you could review them every seven days.
·4· of this exhibit says "CCR Line 4" and is also related
·4· · · Q.· ·Okay.· All right.
·5· to a 24-year-old female now at 22 weeks, and this is
·5· · · A.· ·Most adults we reviewed every other day.
·6· three weeks before.· So this is the same person?
·6· · · Q.· ·And then what if someone is staying in the
·7· · · A.· ·No.
·7· hospital and then the doctor decides -- the treating
·8· · · Q.· ·It's just a coincidence?
·8· physician decides that that person needs a procedure
·9· · · A.· ·Well, we have a different doctor,
·9· that hasn't been already approved, does that then come
10· Dr. Layland, on this, so I -- I cannot for certain say
10· into your queue as well?
11· that this is the same person.
11· · · A.· ·Do you have a procedure in mind?
12· · · Q.· ·Okay.· All right.
12· · · Q.· ·Well, sure.· So you've got a patient who -- I
13· · · · · · · · Okay.· So the review that you're -- you
13· mean, let's just hypothetically use this person who is
14· said you review everybody who is on the census, is
14· described here on the first page of Exhibit 1.
15· that right?
15· · · A.· ·Okay.
16· · · A.· ·Yes.
16· · · Q.· ·She's a 24-year-old female who is 25 weeks
17· · · Q.· ·And is the census every single person who is
17· pregnant, and the doctor says, You know what?· I'm
18· in the hospital on that given day?
18· nervous.· I think that we need to give her an MRI to
19· · · A.· ·That belongs to Superior Health Plan.
19· make sure that everything is okay.· Is that a separate
20· · · Q.· ·Fair.· Okay.· That makes sense.
20· review that happens then?
21· · · · · · · · And so if you have a patient who spends
21· · · A.· ·It could.
22· seven days in the hospital, do you do seven reviews?
22· · · Q.· ·All right.· And in what circumstances would
23· Does Centene do seven reviews?
23· it be reviewed?
24· · · A.· ·Not necessarily.
24· · · A.· ·It would, again, be in a note like this and
25· · · Q.· ·Okay.
25· would be sent to the physician.· Now, they may do a Page 48
Page 49
·1· peer to peer, our doctor and the patient's doctor, to
·1· InterQual?
·2· understand why they want to do an MRI.
·2· · · A.· ·Yes.
·3· · · Q.· ·Okay.· Would there be a scenario where the
·3· · · Q.· ·Okay.· So that's your conclusion?· I mean,
·4· treating physician would say, I want to do an MRI and
·4· that's your conclusion on this whole thing, is we're
·5· it would not get reviewed at all; it would just
·5· done now; it doesn't meet the criteria?
·6· happen?
·6· · · A.· ·Right.
·7· · · A.· ·No.· It would probably get reviewed.
·7· · · Q.· ·Okay.· And then where it says "Review for
·8· · · Q.· ·Okay.· All right.· So going back to the
·8· medical determination," is that you telling
·9· comments on Exhibit 4 -- I think I understand this a
·9· Dr. Edwards that you're kicking this up to him?
10· little bit better now.· Going back to the comments on
10· · · A.· ·Yes.
11· Exhibit 4, under "Requestor's Comments," you've got
11· · · Q.· ·Okay.· Which you have to do every time that
12· again the case number or whatever you want to call
12· the criteria says no, right?
13· that, and then you have "CCR Line 6," and then the
13· · · A.· ·Yes.
14· note about "Previously reviewed," and then it says
14· · · Q.· ·Okay.· Excellent.
15· "Does not meet OB/ante for continued stay."
15· · · · · · · · Do you know -- there appears to be a
16· · · · · · · · What does that mean?
16· series of dates right following that, 9/6 to 9/10/12.
17· · · A.· ·Antepartum.· Predelivery.
17· Do you know what those dates signify?
18· · · Q.· ·And does "OB" stand for obstetrician?
18· · · A.· ·She was in -- those are the dates for which
19· · · A.· ·Obstetrics.
19· I'm sending this concurrent review.
20· · · Q.· ·Obstetrics.· Okay.· So that -- that statement
20· · · Q.· ·So like those are the dates of treatment
21· right there, "Does not meet OB/ante for continued
21· basically?
22· stay," are those -- you're the person who typed that
22· · · A.· ·That she's still in, yeah, inpatient.
23· in there, right?
23· · · Q.· ·All right.· And then in the next sentence --
24· · · A.· ·Yes.
24· first of all, the stuff that comes next but before you
25· · · Q.· ·And is that the result of you using
25· get to "Discharge Planning," so starting with "24 year
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 249 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 155 of 173 Page· 50..53 Page 50
Page 51
·1· old" and ending with "s/p steroids," where does this
·1· · · Q.· ·Okay.
·2· information come from?
·2· · · A.· ·-- by the physicians.
·3· · · A.· ·It comes from the medical record.
·3· · · Q.· ·All right.· And then does the physician write
·4· · · Q.· ·Okay.· And is it -- is it literally copied
·4· that it's an intrauterine pregnancy?
·5· from the medical record or is this your interpretation
·5· · · A.· ·Yes.
·6· of what you've seen there?
·6· · · Q.· ·Okay.· And does the physician write that she
·7· · · A.· ·No.· These are notes that we have copied
·7· was admitted for PROM?
·8· down.
·8· · · A.· ·Yes.
·9· · · Q.· ·Okay.· So let me ask it a different way.
·9· · · Q.· ·Okay.· The next thing it says is "short
10· · · · · · · · The first phrase there is "24 year old
10· cervix."
11· female."· Any person can read a medical chart and know
11· · · A.· ·Uh-huh.
12· how old the person is, right?
12· · · Q.· ·What does it mean to have a short cervix?
13· · · A.· ·Uh-huh.· Yes.
13· · · A.· ·Well, the next -- the cerclage --
14· · · Q.· ·Okay.· Then it says "at 25" and I guess
14· · · Q.· ·Okay.
15· that's 1/7th of a week?
15· · · A.· ·-- is a procedure that they do for a short
16· · · A.· ·Yes.
16· cervix.· In other words, if there's a short cervix,
17· · · Q.· ·So we mean 25 weeks and a day?
17· the baby could be born prematurely.
18· · · A.· ·Yes.
18· · · Q.· ·Okay.· And so what you're saying here is she
19· · · Q.· ·What does "IUP" stand for?
19· has a short cervix, but the cerclage procedure was
20· · · A.· ·Intrauterine pregnancy.
20· done when she was at 13 weeks?
21· · · Q.· ·And then "admitted for PROM"?
21· · · A.· ·Yes.
22· · · A.· ·Premature rupture of membranes.
22· · · Q.· ·Okay.· I assume there's a specific note in
23· · · Q.· ·Okay.· How do you know that she's 25.1 weeks
23· the chart that says the cerclage happened whenever it
24· pregnant?
24· happened?
25· · · A.· ·It's written in the chart --
25· · · A.· ·Yes. Page 52
Page 53
·1· · · Q.· ·How does the physician indicate that it's a
·1· · · Q.· ·And then the blood pressure readings there
·2· short cervix?· Does he actually say that or does it
·2· are --
·3· contain a measurement?
·3· · · A.· ·Yes.
·4· · · A.· ·It contains a measurement.
·4· · · Q.· ·-- also in the chart?
·5· · · Q.· ·And how do you know whether it's short or
·5· · · A.· ·Yes.
·6· not?
·6· · · Q.· ·What is "FHT" one --
·7· · · A.· ·Because they say "short."
·7· · · A.· ·Fetal heart tone.
·8· · · Q.· ·So he says both "short" and it contains a
·8· · · Q.· ·It says "140."· Is that a rate?
·9· measurement?
·9· · · A.· ·Yes.
10· · · A.· ·I'm sorry.· Say that again.
10· · · Q.· ·"And reassuring."· What does that mean?
11· · · Q.· ·Sure.· So I asked you if he said "short" or
11· · · A.· ·That means there's no interference.· It means
12· if he used a measurement, and you said he used a --
12· it's a good heart rate.
13· · · A.· ·No.· They say "short."
13· · · Q.· ·Okay.· Does the chart -- is the chart going
14· · · Q.· ·Okay.· So it doesn't say four centimeters or
14· to say that, "FHT" --
15· whatever?
15· · · A.· ·Yes.
16· · · A.· ·No.
16· · · Q.· ·-- "140 and reassuring"?
17· · · Q.· ·It says "short"?
17· · · A.· ·Yes.
18· · · A.· ·Uh-huh.
18· · · Q.· ·Okay.· You're not interpreting that?· It
19· · · Q.· ·Is that a "yes"?
19· actually says --
20· · · A.· ·Yes.
20· · · A.· ·No.
21· · · Q.· ·Okay.· Then you've got your weight at
21· · · Q.· ·-- that?
22· 225 pounds.· What does "FBS 116" stand for?
22· · · A.· ·It actually says that.
23· · · A.· ·Fasting blood sugar.
23· · · Q.· ·Okay.· "Toco quiet"?
24· · · Q.· ·And that's also in the chart?
24· · · A.· ·That means the measurements for the -- for
25· · · A.· ·Yes.
25· the woman is quiet.· She's not having any
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 250 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 156 of 173 Page· 58..61 Page 58
Page 59
·1· doing right there when you said --
·1· and she came back on the 27th.
·2· · · A.· ·Yes.
·2· · · Q.· ·There you go.· You're right.· So yeah.· So
·3· · · Q.· ·-- "Does not meet," is you're summarizing
·3· she had the surgery, she was in the hospital three
·4· what InterQual said?
·4· days --
·5· · · A.· ·Right.
·5· · · A.· ·Yes.
·6· · · Q.· ·Okay.· So "Does not meet for CNS."· What does
·6· · · Q.· ·-- she was out three days, and then she came
·7· that stand for?
·7· back?
·8· · · A.· ·Central nervous system.
·8· · · A.· ·Yes.
·9· · · Q.· ·And then again you've got the -- it says
·9· · · Q.· ·All right.· "Readmit 5/27 for possible" --
10· "Review for medical determination."· That's you
10· I'm sorry.· What is "TIA"?
11· sending this on to Dr. Edwards?
11· · · A.· ·Transient ischemia attack.
12· · · A.· ·Yes.
12· · · Q.· ·And that's what us nonmedical people
13· · · Q.· ·Okay.· And then below that you've got the
13· sometimes call a mini-stroke?
14· dates here, May 28th to 29th, right?
14· · · A.· ·No, not necessarily.· Maybe just an
15· · · A.· ·Yes.
15· interruption of blood flow.
16· · · Q.· ·And then we've got a 45-year-old female.
16· · · Q.· ·Okay.· So is a TIA always in the brain or can
17· What does "s/p" stand for?
17· it be somewhere else?
18· · · A.· ·Status post.· She had surgery.
18· · · A.· ·It can be in the neck.
19· · · Q.· ·Okay.· "Status post lumbar disc surgery"
19· · · Q.· ·Okay.· All right.
20· about a week before?
20· · · A.· ·Carotid.
21· · · A.· ·Uh-huh.· Three days.
21· · · Q.· ·I'm sorry?
22· · · Q.· ·Yeah.· Like six days, right?· May 22nd, and
22· · · A.· ·Carotid arteries.
23· now you're on May 28th?
23· · · Q.· ·Okay.· I didn't mean to interrupt you. I
24· · · A.· ·Well, she was admitted on -- she had the
24· apologize.
25· surgery on the 22nd, she discharged home on the 25th,
25· · · A.· ·That's okay.
Page 60
Page 61
·1· · · Q.· ·So then it says "c/o weakness."· So she's
·1· medication that she's on, right?
·2· complaining of weakness?
·2· · · A.· ·Yes.
·3· · · A.· ·Yes.
·3· · · Q.· ·And those, of course, are just listed on the
·4· · · Q.· ·She's also complaining of arm numbness I
·4· chart as well, right?
·5· think?
·5· · · A.· ·Yes.
·6· · · A.· ·Yes.
·6· · · Q.· ·And the "Discharge Planning," is that also
·7· · · Q.· ·And I don't know whether she's complaining of
·7· listed on the chart?
·8· it or whether it's observed, but there's a facial
·8· · · A.· ·Yes.· They will say no discharge needs.
·9· droop?
·9· · · Q.· ·And what are discharge needs?· Is that the
10· · · A.· ·Yeah.
10· things that need to get done after a discharge
11· · · Q.· ·And, again, this is all coming straight out
11· happens?
12· of the chart, correct?
12· · · A.· ·Well, sometimes people might need a walker or
13· · · A.· ·Yes.
13· they might need to go to physical therapy as
14· · · Q.· ·And then you've got the blood pressure listed
14· outpatient.
15· there, and then what is "VSS.ECHO"?
15· · · Q.· ·And when the chart -- and, again, does that
16· · · A.· ·A ventricular -- they did an echo of the
16· come from the chart?
17· ventricles of the brain.
17· · · A.· ·Yes.
18· · · Q.· ·And it was --
18· · · Q.· ·When the chart says that there is no
19· · · A.· ·And another CAT scan.
19· discharge needs, does that include both people who are
20· · · Q.· ·Of the neck?
20· going to be discharged but don't have any needs and
21· · · A.· ·Yeah.· These are just tests.· Uh-huh.
21· also people who are not going to be discharged?
22· · · Q.· ·And "unremarkable" means we didn't -- the
22· · · A.· ·Well, discharge planning is done at
23· tests didn't show anything?
23· admission, so it could be either way.
24· · · A.· ·Right.
24· · · Q.· ·Okay.· And then it says "Will continue to
25· · · Q.· ·Right.· And then there's a list of the
25· monitor for D/C."· Is that discharge?
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 251 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 157 of 173 Page· 62..65 Page 62
Page 63
·1· · · A.· ·Yes.
·1· it was not met in either, is that right?
·2· · · Q.· ·Okay.· All right.· Now we get to the whole
·2· · · A.· ·Yes.
·3· reason I was asking about this thing to begin with.
·3· · · Q.· ·So InterQual is saying the illness is not
·4· If you go down below where InterQual says "Criteria
·4· severe enough, which would be enough to deny, but also
·5· Status: Criteria Not Met."· Do you see that?
·5· the intensity of service is not there either, is that
·6· · · A.· ·Yes.
·6· right?
·7· · · Q.· ·And then it says "Review Type: Admission,"
·7· · · A.· ·Correct.
·8· which is a little different than the first page of
·8· · · Q.· ·Okay.· And then it looks to me like even
·9· this exhibit.
·9· below that there is -- the system is generating a bit
10· · · · · · · · But then below that there's "Criteria
10· of explanation, is that right?
11· Component Status," and there's two of them.
11· · · A.· ·For --
12· "Severity of Illness," and it says "Not Met"?
12· · · Q.· ·So if you look under "Decision-Tree Criteria
13· · · A.· ·Uh-huh.
13· Content," it says "Admission, Both" --
14· · · Q.· ·"Yes"?
14· · · A.· ·Yes.
15· · · A.· ·Yes.
15· · · Q.· ·-- and then colon, and it says "Severity of
16· · · Q.· ·And "Intensity of Service," and it says "Not
16· Illness (Onset within 1 week)."
17· Met"?
17· · · A.· ·What are you looking for?
18· · · A.· ·Yes.
18· · · Q.· ·So my question is, is that a more detailed
19· · · Q.· ·Okay.· So I'm gathering from reading this
19· explanation of why the InterQual criteria is not met?
20· form that what this is doing is it's a more specific
20· · · A.· ·Yes.
21· explanation of why the InterQual criteria are not met,
21· · · Q.· ·And is that generated automatically or are
22· is that correct?
22· you typing that in there?
23· · · A.· ·Yes.
23· · · A.· ·Yes.· No.· Uh-uh.· It's generated
24· · · Q.· ·And in this particular case, there were two
24· automatically.
25· ways that it could have been not met, and it turns out
25· · · Q.· ·Okay.· And so just to break it down, up above
Page 64
Page 65
·1· it says "Severity of Illness: Not Met," and then below
·1· that.
·2· it explains that it's not met I think because the
·2· · · Q.· ·Okay.· So you see where it says "Onset within
·3· onset was more than a week ago?
·3· 1 week" in parentheses?
·4· · · A.· ·No.· Severity.· How severe was this incident
·4· · · A.· ·Yes.
·5· that she would qualify for admission.
·5· · · Q.· ·Do you see how it appears immediately below
·6· · · Q.· ·Okay.· So when you use the InterQual
·6· "Severity of Illness"?
·7· guidelines and the question is how severe is the
·7· · · A.· ·Onset.· "Severity of Illness: Not Met"?
·8· incident, how do you answer that question?
·8· · · Q.· ·Right.· And then a couple lines below that
·9· · · A.· ·You select the criteria in the tree that is
·9· the words "Severity of Illness" repeat again.
10· in InterQual.
10· · · A.· ·Uh-huh.
11· · · Q.· ·Okay.· So that's what I'm getting at,
11· · · Q.· ·And then right below that in parentheses it
12· is InterQual doesn't ask you how severe.· InterQual
12· says "(Onset within 1 week)."
13· asks does it meet how many of the following criteria?
13· · · · · · · · Do you see that?
14· · · A.· ·InterQual has criteria, and you select them
14· · · A.· ·Yes.
15· based on the documentation that you take from the
15· · · Q.· ·And it's indented too.· It's not on the same
16· chart.
16· level.
17· · · Q.· ·Okay.· Off the top of your head, do you know
17· · · A.· ·Uh-huh.· Yes.
18· what the criteria are for severity?
18· · · Q.· ·And so just looking at this report, that
19· · · A.· ·For the central nervous system?
19· would indicate to me that that "Onset within 1 week"
20· · · Q.· ·Yes, ma'am.
20· is somehow related to the thing that comes right above
21· · · A.· ·No.
21· it.
22· · · Q.· ·Okay.· Looking at this, it seems to me that
22· · · · · · · · Do you agree?
23· this onset within one week is somehow related to
23· · · A.· ·No.
24· severity of illness on this report.· Is that right?
24· · · Q.· ·Okay.
25· · · A.· ·I don't -- I don't understand where you get
25· · · A.· ·The "Onset within 1 week" might be that it
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 252 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 158 of 173 Page· 82..85 Page 82
Page 83
·1· · · Q.· ·All right.· So if you look just for a second
·1· · · A.· ·Yes.
·2· back at Exhibit 4, there are -- there are eight pages
·2· · · Q.· ·Okay.
·3· to Exhibit 4.
·3· · · A.· ·These are all '12 and '13s.· 2012, 2013.
·4· · · A.· ·Uh-huh.
·4· · · Q.· ·These records are -- right.
·5· · · Q.· ·And if you look at the -- just below where it
·5· · · A.· ·Yes.
·6· says "REDACTED" in big letters on every page, the
·6· · · Q.· ·Did you work less in 2012 and 2013 than you
·7· first thing that's listed there is the "Encounter
·7· did before that?
·8· Date."
·8· · · A.· ·No.
·9· · · · · · · · Do you see that?
·9· · · Q.· ·Okay.· Why did you mention that these were
10· · · A.· ·Yes.
10· all in '12 and '13?
11· · · Q.· ·And that's the date that you're entering this
11· · · A.· ·Well, they only picked a couple from each
12· data into the system?
12· year.
13· · · A.· ·Yes.
13· · · Q.· ·Right.· And that's what I'm asking you, is if
14· · · Q.· ·Okay.· These eight pages reflect entry times
14· we go back and find all of the records, you're telling
15· as early as 11:45 a.m. and as late as three -- no, I'm
15· me that I'm going to find regularly that the last case
16· sorry -- as late as 8:31 p.m.· The seventh page has an
16· that you're entering on a given day is right before
17· 8:31 p.m.
17· 12:15 a.m.?
18· · · A.· ·Uh-huh.
18· · · A.· ·Yes.
19· · · Q.· ·Do you see that?
19· · · Q.· ·Okay.· All right.· I want to talk a little
20· · · A.· ·Yes.
20· bit about performance evaluations and audits.
21· · · Q.· ·Okay.· So you're telling me that if I can
21· · · · · · · · (Deposition Exhibit 7 marked.)
22· find more of these documents, there are going to be a
22· · · · · · · · THE REPORTER:· Exhibit 7.
23· bunch of them where you're inputting data at
23· · · · · · · · (Document tendered.)
24· 11:00 p.m. at night and even 12:00 a.m. in the
24· · · Q.· ·(BY MR. GOLDEN)· All right.· The court
25· morning?
25· reporter has handed you what has been marked as Page 84
Page 85
·1· Exhibit 7.
·1· · · A.· ·No, I don't.
·2· · · · · · · · Do you recognize this document?
·2· · · Q.· ·Okay.· So I'm just guessing it's not yours?
·3· · · A.· ·Yes.
·3· · · A.· ·No.
·4· · · Q.· ·Okay.· What is it?
·4· · · Q.· ·Okay.· The first requirement is listed as
·5· · · A.· ·These are the measurements for the nurses
·5· "TAT," and it says "Maintain 100% Compliance of TAT."
·6· for the work.
·6· · · · · · · · Is that turnaround time?
·7· · · Q.· ·These are the metrics on which your
·7· · · A.· ·Yes.
·8· performance was evaluated?
·8· · · Q.· ·And it says "0-1 Business Day," is that
·9· · · A.· ·Yes.
·9· right?
10· · · Q.· ·Okay.· And how did you know -- who told you
10· · · A.· ·Yes.· Yes.
11· what these measurements were and when did they tell
11· · · Q.· ·And so that's how quickly they expected you
12· you?
12· to get these cases turned around?
13· · · A.· ·The manager.
13· · · A.· ·Yes.
14· · · Q.· ·Okay.
14· · · Q.· ·Okay.· The second one is "Quality of
15· · · A.· ·Norma.
15· Authorization."· It says "Maintain an overall Quality
16· · · Q.· ·And was it in a training; was it in a
16· Audit of 95%."
17· meeting; did it happen regularly?· How did you know
17· · · · · · · · Do you see that?
18· these were your requirements?
18· · · A.· ·Yes.
19· · · A.· ·We probably got them through a department
19· · · Q.· ·Okay.· What is the measurement -- what's
20· meeting.
20· being measured in the quality of authorization?
21· · · Q.· ·Okay.· I want to go through the requirements
21· · · A.· ·Using the correct InterQual criteria.
22· here that are listed on Exhibit 7.
22· · · Q.· ·Anything else?
23· · · · · · · · First of all, there is some handwriting
23· · · A.· ·No.
24· on here.· Do you have any idea who this handwriting
24· · · Q.· ·So if you just always use the correct
25· is?
25· InterQual criteria you're guaranteed to have --
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 253 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 159 of 173 Page· 86..89 Page 86
Page 87
·1· · · A.· ·Well, you have to have the right diagnosis,
·1· those questions, right?
·2· medical necessity, intensity of service.
·2· · · A.· ·Yes.
·3· · · Q.· ·Okay.· Let's go through those one by one.
·3· · · Q.· ·Okay.· And is it -- and it's possible that
·4· You said "you have to have the right diagnosis."
·4· the answer to the medical necessity question might be
·5· · · · · · · · What do you mean when you say "you have
·5· yes while at the same time the answer to the intensity
·6· to have the right diagnosis"?
·6· of service question might be no?
·7· · · A.· ·The right category, medical necessity for
·7· · · A.· ·Yes.
·8· InterQual.
·8· · · Q.· ·And what do you report to the medical
·9· · · Q.· ·So, I mean, is that the same as using the
·9· director when that is the case?
10· proper InterQual criteria?
10· · · A.· ·The whole case goes to the medical director.
11· · · A.· ·Yes.
11· · · Q.· ·Okay.· Does it ever happen that the medical
12· · · Q.· ·Okay.· And then what is intensity of service?
12· director -- okay.· Start over.
13· · · A.· ·That means how they're being treated.· It's
13· · · · · · · · You take a case and determine that the
14· part of InterQual.· It's a two-portion thing, medical
14· case needs to be forwarded to the medical director
15· necessity and intensity of service.
15· because it's not approvable under the guidelines.
16· · · Q.· ·Okay.· Well, I think I know what medical
16· Okay?
17· necessity is, but why don't you tell me.· What is
17· · · A.· ·We don't determine it.· InterQual does.
18· medical necessity?· What does that mean?
18· · · Q.· ·Okay.· You run a case through InterQual and
19· · · A.· ·Well, if they're inpatient, do they need to
19· the determination is that there's not medical
20· be inpatient.
20· necessity, right?
21· · · Q.· ·Okay.· And then what is intensity of service?
21· · · A.· ·Okay.
22· · · A.· ·The treatment.· What is it that they're
22· · · Q.· ·Is there ever a time where the medical
23· getting that they need to be hospitalized.
23· director will call the treating physician and say,
24· · · Q.· ·Okay.· And so I understand this, the
24· Listen, this procedure is not authorized but maybe
25· InterQual guidelines are designed to answer both of
25· another procedure might be?
Page 88
Page 89
·1· · · A.· ·I don't know.
·1· anywhere, but -- telemetry is always a higher level.
·2· · · · · · · · MR. BAGGIO:· Objection, calls for
·2· It's an intermediate level.
·3· speculation.
·3· · · Q.· ·All right.· What does that mean that
·4· · · A.· ·I don't know.
·4· telemetry is always an intermediate level?
·5· · · Q.· ·(BY MR. GOLDEN)· Okay.· All right.· So again,
·5· · · A.· ·It means it's more than med/surgical and less
·6· going back to my question, I asked you what you needed
·6· than intensive care.
·7· to do to get a hundred percent quality of
·7· · · Q.· ·Okay.· What is telemetry, first of all?
·8· authorization, and you said use the correct
·8· · · A.· ·It's cardiac monitoring.
·9· guidelines.
·9· · · Q.· ·Okay.· So is that a -- is telemetry a data
10· · · A.· ·Uh-huh.
10· point that you're evaluating or a procedure that is
11· · · Q.· ·And I asked if that was all, and you said,
11· being considered for approval?
12· No.· You also have to have the right diagnosis,
12· · · A.· ·No.· In order to be in an intermediate level
13· medical necessity and intensity of service.· But if
13· there has to be telemetry stated in the records.
14· InterQual is doing all the work for you, how can you
14· · · Q.· ·Okay.· So telemetry is a data point that
15· get any of that wrong?
15· would go in this summary that's listed here --
16· · · A.· ·You might choose the wrong subset or
16· · · A.· ·Yes.
17· something.
17· · · Q.· ·-- on Exhibit 4?
18· · · Q.· ·When you say "you might choose the wrong
18· · · A.· ·Yes.
19· subset," what does that mean?
19· · · Q.· ·Okay.· And what is telemetry?· Is it the
20· · · A.· ·Well, it could be -- cardiac is a big one.
20· results of --
21· There's a lot of subsets in that.· Or you could choose
21· · · A.· ·It's like a continuous EKG.
22· either observation or acute or ICU.· So there's many
22· · · Q.· ·Okay.· There you go.
23· things in InterQual that you need to be looking at.
23· · · · · · · · And how do you express the results of
24· · · Q.· ·If you --
24· telemetry in writing?· How do you write that down?
25· · · A.· ·And there's some that doesn't -- not written
25· · · A.· ·I don't understand.
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 254 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 160 of 173 Page· 102..105 Page 102
Page 103
·1· criteria to use?
·1· · · Q.· ·Okay.· And how do you know that a TIA comes
·2· · · A.· ·Because of the diagnosis.
·2· under CNS/Musculoskeletal?
·3· · · Q.· ·Okay.· I'll come back to that in a second.
·3· · · A.· ·Because it's written in InterQual.
·4· · · A.· ·Uh-huh.
·4· · · Q.· ·All right.· I'm not really -- okay.· Hold on.
·5· · · Q.· ·Is getting this thing wrong, the criteria
·5· · · · · · · · Somewhere in InterQual you can ask
·6· subset, one of the things that might cause you to have
·6· InterQual what are all the things that fall under
·7· a dip in your quality audit?
·7· CNS/Musculoskeletal?
·8· · · A.· ·It could; however, there might be items
·8· · · A.· ·Well, there is a box, and you can put in
·9· within the subset that you could have chosen but
·9· "TIA," and it will bring you to the place that you
10· didn't.
10· should be.
11· · · Q.· ·Right.· That's another reason why you might
11· · · Q.· ·Okay.· And that's kind of what I'm getting
12· have a quality problem?
12· at.
13· · · A.· ·Yes.
13· · · · · · · · Okay.· So you enter "Acute Adult," and
14· · · Q.· ·Okay.· But one of the reasons why you might
14· then you key into this box "TIA" or you spell it out,
15· have a quality problem is you picked the wrong
15· either way, and it tells you, great, you belong in the
16· criteria subset?
16· CNS/Musculoskeletal criteria subset?
17· · · A.· ·Yes.
17· · · A.· ·Yes.
18· · · Q.· ·Okay.· I missed it.· Some of them actually
18· · · Q.· ·Okay.· Then how is it ever possible to get
19· say "diagnosis."· I don't see a diagnosis on this one.
19· this thing wrong?
20· · · · · · · · How do you know the diagnosis is
20· · · · · · · · MR. BAGGIO:· Objection, calls for
21· CNS/Musculoskeletal (Acute)?
21· speculation.
22· · · A.· ·Where it says it up above.
22· · · A.· ·I don't know.
23· · · Q.· ·I see "Does not meet" --
23· · · Q.· ·(BY MR. GOLDEN)· Well, you said just a minute
24· · · A.· ·"Possible TIA."· The TIA comes under this
24· ago that one of the ways that you could get a ding in
25· category, CNS/Musculoskeletal.
25· your quality audit is to pick the wrong criteria Page 104
Page 105
·1· subset, right?
·1· can just skip the search and actually just go to the
·2· · · A.· ·Yes.
·2· subset?
·3· · · Q.· ·If InterQual is picking the criteria subset
·3· · · A.· ·Yes.
·4· for you, how can you pick the wrong criteria subset?
·4· · · Q.· ·Okay.· And so now I'm asking you, if you can
·5· · · A.· ·I guess I don't know what you're really
·5· use the search box to find the criteria, how is it
·6· looking for or asking.
·6· possible that anyone could get the criteria wrong?
·7· · · Q.· ·I'm trying to figure out how it is that you
·7· · · · · · · · MR. BAGGIO:· Objection, calls for
·8· can do this and I can't, because I know you can do
·8· speculation.
·9· this and I know I can't, and what you're saying is all
·9· · · A.· ·Yeah.· I don't know.
10· I do is ask InterQual and it tells me --
10· · · Q.· ·(BY MR. GOLDEN)· You don't know?
11· · · A.· ·It tells --
11· · · A.· ·No.
12· · · Q.· ·-- and I know that's not right, because it
12· · · Q.· ·Okay.· All right.· Let's mark another exhibit
13· wouldn't tell me.
13· here.
14· · · A.· ·If you used InterQual, are you saying it
14· · · · · · · · (Deposition Exhibit 8 marked.)
15· wouldn't tell you?
15· · · · · · · · THE REPORTER:· Exhibit 8.
16· · · Q.· ·Right.· Because I don't know what a TIA is,
16· · · · · · · · (Document tendered.)
17· I don't know that it belongs in CNS/Musculoskeletal,
17· · · Q.· ·(BY MR. GOLDEN)· All right.· Ms. Townsend,
18· and so I'm asking you how you get there; and what you
18· the court reporter has handed you what has been marked
19· said was, I put TIA in the search box and it gives me
19· as Exhibit 8, and Exhibit 8 appears to be a CCRN
20· CNS/Musculoskeletal.
20· Performance Audit Tool for April 2013.
21· · · A.· ·No.· I said if you didn't know that this
21· · · · · · · · Do you see that?
22· condition was a CNS, you could put TIA in the search
22· · · A.· ·Yes.
23· box and it would bring you to the proper place.
23· · · Q.· ·And if you look in what is the top right-hand
24· · · Q.· ·Okay.· And you can save yourself some time
24· corner of the first page if you're looking at it where
25· because you happen to already know that, and so you
25· you can read it, it says "Townsend0030."
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 255 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 161 of 173
Page 1
IN THE UNITED STATES DISTRICT COURT FOR THE WESTERN DISTRICT OF TEXAS AUSTIN DIVISION KATHY CLARK, AMY ENDSLEY, ) SUSAN GRIMMETT, MARGUERIETTE ) SCHMOLL AND KEVIN ULRICH, ON ) BEHALF OF THEMSELVES AND ALL ) OTHERS SIMILARLY SITUATED, ) ) Plaintiffs, ) ) VS. ) Civil Action ) No. 1:12-CV-00174-SS CENTENE CORPORATION, CENTENE ) COMPANY OF TEXAS, L.P., AND ) SUPERIOR HEALTHPLAN, INC., ) ) Defendants. ) ORAL DEPOSITION OF KEVIN ULRICH On October 18, 2012, between the hours of 8:58 a.m. and 2:04 p.m., in the offices of Dunham & Jones, 1800 Guadalupe Street, Austin, Texas, before me, WILLIAM M. FREDERICKS, a Certified Shorthand Reporter for the State of Texas, appeared KEVIN ULRICH, who, being by me first duly sworn, gave an oral deposition at the instance of the Defendants in said cause, pursuant to the Federal Rules of Civil Procedure.
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM
Appendix Volume 2, p. 256
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 162 of 173
Page 8
1
A.
Right.
2
Q.
Okay?
3
A.
Okay.
4
Q.
So why don't we start with your educational
5
background.
6
have obtained?
So what is the highest degree that you
7
A.
A college certificate for vocational nursing.
8
Q.
And you received that from where?
9
A.
Sul Ross State University in Alpine, Texas.
10
Q.
And in what year?
11
A.
2003.
12
Q.
And what do you -- what did you have to do in
13 14
order to obtain that certificate? A.
I believe there were some prerequisite
15
classes, and then submit a similar application to the
16
school to be accepted into the program.
17
Q.
You say "similar."
Similar to what?
18
A.
Like a job application.
19
Q.
Oh, okay.
20
there?
21
A.
What kind of prerequisites were
I believe human anatomy and physiology, and
22
there was another class, but I don't recall what it
23
was.
24 25
Q.
These were classes you had to take before you
were admitted to the program?
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM
Appendix Volume 2, p. 257
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 163 of 173
Page 48
1
Q.
Okay.
You don't remember which categories
2
they may have been, but you think that there may have
3
been times that you would have been assigned certain
4
categories?
5
A.
Correct.
6
Q.
Okay.
7
For each of these categories, were
there guidelines that you followed?
8
A.
Yes.
9
Q.
And did those guidelines remain the same
10
throughout your employment?
11
A.
Yes.
12
Q.
Okay.
So the same guidelines you were
13
following on the first day of your employment were the
14
same guidelines that were in effect on the last day of
15
your employment?
16
A.
To the best of my knowledge.
17
Q.
Okay.
18
Did all of the procedures that you
were being asked to authorize have guidelines?
19
A.
Yes.
20
Q.
And where were those guidelines found?
21
A.
They were found either in a software platform
22
that we were required to use called InterQual, also
23
known as IQ, or TMHP guidelines, and then Centene had
24
their own policies and procedures, but to my
25
recollection there were very few of those.
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM
Appendix Volume 2, p. 258
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 164 of 173
Page 51
1
participated in that?
2
A.
I do not know.
3
Q.
Okay.
4
Do you know whether the policies that
were Centene policies were specific to Texas?
5
A.
I do not know.
6
Q.
Okay.
So when you used InterQual -- I mean,
7
obviously we've had a lot of testimony over the last
8
couple of days, but you understand there's a lot of
9
questions that I have to ask you even though we
10
already know what the answers are just because we want
11
to make sure that your answers are consistent or
12
inconsistent or what your understanding is.
13 14
Can you explain to me how InterQual worked?
How you would work with InterQual.
15 16
MR. BLEICH: A.
Objection, form.
InterQual was a software application that was
17
part of our primary software application called CCMS.
18
So you would have to be logged into CCMS to utilize
19
InterQual.
20
THE WITNESS:
God bless you.
21
MR. KAISER:
That's my fault.
22
MR. BLEICH:
I knew it wasn't allergies.
23
MR. KAISER:
Yeah.
24 25
Q.
(BY MR. KAISER)
Okay.
So what was it that
you were using InterQual for?
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM
Appendix Volume 2, p. 259
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 165 of 173
Page 68
1
A.
Yes.
2
Q.
And then so your first awareness of a file
3
would be what?
4
A.
The in-box in CCMS.
5
Q.
When it showed up in your in-box?
6
A.
Yes.
7
Q.
Okay.
8
And how it got to your in-box you do
or don't know?
9
A.
Correct.
10
Q.
Okay.
11
to you?
12
A.
No.
13
Q.
Okay.
14
Do you know who assigned those files
Do you know whether there were any
criteria on how those files were assigned to you?
15
A.
No.
16
Q.
Okay.
Did you have any understanding of
17
whether -- I mean, you called it I think a
18
free-for-all, but were they being assigned randomly to
19
each of the preauthorization nurses or did people have
20
particular fields --
21
A.
Right.
22
Q.
-- other than foster care?
23
A.
Right.
24 25
To my knowledge, they would just grab
whatever certain number and divvy them out. Q.
And were there a certain number of files or
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM
Appendix Volume 2, p. 260
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 166 of 173
Page 99
1
A.
Possibly.
2
Q.
Possibly or possibly not?
3
A.
To ask them to redirect them to the
4
supervisor.
5
Q.
6
Would you have provided the information, your
interpretation?
7
A.
No.
8
Q.
Okay.
9
A.
I don't have that capacity.
10
Q.
Is it that you don't have the capacity at
11
Why not?
Centene or you don't have the capacity as a nurse?
12
A.
At Centene.
13
Q.
Do you have the capacity as the nurse?
14
A.
No.
15
Q.
Okay.
You couldn't -- you did not have the
16
skills or knowledge to look at a clinical record and
17
make a judgment as to whether somebody had an
18
incapacitating mental illness?
19
A.
No, not unless it's stated such.
20
Q.
Not unless it states exactly "incapacitating
21
mental illness"?
22
A.
Correct.
23
Q.
When you used the Centene policy, was it -- I
24
understand for the InterQual it had this red light/
25
green light system, right?
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM
Appendix Volume 2, p. 261
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 167 of 173
Page 100
1
A.
Correct.
2
Q.
And can you just briefly for the record
3
describe how that works.
4
MR. BLEICH:
Object to form.
5
A.
I don't understand what you're asking.
6
Q.
(BY MR. KAISER)
How did the red light/green
7
light system work?
8
green light in other words?
9 10 11
A.
What would prompt a red light or a
An indication of whether or not the request
met the guidelines to be approved or escalated. Q.
Okay.
So, for example, if we look at the
12
InterQual, Exhibit 9, and we take an easy one on
13
Page 86 under the category "Impairment" -- do you see
14
that?
15
A.
Yes.
16
Q.
And it says "One."
17
So you had to have at
least one of the following bullet points, right?
18
A.
Yes.
19
Q.
And if you weren't able to check
20
"Cardiopulmonary" and at least one of the things
21
that's under the next item that says "Requiring at
22
least minimum assistance," then you would get a red
23
light?
24
A.
That I recall, yes.
25
Q.
Okay.
And if you did check at least one,
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM
Appendix Volume 2, p. 262
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 168 of 173
Page 101
1
then it would move you along in the process to the
2
next item, which would then be "Skilled therapy"?
3
A.
I believe so, yes.
4
Q.
Okay.
5
So one screen -- you'd have to pass
one screen to go to the next screen?
6
A.
Correct.
7
Q.
Okay.
8
And if you didn't pass one screen, you
got a red light?
9
A.
Essentially, yes.
10
Q.
Okay.
11
And if you did pass it, then you'd get
a green light and you'd get a new screen, right?
12
A.
There were only lights at the end.
13
Q.
Oh, okay.
So it wasn't as you went on there
14
were red lights and green lights.
You would just --
15
you would go through the whole review, and then at the
16
end it would just say -- you'd have a red light or a
17
green light?
18
A.
Yes.
19
Q.
And would it list for you why -- if there
20
were a red light, would it list for you why there was
21
a red light?
22
A.
I don't recall.
23
Q.
If there was a green light, what would you
A.
Finish making notations and fax back the
24 25
do?
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM
Appendix Volume 2, p. 263
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 169 of 173
Page 102
1
authorization.
2
Q.
You were authorized to authorize it?
3
A.
Essentially, yes.
4
Q.
And you would just have to say it met the
5
guidelines?
6
A.
Yes, InterQual guidelines.
7
Q.
Okay.
And was there a review process for
8
reviewing your authorizations for those that you
9
authorized?
10
A.
I don't understand the question.
11
Q.
Well, when you authorized something, did you
12
have to send it on to someone else to give it final
13
approval?
14
A.
No.
15
Q.
Okay.
16
authorized?
17
A.
Yes.
18
Q.
Okay.
19
So when you authorized it, it was
And then what would you do -- how was
that communicated to the provider?
20
A.
Via fax.
21
Q.
And who would send that fax?
22
A.
The nurse.
23
Q.
In your case, it would be you?
24
A.
Yes.
25
Q.
So if you had an authorization and you ran it
FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM
Appendix Volume 2, p. 264
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 170 of 173 Page 1
·1· · · · · · · IN THE UNITED STATES DISTRICT COURT · · · · · · · · ·FOR THE WESTERN DISTRICT OF TEXAS ·2· · · · · · · · · · · · AUSTIN DIVISION ·3· · · ·4· · · ·5· · · ·6· · · ·7· · · ·8· · · ·9· · · 10· · · 11
· · · · · · · · · · · · · · · ·
·KATHY CLARK, AMY ENDSLEY,· ) ·SUSAN GRIMMETT,· · · · · · ) ·MARGUERIETTE SCHMOLL, AND· ) ·KEVIN ULRICH, ON BEHALF· · ) ·OF THEMSELVES AND ALL· · · ) ·OTHERS SIMILARLY· · · · · ·) ·SITUATED,· · · · · · · · · ) · · · · · · · · · · · · · · ) · · · · · · · PLAINTIFFS,· ·) · · · · · · · · · · · · · · ) ·VS.· · · · · · · · · · · · ) CIVIL ACTION · · · · · · · · · · · · · · ) ·CENTENE COMPANY OF TEXAS,· ) NO.: 1:12-CV-00174-SS ·L.P.,· · · · · · · · · · · ) · · · · · · · · · · · · · · ) · · · · · · · DEFENDANT.· · )
12· · · · · · · ----------------------------------13· · · · · · · · · · · ORAL DEPOSITION OF 14· · · · · · · · · · · · · RITA VALDEZ 15· · · · · · · · · · · · JUNE 20, 2014 16· · · · · · · ----------------------------------17· · · · ORAL DEPOSITION OF RITA VALDEZ, produced as a 18· ·witness at the instance of the Defendant, and duly 19· ·sworn, was taken in the above-styled and numbered cause 20· ·on JUNE 20, 2014, from 9:03 a.m. to 12:35 p.m., before 21· ·LEAH MALONE, CSR in and for the State of Texas, reported 22· ·by machine shorthand, at the Embassy Suites, 4337, S. 23· ·Padre Island Dr., Corpus Christi, Texas 78411, pursuant 24· ·to the Federal Rules of Civil Procedure and the 25· ·provisions stated on the record or attached hereto. FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 265
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 171 of 173 Page· 44
·1· · · · A.· Yes.· Sometimes we can make copies.· It ·2· ·depended on which hospital lets you do that. ·3· · · · Q.· Okay.· Making copies seems pretty straight ·4· ·forward.· If you were going to take notes, first of all, ·5· ·in what format do you take notes?· Like on a legal pad ·6· ·or -- is that a yes? ·7· · · · A.· Yes, sorry. ·8· · · · Q.· That's okay.· Do you copy down everything ·9· ·that's written in the chart on your notes? 10· · · · A.· No. 11· · · · Q.· Okay.· How do you know what parts of the chart 12· ·to include in your notes and what parts to not include? 13· · · · A.· Basically I look at the diagnosis, write that 14· ·down, and then I would turn to my book and look for 15· ·these specific things.· If I didn't find these specific 16· ·things, then I would write anything that I could find as 17· ·far as treatment-wise, what medications they were given, 18· ·what treatment they were given, vital signs, and then 19· ·what the physician plans to do with his notes. 20· · · · Q.· So when you say that you look at these criteria 21· ·in InterQual to figure out what you're going to write in 22· ·your notes, by the time you're done taking your notes 23· ·have you already pretty much determined whether the 24· ·criteria are met or not? 25· · · · A.· Sometimes. FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 266 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 172 of 173 Page· 72
·1· · · · A.· And I can't tell you what that... ·2· · · · Q.· That's okay.· And here's the reason I ask that ·3· ·question -- I don't know, so that's okay. ·4· · · · A.· Okay. ·5· · · · Q.· The reason I ask the question is when you're ·6· ·looking in InterQual, does it say -- did it ask whether ·7· ·the patient is on aspirin versus whether the patient is ·8· ·on an NSAID? ·9· · · · A.· No, it says the category of the medication. 10· · · · Q.· So the InterQual asks for the category of the 11· ·medication, not the specific name? 12· · · · A.· Correct.· So you'd have to look up each 13· ·medication and see what it falls under. 14· · · · Q.· And so if you didn't know -- for example, let's 15· ·just use Plavix.· If you didn't know what kind of 16· ·medication Plavix is, how would you go about figuring it 17· ·out? 18· · · · A.· I would just look it up in the computer. 19· · · · Q.· Okay. 20· · · · A.· What Plavix is and what it's used for. 21· · · · Q.· And when you say in the computer, I'm curious 22· ·do you mean Google or do y'all like have a database? 23· · · · A.· We have a database on medications -- like a 24· ·pharmacy kind of database, but you can just look it up 25· ·on Google. FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 267 YVer1f
Case 1:12-cv-00174-SS Document 114-1 Filed 08/01/14 Page 173 of 173 Page· 145
·1· ·some time off? ·2· · · · A.· Yes. ·3· · · · Q.· I just have a question about the phrase you ·4· ·use.· You say I'll be late logging in tomorrow morning. ·5· · · · A.· Right.· Logging in to the computer system.· If ·6· ·she was out of town or out of the office, then basically ·7· ·from anywhere she could see if we were logged into the ·8· ·computer, so... ·9· · · · Q.· Okay.· Do you know whether she was monitoring 10· ·when you were logging in or when you weren't? 11· · · · A.· I don't. 12· · · · Q.· You mentioned earlier that you were aware of at 13· ·least one person who was doing your job in the Corpus 14· ·Christi office who was not an RN? 15· · · · A.· Yes. 16· · · · Q.· Do you have an opinion about whether it would 17· ·be harder to do your job without being an RN? 18· · · · A.· Do I have an opinion about it? 19· · · · Q.· Yeah, do you think it would be harder to do 20· ·your job if you weren't an RN? 21· · · · A.· No. 22· · · · Q.· Why not? 23· · · · A.· Basically you just need to know the medical 24· ·terminology and you can apply the same criteria that's 25· ·in the book. FREDERICKS REPORTING & LITIGATION SERVICES, LLC WWW.FRLTEXAS.COM· (512) 477-9911
Appendix Volume 2, p. 268 YVer1f
Exhibit 8
Appendix Volume 2, p. 269
Case 1:12-cv-00174-SS Document 110-16 Filed 07/31/14 Page 1 of 7
IN THE UNITED STATES DISTRICT COURT FOR THE WESTERN DISTRICT OF TEXAS AUSTIN DIVISION
KATHY CLARK, AMY ENDSLEY, SUSAN GRIMMETT, MARGUERIETTE SCHMOLL, AND KEVIN ULRICH, ON BEHALF OF THEMSELVES AND ALL OTHERS SIMILARLY SITUATED, Plaintiffs, vs. CENTENE CORPORATION, CENTENE COMPANY OF TEXAS, L.P., AND SUPERIOR HEALTHPLAN, INC., Defendants.
) ) ) ) ) ) ) No. 1:12-CV-00174-SS ) ) ) ) ) ) ) ) )
DISCOVERY DEPOSITION OF SHELLY CATTOOR
Taken on behalf of the Plaintiffs May 14, 2014
Christopher C. Wiegers, CCR Missouri CCR 848
10 South Broadway, Suite 1400 Saint Louis, MO 83102
20 South Clark Street, Suite 2478 Chicago, IL 80803
PohlmanUSA.com 877.421.0099
PohlmanUSAT
EXHIBIT M Appendix Volume 2, p. 270
Case 1:12-cv-00174-SS Document 110-16 Filed 07/31/14 Page 2 of 7 Page 9 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
A. It's interchangeable to me. My team is the compensation team within the HR department, human resources department. Q. Okay. So you've got compensation is a functional area or a department within the HR department? A. Correct. Q. What other functional areas or departments are within the HR department? A. There's a benefits team, there's a training team, there's recruiting, and there's also human resources generalists. Q. Okay. A. And then there's also a couple of foils that deal with performance management and they're sort of a part of the training team as well. Q. What do you mean by performance management? A. They're the team that rum the systems and policies and programs for handling performance appraisals for employees on a regular basis. Q. Sure. They handle the sort of annual review process? A. Exactly. Q. Any other teams within the HR department at Centene Management Company? A. I think that covers it
Page 11 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
incentives than what you would see with the other types of jobs other than executives. Q. How much to pay the CEO? A. Exactly. Q. Okay. A. We obviously work with consultants with that too and consult — my boss consults the compensation committee of the board of directors at the — well, there's four quarterly meetings, and then there's an additional one at the end of the year. So we help him prepare for those meetings. We benchmark jobs to make sure that job descriptions — jobs are appropriately placed into our salary structure, our base pay program. Q. What else goes into benchmarking a job other than figuring out if they're in the appropriate salary range? A. Well, the process typically starts with a member of the human resources generalist team out at the various department or business unit subsidiary that is requesting the job evaluation to take place. They will contact us and say either we need a new job or we need this job to be revised or just re-looked at. They'll either provide us with a job description questionnaire or the existing job description, you know, modified as they seem necessary. Q. Who are you referring to when you're saying they? Are you talking about the HR generalist is providing it to
Page 10 1 2 3 4 5 6 7 8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
Q. So within your team there's you, the director of compensation, and then there's a manager of compensation, and then the part-time intern? A. And then there's two people that report to the manager of compensation. That's where I was going with Q. Sure. What are their — the two that report to the manager of compensation, what's their role? A. They're compensation analysts. Q. And your entire team offices here in St. Louis? A. Correct. Q. Was there a director of compensation when you started? A. No. It was an open position. Q. And if you can just describe for me your primary responsibilities and duties as the director of compensation at CMC, which is -- that's my shorthand for Centene Management Company. A. We administer all of the compensation programs for the Centene subsidiary family. And when I say administer, we're more involved in the centralized ones which are the basics, merit. So your annual increase would be tied to your annual performance appraisal. We have an annual bonus plan that most of our employees are members in. Myself and my manager support my boss in the executive compensation procerses. So that's related to, you know, more stock
Page 12 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
you — A. Correct. Q. — or the business unit? A. The HR generalist is the liaison between my team and the business unit management, the local management Q. When you talk about — are you using the term business unit and subsidiary interchangeably? A. I say business unit because we have some corporate departments. We support other Centene Management Company departments as well from a compensation function perspective. But when I say liminess unit, yeah, I would always include our subsidiaries such as oor Medicaid health plans, our specialty companies. Q. So when you were talking about administering all compensation programs, does that include the administration of compensation programs for the business units as well as CMC corporate itself? A. Correct And I will say that some of them are more centralized than others if they're more specific. Like, for example, an incentive plan is specific to a particular role at a particular health plan they come to us with the incentive plan design. You know, we review it for reasonableness, appropriateness, you know, compare it to similar plans that we might have across our other subsidiaries, make recommendations, finalize it, and then we
3 (Pages 9 to 12) POHLMANUSA COURT REPORTING (877) 421-0099 EXHIBIT M Appendix Volume 2, p. 271
Case 1:12-cv-00174-SS Document 110-16 Filed 07/31/14 Page 3 of 7 Page 23
Page 21 1 2 3
4 5 6 7 8 9
10 11 12 13 14
15 16 17 18 19 20 21 22 23 24 25
recently. I'm not 100 percent certain at this time. believe it's Ezme Baig. It was Christine Brzycki recently, but her role changed. Q. Okay. Do you know what it changed from to what it changed to? A. Christine Brzycki was the senior vice president — I believe that was her title — of medical management. And within the last six or twelve months she became the plan product president — tongue twister title. I think that's right. She's still at Superior HealthPlan. Q. Okay. And you mentioned there was a small medical management department at CMC? A. Yes. Q. Does it employ the same type of nurses that the medical management department at Superior HealthPlan employees? A. No. Q. In terms of job descriptions, what is your role with respect to the job descriptions for Superior that are used at Superior? A. Can you kind of explain a little bit more? Q. Sure. As the director of compensation — or in your compensation department do you guys have a role in either creating job descriptions that are used at CTX or Superior for their employees?
1 2 3
4 5 6 7 8
9 10 11 12 13
14 15 16 17 18
19 20 21 22 23 24 25
lists responsibilities of the job, the primary purpose, if the job has direct reports, how many you know, kind of what the job's financial impact is from a budget perspective. And then they'll also review some questions about, you know, what kind of supervisory responsibility the role has, what kind of decision making authority they have to determine what level the job is. Q. By level do you mean the job grade? A. I mean the titling, making sure the titling is correct, making sure the FLSA status is correct. Q. So who within your department would determine the job tide -A. The job title? Q. — for a brand new job? A. Typically the local management will recommend a title. Q. Okay. A. And then as long as it's not totally misaligned with the rest of the organization, which is not unheard of, it would stick. But then we would make a recommendation for a revised title if they were, for example, saying that some job should be a vice president and clearly it wasn't that big of a scope of responsibility. Q. So within your compensation department who would be doing that?
Page 22 1 2 3
4 5 6 7 8 9
10 11 12 13 14
15 16 17 18 19 20 21 22 23 24 25
A. Well, most of the health plan job descriptions have been around for a long time. But as, you know, needed, we review them or the need for a new job description might arise. And as I mentioned before — I can't remember which question it was when we were talking about how the human resources generalist local representative will work with the local operational management if they need either a new job description or a current job description revised. So they'll work together with the human resources representative before they bring that forward towards my department, and then someone on my team will review the job description, you know, ask questions if needed, and then they will benchmark the job using third-party provided salaries surveys. Because we use a market pricing approach to determine salaries and salary grades — or I shook! say salary grades and therefore salaries. Q. So someone in your department at CMC would benchmark the job in terms of the appropriate salary. What else would they do if there was a new job created or a revision that needed to be made? A. Yes. Q. Anything else besides benchmarking the job? A. Well, they would also — if it was a brand new job and they filled out a job description questionnaire, they would obviously review that entire document, which mainly
Page 24 1 2 3
4 5 6
7 8 9 10
11 12 13 14 15 16
17 18 19 20 21 22 23
24 25
A. Well, it would be one of the people reporting to me. But if there were, you know, conflict between what they were recommending and what the human resources representative or the local management was recommending, they would come to me or even my boss to make sure that it's appropriately decided what the title or level should be. Q. So would that be either the compensation analyst, the manager of compensation, or both? A. It could be either. Typically the compensation analysts will work on jobs at the manager level and below, and typically the manager of compensation will evaluate jobs at the director level and above. Clearly if somebody comes to us and says this job is a vice president level and then it's not, there's a little bit of a gray area. But that's how we try to stratify the work. Q. Sure. So the compensation analyst you said that they would work with supervisors or managers and below, and then the compensation manager would work for people above that in terms of hierarchy? A. For job descriptions for those new or revised jobs. I just want to make sure I'm being clear about the job being evaluated and the person they're working with to make the job evaluation. Q. Sure. A. Okay.
6 (Pages 21 to 24) POHLMANUSA COURT REPORTING (877) 421-0099 EXHIBIT M Appendix Volume 2, p. 272
Case 1:12-cv-00174-SS Document 110-16 Filed 07/31/14 Page 4 of 7 Page 31
Page 29 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
percent. Q. Came from where? A. WoridatWork. Q. What's that? A. It's a professional organization for compensation and benefits and human resources professionals. They provide certifications in various human resources areas. Q. So I'm going to show you some job descriptions that have been produced in this case. A. Okay. (Deposition Exhibit No. I marked for identification.) Q. (By Ms. Srey) Ms. Cattoor, I've handed you what's been marked as Deposition Exhibit I. I'll give you a moment to look at that and then I'll ask you some questions about
it. A. Okay. Q. Are you ready? A. Yes. Q. Okay. Do you see the date at the bottom, 7/29/2011? A. Yes. Q. What does that represent, do you know? A. That represents the last time the job description was modified.
1 2 3 4 5 6 7 8 9 10
11 12 13 14 15 16 17 18 19
20 21 22 23 24 25
a brand new job. So the exempt status has been what it's been since prior to my team's arrival at Centene Management Company. But if they would have thought that exempt was inappropriate they would have voiced their opinion about that. Q. So I guess my question is when a job description is reviewed which it looks like it was reviewed or revised some time around July of 2011 -- would your department review the classification decision to either decide whether it was correct or incorrect or maintain status quo?
A. They determined to maintain status quo because the changes that were presented at this time were minor. Just some additional wording was added to the knowledge and experience and some of the position responsibilities. Q. Do you have any specific recollection in terms of the review process for deciding to maintain status quo, maintaining the exemption classification for this job position around this time?
A. I do not recall Q. Do you know who made — I think you said the job position has been in existence for a long time. Do you know who made the initial decision to classify this position as exempt?
A. Weil, as far as I know this job's been in existence since Centene's been existence. So I have no idea who would
Page 30 1
Q. And on 7/292011 you were in the role of director
Page 32
A. Yes. Q. I'm assuming SHP only stands for Superior HealthPlan only, right? A. Correct. Q. In terms of — is this a job description that your compensation department would have created? A. They did not create it, but they reviewed the submitted job description from local management and — you know, they must have — you know, they probably provided some recommendation on if it needed to be changed at all, and then they published it when they were in agreement with the revisions. Q. So where it states FLSA status exempt, is that
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
20
something that your — I guess my question is did your
20
21 22 23 24 25
department of compensation decide the exempt status for the pre-certification nurse for SHP only? A. This job — the core responsibilities and the case manager I pre-certification nurse has been in existence well before my time. So the job was slightly revised. It wasn't
21 22 23 24 25
2 3 4 5 6
7 8 9 10 11 12 13 14 15 16 17 18 19
of compensation, is that right? A. Yes. Q. And this is a job description for case manager I, parentheses, pre-certification nurse, SHP only. Do you see that at the top?
have originally created the first case manager pre-certification or prior authorization nurse job description. It's what you would call a benchmark job in our industry. Q. What do you mean? What is benchmark job in your industry? A. It's a common role in the managed care industry. Q. Do you — does your department go through any sort of annual review process where you're reviewing the exempt status — the FLSA exempt status for various positions within the company, particularly for the pre-certification nurse or the concurrent review nurse roles? A. My particular department does not. We have a policy that encourages managers — local managers to review their own staff's job descriptions and provide us with any feedback on any necessary changes on an annual basis. But it's up to them to notify us. We don't proactively review every single job description, because we have over 2,000. Q. So is there a formal review process in terms of exempt status for employees at CTX for some of the nurse roles? A. From a compensation department's perspective it would just be when the job description is brought forward by the local HR rep and local management to be reviewed. But that's not an annual requirement, as I mentioned.
8 (Pages 29 to 32) POHLMANUSA COURT REPORTING (877) 421-0099
EXHIBIT M Appendix Volume 2, p. 273
Case 1:12-cv-00174-SS Document 110-16 Filed 07/31/14 Page 5 of 7 Page 39
Page 37 1 2 3 4 5 6
function or that role. A. I could tell you by title. I don't know if Ezmerelda Baig is in a management level in medical management. I think she is. And it was Christine Brzycki, but as I mentioned before, her roles changed somewhat
7
Q. Ms. Cattoor, do you recall reviewing the classification decision for pm-certification and prior authorization and concurrent review nurses for CTX any time within the last three years? A. No. It was never brought to my attention by management, so no. Q. Do you know — as you sit here today do you know one way or another whether anyone on your compensation team reviewed the classification decisions for those positions within the last three years for CTX? A. The revision date tells me obviously that someone on my team revised the job description, but it's my recollection that the job description didn't substantively change. There was just some wordsmithing additional verbiage on the position responsibilities. It was nothing changing the essential job functions or minimum qualifications I believe. Q. Is your department responsible for compliance with the FLSA or state wage and hour laws?
8 9 10
11 12 13 14 15 16
17
18 19 20 21 22 23 24 25
recently.
1 2 3 4 5 6 7
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
A. I think I would have been aware if the DOL was investigating, and I have not been made aware of any DOL investigation since I've been at Centene Management Company. Q. At the CTX subsidiary or any subsidiary? A. Any subsidiary. But correct, the C17{ company as well. Q. So going back to my prior question that you asked for clarification on. I think I asked you about compliance efforts, and you said that your department would review the job description for the FLSA exemption status — A. Yes. Q. — and make a recommendation, is that right? A. For a new role, yes. Ora significantly modified role, yes. Q. And then for a current role would you review it to make sure that it was correct? A. I mean, if the responsibilities were being significantly modified, yes. Q. Even if the responsibilities were not being significantly modified, would your department review it to make sure that it was correct within your — A. Sure. They would read the job description obviously and make sure that no one, you know, hopefully made an incorrect recommendation in the past, if that's what you mean, on Fair Labor Standards Act status.
Page 38 1 2 3 4 5
6 7
8 9 10 11 12 13 14 15 16 17
18 19 20 21 22 23 24 25
A. I suppose, yes. Q. And are you familiar with the company's efforts in terms of compliance with the FLSA? A. Yes. Q. And are you responsible for the compliance efforts for the — for CTX as well? A. We are not responsible for knowing daily activities of individuals within job descriptions and making sure the right people are In the right role. That would be local management's responsibility. But we are responsible for taking job descriptions that local management provides in and providing our recommendation on what the FLSA status should be. Q. Besides providing recommendations about what the FLSA status should be for when you review a job description, anything else that you can think of in terms of your department's role in FLSA compliance? A. I'm not sure I understand your question. Q. Sure. Do you guys do any sort of internal audits or external audits or hire any third-party companies to come look at exemption status? A. No. Q. Have you — are you aware of whether CMC or CTX or CMC on behalf of CTX has requested the Department of Labor to do any type of audit of the classification decisions?
Page 40 2 3 4
5
Q. So besides reviewing job descriptions, anything else that you do from a compliance standpoint? A. With regards to FLSA status? Q. Yes.
7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
A. We do, I believe, quarterly — I'm not 100 percent certain on the frequency — audits to make sure that the data in our human resources information system adequately — accurately reflects that anybody who is in a non-exempt role is being paid hourly. I know that sounds very basic, but that's one thing that we do. Q. Just so that I'm clear, on a quarterly basis your department will review non-exempt hourly positions to make sure they are, in fact, being paid hourly? A. I believe it's quarterly. It could be more frequently, but at a minimum it's quarterly. Q. Besides those two things that we've talked about, anything else that you can think of that your department does from an FLSA compliance standpoint? A. No. Q. Do you know whether CTX has people who have a role or responsibility in FLSA compliance at their localized
22 23 24
level? A. I am not aware. Q. Are you familiar with the — do you know what the
25
factual basis for classifying the nurses identified in
6
10 (Pages 37 to 40) POHLMANUSA COURT REPORTING (877) 421-0099 EXHIBIT M Appendix Volume 2, p. 274
Case 1:12-cv-00174-SS Document 110-16 Filed 07/31/14 Page 6 of 7 Page 45 1 2 3 4 5 6 7 8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
was appropriate. Q. Okay. So you did decide to maintain the classification decision? A. Yes. Q. And you mentioned escalate it. Who would you escalate it to if you had disagreed? A. My boss, H. Robert Sanders. Q. Had you also — when you reviewed the classification decision, do you remember when that actually happened? It was sometime before October 2012? Do you remember what the month or date was? A. I don't recall when it happened. Q. Would there be a job description prior to October 2012 that would have prompted you to have reviewed the exemption status? A. My team obviously reviewed it in 2011. Q. Okay. And then if there was a job description dated post July of 2011, would your team have reviewed it again and maintained the decision to classify them as exempt? A. Yes. MS. SREY: I just wrote all over this exhibit. I'm sony. Let's go off the record. (A short break was taken.) MS. SREY: Okay. Plaintiff's Exhibit 2 is
Page 47 1 2 3 4 5 6 7 8 9 10 13.
12 13 14 15 16 17
18 19
Q. And what do you recall about in terms of when your team brought Exhibit 3 to you, the discussion? A. Well, I'm sure if my team brought this to me it was with regards to reading a job description.
MR. KAISER: Don't guess. THE WITNESS: Okay. Q. (By Ms. Srey) Do you recall having any discussions with your team about Exhibit No. 3? A. Not specifically. Q. Okay. What would you use Exhibit 3 for A. To market price a job. Q. In terms of salary? A. Correct. Q. Would you use Exhibit 3 in terms of deciding FLSA exemption status? A. Not solely, no.
Q. In part at all?
20 21 22
A. We would look and see what the typical FLSA status is, but that's not all we would utilize to help us understand if a job should be non-exempt or exempt from our recommendation. Q. Besides the checklist that you identified earlier,
23 24 25
that WorldatWork — anything else that you would look at documentation-wise for -A. The job description.
Page 46 1 2 3 4 5 6 7 8 9 10
defendant's first supplemental objections and answers to plaintiffs first set of interrogatories to Defendant Centene Company of Texas, LP. And we will retain a copy. And I will not write on it anymore. (Deposition Exhibit No. 3 marked for identification.) Q. (By Ms. Srey) Ms. Cattoor, I've handed you what's been marked as Deposition Exhibit 3. Prior to today have you seen this document before? A. I believe it was this document. Surveys look
11
similar.
12 13 14 15 16 17 18 19 20 21 22 23 24 25
Q. And what is it? A. It is a salary survey for a case manager. Q. And why would you review a salary survey for case manager or what was the occasion that you did last time? A. I believe, if I recall correctly, my team brought this to me when they were looking at job descriptions. Q. So when do you recall the last time that you reviewed Exhibit 3 or something similar to it? A. I don't know. Q. And what — do you know what Mercer is? A. Yes. Q. What is it? A. It's a third-party salary survey provider. They do
other HR services as welL
Page 48 1 2 3 4 5
6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
21 22 23 24 25
Q. Hang on one second. A. Sorry. Q. — for deciding FLSA exemption status? A. Mainly the job description, the WoridatWork Fair Labor Standards Act exemption test checklist. This if it's available. A lot of salary surveys don't even provide FLSA status information. Mercer I think is one of the few, and we don't even utilize this survey anymore. Q. Is there a different survey that you utilize? A. We use several. Q. In terms of determining salary range or for FLSA exemption status? A. For salary, yeah. Q. Do you have any specific recollection of relying on Exhibit 3 for determining to maintain the exemption status of the nurses identified in Exhibit 1? A. We wouldn't have solely maintained the status based
on this document, no. Q. Do you have any specific recollection of actually
relying on Exhibit 3?
A. No, not relying on it, no. Q. In terms of deciding to maintain the exemption status for the nurses involved in this case, including those identified in Exhibit 1, did you do any type of individual interviews with any employees?
12 (Pages 45 to 48) POHLMANUSA COURT REPORTING (877) 421-0099 EXHIBIT M Appendix Volume 2, p. 275
Case 1:12-cv-00174-SS Document 110-16 Filed 07/31/14 Page 7 of 7 Page 49 1 2 3 4 5
6 7
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
A. No. Q. Did you take into consideration — other than the things that you've identified, did you take into consideration where they worked in terms of location? A. Do you mean from a perspective of how their
location affected their job responsibilities? Q. Right. A. No.
Q. Did you take into consideration the fact that they were supervised by different managers at the local level? A. No. We rely on the local Superior HealthPlan
management. So the management team that's responsible for all of the Superior HealthPlan locations in Texas to give us an accurate job description that reflects the responsibilities for someone in that job title at any of those Superior HealthPlan locations. Q. And are they I mean, they aren't providing you with multiple job descriptions for one position, are they? A. No. Q. Just one job description? A. Correct. Q. And do you have any knowledge about whether they individually interviewed every single person to determine the recommendation that they would make to corporate compensation about FLSA except status?
Page 53. 1 2 3 4 5 6 7 8 9 10
11 12 13 14 15 16 17 18 19 20 21.
22 23 24 25
the last few years or the last couple years? A. No. We just look at it based on the job
description, not the employees in the job. Q. Okay. And as you sit here today do you know whether CTX, in making that recommendation to classify them as exempt, took into consideration any variances in terms of where they worked, who their supervisor was, their dates of employment, types of claims they reviewed? A. I'm not aware. I don't know.
(Deposition Exhibit No. 4 marked for identification.) Q. (By Ms. Srey) Ms. Cattoor, I've handed you what's been marked as Deposition Exhibit No. 4. Do you want to take a moment to look at it and let me know when you're finished. I just have a couple of questions on it. A. Okay. Q. Actually going back a little bit. You said when you made the decision to classify them as exempt, you just looked on Exhibit 1 and looked at the description of the job. Why don't you interview each person individually? A. We don't have the manpower, and we rely on the
local management to do that because they know the jobs best anyway. Q. The local management to do what? A. To evaluate the job responsibilities of the
Page 50 1 2 3 4 5 6 7 8 9 10 11 12
1
A. I don't know. Q. You don't know if they did individualized surveys of people or not?
A. I don't know. Q. You certainly didn't receive any individualized surveys or questionnaires about each individual person that worked in that position that they recommended for exemption status?
A. No, I did not receive anything like that Q. Did you take into consideration their job schedules or their work schedule in deciding to classify them as exempt?
13
A. No. I have no idea what their schedules are.
14
Q. Do you take into consideration the fact that some of the nurses identified in Exhibit 1, for example, are reviewing certain types of authorization requests, let's say, for durable medical equipment versus an outpatient
15 16 17
18
19 20 21 22 23 24 25
Page 52
procedure? A. No. All we would have utilized to determine the types of authorization is what's listed here in the job description. So for example, it says in the purpose some types, but that's as far as we would have looked into it. Q. Okay. And are you — when you decided to maintain the classification as exempt, did you consider their dates of employment or whether they worked for the company within
2 3 4 5 6 7 8 9 10 11 12 13 14 15
16 17 18 19 20 21 22 23 24 25
position, properly document them, and provide them to us so we can make an educated recommendation. Q. And as you stated, you don't know whether the local management is actually interviewing anyone individually? A. 1 don't require them to tell me if they did or not
They could be. Q. But you don't know one way or another? A. I do not know. Q. I've just handed you whars been marked as Exhibit 4. Have you seen this document before? A. It looks similar to all of the compensation analyst job data that we utilize to benchmark jobs. Q. And then do you have any — to benchmark jobs from what standpoint, salary or exemption status? A. Salary. Q. And did you rely on Exhibit 4 in determining to classify the nurses in Exhibit I and those in this lawsuit as exempt? A. No. Q. Are you familiar with the accreditation process that Centene goes through in terms of accrediting its health plans? A. At a very high level. Not specifically. Q. Do you know who is in charge of that process? A. When you talk about accreditation, do you talk
13 (Pages 49 to 52) POHLMANUSA COURT REPORTING (877) 421-0099
EXHIBIT M Appendix Volume 2, p. 276
Exhibit 9
Appendix Volume 2, p. 277
Case 1:12-cv-00174-SS Document 110-27 Filed 07/31/14 Page 1 of 3
Case: Kathy Clark, et al v. Centene Corporation, et al
Transcript of Stephanie Hall
Date: October 24, 2012
This transcript is printed on 100% recycled paper
GOREPERRY REPORTING & VIDEO
515 Olive Street, Suite 300 St. Louis, MO 63101 Phone:314-241-6750 1-800-878-6750 Fax:314-241-5070 Email:schedule@goreperry.com Internet: www.goreperry.com
EXHIBIT X
Appendix Volume 2, p. 278
Case 1:12-cv-00174-SS Document 110-27 Filed 07/31/14 Page 2 of 3
Stephanie Hall Kathy Clark, et al v. Centene Corporation, et al
10/24/2012
55 1
Q
Right. But I'm assuming that the only way
2
for CNET to know whether or not I'm an employee is
3
whether or not I have a password.
4
A
5
Q Okay. So who issues the passwords to the
6
Correct.
users of CNET; do you know?
7
A
8
Q The determination of whether a job title or
9
I don't.
a job is considered exempt or non-exempt, that
10 determination is made by Centene Management Company; 11
is that right?
12
A
Yes.
13
Q
Why is it important to classify a job as
14
either exempt or non-exempt?
MR. KAISER: I'm going to object insofar as
15 16
it goes beyond the scope of the inquiry from this
17
witness. The Plaintiffs have chosen to do this by
18
30(b)(6) rather than taking a specific deposition.
19
MR. LANGENFELD: Well, employment practices.
20
MR. KAISER: This is not asking about the
21
employment practices of any particular employer.
22
QUESTIONS BY MR. LANGENFELD:
23
Q
Well, let's talk about Centene Company of
24
Texas, okay? You provide management services for
25
Centene Company of Texas; correct?
Gore Perry Reporting and Video EXHIBIT X 314-241-6750 www.goreperry.com FAX 314-241-5070
Appendix Volume 2, p. 279
d38a7086-e477-401b-926b4024d004b6ec
Case 1:12-cv-00174-SS Document 110-27 Filed 07/31/14 Page 3 of 3
Stephanie Hall Kathy Clark, et al v. Centene Corporation, et al
10/24/2012
56 1
A
Yes.
2
Q
And part of what you do is to provide
3
information as to whether a job should be classified
4
as exempt or non-exempt; is that right?
5
A
We review those, the circumstances, as a --
6
that's a service we provide. We consult with them,
7
they consult with us.
8
Q
And so, then, the answer is you do give them
9 guidance on whether to classify jobs as exempt or 10 11 12
non-exempt? A
Centene Management Company partners with
Centene Company of Texas.
13
Q
Right. To make that determination?
14
A
Correct.
15
Q
I'm just trying to understand generally why
16 17 18 19
is it important to make that determination at all? A
It depends on the -- the local plan and the
circumstances. Q
Well, in just general terms, why is that
20
distinction important? I mean, if you're providing
21
management services, and that's one of the things
22
that you're providing, why is that important?
23 24 25
A
So that we have consistency across our
organization. Q Does it have to do with whether to pay those
Gore Perry Reporting and Video EXHIBIT X 314-241-6750 www.goreperry.com FAX 314-241-5070
Appendix Volume 2, p. 280
d38a7086-e477-401b-926b-f024d004b6ec
Exhibit 10
Appendix Volume 2, p. 281
Provider Manual
HEALTHCHOICE ILLINOIS & MEDICARE-MEDICAID ALIGNMENT INITIATIVE Updated 6/18/2019
Appendix Volume 2, p. 282
1
We thank you for being part of IlliniCare Health’s network of participating physicians, hospitals, and other healthcare professionals. Our number one priority is the promotion of healthy lifestyles through preventive healthcare. IlliniCare Health works to accomplish this goal by partnering with the providers who oversee the healthcare of our members. ABOUT US
MISSION
IlliniCare Health is a Managed Care Organization (MCO) contracted with the Illinois Department of Healthcare and Family Services (HFS) to serve Illinois members through the HealthChoice Illinois plan. We are also contracted with both HFS and the Centers for Medicare and Medicaid Services (CMS) for the MedicareMedicaid Alignment Initiative (MMAI), also known as the Duals program or Medicare-Medicaid Plan (MMP).
IlliniCare Health focuses on improving members’ health status, encouraging successful outcomes, and striving for member and provider satisfaction in a coordinated care environment. IlliniCare Health was designed to achieve the following goals:
IlliniCare Health also offers health insurance plans on the Health Insurance Marketplace under Ambetter Insured by Celtic. For more information about Ambetter, including the Ambetter Provider Manual, visit Ambetter.IlliniCare.com. IlliniCare Health has the expertise to improve members’ health status and quality of life. Our parent company, Centene Corporation, has been providing comprehensive managed care services to individuals receiving benefits under Medicaid and other government-sponsored healthcare programs for more than 30 years. Centene operates local health plans in multiple states and offers a wide range of health insurance solutions to a variety of individuals. Centene also contracts with other healthcare and commercial organizations to provide specialty services. For more information about Centene, visit centene.com. IlliniCare Health is a physician-driven organization that is committed to building collaborative partnerships with providers. IlliniCare Health will serve our members consistent with our core philosophy that quality healthcare is best delivered locally.
2
Ε Ensure access to primary and preventive care services.
Ε Ensure care is delivered in the best setting to achieve an optimal outcome. Improve access to all necessary healthcare services. Encourage quality, continuity, and appropriateness of medical care. Provide medical coverage in a cost-effective manner. All of our programs, policies, and procedures are designed with these goals in mind. We hope that you will assist IlliniCare Health in reaching these goals and look forward to your active participation.
HOW TO USE THIS MANUAL IlliniCare Health is committed to working with our network of providers to achieve a high level of satisfaction in delivering quality healthcare benefits. The Provider Manual contains a comprehensive overview of IlliniCare Health operations, benefits, policies, and procedures. Please contact the Provider Services department if you need further explanation on any topics covered in the Provider Manual.
Appendix Volume 2, p. 283
Contact Information The following chart contains contact information for IlliniCare Health. When contacting any department, please have the following information on hand:
Ε National Provider Identifier (NPI); Tax ID Number (TIN); and If calling about a member-related issue, please know the member’s ID Number.
IlliniCare Health’s hours of operation are Monday – Friday 8:30 a.m. to 5 p.m. (CST).
HealthChoice Illinois Member and Provider Services
866-329-4701 TTY: 711
MMAI Member and Provider Services
877-941-0482 TTY: 711
Website
IlliniCare.com
Mailing Address
PO Box 92050 Elk Grove Village, IL 60009-2050
Appendix Volume 2, p. 284
3
Claims Contact Information Use the below contact information when submitting claims-related requests to IlliniCare Health.
CLAIMS TYPE
FIRST SUBMISSION OF CLAIMS (MEDICAL AND BEHAVIORAL HEALTH)
IlliniCare Health Attn: Claims PO Box 4020 Farmington, MO 63640-4402
MEDICAL REQUESTS FOR RECONSIDERATION AND CORRECTED CLAIMS
IlliniCare Health Attn: Reconsideration PO Box 4020 Farmington, MO 63640-4402
MEDICAL CLAIM DISPUTE
IlliniCare Health Attn: Claim Dispute PO Box 3000 Farmington, MO 63640-3800
BEHAVIORAL HEALTH REQUESTS FOR RECONSIDERATION AND CORRECTED CLAIMS
IlliniCare Health Attn: BH Reconsideration PO Box 7300 Farmington, MO 63640-3828
BEHAVIORAL HEALTH CLAIM DISPUTE
IlliniCare Health Attn: BH Dispute PO Box 6000 Farmington, MO 63640-3809
PHARMACY CLAIMS
4
ADDRESS
Envolve Pharmacy Solutions 5 River Park Place East Suite 210 Fresno, CA 93720
Appendix Volume 2, p. 285
Payer IDs For Clearinghouses If you would like to submit your claims through a clearinghouse, please use IlliniCare Health’s Payer ID #: 68069. If you have any question about submitting claims through clearinghouses, please contact: IlliniCare Health c/o Centene EDI Department 800-225-2573, ext. 6075525 EDIBA@centene.com
Appendix Volume 2, p. 286
5
IlliniCare Health’s Products HEALTHCHOICE ILLINOIS HealthChoice Illinois is a statewide Medicaid product available to seniors (age 65 and older) and; individuals age 19 and older who receive medical benefits under the Aid to the Aged, Blind, and Disabled (AABD) program.; pregnant women and families with children under the age of 19; and individuals age 19 to 64 with incomes up to 138% of the Federal Poverty Level (FPL). MEDICARE-MEDICAID ALIGNMENT INITIATIVE (MMAI) The Medicare-Medicaid Alignment Initiative (MMAI), also known as the Medicare-Medicaid Plan (MMP) and Duals, is available to individuals who qualify for both Medicaid and Medicare. MMAI is available in Cook, DuPage, Kane, Kankakee, Lake, and Will counties.
6
Appendix Volume 2, p. 287
OTHER SERVICES IlliniCare Health also provides the following services to members who qualify:
HOME AND COMMUNITY BASED SERVICES (HCBS) WAVIER PROGRAMS IlliniCare Health manages home and community based services (HCBS) waivers for our members. These services are provided to members to assist them in remaining out of nursing homes and live independently in the community. IlliniCare Health is responsible for managing the following HCBS waivers:
Ε Persons who are Elderly Waiver: For individuals 60 years and older that live in the community. Persons with Disabilities Waiver: For individuals that have a physical disability, that are between the ages of 19-59. Persons with HIV or AIDS Waiver: For individuals that have been diagnosed with HIV or AIDS.
LONG TERM CARE (LTC) IlliniCare Health manages room and board for members that reside in Long Term Care (LTC) facilities. This also includes managing their medical, behavioral health, dental, vision, and pharmacy benefits.
MANAGED LONG TERM SERVICES AND SUPPORTS (MLTSS) For members with Managed Long Term Services and Support (MLTSS) benefits, some services are covered by Medicaid, by Medicare, and by IlliniCare Health. IlliniCare Health covers the services available in HCBS waivers. MLTSS services include:
Persons with Brain Injury Waiver: For individuals with an injury to the brain. Supportive Living Facilities: For individuals that need assistance with the activities of daily living, but do not need the care of a nursing facility.
Behavioral Health and non-emergency transportation services from Service Package I and the Nursing Facility and waiver services from Service Package II that are not covered by Medicare (Medicare remains the primary payer of Medicare-covered services for MLTSS enrollees). Crossover claims and other federally approved Medicaid services not covered by Medicare are not covered MLTSS Services and will be billed to Fee-for-Service. Personal Assistant services are considered MLTSS Services only if such services can be included in a manner consistent with any existing collective bargaining agreement, or pertinent side letter, between DCMS and SEIU Healthcare Illinois. IlliniCare Health will abide by the rules and policies provided in each HCBS Waiver.
Appendix Volume 2, p. 288
7
Member Eligibility MEMBER ID CARDS All IlliniCare Health members receive an ID card (see samples below). Members should present their ID card at the time of service, but an ID card in and of itself is not a guarantee of eligibility; therefore, providers must verify a member’s eligibility on each date of service. The member ID number, effective date, contact information for IlliniCare Health, and PCP information are included on the ID card. If you are not familiar with the member seeking care, please ask to see photo identification for confirmation. If you suspect fraud, please contact Provider Services immediately. HealthChoice Illinois ID Card:
MMAI ID Card:
HealthChoice Illinois Member Name: jane doe Medicaid ID#: XXXXXXXXXXX
RXBIN: 004336 RXPCN: MCAIDADV RXGROUP: RX5437
Effective Date: xx/xx/xxxx PCP Name: john doe PCP Number: xxx-xxx-xxxx
MEMBERS Member Services, Behavioral Health, Dental, Transportation, 24/7 Nurse Advice Line: 866-329-4701 TTY: 711 www.IlliniCare.com
Mailing Address IlliniCare Health PO Box 92050 Elk Grove Village, IL 60009-2050
PROVIDERS 24/7 Eligibility and Prior Auth Check: 866-329-4701 Envolve Pharmacy Solutions Help Desk: 844-276-1408
Paper Claims IlliniCare Health Attn: Claims PO Box 4020 Farmington, MO 63640-4402
Payer ID #: 68069 Claim and EFT/ERA information on www.IlliniCare.com
If you have an emergency, call 911 or go to the nearest emergency room (ER). You do not have to call IlliniCare Health for an ok before you get emergency care. If you are unsure if you need to go to the ER, call your PCP or Nurse Advice Toll-free at 1-877-941-0482 or TTY at 711 (Illinois Relay) 24 hours a day.
8
Member Service:
1-877-941-0482
Behavioral Health: Website: Pharmacy Help Desk: Send claims to:
1-877-941-0482 http://mmp.illinicare.com 1-855-854-0270 IlliniCare Health PO Box 4020 Farmington, MO 63640-4402
Appendix Volume 2, p. 289
VERIFYING ELIGIBILITY Use one of the following methods to verify a member’s eligibility:
1 2 3
Log on to the Provider Portal at Provider.IlliniCare.com. Providers can search by date of service plus any of the following: member name and date of birth, or member ID number. You can submit multiple member ID numbers in a single request.
Call our automated member eligibility Interactive Voice Response (IVR) system.
Call Provider Services from any touch tone phone and follow the appropriate menu options to reach our automated member eligibility-verification system 24 hours a day. The automated system will prompt you to enter the member ID number, the member date of birth, and the month of service to check eligibility.
Call Provider Services.
If you cannot confirm a member’s eligibility using the methods above, call Provider Services. Follow the menu prompts to speak to a representative to verify eligibility before rendering services. Provider Services will need the member name or member ID number and the member date of birth to verify eligibility.
ELIGIBILITY FOR HCBS WAIVERS, SLFS, AND LTC IlliniCare Health members may qualify for home and community-based services (HCBS) waivers, supportive living facilities (SLFs), or long term care (LTC). Eligibility for these programs is determined by the State of Illinois. This is done through an assessment tool, the Determination of Need (DON). The member will be asked a series of questions, and given an overall score. Based on the member’s DON score, the State will determine if the member is eligible for a waiver service. To confirm if a member is eligible for these services, visit the Provider Portal or contact Provider Services.
Appendix Volume 2, p. 290
9
Benefit Explanation & Limitations IlliniCare Health providers supply a variety of medical benefits and services, some of which are outlined on the following pages. All services must be medically necessary and some services require prior authorization. See page 19 for information regarding the prior authorization process. Please note we will NOT authorize services for out of network or non-participating providers, unless the services are necessary for continuity of care reasons. We may also authorize services for out of network providers at our discretion if the services are not available through our in-network providers. For specific benefit information not covered in this Manual, please contact Provider Services. Providers can also reference IlliniCare.com for the most recent benefit updates.
10
Appendix Volume 2, p. 291
COVERED SERVICES Note: Some services require prior authorization. Always check if services need prior authorization before completing. See page 19 for information regarding the prior authorization process.
Ε Abortion services in limited situations Advanced Practice Nurse services Ambulatory Surgical Treatment Center services Audiology services Behavioral health outpatient services
• Community case services • Crisis services ••Inpatient psychiatric services • Intensive outpatient services • Partial hospitalization services • Residential rehabilitation services Ε Chiropractic services Ε Clinic services Ε Dental services ΕΕDurable medical equipment ΕΕEarly and Periodic Screening, Diagnostics, and Treatment (EPSDT) services to members under the age of twenty-one (21)
ΕΕFamily Planning services and supplies
ΕΕHome Health Agency visits ΕΕHospice services ΕΕHospital ambulatory (outpatient) services ΕΕHospital inpatient services ΕΕHospital emergency department services ΕΕImaging services ΕΕLaboratory services ΕΕLong Term Care services ΕΕMedical supplies, equipment, prostheses, and orthoses
ΕΕPharmacy services ΕΕPhysician services ΕΕPodiatric services ΕΕPreventive medicine schedule (services to members age twenty-one (21) year or older)
ΕΕRenal dialysis services ΕΕSub-acute alcohol and substance abuse services ΕΕTelehealth services ΕΕTransportation to secure covered medical services
ADDITIONAL BENEFITS HEALTHCHOICE ILLINOIS No Copays
No copays for medical visits or prescriptions.
Prescriptions
Option for 90-day supply mailed to members’ home.
Dental Services
Additional care for adults.
Practice Visits
“Practice visits” to the dentist or certain specialists if needed.
Telemonitoring
Eligible members get devices to help check on health problems.
CentAccount
Rewards program that provides prepaid debit card with funds added when members utilize certain screenings and preventive care.
Connections Plus
Cell phones provided to eligible members who don’t have access to a phone to call providers, 911, or care coordinators.
Vision Services
$100 credit for eyeglass frames or an $80 credit for contact lenses.
Nurse Advice Line
Members can call a nurse for advice 24 hours a day, 7 days a week.
Appendix Volume 2, p. 292
11
General Preventive Care Services
Ε Eye exams. We cover an eye exam every 2 years
ΕΕOutpatient services including routine prenatal
(unless the member has a medical need for more frequent exams). We cover refractions to determine a prescription for glasses.
care before and after delivery for problems or complications resulting from pregnancy or childbirth.
Health education programs including: diabetes education, heart health education, nutritional education, etc.
ΕΕInpatient hospital services in participating
Child and adult immunizations.
Ε Care from the Comprehensive Perinatal Services
••Immunizations are covered according to the Advisory Committee on Immunization Practices (ACIP), the Illinois Adult Immunization and the United States Preventive Services Task Force recommendations.
ΕΕPeriodic check-ups. A complete history and physical exam every one to three years.
ΕΕMedical screenings for: diabetes, high cholesterol, osteoporosis, tuberculosis, etc.
ΕΕCancer screening for cervical, breast, colorectal, prostate, and skin. Well-Child Care The Child Health & Disability Prevention (CHDP) program offers:
ΕΕHealth history. Ε Medical, dental, nutritional and developmental assessment.
ΕΕImmunizations. ΕΕVision and hearing testing. ΕΕSome laboratory tests (e.g., tuberculin, sickle cell, blood and urine tests, pap smears).
ΕΕHealth education, including smoking and information on second-hand smoke.
ΕΕAny test recommended by IlliniCare Health and medical professionals, and that meets medical necessity criteria, is covered.
12
Pregnancy and Maternity Services
hospitals and out-of-network emergency labor and delivery services. Program (CPSP), including a medical/obstetrical, nutritional, psychosocial, and health education assessment at the first prenatal visit, one visit during each trimester thereafter, and at the postpartum visit.
ΕΕThe newborn child’s healthcare for the month of delivery and the month after delivery. By that time, the newborn should be enrolled separately. Voluntary Family Planning Services IlliniCare Health covers the cost of contraceptives, including the birth control device, and fitting or inserting the device (such as diaphragms, IUDs, Norplant). Members can get services from any qualified family planning provider. He/she does not have to be a participating provider. Our members do not need a referral from PCP and do not have to get permission from IlliniCare Health to get these services. Voluntary Sterilization Services We cover vasectomies and tubal ligations. Screening and Brief Intervention, Referral for Treatment (SBIRT) This is a billable service for primary care providers as a way to screen members and refer them to appropriate behavioral health services. IlliniCare Health also offers training for PCPs on the use of this screening tool.
Appendix Volume 2, p. 293
MMAI Over-the-Counter Medications
$25/month.
Nurse Advice Line
Members can call a nurse for advice 24 hours a day, 7 days a week.
Rewards Program
Members can earn rewards when they utilize certain screenings and preventive care.
Comprehensive Dental Services
• No copays/coinsurance, diagnostic, restorative, endodontics/ periodontics/extractions, prosthodontics, other oral/maxillofacial surgery • $1,000 annual maximum
Vision Services
• No copays/coinsurance • Routine eye exam: 1 per year, or as medically necessary • 1 pair of glasses every two (2) years, no maximum
Hearing Services
• No copays/coinsurance • Routine hearing exam: 1 per year • Hearing aid fitting/evaluation: 1 every three (3) years • Hearing aid: no maximum
HCBS WAIVERS All services covered under the HCBS Waivers need prior authorization. See page 19 for information regarding the prior authorization process.
ELDERLY WAIVER
SERVICE
DISABILITY WAIVER
BRAIN INJURY WAIVER
HIV/AIDS WAIVER
Adult Day Service
Adult Day Services Transportation
Behavioral Services
Day Habilitation
Environmental Accessibility Adaptations - Home
Home Delivered Meals
Home Health Aide
Nursing - Skilled
Nursing - Intermittent
Personal Assistant
Family Training
Homemaker
Individual Provider Nurse Training
Personal Emergency Response System Physical, Occupational, and Speech Therapy
Placement Maintenance Counseling Prevocational Services
Appendix Volume 2, p. 294
13
SERVICE
ELDERLY WAIVER
DISABILITY WAIVER
BRAIN INJURY WAIVER
HIV/AIDS WAIVER
Respite
Specialized Medical Equipment and Supplies
Supported Employment
SUPPORTIVE LIVING FACILITY WAIVERS Supportive living provides an alternative to traditional nursing home care by mixing housing with personal care and supportive services. This waiver includes these services:
NON-COVERED SERVICES Medical procedures solely for cosmetic purposes. Diagnostic and/or therapeutic procedures related to infertility/sterility. Services that are experimental and/or investigational in nature.
Ε24 Hour Response/Security Housekeeping
Intermediate Care Facilities for Mentally Retarded/ Developmentally Disabled.
Laundry Maintenance Meals & Snacks
Nursing Facilities beginning on the ninety-first (91st) day.
Medication Assistance
Ε Services provided by an out-of-network provider
Nursing Assessments
not prior-authorized by IlliniCare Health.
• Exceptions: Family planning services (in state)
Nursing – Intermittent
and emergency services.
Personal Care Personal Emergency Response System Social & Health Promotion Activities
Ε Services that are provided without first obtaining a required referral or prior authorization as per IlliniCare Health policy.
• All waiver services require prior authorization.
Well-Being Check
LTC IlliniCare Health covers room and board for eligible members residing in Long Term Care (LTC) facilities.
14
Appendix Volume 2, p. 295
Preventive Screenings IlliniCare Health encourages our members to undergo routine preventive screenings to diagnosis and treat conditions in a timely fashion. Below is an overview of the preventive screenings covered by IlliniCare Health.
EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit is Medicaid’s comprehensive and preventive child health program for individuals under the age of 21, which is mandated by state and federal law. IlliniCare Health provides coverage for the full range of EPSDT services in accordance with HFS policies and procedures. These services include periodic health screenings and appropriate up-todate immunizations using the Advisory Committee on Immunization Practices (ACIP) recommended immunization schedule and the American Academy of Pediatrics (AAP) periodicity schedule for pediatric preventative care. The following services are included in the EPSDT benefit:
treatment, and other measures to ameliorate defects, physical, and mental illnesses and conditions identified.
Ε Appropriate children immunizations. All components of the EPSDT benefit must be clearly documented in the PCP’s medical record for each member. IlliniCare Health requires that providers cooperate to the maximum extent possible with efforts to improve the health status of Illinois citizens, and to actively participate in the increase of percentage of eligible members obtaining EPSDT services in accordance with the adopted periodicity schedules. IlliniCare Health will cooperate and assist providers to identify and immunize all members whose medical records do not indicate up-to-date immunizations. IlliniCare Health providers shall participate in the Vaccines for Children (VFC) program. Vaccines from VFC should be billed with the specific antigen codes for administrative reimbursement. No payment will be made on the administration codes alone.
Ε Comprehensive health history
ADULT PREVENTIVE CARE
Developmental history – including assessment of both physical and mental health development
The below guides are the recommended preventive care schedules for adults in IlliniCare Health’s products. Members should consult with their PCP to determine which screenings are right for them and when to undergo each screening.
Comprehensive physical exam (with clothes off when clinically appropriate). Laboratory tests (including blood lead level assessment). Vision screening and necessary follow-up services.
Wellness Visits Age Under age 21 Ages 21-65 Over age 65
Dental screening and necessary follow-up services.
Adult wellness visits include:
Health education.
Frequency Annually Every 1–3 years Annually
Hearing screening and necessary follow-up services.
Complete health history
Ε Other necessary healthcare, diagnostic services,
Ε Preventive screenings (as needed)
Comprehensive physical exam
Appendix Volume 2, p. 296
15
Recommended Adult Preventive Screenings
16
Screening
Recommendation
Abdominal aortic aneurysm screening
One-time screening for men ages 65–75 who have smoked.
Alcohol misuse: screening and counseling
Adults age 18 and older.
Aspirin preventive medicine
Adults age 50-59 with a greater than 10% 10-year cardiovascular risk.
Bacteriuria screening
Women 12-16 weeks pregnant.
Blood pressure screening
Annually for adults age 18 and older.
BRCA risk assessment and genetic counseling/testing
Women with family members with breast, ovarian, tubal, or peritoneal cancer.
Breast cancer preventive medications
Women at an increased risk for breast cancer.
Breast cancer screening
Every 1 to 2 years for women age 40 and older.
Breastfeeding interventions
Women during pregnancy and after birth.
Cervical cancer screening
Every 3 years for women age 21-65. Every 5 years for women age 30-65 if screening done with cytology and HPV test.
Chlamydia screening
Sexually active women age 24 or younger and in older women at an increased risk for infection.
Colorectal cancer screening
Adults age 50-75.
Depression screening
General adult population, including pregnant and postpartum women.
Diabetes (Type II) screening
Adults age 40-70 who are overweight or obese.
Fall prevention: exercise or physical therapy
Community-dwelling adults age 65 and older who are at increased risk for falls.
Fall prevention: vitamin D
Community-dwelling adults age 65 and older who are at increased risk for falls.
Folic acid supplementation
Women who are planning or capable of pregnancy.
Gestational diabetes screening
Asymptomatic pregnant women after 24 weeks of gestation.
Gonorrhea screening
Sexually active women age 24 or younger and in older women at an increased risk for infection.
Healthy diet and physical activity counseling to prevent cardiovascular disease (CVD)
Adults who are overweight or obsess and have additional CVD risk factors.
Hepatitis B screening
Persons at high risk for infection. Pregnant women at first prenatal visit.
Hepatitis C screening
Adults at high risk for infection. 1-time screening for adults born during 1945-1965.
HIV screening
Adolescents and adults 15-65 years old. Pregnant women.
Intimate partner violence screening
Women of childbearing age.
Lung cancer screening
Adults age 55-80 with a history of smoking.
Obesity screening and counseling
All adults.
Osteoporosis screening
Women age 65 and older.
Preeclampsia prevention: aspirin
Pregnant women at high risk for preeclampsia after 12 weeks of gestation.
Preeclampsia screening
Pregnant women.
Appendix Volume 2, p. 297
Screening
Recommendation
Rh incompatibility screening
Pregnant women at first prenatal visit. Repeated test at 24-28 weeks for unsensitized Rh(D)-negative pregnant women.
Sexually transmitted infections counseling
Sexually active adolescents. Adults with an increased risk for infection.
Skin cancer counseling
Children, adolescents, and young adults age 10-24 with fair skin.
Statin preventive medication
Adults age 40-75 with no history of CVD, 1 or more CVD risk factors, and a calculated 10-year CVD event risk of 10% or greater.
Tobacco use counseling and interventions
All adults. All pregnant women.
Tuberculosis screening
Adults at increased risk for infection.
Syphilis screening
Adults at increased risk for infection. All pregnant women.
Appendix Volume 2, p. 298
17
Medical Management UTILIZATION MANAGEMENT The IlliniCare Health Utilization Management (UM) Program is designed to ensure members of IlliniCare Health receive access to the right care at the right place and right time. Our program is comprehensive and applies to all eligible members across all product types, age categories, and range of diagnoses. The UM program incorporates all care settings including preventive care, emergency care, primary care, specialty care, acute care, short-term care, long term care, ancillary care, and behavioral health services. IlliniCare Health’s UM program seeks to optimize a member’s health status, sense of well-being, productivity, and access to quality healthcare, while at the same time actively managing cost trends. The UM program aims to provide services that are a covered benefit, medically necessary, appropriate to the patient’s condition, rendered in the appropriate setting and meet professionally recognized standards of care. Our program goals include:
ΕΕMonitoring utilization patterns to guard against over- or under-utilization.
Ε Development and distribution of clinical practice guidelines to providers to promote improved clinical outcomes and satisfaction.
Ε Identification and provision of care coordination and/or disease management for members at risk for significant health expenses or ongoing care.
ΕΕDevelopment of an infrastructure to ensure that all IlliniCare Health members establish relationships with their PCPs to obtain preventive care.
ΕΕImplementation of programs that encourage preventive services and chronic condition selfmanagement. Creation of partnerships with members/providers to enhance cooperation and support for UM program goals.
18
Utilization Management Contact Information HealthChoice Illinois Phone: 866-329-4701 MMAI Phone: 877-941-0482
PRIOR AUTHORIZATION
There are 3 ways to submit for prior authorization:
1.
Provider Portal: Provider.IlliniCare.com
2.
Fax: HealthChoice Illinois: Medical: 877-779-5234 Behavioral Health: 844-528-3453 MMAI: 844-409-5557
3.
Phone: HealthChoice Illinois: 866-329-4701 MMAI: 877-947-0482
Please ensure that the TIN and NPI provided in prior authorization requests are accurate to avoid downstream claims payment issues. Authorization must be obtained prior to the delivery of certain elective and scheduled services. Services that require authorization by IlliniCare Health are listed on IlliniCare.com. The PCP should contact the UM department via telephone, fax or through our website with appropriate supporting clinical information to request an authorization. All out-ofnetwork services require prior authorization. Emergency Room (ER) and urgent care services never require prior authorization. Providers should notify IlliniCare Health of post-stabilization services such as but not limited to the weekend or holiday provision of home health, durable medical equipment, or urgent outpatient surgery, within two (2) business days of the service initiation. If notified after the 2 days, an administrative denial will take place.
Appendix Volume 2, p. 299
Clinical information is required for ongoing care authorization of the service. Failure to obtain authorization may result in administrative claim denials. IlliniCare Health providers are contractually prohibited from holding any IlliniCare Health member financially liable for any service administratively denied by IlliniCare Health for the failure of the provider to obtain timely authorization. Authorization Timelines Prior authorization should be requested at least 14 calendar days before the requested service delivery date. IlliniCare Health decisions for requests for standard services will be made within 4 days. “Necessary information” includes the results of any face-to-face clinical evaluation (including diagnostic testing) or second opinion that may be required. The provider and member will be notified of the decision within one business day of the determination. Failure to submit necessary clinical information can result in an administrative denial of the requested service. For urgent/expedited requests, a decision is made within 48 hours of receipt of all necessary information. Urgent criteria is defined as a medical/ behavioral health event that could seriously jeopardize the life, health or safety of the member or others, due to the member’s psychological state. Or, in the opinion of a practitioner with knowledge of the member’s medical or behavioral condition, would subject the member to adverse health consequences without the care or treatment that is the subject of the request. The provider and member will be notified of the decision within one business day of the determination. Clinical Information Authorization requests may be submitted by fax, phone, or provider portal. A referral specialist will enter the demographic information and transfer the information to an IlliniCare Health nurse for the completion of medical necessity screening. For all services on the prior authorization list, documentation supporting medical necessity will be required. IlliniCare Health clinical staff will request clinical information that is minimally necessary for clinical decision making. All clinical information is collected according to federal and state regulations regarding the confidentiality of medical information. Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), IlliniCare Health is entitled to request and receive protected health information (PHI) for purposes of treatment, payment and healthcare operations.
Information necessary for authorization of covered services may include but is not limited to:
Ε Member name and member ID number ΕΕProvider name and telephone number ΕΕProvider location, if the request is for an ambulatory or office procedure
ΕΕReason for the authorization request (e.g., primary and secondary diagnoses, planned surgical procedures, surgery date)
ΕΕRelevant clinical information (e.g., past/ proposed treatment plan, surgical procedure, and diagnostic procedures to support the appropriateness and level of service proposed)
ΕΕDischarge plans Notification of newborn deliveries should include the mother’s name, date of delivery, method of delivery, and weight. If additional clinical information is required, an IlliniCare Health nurse or medical management representative will notify the caller of the specific information needed to complete the authorization process. Clinical Decisions IlliniCare Health affirms that utilization management decision making is based only on appropriateness of care and service and the existence of coverage. IlliniCare Health does not specifically reward practitioners or other individuals for issuing denials of service or care. The treating physician, in conjunction with the member, is responsible for making all clinical decisions regarding the care and treatment of the member. The PCP, in consultation with the IlliniCare Health Medical Director and other clinical staff, is responsible for making utilization management decisions in accordance with the member’s plan of covered benefits and established medical necessity criteria. Failure to obtain authorization for services that require plan approval may result in payment denials. Medical Necessity Medical necessity is defined for IlliniCare Health members as healthcare services, supplies or equipment provided by a licensed healthcare professional that are:
Ε Appropriate and consistent with the diagnosis or treatment of the patient’s condition, illness, or injury. In accordance with the standards of good medical practice consistent with evidence based and
Appendix Volume 2, p. 300
19
clinical practice guidelines.
ΕΕNot primarily for the personal comfort or convenience of the member, family, or provider.
ΕΕThe most appropriate services, supplies, equipment, or level of care that can be safely and efficiently provided to the member.
ΕΕFurnished in a setting appropriate to the patient’s medical need and condition and, when supplied to the care of an inpatient, further mean that the member’s medical symptoms or conditions require that the services cannot be safely provided to the member as an outpatient service.
Ε Not experimental or investigational or for research or education.
Members or healthcare professionals with the member’s consent may request an appeal related to a medical necessity decision made during the authorization or concurrent review process orally or in writing to: IlliniCare Health Attn: Prior Auth Appeal PO Box 92050 Elk Grove Village, IL 60009-2050
RETROSPECTIVE REVIEW
Review Criteria IlliniCare Health has adopted utilization review criteria developed by McKesson InterQual® products to determine medical necessity for healthcare services. Behavioral health UM uses InterQual in addition to American Society of Addiction Medicine (ASAM) criteria for all inpatient services; state service definitions are used for behavioral health community-based services. InterQual appropriateness criteria are developed by specialists representing a national panel from community-based and academic practice. InterQual criteria cover medical and surgical admissions, outpatient procedures, referrals to specialists, and ancillary services. Criteria are established and periodically evaluated and updated with appropriate involvement from physicians. InterQual is utilized as a screening guide and is not intended to be a substitute for practitioner judgment. The Medical Director reviews all potential medical necessity denials and will make a decision in accordance with currently accepted medical or healthcare practices, taking into account special circumstances of each case that may require deviation from the norm in the screening criteria. Providers may obtain the criteria used to make a specific adverse determination by contacting the Medical Management department. Practitioners also have the opportunity to discuss any medical or pharmaceutical utilization management adverse determination with a physician or other appropriate reviewer at the time of notification to the requesting practitioner/facility of an adverse determination. The Medical Director may be contacted by calling Provider Services and asking for the Medical
20
Director. A medical management nurse may also coordinate communication between the Medical Director and requesting practitioner.
Retrospective review is an initial review of services provided to a member, but for which authorization and/or timely notification to IlliniCare Health was not obtained due to extenuating circumstances related to the member. Requests for retrospective review, for services that require authorization by IlliniCare Health, must be submitted promptly upon identification but no later than 90 days from the first date of service. A decision will be made within 30 calendar days following receipt of all necessary information for any qualifying service cases.
REFERRALS As promoted by the Medical Home concept, PCPs should coordinate most of the healthcare services for IlliniCare Health members. PCPs can refer a member to a specialist when care is needed that is beyond the scope of the PCP’s training or practice parameters; however, paper referrals are not required. To better coordinate a members’ healthcare, IlliniCare Health encourages specialists to communicate to the PCP the need for a referral to another specialist rather than making such a referral themselves.
SECOND OPINION Members or a healthcare professional with the member’s consent may request and receive a second opinion from a qualified professional within the IlliniCare Health network. If there is not an appropriate provider to render the second opinion within the network, the member may obtain the second opinion from an out-of-network provider at no cost to the member. Out-of-network providers will require prior authorization by IlliniCare Health.
ASSISTANT SURGEON Reimbursement for an assistant surgeon’s service is based on the medical necessity of the procedure itself and the assistant surgeon’s presence at the
Appendix Volume 2, p. 301
time of the procedure. IlliniCare Health follows the guidelines for assistant surgeons set forth in the State of Illinois Medicaid fee schedule. Hospital medical staff by-laws that require an assistant surgeon be present for a designated procedure are not in and of themselves grounds for reimbursement as they may not constitute medical necessity, nor is reimbursement guaranteed when the patient or family requests that an assistant surgeon be present for the surgery, unless medical necessity is indicated.
NEW TECHNOLOGY IlliniCare Health evaluates the inclusion of new technology and the new application of existing technology for coverage determination. This may include medical procedures, drugs and/ or devices. The Medical Director and/or Medical Management staff may identify relevant topics for review pertinent to the IlliniCare Health population. Centene’s Clinical Policy Committee (CPC) reviews all requests for coverage and makes a determination regarding any benefit changes that are indicated. If you need a new technology benefit determination or have an individual case review for new technology, please contact the Medical Management department.
DISCHARGE PLANNING The IlliniCare Health UM staff will coordinate the discharge planning efforts with the member/ member’s family or guardian, the hospital’s UM and discharge planning departments and the member’s attending physician/PCP in order to ensure that IlliniCare Health members receive appropriate posthospital discharge care.
NOTIFICATION OF PREGNANCY IlliniCare Health provides care coordination for pregnant members. It is critical to identify members as early in their pregnancy as possible. IlliniCare Health asks that managing physician notify the IlliniCare Health prenatal team by completing the Notification of Pregnancy (NOP) within five days of the first prenatal visit. Providers are expected to identify the estimated date of confinement and delivery facility. IlliniCare Health will facilitate the physician’s order of a 90-day supply of prenatal vitamins for the member to be delivered to the managing provider’s office by the member’s next prenatal visit. See the Care Coordination/Case Management section for information related to our Start Smart for Your Baby® Program and our 17-P Program for women with a history of early delivery.
Appendix Volume 2, p. 302
21
Pharmacy IlliniCare Health is committed to providing appropriate, high quality, and cost effective drug therapy to all members. IlliniCare Health works with providers and pharmacists to ensure that medications used to treat a variety of conditions and diseases are covered. Prescription drugs and certain over-the-counter (OTC) drugs are covered when ordered by an IlliniCare Health physician/ clinician. The pharmacy program does not cover all medications. Some medications require prior authorization or have limitations on age, dosage and/or maximum quantities. For a complete list of covered medications, please visit IlliniCare.com.
PHARMACY BENEFIT MANAGER IlliniCare Health works with Envolve Pharmacy Solutions to administer pharmacy benefits including the prior authorization process. Certain drugs require prior authorization to be approved for payment by IlliniCare Health. These include:
ΕΕAll medications not listed on the PDL ΕΕMedications marked “PA” on the PDL Follow these steps for efficient processing of your prior authorization requests: 1. Complete the Medication Prior Authorization Request Form. 2. Fax to Envolve Pharmacy Solutions at 866-399-0929. 3. Once approved, Envolve Pharmacy Solutions notifies the prescriber by fax. 4. If the clinical information provided does not explain the reason for the requested prior authorization medication, Envolve Pharmacy Solutions responds to the prescriber by fax, offering PDL alternatives. 5. For urgent or after-hours requests, a pharmacy can provide up to a 72-hour supply of most medications by calling the Envolve Pharmacy Solutions Help Desk at 800-460-8988.
22
All prior authorization requests, Medicaid and Medicare Part D, should be submitted to Envolve Pharmacy Solutions. Envolve Pharmacy Solutions Contact Information Prior Authorization Fax: 866-399-0929 Prior Authorization Phone: 866-399-0928 Clinical Hours: Monday - Friday 10:00 a.m.-8:00 p.m. (EST) Envolve Pharmacy Solutions 5 River Park Place East Suite 210 Fresno, CA 93720 When calling, please have the patient information available: member ID number, complete diagnosis, medication history, and current medications.
ΕΕIf the request is approved, information in the online pharmacy claims processing system will be changed to allow the specific members to receive this specific drug.
ΕΕIf the request is denied, information about the denial and appeal rights will be provided to the clinician. Clinicians are requested to utilize the PDL when prescribing medication for those patients covered by the IlliniCare Health pharmacy program. If a pharmacist receives a prescription for a drug that requires a prior authorization request, the pharmacist should attempt to contact the clinician to request a change to a product included in the IlliniCare Health PDL.
SPECIALTY PHARMACY PROVIDER Certain medications are only covered when supplied by an in-network specialty pharmacy provider. IlliniCare Health works with Envolve Pharmacy Solutions and AcariaHealth Specialty Pharmacy to review and dispense these products, which are listed on the AcariaHealth Supplied Biopharmaceutical document available on the IlliniCare Health website.
Appendix Volume 2, p. 303
Providers can request that AcariaHealth deliver the specialty drug to the office or member. For prior authorization, call AcariaHealth at 855-535-1815 or fax the AcariaHealth prior authorization form to 855-217-0926. If approved, AcariaHealth will contact the provider or member for delivery confirmation. Specialty medication prior authorization forms are available on the IlliniCare Health website. AcariaHealth Contact Information Prior Authorization Phone: 855-535-1815 Prior Authorization Fax: 855-217-0926
MAINTENANCE MEDICATIONS IlliniCare Health offers a 90 day supply (3 month supply) of maintenance medications at most retail pharmacies or through IlliniCare Health’s mail order pharmacy, Homescripts. There is no cost to members for utilizing the maintenance program. To call in a new prescription to mail order you may call Homescripts at 888-239-7690.
PHARMACY & THERAPEUTICS COMMITTEE The IlliniCare Health Pharmacy and Therapeutics (P&T) Committee continually evaluates the therapeutic classes included in the PDL. The committee is composed of the IlliniCare Health Medical Director, the IlliniCare Health pharmacy program director (Pharmacy Program Director), and several community-based primary care physicians and specialists. The primary purpose of the P&T Committee is to assist in developing and monitoring the IlliniCare Health PDL and to establish programs and procedures that promote the appropriate and cost-effective use of medications. The P&T committee schedules meetings at least quarterly during the year and coordinates therapeutic class reviews with the parent company’s national P&T Committee.
PREFERRED DRUG LIST The IlliniCare Health Preferred Drug List (PDL) describes the circumstances under which contracted pharmacy providers will be reimbursed for medications dispensed to members covered under the program. The PDL does not:
ΕΕRequire or prohibit the prescribing or dispensing of any medication;
ΕΕSubstitute for the independent professional judgment of the physician/clinician or pharmacist; or,
IlliniCare Health’s Pharmacy and Therapeutics (P&T) Committee has reviewed and approved, with input from its members and in consideration of medical evidence, the list of drugs requiring prior authorization. The PDL attempts to provide appropriate and cost effective drug therapy to all participants covered under the IlliniCare Health pharmacy program. If a patient requires medication that does not appear on the PDL, the clinician can submit a prior authorization request for a nonpreferred medication. It is anticipated that such exceptions will be rare and that currently available PDL medications will be appropriate to treat the vast majority of medical conditions encountered by IlliniCare Health providers. The PDL can be found on IlliniCare.com. Please note that MMAI members have a separate PDL, located on the MMAI section at mmp.IlliniCare.com Specific Exclusions The following drug categories are not covered by IlliniCare Health:
ΕΕDrugs manufactured by companies that have not signed a rebate agreement with the federal government
ΕΕFertility enhancing drugs ΕΕAnorexia, weight loss, or weight gain drugs ΕΕExperimental or investigational drugs Ε Drug Efficacy Study Implementation (DESI) and Identical, Related and Similar (IRS) drugs that are classified as ineffective Oral vitamins and minerals (except those listed in the PDL) Drugs and other agents used for cosmetic purposes or for hair growth
ΕErectile dysfunction drugs prescribed to treat impotence
ΕDrugs dispensed after the termination date included on the quarterly drug tape provided by the federal Centers for Medicare and Medicaid Services (CMS)
ΕOver-the-Counter (OTC) Medications (except those listed in the PDL) The IlliniCare Health pharmacy program covers a variety of OTC medications. All covered OTC medications appear in the PDL. All OTC medications must be written on a valid prescription, by a licensed provider.
ΕΕRelieve the physician/clinician or pharmacist of any obligation to the patient or others.
Appendix Volume 2, p. 304
23
Members enrolled in MMAI are encouraged to utilize the IlliniCare Health OTC Catalog Benefit. Through the program, members may get many OTC products delivered to their home free of charge. Orders may be placed by calling HomeScripts at 888-239-7690. A list of available products and program details may be found on the IlliniCare Health website. Step Therapy Medications requiring Step Therapy are listed with an “ST” notation throughout the preferred drug list. The Envolve Pharmacy Solutions claims system will automatically check the member profile for evidence of prior or current usage of the required agent. If there is evidence of the required agent on the member’s profile, the claim will automatically process. If not, the claims system will notify the pharmacist that a prior authorization is required. Quantity Limitations Quantity limitations have been implemented on certain medications to ensure the safe and appropriate use of the medications. Quantity limitations are approved by the IlliniCare Health P&T Committee and noted throughout the PDL. Age Limits Some medications on the IlliniCare Health PDL may have age limits. These are set for certain drugs based on FDA approved labeling and for safety concerns and quality standards of care. Age limits align with current FDA alerts for the appropriate use of pharmaceuticals. Newly Approved Products Newly approved drug products will not normally be placed on the PDL during their first six months on the market. During this period, access to these medications will be considered through the prior authorization review process.
Generic Substitutions IlliniCare Health requires that generic substitution be made when a generic equivalent is available. All branded products that have an A-rated generic equivalent will be reimbursed at the maximum allowable cost (MAC). The provision is waived for the following products due to their narrow therapeutic index: Aminophylline, Amiodarone, Carbamazepine, Clozapine, Cyclosporine, Digoxin, Disopyramide, Ethosuximide, Flecainide, L-thyroxine, Lithium, Phenytoin, Procainamide, Propafenone, Theophylline, Thyroid, Valproate Sodium, Valproic Acid, and Warfarin. The IlliniCare Health MMAI program covers many branded products. These products are available under Tier 2, and may require a copay. Please see the MMAI PDL, located at mmp.IlliniCare.com, for details. Exception Requests In the event that a clinician or member disagrees with the decision regarding coverage of a medication, the clinician may request an appeal by submitting additional information to IlliniCare Health. The additional information may be provided verbally or in writing. A decision will be rendered and the clinician will be notified with a faxed response. If the request is denied, the clinician will be notified of the appeals process at that time. An expedited appeal may be requested at any time the provider believes the adverse determination might seriously jeopardize the life or health of a patient. Call the IlliniCare Health complaint and grievance coordinator. A response will be rendered within 24 hours of receipt of complete information. In circumstances that require research, a 24 hour response may not be possible.
Unapproved Use Of Preferred Medication Medication coverage under this program is limited to non-experimental indications as approved by the FDA. Other indications may also be covered if they are accepted as safe and effective using current medical and pharmaceutical reference texts and evidence-based medicine. Reimbursement decisions for specific non-approved indications will be made by IlliniCare Health. Experimental drugs, investigational drugs and drugs used for cosmetic purposes are excluded from coverage.
24
Appendix Volume 2, p. 305
Behavioral Health IlliniCare Health offers our members access to all covered, medically necessary behavioral health (BH) services. IlliniCare Health members seeking mental health or substance abuse services may self-refer to a network provider for twelve (12) standard outpatient sessions per member, but prior authorization is required for subsequent visits. For assistance in identifying a behavioral health provider or for prior authorization for inpatient or outpatient services, please call Member Services. In the event that the physician or practitioner is unable to provide timely access for a member, IlliniCare Health will assist in securing authorization to a physician or practitioner to meet the member’s needs in a timely manner. For information regarding behavioral health services, locating providers, or for assistance in coordinating services for the member, contact Member Services.
CONTINUITY OF CARE When members are newly enrolled and have been previously receiving behavioral health services, IlliniCare Health will make best efforts to maximize the transition of members care through providing for the transfer of pending prior authorization information; and work with the member’s provider to honor those existing prior authorizations.
BH PROVIDERS AND PCP COORDINATION IlliniCare Health encourages PCPs to consult with their members’ mental health and substance use treatment practitioners. In many cases the PCP has extensive knowledge about the member’s medical condition, mental status, psychosocial functioning, and family situation. Communication of this information at the point of referral or during the course of treatment is encouraged with member consent, when required. We encourage all service providers to coordinate care with a member’s entire treatment team, including but not limited to PCPs
and mental health and/or substance use treatment practitioners. Additionally, IlliniCare Health will offer trainings to PCPs and mental health and/or substance use treatment practitioners focused on the concepts of integrated care; cross training in medical, behavioral and substance use disorder; and screening tools. BH providers should communicate and coordinate with the member’s PCP and with any other behavioral health service providers whenever there is a behavioral health problem or treatment plan that can affect the member’s medical condition or the treatment being rendered to the member. Examples of some of the items to be communicated include: Prescription medication. Results of health risk screenings.
Ε If the member is known to abuse over-thecounter, prescription or illegal substances in a manner that can adversely affect medical or behavioral health treatment.
ΕΕIf the member is receiving treatment for a behavioral health diagnosis that can be misdiagnosed as a physical disorder (such as panic disorder being confused with mitral valve prolapse).
ΕΕIf the member’s progress toward meeting the goals established in their treatment plan. A form to be used in communicating with the PCP and other behavioral health providers is located on our website at IlliniCare.com. BH providers can identify the name and contact information for a member’s PCP by performing an eligibility inquiry on the IlliniCare Health Provider Portal or by contacting Provider Services. Practitioners should screen for the existence of co-occurring mental health and substance use conditions and make appropriate referrals. Practitioners should refer members with known or suspected untreated physical health problems or
Appendix Volume 2, p. 306
25
disorders to the PCP for examination and treatment. We also offer provider training on screening tools that can be used to identify possible behavioral health and substance use disorders. Resources and training will include referral processes for providers to assist members in accessing supports.
Division of Alcohol and Substance Abuse Services (DASA)
IlliniCare Health requires that practitioners report specific clinical information to the member’s PCP in order to preserve the continuity of the treatment process. With appropriate written consent from the member, it is the practitioner’s responsibility to keep the member’s PCP abreast of the member’s treatment status and progress in a consistent and reliable manner.
Community Mental Health Clinic Services, including crisis services
The following information should be included in the report to the PCP:
ΕΕA copy or summary of the intake assessment; ΕΕWritten notification of member’s noncompliance with treatment plan (if applicable);
ΕΕMember’s completion of treatment; ΕΕThe results of an initial psychiatric evaluation, and initiation of and major changes in psychotropic medication(s) within fourteen (14) days of the visit or medication order; and
ΕΕThe results of functional assessments.
Residential Rehabilitation
Ε Day Treatment
See the Behavioral Health Billing Guidelines for information about billing IlliniCare Health for behavioral health services, available on IlliniCare.com. Children’s Mental Health and Mobile Crisis Response Services IlliniCare Health’s HealthChoice Illinois plan includes working with Mobile Crisis Response Program providers to administer crisis intervention services for eligible members who require behavioral health services. Mobile Crisis Response Program providers are responsible for the following:
ΕΕMust hold the following credentials: • Mental Health Professional (MHP) with direct access to a Qualified Mental Health Professional; Qualified Mental Health Professional;
BH PRIOR AUTHORIZATION REQUIREMENTS
Licensed Practitioner of the Healing Arts;
Please see the benefit grid online at IlliniCare.com for the most up-to-date authorization requirements and a comprehensive list of covered benefits.
or Crisis Services Program approval from HFS as outlined in Rule 140. Table N(c)(4).
BH Services, including substance use disorder
Ε Inpatient Psychiatric Ε Partial Hospitalization Ε Intensive Outpatient Therapy Ε Psychological Testing Ε Neuropsychological Testing Ε Electroconvulsive Therapy (ECT) Ε Substance Use Disorder Treatment/Rehabilitation Ε Individual, Family, and Group Therapy
• If you intend to provide Mobile Crisis Response and/or Crisis Stabilization services, and are seeking Program approval, please contact HFS Bureau of Behavioral Health at HFS.CBH@illinois. gov or 217-557-1000
ΕΕPerforming a face-to-face crisis screening within ninety (90) minutes of notification that a member is experiencing a behavioral health crisis, which will include, at a minimum, the completion of the IM-CAT and the Crisis Stabilization Plan
ΕΕProviding immediate care and stabilization services when a member in crisis can be stabilized in the most appropriate setting;
ΕProvide the member’s family with contact information
Community Support Services
Ε Community Support: Prior authorization required after 200 units Case Management: Prior authorization required after 200 units Psychological Rehabilitation: Prior authorization required after 800 units
26
Detoxification
that may be used at any time, twenty-four ( ) hours a day, to contact Mobile Crisis Response system in moments of crisis Establishing a Crisis Safety Plan unique for • members who present in behavioral health crisis and to provide families of Members with physical copies of the Crisis Safety Plan consistent with the following timelines;
Appendix Volume 2, p. 307
• Prior to the completion of the crisis screening event for any member stabilized in the community; and
• Prior to member discharging from an inpatient psychiatric hospital The Crisis Safety Plan must be done in collaboration and reviewed with the member and member’s family;
• Mobile Crisis Response providers must educate and orient the member’s family to the components of the Crisis Safety plan
IlliniCare Health will closely follow the process and procedures of the Illinois Crisis and Referral Entry Services (CARES) program. CARES, in addition to IlliniCare’s Mobile Crisis Response Services, can authorize and dispatch Mobile Crisis Services. In the event that CARES is unable to locate a provider within the IlliniCare Health Mobile Crisis Response Service to provide a face-to-face screening for a member experiencing a behavioral health crisis, CARES will contact the Mobile Crisis Response program to ensure crisis response to the member.
• Ensure the plan is reviewed with the family
regularly, and detail how the plan is updated as necessary
Mobile Crisis Response providers must share the Crisis Safety Plan with all necessary medical professionals, including IlliniCare Health Care Coordinator staff as consistent with the authorizations established by consent or release Members that experience a Crisis event, IlliniCare Health shall convene an Interdisciplinary Care Team (ICT) meeting for the member
• within fourteen (14) days after the event if the member is stabilized within the community;
• within fourteen (14) days post discharge if the member is hospitalized IlliniCare Health will ensure that the member has a scheduled appointment with Behavioral Health Provider and the member’s PCP or psychiatric resource within thi days after the member discharges from hospitalization; If member has been identified by DCFS as a Youth at Risk, IlliniCare Health will involve DCFS on the members ICT; Providers are to facilitate the member’s admission to an appropriate inpatient treatment setting when the member cannot be stabilized in the community, including education to the member’s parents, guardian, caregivers, or residential staff to select an appropriate inpatient treatment setting and network providers.
Appendix Volume 2, p. 308
27
Care Coordination IlliniCare Health’s care coordination model consists of a team of registered nurses, licensed mental health professionals, social workers, and non-clinical staff. The model is designed to help your IlliniCare Health members obtain needed services and assist them in coordination of their healthcare needs whether they are covered within the IlliniCare Health array of covered services, from the community, or from other non-covered venues. Our model will support our provider network whether you work in an individual practice, large multi-specialty group setting, long term care facility, supportive living facility, or a home and communitybased service provider. The program is based upon a coordinated care model that uses a multi-disciplinary care coordination team in recognition that multiple co-morbidities will be common among our membership. The goal of our program is to collaborate with the member and the member’s PCP to achieve the highest possible levels of wellness, functioning, and quality of life. The program includes a systematic approach for early identification of members, completion of their needs assessment tools, and development and implementation of an individualized care plan that includes member/family education and actively links the member to providers and support services as well as outcome monitoring and reporting back to the PCP. The PCP is included in the creation of the Care Plan as appropriate to assure that the plan incorporates considerations related to the medical treatment plan and other observations made by the provider. The Care Plan is made available to the provider in writing or verbally. Our care coordination team will integrate covered and noncovered services and provide a holistic approach to a member’s medical and behavioral healthcare, as well as functional, social, and other needs. Our program incorporates clinical determinations of need, functional status, and barriers to care such as lack of caregiver supports, impaired cognitive abilities and transportation needs.
28
A care coordination team is available to help all providers improve the health of IlliniCare Health members. Contact us to refer a member for care coordination. Care Coordination Department HealthChoice Illinois: 866-329-4701 MMAI: 877-941-0482
INTEGRATED CARE TEAMS Care Coordinators are familiar with evidence-based resources and best practice standards specific to conditions common among IlliniCare Health members. These teams will be led by clinical licensed care coordinators with experience working with people with physical and/or mental health conditions. In addition, a team will be specifically dedicated to assisting members with developmental disabilities. The teams will have experience with the member population, the barriers and obstacles they face, and socioeconomic impacts on their ability to access services. IlliniCare Health will use a holistic approach by integrating referral and access to community resources, transportation, follow-up care, medication review, specialty care, and education to assist members in making better healthcare choices.
CARE PLANS The following members can have a Care Plan developed and implemented:
Ε HealthChoice Illinois: Members in high and moderate acuity
Ε MMAI: All members Ε HCBS Waivers and LTC: All members This Care Plan will be developed in conjunction with the member, his or her family and caregiver, as well as individuals in the member’s care team. The member will agree to the developed Care Plan, and it will be signed off by a physician before implementation.
Appendix Volume 2, p. 309
For members receiving waiver services, the Care Plan will include services such as home health, home delivered meals, personal emergency response systems, adult day service, home modification, adaptive equipment, etc. Based each members plan, IlliniCare Health care coordinators will work directly with home and community-based services providers in order to execute the Care Plan. This includes securing the service with the provider and authorizing the number of hours/ units approved. The care coordinator will give an authorization number to the provider. The provider is then able to render the service that has been authorized. IlliniCare Health’s care coordination team will guide members through the process of obtaining covered services. Each member is assigned to a care coordinator. Care coordinators responsibilities include:
Ε Help members obtain services. Visit members in their residence to assess health status, needs, and develop a Care Plan. Communicate with providers on services that are authorized according to the Care Plan. Discharge planning. Support quality of life for members. Please contact the care coordination department for changes in a member’s status, questions regarding services, or other member issues.
TRANSITION OF CARE COORDINATION FUNCTIONS Once the appropriate state agency determines eligibility, IlliniCare Health will be responsible for all care coordination for IlliniCare Health members including those members part of the home and community-based waiver services and residing in long term care facilities or supportive living facilities. IlliniCare Health has processes and procedures in place to ensure smooth transitions to and from IlliniCare Health’s care coordination to other plans/agencies such as another Managed Care Organization, the Department on Aging, the Department of Rehabilitative Services and the Department of Healthcare and Family Services. During transitions between entities, IlliniCare Health will assure 180 days of continuity of services and will not adjust services without the member’s consent during that time frame.
HIGH RISK PREGNANCY PROGRAM IlliniCare Health will place high risk pregnancy members in our Start Smart for Your Baby (Start Smart) program which incorporates case management, care coordination, and disease management with the aim of decreasing preterm delivery and improving the health of moms and their babies. Start Smart is a unique prenatal program with a goal of improving maternal and child health outcomes by providing pregnancy and parenting education to all pregnant members and providing case management to high and moderate risk members through the postpartum period. A care coordinator will work with members at high risk of early delivery or who experience complications from pregnancy. The care coordinators have physicians advising them on overcoming obstacles, helping identify high risk members, and recommending interventions. These physicians will provide input to IlliniCare Health’s Medical Director on obstetrical care standards and use of newer preventive treatments such as 17 alpha-hydroxyprogesterone caproate (17-P). IlliniCare Health offers a premature delivery prevention program by supporting the use of 17P. When a physician determines that a member is a candidate for 17-P, which use has shown a substantial reduction in the rate of preterm delivery, he/she will write a prescription for 17-P. This prescription is sent to the IlliniCare Health care coordinator who will check for eligibility. The care coordinator will coordinate the ordering and delivery of the 17-P directly to the physician’s office. The care coordinator will contact the member and complete an assessment regarding compliance. The nurse will remain in contact with the member and the prescribing physician during the entire treatment period. Contact the IlliniCare Health medical management at with any questions regarding this program.
TRANSPLANTS A Transplant Coordinator will provide support and coordination for members who need organ transplants. All members considered as potential transplant candidates should be immediately referred to the IlliniCare Health medical management department for assessment and case management services. Each candidate is evaluated for coverage requirements and will be referred to the appropriate agencies and transplant centers.
Appendix Volume 2, p. 310
29
Value Added Services 24/7 NURSE ADVICE LINE When our members have questions about their health, their primary care provider, and/or access to emergency care, we are here for them. IlliniCare Health offers a 24/7 Nurse Advice Line service to encourage members to talk with their physician and to promote education and preventive care. Registered nurses provide basic health education, nurse triage, and answer questions about urgent or emergency access. The staff often answers basic health questions, but is also available to triage more complex health issues using nationally-recognized protocols. Members with chronic problems, like asthma or diabetes, are referred to case management for education and encouragement to improve their health.
Medicare Rewards Program The Medicare Rewards Program if offered to MMAI members. This program rewards members with gift cards to purchase healthcare items when they complete healthy behaviors. Healthy behaviors that may qualify for rewards through this program include: annual flu vaccine, annual wellness exams, and certain disease-specific screenings.
Members may use the Nurse Advice Line to request information about providers and services available in your community after hours, when the Member Services department is closed. The staff is available in both English and Spanish and can provide additional translation services if necessary.
TRANSPORTATION
We provide this service to support your practice and offer our members access to a registered nurse on a daily basis. If you have any additional questions, please call Provider Services or the Nurse Advice Line.
MEMBERCONNECTIONS® COMMUNITY HEALTH SERVICES
REWARDS PROGRAMS The goal of IlliniCare Health’s rewards programs is to increase appropriate utilization of preventive services by rewarding members for healthy behaviors. The programs encourage members to regularly access preventive services, and promotes personal responsibility for and ownership of the member’s own healthcare. HealthChoice Illinois Rewards Program – Centaccount® The CentAccount® rewards program is offered to members in the HealthChoice Illinois plan. CentAccount® rewards members with a prepaid debit card to purchase healthcare items,
30
such as over-the-counter medications that they might otherwise not be able to afford. Preventive services that may qualify for rewards through the program include completion of an initial health risk screening, primary care medical home visits within 90 days of enrollment, annual adult well visits, certain disease-specific screenings, and completion of prenatal and postpartum care.
Members can schedule transportation to and from a medical visit. Members should call us at least two (2) business days in advance. Call Member Services and ask for a transportation specialist, and they will arrange appropriate transportation.
MemberConnections® Community Health Services is IlliniCare Health’s outreach program designed to provide coaching and education to our members on how to access healthcare and develop healthy lifestyles in a setting where they feel most comfortable. The program components are integrated as a part of our case management program in order to link IlliniCare Health and the community served. The program recruits staff from the communities serviced to establish a grassroots support and awareness of IlliniCare Health within the community. The program has various components that can be provided depending on the need of the member. MemberConnections® Community Health Services representatives are non-clinical outreach employees hired from within the communities
Appendix Volume 2, p. 311
we serve to ensure that our outreach is culturally competent and conducted by people who know the unique characteristics and needs of the local area. These representatives are an integral part of our Integrated Care Team which benefits our members and increases our effectiveness. Representatives will make home visits to members we cannot reach by phone or that require a face-to-face approach. They assist with member outreach, conduct member home visits, coordinate with social services, and attend community functions to provide health education and outreach. MemberConnections® Community Health Services works with providers to organize healthy lifestyle events and work with other local organizations for health events. To refer a member, contact us: Member Connections HealthChoice Illinois: 866-329-4701 MMAI: 877-941-0482
CONNECTIONS PLUS® Connections Plus® is a program where IlliniCare Health provides phones to high risk members who do not have safe, reliable phone access. Members who qualify receive a pre-programmed cell phone with limited use. Members may use this cell phone to call their case manager, PCP, specialty physician, the 24/7 Nurse Advice Line, 911, or other members of their healthcare team. In some cases, IlliniCare Health may provide MP-3 players with preprogrammed education programs for those with literacy issues or in need of additional education.
coordinator for case management services. The disease management programs target members with selected chronic diseases which may not be under control. The new members are assessed and stratified in order to accurately assign them to the most appropriate level of intervention. Interventions may include mailed information for low intensity cases, telephone calls and mailings for moderate cases, or include home visits by a health coach for members categorized as high risk. In addition, IlliniCare Health provides telemonitoring services to the highest-risk members. These home wireless biometric monitoring devices will allow health coaches, care coordinators and treating Providers to monitor key health indicators and provide opportunities for real-time, “teachable moment” interventions. IlliniCare Health’s affiliated disease management company, Envolve Health, will administer disease management programs which include services for chronic diseases such as asthma, diabetes, hypertension, heart failure and obesity. Our specialty pharmacy, offers disease management services for IlliniCare Health members with hemophilia. To refer a member for disease management call: Disease Management HealthChoice Illinois: 866-329-4701 MMAI: 877-941-0482
DISEASE MANAGEMENT PROGRAMS As a part of IlliniCare Health’s services, disease management programs are offered to members. Components of the programs available include:
Ε Increasing coordination between medical, social and educational communities. Severity and risk assessments of the population. Profiling the population and providers for appropriate referrals to providers. Ensuring active and coordinated physician/ specialist participation. Identifying modes of delivery for coordination care services such as home visits, clinic visits, and phone contacts depending on the circumstances and needs of the member and his/her family. Increasing the member’s and member’s caregiver ability to self-manage chronic conditions. Coordination with an IlliniCare Health care
Appendix Volume 2, p. 312
31
Billing & Claims Submission GENERAL BILLING GUIDELINES Physicians, other licensed health professionals, facilities, and ancillary providers contract directly with IlliniCare Health for payment of covered services. It is important that providers ensure IlliniCare Health has accurate billing information on file. Please confirm with our Provider Relations department that the following information is current in our files:
Ε Provider name (as noted on current W-9 form). Ε National Provider Identifier (NPI). Ε Tax Identification Number (TIN). Ε Taxonomy code. Ε Physical location address (as noted on current W-9 form).
Ε Billing name and address. Providers must bill with their NPI number in box 24Jb. Providers must bill with their taxonomy code in box 24Ja to avoid possible delays in processing. Claims missing the required data will be returned, and a notice sent to the provider, creating payment delays. Such claims are not considered “clean” and therefore cannot be accepted into our system. We recommend that providers notify IlliniCare Health 30 days in advance of changes pertaining to billing information. Please submit this information on a W-9 form. Changes to a Provider’s TIN and/or address are NOT acceptable when conveyed via a claim form. Claims eligible for payment must meet the following requirements:
ΕΕThe member is effective on the date of service; ΕΕThe service provided is a covered benefit under the member’s contract on the date of service; and
Ε The referral and prior authorization processes were followed, if applicable.
TIMELY FILING To be eligible for reimbursement, providers must file claims within a qualifying time limit. A claim will be considered for payment only if it is received by IlliniCare Health no later than 180 days from the date on which services or items are provided. This time limit applies to both initial and corrected claims. Corrected claims, as well as initial claims, received more than 180 days from the date of service will not be paid. A “request for reconsideration” must be submitted before a claim dispute. Requests for Reconsideration received prior to July 1, 2019 must be submitted within 180 calendar days from the date of service or date of discharge, whichever is later. Requests for Reconsideration received on or after July 1, 2019 must be submitted within 90 calendar days of the original determination or Explanation of Payment (EOP). Claim disputes must be received within 90 days of the reconsideration response date, not to exceed 1 year from the DOS. When IlliniCare Health is the secondary payer, claims must be received within 90 calendar days of the final determination of the primary payer.
BILLING FORMS Submit claims for professional services and durable medical equipment on a CMS 1500. Here are some tips for completing the CMS 1500 claim form:
Ε Use one claim form for each recipient. Ε Enter on procedure code and date of service per claim line.
Ε Enter information with a typewriter or a computer using black type.
Ε Enter information within the allotted spaces. Ε Make sure whiteout is not used on the claim form. Ε Complete the form using the specific procedure or billing code for the service.
Payment for service is contingent upon compliance with referral and prior authorization policies and procedures, as well as the billing guidelines outlined in this manual. For additional information on IlliniCare Health billing guidelines, please refer to our Billing Manual available on IlliniCare.com.
the same claim form for all services provided • Use for the same recipient, same provider, and same date of service. dates of service encompass more than one • Ifmonth, a separate billing form must be used for each month.
32
Appendix Volume 2, p. 313
Don’ts
Ε Don’t submit handwritten claim forms Ε Don’t use red ink on claim forms Ε Don’t circle any data on claim forms Ε Don’t add extraneous information to any claim form field
Submit claims for hospital based inpatient and outpatient services, as well as swing bed services, on a UB 04 form. For detailed requirements for either the CMS 1500 or the UB 04 form, see the Billing Manual.
CLAIMS SUBMISSION There are 3 ways to submit claims to IlliniCare Health: 1. On the Provider Portal at Provider.IlliniCare.com 2. Paper Claims mailed to: IlliniCare Health Attn: Claims P.O. Box 4020 Farmington, MO 63640-4402
and white claim forms)
Ε Don’t submit carbon copied claim forms Ε Don’t submit claim forms via fax Clean Claim Definition A clean claim means a claim received by IlliniCare Health for adjudication in a nationally accepted format in compliance with standard coding guidelines and which requires no further information, adjustment, or alteration by the provider of the services in order to be processed and paid by IlliniCare Health. Clean claims will be adjudicated (finalized as paid or denied) at the following levels:
Ε 90% within 30 business days of the receipt Ε 99% within 90 business days of the receipt
3. Through Clearinghouses: Payer ID #: 68069 For more information about clearinghouse, please contact: IlliniCare Health c/o Centene EDI Department 800-225-2573 ext. 6075525 EDIBA@centene.com Dos & Don’ts of Claims Submission Dos
Ε Do use the correct P.O. Box number Ε Do submit all claims in a 9” x 12” or larger envelope Ε Do type all fields completely and correctly Ε Do use typed black or blue ink only at 9-point font or larger
Ε Do include all other insurance information (policy holder, carrier name, ID number and address) when applicable
Ε Do attach the EOP from the primary insurance carrier when applicable
• Note: IlliniCare Health is able to receive primary insurance carrier EOP [electronically]
Ε Do submit on a proper original form: CMS 1500 or UB 04
Ε Don’t use highlighter on any claim form field Ε Don’t submit photocopied claim forms (no black
Non-Clean Claim Definition Non-clean claims are submitted claims that require further documentation or development beyond the information contained therein. The errors or omissions in claims result in the request for additional information from the provider or other external sources to resolve or correct data omitted from the bill; review of additional medical records; or the need for other information necessary to resolve discrepancies. In addition, non-clean claims may involve issues regarding medical necessity and include claims not submitted within the timely filing deadlines.
COMMON CAUSES OF UPFRONT REJECTIONS
Ε Unreadable Information. Ε Missing Member Date of Birth. Ε Missing Member Name or Identification Number. Ε Missing Provider Name, Tax ID, or NPI Number. Ε The Date of Service on the Claim is Not Prior to Receipt Date of the Claim.
Ε Dates Are Missing from Required Fields. Ε Invalid of Missing Type of Bill. Ε Missing, Invalid or Incomplete Diagnosis Code.
Appendix Volume 2, p. 314
33
Ε Missing Service Line Detail. Member Not Effective on the Date of Service. Admission Type is Missing. Missing Patient Status. Missing or Invalid Occurrence Code or Date. Missing or Invalid Revenue Code. Missing or Invalid CPT/Procedure Code. Incorrect Form Type. IlliniCare Health will send providers a detailed letter for each claim that is rejected explaining the reason for the rejection.
COMMON CAUSES OF CLAIM PROCESSING DELAYS & DENIALS
Ε Incorrect Form Type. Diagnosis Code Missing 4th, 5th, and 6th character requirements and 7th character extension requirements. Missing or Invalid Procedure or Modifier Codes. Missing or Invalid DRG Code. Explanation of Benefits from the Primary Carrier is Missing or Incomplete. Invalid Member ID. Invalid Place of Service Code. Provider TIN and NPI Do Not Match. Invalid Revenue Code. Dates of Service Span Do Not Match Listed Days/ Units. Missing Physician Signature. Invalid TIN. Missing or Incomplete Third Party Liability Information. IlliniCare Health will send providers written notification via the EOP for each claim that is denied, which will include the reason(s) for the denial.
CLAIMS FOR BEHAVIORAL HEALTH See the Behavioral Health Billing Guidelines for information about billing IlliniCare Health for behavioral health services, available on IlliniCare. com.
CLAIMS FOR WAIVER SERVICES & SLFS Through IlliniCare Health’s waiver services program, a variety of atypical providers contract directly with IlliniCare Health for payment of covered services. Atypical providers include adult day service, home
34
health agencies, day habilitation, homemaker services, home delivered meals, personal emergency response systems, respite, specialized medical equipment and supplies and supportive living facilities (SLFs). Atypical providers and supportive living facilities will be required to submit claims to IlliniCare Health on a CMS 1500 form. This can be done through our Provider Portal or via submission of paper claims. Billing guides and instructions for our online secure provider portal are available on our website at IlliniCare.com.
CLAIMS FOR LONG TERM CARE FACILITIES Long Term Care facilities are required to bill on a UB-04 claim form. Both short term acute stays and custodial care are covered benefits. When submitting claims for short term sub-acute stays, facilities must ensure they are utilizing the appropriate revenue codes reflecting the short term stay. Patient Credit File In order for Long Term Care facility claims to be processed, the member the facility is billing for must be on the Patient Credit File. This file is provided by the Department of Healthcare and Family Services and shows the amount the member needs to pay for residing in the facility. In certain instances, there can be a delay in the member appearing on the Patient Credit File. As a result, some LTC facility claims may be denied. A specific code, call an Explanation Code or an EX code will display on the denied claim that reads “DENY: Mbr not currently on PT Credit File – will reconsider once on file.” IlliniCare Health has put a process in place to ease the administrative burden of long term care facilities in these instances. Each month when the Patient Credit File is received, IlliniCare Health will check each member on the fi e against any previously denied claims. If there are claims that have been denied as a result of the member not appearing on the Patient Credit File, and all other necessary information is included in the claim, IlliniCare Health will process and pay the previously denied claim.
REQUESTS FOR RECONSIDERATION, CLAIM DISPUTES, & CORRECTED CLAIMS If a provider has a question or is not satisfied with the information they have received related to a claim, there are four effective ways in which the provider can contact IlliniCare Health.
Appendix Volume 2, p. 315
1. Contact Provider Services. Providers may discuss questions regarding amount reimbursed or denial of a particular service. 2. Submit an Adjusted or Corrected Claim to: Medical IlliniCare Health Attn: Corrected Claim P.O. Box 4020 Farmington MO 63640-4402
4. Submit a Claim Dispute Form to: Medical IlliniCare Health Attn: Dispute P.O. Box 3000 Farmington MO 63640-4402 Behavioral Health IlliniCare Health Attn: Dispute PO Box 6000 Farmington, MO 63640-3828
Behavioral Health IlliniCare Health Attn: Corrected Claim PO Box 7300 Farmington, MO 63640-3828 The claim must clearly be marked as “RESUBMISSION” and must include the original claim number or the original EOP must be included with the resubmission. Failure to mark the claim as a resubmission and include the original claim number (or include the EOP) may result in the claim being denied as a duplicate, a delay in the reprocessing, or denial for exceeding the timely filing limit. 3. Submit a Request for Reconsideration to: Medical IlliniCare Health Attn: Reconsideration P.O. Box 4020 Farmington MO 63640-4402
A claim dispute is to be used only when a provider has received an unsatisfactory response to a request for reconsideration. The Claim Dispute Form can be found in the provider section of our website at IlliniCare.com. Do not include a copy of the claim with your Claim Dispute. If the claim dispute results in an adjusted claim, the provider will receive a revised EOP. If the original decision is upheld, the provider will receive a revised EOP or a letter detailing the decision and steps for escalated reconsideration. IlliniCare Health shall process, and finalize all adjusted claims, requests for reconsideration, and disputed claims to a paid or denied status within 45 business days of receipt.
THIRD PARTY LIABILITY Third party liability refers to any other health insurance plan or carrier (e.g., individual, group, employer-related, self-insured or self-funded, or commercial carrier, automobile insurance, and worker’s compensation) or program that is or may be liable to pay all or part of the healthcare expenses of the member.
Behavioral Health IlliniCare Health Attn: Reconsideration PO Box 7300 Farmington, MO 63640-3828 If arequest claim does not require anyischanges, A for reconsideration a writtenbut acommunication provider is notfrom satisfied with the the provider claims about a disposition, a Request for Reconsideration disagreement in the way a claim was processed can be submitted using the Provider but does not require a claim to be corrected and Reconsideration Request Form located at does not require medical review. www.IlliniCare.com. Please ensureThe all request fields must include sufficient identifying information on the Provider Reconsideration Request which includes, at minimum, patient Form are completed. Do not the include a name, patient number, date your of service, totalfor charges copy ofID the claim with Request and provider name. The documentation must Reconsideration. also include a detailed description of the reason for the request.
IlliniCare Health, like all Medicaid programs, is always the payer of last resort. IlliniCare Health providers shall make reasonable efforts to determine the legal liability of third parties to pay for services furnished to IlliniCare Health members. If the provider is unsuccessful in obtaining necessary cooperation from a member to identify potential third party resources, the provider shall inform IlliniCare Health that efforts have been unsuccessful. IlliniCare Health will make every effort to work with the provider to determine liability coverage.
Appendix Volume 2, p. 316
35
If third party liability coverage is determined after services are rendered, IlliniCare Health will coordinate with the provider to pay any claims that may have been denied for payment due to third party liability.
ELECTRONIC FUNDS TRANSFERS (EFTS) & ELECTRONIC REMITTANCE ADVICES (ERAS) IlliniCare Health provides Electronic Funds Transfers (EFTs) and Electronic Remittance Advices (ERAs) to its participating providers to help them reduce costs, speed secondary billings, and improve cash flow by enabling online access of remittance information, and straight forward reconciliation of payments. As a provider, you can gain the following benefits from using EFTs and ERAs:
ΕΕReduce accounting expenses – Electronic remittance advices can be imported directly into practice management or patient accounting
Ε systems, eliminating the need for manual rekeying
Ε Improve cash flow – Electronic payments mean faster payments, leading to improvements in cash flow
Ε Maintain control over bank accounts – You keep TOTAL control over the destination of claim payment funds and multiple practices and accounts are supported
Ε Match payments to advices quickly – You can associate electronic payments with electronic remittance advices quickly and easily For more information on our EFTs and ERAs services, please contact Provider Services.
OVERPAYMENT RECOVERY PROCEDURES An overpayment may occur due to, but not limited to, the following reasons:
Ε Duplicate payment by IlliniCare Health; Payment to incorrect provider or incorrect member; or Overlapping payment by IlliniCare Health and a third party resource (TPR). The provider has the option of refunding the overpayment by issuing a check to IlliniCare Health or by requesting a recoupment by contacting their Provider Relations representative. The refund check should be accompanied with documentation regarding the overpayment, including:
Ε Refunding provider’s name and provider identifier; Member name and ID;
36
Date of service; and
Ε A copy of the Explanation of Payment (EOP) showing the claim to which the refund is being applied. Failure to refund an overpayment may result in an offset against future claim payments until the amount of overpayment has been fully recovered. To submit a refund check, please mail the check and supporting documents to: IlliniCare Health 75 Remittance Drive Department 6903 Chicago, IL 60675-6903
ENCOUNTERS An encounter is a claim which is paid at zero dollars as a result of the provider being pre-paid or capitated for the services he/she provided our members. For example; if you are the PCP for an IlliniCare Health member and receive a monthly capitation amount for services, you must file an encounter (also referred to as a “proxy claim”) on a CMS 1500 for each service provided. Since you will have received a pre-payment in the form of capitation, the encounter or “proxy claim” is paid at zero dollar amounts. It is mandatory that your office submits encounter data. IlliniCare Health utilizes the encounter reporting to evaluate all aspects of quality and utilization management, and it is required by HFS and by the Centers for Medicare and Medicaid Services (CMS). Encounters do not generate an EOP. A claim is a request for reimbursement either electronically or by paper for any medical service. A claim must be filed on the proper form, such as CMS 1500 or UB 04. A claim will be paid or denied with an explanation for the denial. For each claim processed, an EOP will be mailed to the provider who submitted the original claim. Claims will generate an EOP. Providers are required to submit either an encounter or a claim for each service that you render to an IlliniCare Health member. Procedures for Filing Encounter Data IlliniCare Health encourages all providers to file encounters and claims electronically. See the Electronic Claims Submission section in this Provider Manual and the Billing Manual for more information on how to initiate electronic claims/ encounters.
Appendix Volume 2, p. 317
BILLING THE MEMBER IlliniCare Health reimburses only services that are medically necessary and covered through each IlliniCare Health product. Providers are not allowed to “balance bill� for covered services. Providers may bill members for services NOT covered by either Medicaid or IlliniCare Health or for applicable copayments, deductibles or coinsurance as defined by the State of Illinois. In order for a provider to bill a member for services not covered under the IlliniCare Health program, or if the service limitations have been exceeded, the provider must obtain a written acknowledgment in advance of services being rendered from the member using the following language: I understand that, in the opinion of (provider’s name), the services or items that I have requested to be provided to me on (dates of service) may not be covered under the Integrated Care Program as being reasonable and medically necessary for my care. I understand that IlliniCare Health through its contract with the Illinois Department of Healthcare and Family Services determines the medical necessity of the services or items that I request and receive. I also understand that I am responsible for payment of the services or items I request and receive if these services or items are determined not to be reasonable and medically necessary for my care. For more detailed information on IlliniCare Health billing requirements, please refer to the Billing Manual available on IlliniCare.com.
Appendix Volume 2, p. 318
37
Member Rights & Responsibilities IlliniCare Health members have the following rights and responsibilities.
GENERAL MEMBER RIGHTS AND RESPONSIBILITIES: Safety and Respect
ΕΕTo be treated with respect and with due consideration for his/her dignity and the right to privacy and non-discrimination as required by law.
ΕΕTo be honest with providers and treat them with respect and kindness.
ΕΕTo not be discriminated against because of race, color, national origin, religion, sex, ancestry, marital status, physical or mental disability, unfavorable military discharge or age. To do so is a Federal offense.
ΕΕTo be free from mental, emotional, social and physical abuse, neglect and exploitation.
ΕΕTo be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation, as specified in the Federal regulations on the use of restraints and seclusion.
ΕΕTo make recommendations regarding IlliniCare Health’s member rights and responsibilities policy.
ΕΕTo exercise his or her rights, and that the exercise of these rights does not adversely affect the way IlliniCare Health and its providers treat the members. Full Benefits and Plan Information
ΕΕTo receive information about IlliniCare Health, its benefits, its services, its practitioners and providers and member rights and responsibilities.
ΕΕTo information about your rights and responsibilities, as well as the IlliniCare Health providers and services.
ΕΕTo receive materials – including enrollment notices, information materials, instructional materials, available treatment options and alternatives, etc. – in a manner and format that may be easily understood.
38
ΕΕAs a potential member, to receive information about the basic features of managed care; which populations may or may not enroll in the program and IlliniCare Health responsibilities for coordination of care in a timely manner in order to make an informed choice.
ΕΕTo receive assistance from both Illinois Department of Healthcare and Family Services and IlliniCare Health in understanding the requirements and benefits of IlliniCare Health.
ΕΕTo receive services that are appropriate and are not denied or reduced solely because of diagnosis, type of illness, or medical condition.
ΕΕIf you access care without following IlliniCare Health rules, you may be responsible for the charges.
Ε To receive IlliniCare Health’s policy on referrals for specialty care and other benefits not provided by the member’s PCP.
ΕΕTo receive information on the following: ••Benefits covered; ••Procedures for obtaining benefits, including any authorization requirements;
••Cost sharing requirements; ••Service area; • Names, locations, telephone numbers of and non-English language spoken by current IlliniCare Health providers, including at a minimum, PCPs, specialists and hospitals;
••Any restrictions on member’s freedom of choice among network providers;
••Providers not accepting new patients; and • Benefits not offered by IlliniCare Health but available to members and how to obtain those benefits, including how transportation is provided.
ΕΕTo notify IlliniCare Health, Illinois and your providers of any changes that may affect your membership, healthcare needs or access to benefits. Some examples may include:
Appendix Volume 2, p. 319
••If you have a baby; ••If your address changes, even if temporarily; • If your telephone number changes; ••If you or one of your children are covered by another plan;
••If you have a special medical concern; or ••If your family size changes. ••To follow the policies and procedures of IlliniCare Health and the State Medicaid program.
• To receive notice of any significant changes in the Benefits Package at least 30 days before the intended effective date of the change.
••To receive a complete description of disenrollment rights at least annually.
••To inform IlliniCare Health of the loss or theft of their ID card.
••To present their ID card when using healthcare services.
••To be familiar with IlliniCare Health procedures to the best of their ability.
••To call or contact IlliniCare Health to obtain information and have questions clarified. Quality Care
ΕΕTo receive healthcare services that are accessible, are comparable in amount, duration and scope to those provided under Medicaid Fee-For-Service (FFS) and are sufficient in amount, duration and scope to reasonably be expected to achieve the purpose for which the services are furnished.
ΕΕTo provide information (to the extent possible) that IlliniCare Health and its practitioners and providers need in order to provide care.
ΕΕTo follow the prescribed treatment (plans and instructions) for care that has been agreed upon with your practitioners/providers.
Ε To inform your provider on reasons you cannot follow the prescribed treatment of care recommended by your provider.
ΕΕTo access preventive care services. ΕΕTo get regular medical care from their PCP before seeing a specialist.
ΕΕTo access all covered services, including certified nurse midwife services and pediatric or family nurse practitioner services.
ΕΕTo receive family planning services from any participating Medicaid doctor without prior authorization.
Medical Autonomy
ΕΕMake and act upon decisions (except those decisions delegated to a legal guardian) so long as the health, safety and well-being of others is not endangered by your actions. The member may also design or accept a representative to act on their behalf.
ΕΕTo understand your health problems and participate in developing mutually agreed-upon treatment goals to the degree possible.
ΕΕTo receive information on available treatment options and alternatives, presented in a manner appropriate to the member’s condition and ability to understand.
ΕΕTo participate with their providers and practitioners in making decisions regarding their healthcare, including the right to refuse treatment.
ΕΕTo a candid discussion of appropriate or medically necessary treatment options for all conditions, regardless of cost or benefit coverage.
ΕΕTo make an advance directive, such as a living will. ••IlliniCare Health is committed to ensure that its members are aware of and are able to avail themselves of their rights to execute advance directives. IlliniCare Health is equally committed to ensuring that its providers and staff are aware of and comply with their responsibilities under federal and state law regarding advance directives. PCPs and providers delivering care to IlliniCare Health members must ensure adult members 19 years of age and older receive information on advance directives and are informed of their right to execute advance directives. Providers must document such information in the permanent medical record. IlliniCare Health recommends to its participating providers that they inquire about advance directives and document the member’s response in the medical record, and, for members who have executed advance directives, that a copy of the advance directive be included in the member’s medical record inclusive of mental health directives. If an advance directive exists, the physician should discuss potential medical emergencies with the member and/or designated family member/significant other (if named in the advance directive and if available) and with the referring physician, if applicable. Any such discussion should be documented in the medical record.
Appendix Volume 2, p. 320
39
Ε To choose a person to represent them for the use of their information by IlliniCare Health if they are unable to.
ΕΕTo make suggestions about their rights and responsibilities.
Ε To get a second opinion from a qualified healthcare professional.
including medical interpreters for all members, hearing impaired services for those who are deaf or hard of hearing, and accommodations for enrollees with cognitive limitations).
ΕΕTo receive oral interpretation services free of charge for all non-English languages.
ΕΕTo be notified that oral interpretation is available and how to access those services.
Timely Access to Care
ΕΕTo receive timely access to care, including referrals to specialists when medically necessary without barriers.
ΕΕTo keep your medical appointments and follow-up appointments.
ΕΕTo keep all your scheduled appointments; be on time for those appointments, and cancel twentyfour (24) hours in advance if you cannot keep an appointment.
Ε To receive detailed information on emergency and after-hours coverage, to include, but not limited to:
••What constitutes an emergency medical condition, emergency services, and poststabilization services;
••Emergency services do not require prior authorization;
••The process and procedures for obtaining
ΕΕTo receive services at an Indian Healthcare Provider if the member is an American Indian.
• Critical Incident Prevention and Reporting ΕΕTo know that IlliniCare Health will report any concerns of critical incidents to promote member safety.
ΕΕMembers can also report critical incidents if they are concerned that one has occurred. Patient Privacy
ΕΕTo expect their medical records and care be kept confidential as required by law.
Ε To privacy of healthcare needs and information as required by federal law (Standards for Privacy of Individually Identifiable Health Information).
ΕΕTo allow or refuse their personal information be sent to another party for other uses unless the release of information is required by law.
emergency services;
••The locations of any emergency settings and other locations at which providers and hospitals furnish emergency services and post- stabilization services covered under the contract;
••Member’s right to use any hospital or other setting for emergency care; and
••Post-stabilization care services rules in accordance with Federal guidelines.
••Cultural, Linguistic, and Disability Competency ΕΕTo receive full and equal access to healthcare services and facilities, reasonable modifications necessary for accessible services, and effective communication methods to meet their needs.
ΕΕTo receive, upon request, information regarding accessibility, and languages, including the ability to communicate with sign language.
ΕΕTo receive accessible, culturally and linguistically competent care.
ΕΕTo communicate in a manner that accommodates their individual needs and to work with IlliniCare Health to coordinate specialized services (e.g.,
40
Medical Records To request and receive a copy of your medical record.
Ε To request that your medical record be corrected. Fraud, Waste, and Abuse (FWA)
ΕΕTo report any suspected FWA. Grievances, Appeals, or Medicaid Fair Hearing Procedures To receive information on the Grievance, Appeal and Medicaid Fair Hearing procedures. To voice grievances or file appeals about IlliniCare Health decisions that affect their privacy, benefits or the care provided.
Ε Be free to file grievances, appeals, or Medicaid Fair Hearing and be free from retaliation. Provider Termination
Ε To be notified that their provider is leaving IlliniCare Health.
Ε If their provider is a PCP, members may select a
Appendix Volume 2, p. 321
new PCP. If the member does not select a PCP prior to the provider’s termination date, IlliniCare Health will automatically assign a PCP to them.
ΕΕTo continue to receive covered services until 60 calendar days after termination or until IlliniCare Health can arrange appropriate healthcare for the member with a participating provider.
ΕΕTo continue to receive covered services for 90 calendar days if the member is undergoing active treatment related to a chronic or acute condition.
ΕΕTo continue to receive covered services if the member is in the second or third trimester of pregnancy.
SPECIFIC MEMBER RIGHTS AND RESPONSIBILITIES:
Members receiving the Persons with Disabilities, Persons with HIV or AIDs, and Persons with Brain Injury HCBS Waivers have specific rights and responsibilities, which include:
ΕΕApply or reapply for waiver services. ΕΕReceive a timely decision on eligibility for waiver services based on a complete assessment of member’s disability.
ΕΕReceive an explanation in writing, should they be determined ineligible for waiver services, telling the member why services were denied.
ΕΕReceive an explanation about waiver services that the member may receive.
ΕΕPartner with care coordinator in making informed choices for waiver services care plan.
ΕΕAppeal any decision which the member does not agree.
ΕΕBe informed of the Client Assistance Program (CAP).
ΕΕBe provided with a form of communication appropriate to accommodate the member’s disability.
ΕΕFully participate in the waiver services care plan. ΕΕSet realistic goals and participate in writing waiver services care plan with care coordinator.
ΕΕFollow through with member’s plan for rehabilitation.
ΕΕReview rehabilitation case record with a staff member present.
ΕΕCommunicate with care coordinator and ask questions when member does not understand services.
ΕΕKeep a copy of waiver services plan and any amendments related to the plan.
ΕΕKeep original documents and send only copies to care coordinator’s office.
ΕΕNotify care coordinator of any change in personal condition or work status.
ΕΕBe aware of financial eligibility requirements for some services.
ΕΕParticipate with care coordinator in any decision to close member’s case. Members receiving the Persons who are Elderly HCBS Waiver have specific rights and responsibilities, which include:
ΕΕAll information about the member and his or her case is confidential, and may be used only for purposes directly related to the administration of his or her aging waiver services as follows:
••Finding and making needed services and resources available.
••Assuring the health and safety of the member. ΕΕInformation about the member and his or her case cannot be used for any other purpose as indicated above, unless the member has given his or her consent to release that information.
ΕΕFreedom of choice of member’s providers for waiver services.
ΕΕThe right to choose not to receive waiver services. ΕΕThe right to transfer from one provider to another provider.
ΕΕThe right to request a provider to furnish more services than are allowed by the member’s care plan. The member will be required to pay 100% of the cost for any additional services not included in his or her care plan.
ΕΕThe right to report instances to his or her provider’s supervisor or an IlliniCare Health care coordination when the member does not believe his or her personal care worker:
••Is following the care plan; ••Does not come to the member’s home as scheduled; or
••Is always late. ΕΕThe member must report changes that affect him or her. This includes:
••Change of address, even if temporary; • Change in number of family members; and ••Changes needed in waiver services. ΕΕNotify the member’s IlliniCare Health care coordinator if the member is away from his or
Appendix Volume 2, p. 322
41
her home, for any reason, for over 60 calendar days. Services cannot be provided if the member is not at home. If this is the case, services will be terminated.
••To notify the member’s IlliniCare Health care coordinator if the member is entering a hospital, nursing home or other institution for any reason. The member’s services will be temporarily suspended until he or she returns home.
••Notify the member’s care coordinator in advance of his or her return home.
••If the member returns home after such termination and need services, he or she must contact the Illinois Department of Human Services to reapply.
ΕΕMust cooperate in the delivery of services. The member must:
••Must notify the provider and the member’s IlliniCare Health care coordinator, at least one day in advance, if the member intends to be absent from his or her home when scheduled services are to be provided. The member must notify the provider when they are leaving and when they is expected to return. The provider will resume services upon the member’s return.
••Allow the authorized worker into the home; ••Allow the worker to provide the services included in the care plan; and
••Do not require the worker to do more or less than what is in the care plan.
ΕΕIf the member wants to change the care plan, he or she must contact an IlliniCare Health care coordinator. The worker is unable to change it.
ΕΕThe member or other persons in his or her home must not harm or threaten to harm the worker or other participants, or display any weapon.
••Members residing in a Supporting Living Facility (SLF) have specific rights, which include:
ΕΕAll housing and services for which the member has contracted and paid.
ΕΕRefuse to receive or participate in any service or activity once the potential consequences of such refusal have been explained to the member and a negotiated risk agreement has been reached between the member, his or her designated representative and the service provider, so long as others are not harmed by the refusal.
ΕΕParticipate in the development, implementation and review of their own service plans.
ΕΕRemain in the supportive living facility, forgoing 42
recommended or needed services from the facility or available from others.
ΕΕArrange and receive non-Medicaid covered services not available from the contracted facility service provider at the member’s own expense so long as he or she does not violate conditions specified in the resident contract.
ΕΕControl time, space and lifestyle to the extent the health, safety and well-being of others is not disturbed.
••Have visitors of the member’s choice to the extent the health, safety and well-being of others is not disturbed and the provisions of the resident contracts are upheld.
••Have roommates only by the member’s choice. ••Maintain personal possessions to the extent they do not pose a danger to the health, safety and well-being of themselves and others.
••Store and prepare food in the member’s apartment to the extent the health, safety and well-being of the member and others is not endangered and provisions of the resident contract are not violated.
••Consume alcohol and use tobacco in accordance with the facility’s policy specified in the resident contract and any applicable statutes.
••Not be required to purchase additional services that are not part of the resident contract; and not be charged for additional services unless prior written notice is given to the member of the amount of the charge.
MEMBER FREEDOM OF CHOICE IlliniCare Health ensures that members have freedom of choice of the providers they utilize for waiver services and long term care. IlliniCare Health members have the option to choose their providers, which includes all willing and qualified providers. Subject to the member’s care plan, member access to in-network non-medical providers offering wavered services will not be limited or denied except when quality, reliability or similar threats pose potential hazards to the well-being of our members. Freedom of choice with network providers will not be limited for plan participants, nor will providers of qualified services be stopped from providing such service as long as the goal of high quality, cost efficient care is met or exceeded and providers adhere to the contractual standards outlined in the IlliniCare Health contract with the state of Illinois. We encourage our providers to share this information with members as well.
Appendix Volume 2, p. 323
Provider Rights & Responsibilities All IlliniCare Health providers have the following rights and responsibilities.
GENERAL PROVIDER RIGHTS AND RESPONSIBILITIES: Safety and Respect
ΕΕBe treated by their patients and other healthcare workers with dignity and respect.
ΕΕTreat members with fairness, dignity, and respect. ΕΕNot discriminate against members on the basis of race, color, national origin, disability, age, religion, mental or physical disability, or limited English proficiency.
ΕΕFollow all state and federal laws and regulations related to patient care and patient rights. Full Benefits and Plan Information
ΕΕContact IlliniCare Health’s Provider Services with any questions, comments, or problems, including suggestions for changes in the QIP’s goals, processes, and outcomes related to member care and services.
ΕΕObtain and report to IlliniCare Health information regarding other insurance coverage.
ΕΕParticipate in IlliniCare Health data collection initiatives, such as HEDIS and other contractual or regulatory programs. Quality Care and Utilization Management
ΕΕReceive accurate and complete information and medical histories for members’ care.
ΕΕCollaborate with other healthcare professionals who are involved in the care of members.
ΕΕExpect other network providers to act as partners in members’ treatment plans.
ΕΕExpect members to follow their directions, such as taking the right amount of medication at the right times.
ΕΕHave their patients act in a way that supports the care given to other patients and that helps keep the doctor’s office, hospital, or other offices running smoothly.
ΕΕHelp members or advocate for members to make decisions within their scope of practice about their relevant and/or medically necessary care and treatment, including the right to:
••Recommend new or experimental treatments; ••Provide information regarding the nature of treatment options;
• Provide information about the availability of alternative treatment options, therapies, consultations, and/or tests, including those that may be self-administered; and
••Be informed of the risks and consequences associated with each treatment option or choosing to forego treatment.
ΕΕHave access to information about IlliniCare Health’s quality improvement programs, including program goals, processes, and outcomes that relate to member care and services.
••Including information on safety issues. ΕΕReview clinical practice guidelines distributed by IlliniCare Health.
ΕΕComply with IlliniCare Health’s Medical Management program as outlined in this manual.
ΕΕObject to providing relevant or medically necessary services on the basis of the provider’s moral or religious beliefs or other similar grounds.
ΕΕContact IlliniCare Health to verify member eligibility or coverage for services, if appropriate.
ΕΕProvide members, upon request, with information regarding the provider’s professional qualifications, such as specialty, education, residency, and board certification status. Medical Autonomy
ΕΕProvide clear and complete information to members, in a language they can understand, about their health condition and treatment, regardless of cost or benefit coverage, and allow the member to participate in the decision-making process.
ΕΕTell a member if the proposed medical care or treatment is part of a research experiment and
Appendix Volume 2, p. 324
43
give the member the right to refuse experimental treatment.
ΕΕInvite member participation, to the extent possible, in understanding any medical or behavioral health problems that the member may have and to develop mutually agreed upon treatment goals, to the extent possible.
ΕΕAllow a member who refuses or requests to stop treatment the right to do so, as long as the member understands that by refusing or stopping treatment the condition may worsen or be fatal.
Ε Respect members’ advance directives and include these documents in the members’ medical record.
ΕΕAllow members to appoint a parent, guardian, family member, or other representative if they can’t fully participate in their treatment decisions.
ΕΕAllow members to obtain a second opinion, and answer members’ questions about how to access healthcare services appropriately. Timely Access to Care
ΕΕProvide members, upon request, with information regarding office location and hours of operation. Cultural, Linguistic, and Disability Competency
ΕΕTo follow IlliniCare Health’s policies and procedures on providing accessible, culturally and linguistically competent care.
ΕΕProvide full and equal access to healthcare services and facilities, make reasonable modifications necessary to make services accessible, and provide effective communication methods to meet the needs of all members, including those with disabilities.
ΕΕProvide flexible scheduling to meet the needs of their members.
ΕΕProvide members, upon request, with information regarding accessibility, and languages, including the ability to communicate with sign language.
ΕΕProvide accessible, culturally and linguistically competent care.
ΕΕTo communicate with members in a manner that accommodates their individual needs and work with IlliniCare Health to coordinate specialized services (e.g., including medical interpreters for all members, hearing impaired services for those who are deaf or hard of hearing, and accommodations for enrollees with cognitive limitations).
44
ΕΕTo provide oral interpretation services free of charge for all non-English languages.
ΕΕTo notify members that oral interpretation is available and how to access those services.
ΕΕTo receive services at an Indian Healthcare Provider if the member is an American Indian. Critical Incident Prevention and Reporting
ΕΕTo follow IlliniCare Health’s policies and procedures related to reporting Critical Incidents such as Abuse, Neglect, and Exploitation. Patient Privacy and Security
ΕΕMaintain the confidentiality of members’ personal health information, including medical records and histories, and adhere to state and federal laws and regulations regarding confidentiality.
ΕΕTo follow IlliniCare Health’s policies and procedures on Patient Privacy, Confidentiality, and Security.
Ε Give members a notice that clearly explains their privacy rights and responsibilities as it relates to the provider’s practice/office/facility.
Ε Provide members with an accounting of the use and disclosure of their personal health information in accordance with HIPAA.
Ε Allow members to request restriction on the use and disclosure of their personal health information.
ΕΕAll health information, including that related to patient conditions, medical utilization and pharmacy utilization, available through the portal or any other means, will be used exclusively for patient care and other related purposes as permitted by the HIPAA Privacy Rule. Medical Records
ΕΕProvide members, upon request, access to inspect and receive a copy of their personal health information, including medical records. Billing, Claims, and Preventing Fraud, Waste, and Abuse
ΕΕTo follow IlliniCare Health’s policies and procedures on preventing Fraud, Waste, and Abuse, and billing and claims.
Ε Disclose overpayments or improper payments to IlliniCare Health.
Ε Not be excluded, penalized, or terminated from participating with IlliniCare Health for having developed or accumulated a substantial number
Appendix Volume 2, p. 325
of patients in the IlliniCare Health with high-cost medical conditions.
ΕΕDisclose to IlliniCare Health, on an annual basis, any physician incentive plan (PIP) or risk arrangements the provider or provider group may have with physicians either within its group practice or other physicians not associated with the group practice even if there is no substantial financial risk between IlliniCare Health and the physician or physician group. Member Suspension
ΕΕMake a complaint or file an appeal against IlliniCare Health and/or a member. Provider Termination
ΕΕNotify IlliniCare Health in writing if the provider is leaving or closing a practice.
ΕΕProviders must give IlliniCare Health notice, in writing, if they wish to initiate voluntary termination procedures following the terms of their participating agreement with our health plan. In order for a termination to be considered valid, providers are required to send termination notices via certified mail (return receipt requested) or overnight courier. In addition, providers must supply copies of medical records to the member’s new provider upon request and facilitate the member’s transfer of care at no charge to IlliniCare Health or the member.
ΕΕIlliniCare Health will notify affected members in writing of a provider’s termination. If the terminating provider is a PCP, IlliniCare Health will request that the member select a new PCP. If a member does not select a PCP prior to the provider’s termination date, IlliniCare Health will automatically assign one to the member.
ΕΕProviders must continue to render covered services to members who are existing patients at the time of termination until the later of 60 calendar days or until IlliniCare Health can arrange for appropriate healthcare for the member with a participating provider.
ΕΕUpon request from a member undergoing active treatment related to a chronic or acute medical condition, IlliniCare Health will reimburse the provider for the provision of covered services for up to 90 calendar days from the termination date. In addition, IlliniCare Health will reimburse providers for the provision of covered services to members who are in the second or third trimester of pregnancy extending through the completion of postpartum care relating to the delivery.
PCP RESPONSIBILITIES The Primary Care Provider (PCP) is the cornerstone of IlliniCare Health’s service delivery model. The PCP serves as the “medical home” for the member. The “medical home” concept assists in establishing a member-provider relationship, supports continuity of care, eliminates redundant services, and ultimately improves outcomes in a more cost effective way. IlliniCare Health offers a robust network of PCPs to ensure every member has access to a PCP within reasonable travel distance standards. Physicians who may serve as PCPs include Internists, Pediatricians, Obstetrician/Gynecologists, and Family and General Practitioners. Non-physicians who may serve as PCPs include physician assistants and nurse practitioners. Physicians, physician assistants, and nurse practitioners in a Federally Qualified Health Center (FQHC), Rural Health Clinic (RHC), or Health Department setting may also serve as PCPs. IlliniCare Health offers pregnant members, or members with chronic illnesses, disabilities, or special healthcare needs the option of selecting a specialist as their PCP. A member, family member, caregiver or medical consenter may request a specialist as a PCP at any time. A member of our Integrated Care Team (ICT) will contact the member, caretaker or medical consenter, as applicable, within three (3) business days of the request to schedule an assessment. Our Chief Medical Officer will review assessment results and approve requests after determining that the member meets criteria and that the specialist is willing to fulfill the PCP role. The ICT member will work with the member and previous PCP if necessary, to safely transfer care to the specialist. PCP Rights and Responsibilities include:
Ε Educating members on how to maintain healthy lifestyles and prevent serious illness.
Ε Providing screening, well care, and referrals to community health departments and other agencies in accordance with HFS provider requirements and public health initiatives.
ΕΕObtaining authorizations for selected inpatient and outpatient services as listed on the current prior authorization list, except for emergency services up to the point of stabilization.
ΕΕBeing available for, or provide on-call coverage through another source, 24-hours a day for management of member care. After-hour access
Appendix Volume 2, p. 326
45
to the Health Home or covering IlliniCare Health provider can be via answering service, pager, or phone transfer to another location; recorded message instructing the member to call another number; or nurse helpline. In each case, all calls must be returned within 30 minutes.
ΕΕAgreeing to all of IlliniCare Health’s provider compliance policies and procedures, including those related to patient privacy, confidentiality, and security; preventing fraud, waste, and abuse; and reporting critical incidents such as abuse, neglect, and exploitation.
ΕΕIlliniCare Health PCPs should refer to their contract for complete information regarding providers’ obligations and mode of reimbursement.
ΕΕIlliniCare Health PCPs should refer to their contract for complete information regarding providers’ obligations and mode of reimbursement. Primary Care Case Management (PCCM) Program To promote the “medical home” concept, IlliniCare Health allows PCPs to participate in our “Primary Care Case Management” (PCCM) Program. Providers who participate in this program are eligible to receive a monthly capitation amount for each member who either selects the provider as his/her PCP, or who has been assigned to him/her as a PCP. A provider must be willing to meet the criteria described below in order to qualify for the PCCM program reimbursement: 1. Participate in or coordinate the members’ care during and after an inpatient admission; 2. Provide members with comprehensive primary care services and covered preventive services in accordance with the recommendation of the U.S. Preventive Health Services Task Force: medically indicated physical examinations, health education, laboratory services referrals for necessary prescriptions and other services such as mammograms and pap smears; 3. Provide or arrange for all appropriate immunizations for members; 4. Maintain office hours of no less than thirty (30) hours per week for PCP’s in an individual (solo) practice. PCP’s in a group practice may have office hours less than twenty four (24) hours per week as long as their group practice hours equal or exceed forty (40) hours per week; 5. Maintain the appointment accessibility standards defined in page 14 and, upon notification of a member’s hospitalization or
46
emergency room visit, a follow up appointment available within seven days of discharge; 6. Coordinate with IlliniCare Health’s Disease Management program including collaborating with case managers as requested; 7. Set up a recall system to outreach to members who miss an appointment to reschedule the appointment as needed; 8. Educate members and remind them of preventive and immunization services, or preventive services missed or due based on the periodicity schedule; 9. Use electronic claim submission for claim transactions IlliniCare Health is able to accept, within six months of the execution of the provider’s agreement; and 10. Register with IlliniCare Health Electronic Funds Transfer (EFT) vendor to receive electronic claim payments and remittance advices, upon execution of the Provider Agreement. Assignment To PCP For members who have not selected a PCP within 30 days of their enrollment date, IlliniCare Health will use an auto-assignment algorithm to assign an initial PCP by the 45th day. The algorithm assigns members to a PCP according to the following criteria, and in the sequence presented below: 1. Member history with a PCP. The algorithm will first look for a previous relationship with a provider. 2. Family history with a PCP. If the member him or herself has no previous relationship with a PCP, the algorithm will look for a PCP to which someone in the member’s family, such as a sibling, is or has been assigned. 3. Appropriate PCP type. The algorithm will use age, gender, and other criteria to ensure an appropriate match, such as children assigned to pediatricians and pregnant moms assigned to OB/GYNs. 4. Geographic proximity of PCP to member residence. The auto-assignment logic will ensure members travel no more than 30 minutes or 30 miles
Appendix Volume 2, p. 327
Terminating Care of a Member A PCP may terminate the care of a member in his/ her panel if the member: 1. The incidents have been properly documented in the member’s chart;
management of member care. After-hours access can be via answering service, pager, or phone transfer to another location; recorded message instructing the member to call another number; or nurse helpline. In each case, all calls must be returned within 30 minutes.
2. A certified letter has been sent to the member documenting the reason for the termination, indicating the date for the termination, informing the member that the provider will be available for emergency care for the next 30 days from the date of the letter, and instructing the member to call IlliniCare Health’s member services department for assistance in selecting a new primary care provider; and
ΕΕAgreeing to communicate with enrollees in
3. A copy of the letter must be sent to IlliniCare Health and a copy must be kept in the member’s chart.
HCBS Waiver Service Provider Rights and Responsibilities include:
ΕΕRepeatedly breaks appointments; ΕΕRepeatedly fails to keep scheduled appointments; ΕΕIs abusive to the provider or the office staff (physically or verbally); or
ΕΕFails to comply with the treatments plan. The provider may discontinue seeing the member after the following steps have been taken:
SPECIALIST RESPONSIBILITIES The PCP is responsible for coordinating the members’ healthcare services and making referrals to specialty providers when care is needed that is beyond the scope of the PCP. The specialty physician may order diagnostic tests without PCP involvement by following IlliniCare Health referral guidelines. The specialty physician must abide by the prior authorization requirements when ordering diagnostic tests; however, the specialist may not refer to other specialists or admit to the hospital without the approval of a PCP, except in a true emergency situation. Specialist Rights and Responsibilities include:
ΕΕMaintaining contact with the PCP and coordinate the member’s care.
ΕΕObtaining referral or authorization from the member’s PCP and/or IlliniCare Health Medical Management department (Medical Management) as needed before providing services.
ΕΕProviding the PCP with consult reports and other appropriate records within five business days.
ΕΕBeing available for or providing on-call coverage through another source 24-hours a day for
a manner that accommodates the enrollee’s individual needs and work with IlliniCare Health to coordinate specialized services (e.g., interpreters, hearing impaired services for those who are deaf or hard of hearing and accommodations for enrollees with cognitive limitations).
HCBS WAIVER PROVIDER RESPONSIBILITIES
ΕΕWorking collaboratively with IlliniCare Health’s care coordination team to provide services according to the care plan.
ΕΕProviding only the services as outlined in the care plan. If you believe a change is necessary for the member’s well-being, contact IlliniCare Health’s Integrated Care Team to discuss the change.
ΕΕMaintaining contact with the PCP. ΕΕObtaining authorization from an IlliniCare Health Care Coordinator as needed before providing services.
Ε Obtaining authorizations for selected inpatient and outpatient services as listed on the current prior authorization list, except for emergency services up to the point of stabilization. Suspending Waiver Services A home and community-based services provider may suspend the services of a member if the member or authorized representative causes a barrier to care or unsafe conditions. Any incidents of barriers to care and/or unsafe conditions should be reported to the IlliniCare Health Care Coordinator by calling Member Services. The Care Coordinator will work directly with the provider to resolve any potential issues, and if necessary, temporarily suspend services.
SLF & LTC PROVIDER RESPONSIBILITIES SLF & LTC Provider Rights and Responsibilities include:
ΕΕNotifying IlliniCare Health’s Medical Management department of emergency hospital admissions, elective hospital admissions within 24-48 hours of the admission.
Ε Notifying the PCP, when possible, within 24-48
hours after the member’s visit to the emergency Appendix Volume 2, p. 328
47
VOLUNTARILY LEAVING THE NETWORK
department.
Ε Notifying IlliniCare Health’s Medical Management department of IlliniCare Health member emergency room visits for the previous business day. This can be done via Fax or electronic file. The notification should include member’s name, Medicaid ID, presenting symptoms, diagnosis, date of service, and member phone number, if available.
HOSPITAL RESPONSIBILITIES IlliniCare Health utilizes a network of hospitals to provide services to IlliniCare Health members. Hospital Rights and Responsibilities include:
ΕΕObtaining authorizations for selected outpatient and ALL inpatient services as listed on the current prior authorization list. Emergency Room care does not require prior authorization.
ΕΕNotifying IlliniCare Health’s Medical Management department of emergency hospital admissions, elective hospital admissions and new born deliveries within 24-48 hours of the admission.
Ε Notifying the PCP, when possible, within 24-48 hours after the member’s visit to the emergency department.
ΕΕNotifying IlliniCare Health’s Medical Management department of members who may benefit from care coordination services – such as members who may have frequent visit to the emergency room.
Ε Notifying IlliniCare Health’s Medical Management department of IlliniCare Health member emergency room visits for the previous business day. This can be done via Fax or electronic file. The notification should include member’s name, Medicaid ID, presenting symptoms, diagnosis, date of service, and member phone number, if available.
Providers must give IlliniCare Health notice, in writing, if they wish to initiate voluntary termination procedures following the terms of their participating agreement with our health plan. In order for a termination to be considered valid, providers are required to send termination notices via certified mail (return receipt requested) or overnight courier. In addition, providers must supply copies of medical records to the member’s new provider upon request and facilitate the member’s transfer of care at no charge to IlliniCare Health or the member. IlliniCare Health will notify affected members in writing of a provider’s termination. If the terminating provider is a PCP, IlliniCare Health will request that the member select a new PCP. If a member does not select a PCP prior to the provider’s termination date, IlliniCare Health will automatically assign one to the member. Providers must continue to render covered services to members who are existing patients at the time of termination until the later of 60 calendar days or until IlliniCare Health can arrange for appropriate healthcare for the member with a participating provider. Upon request from a member undergoing active treatment related to a chronic or acute medical condition, IlliniCare Health will reimburse the provider for the provision of covered services for up to 90 calendar days from the termination date. In addition, IlliniCare Health will reimburse providers for the provision of covered services to members who are in the second or third trimester of pregnancy extending through the completion of postpartum care relating to the delivery.
IlliniCare Health hospitals should refer to their contract for complete information regarding the hospitals’ obligations and reimbursement.
48
Appendix Volume 2, p. 329
Provider Accessibility Standards & Procedures APPOINTMENT ACCESSIBILITY STANDARDS IlliniCare Health follows the accessibility requirements set forth by applicable regulatory and accrediting agencies. IlliniCare Health monitors compliance with these standards on an annual basis. Providers must offer hours of operation to IlliniCare Health members no less than those hours offered to commercial enrollees or Medicaid fee-for-service enrollees. The following table outlines the scheduling timeframe for each type of service that must be followed by all providers:
TYPE OF SERVICE
SCHEDULING TIMEFRAME
Emergency Care
Immediate
Urgent Care
One (1) business day
Non-Urgent Symptomatic
Within three (3) weeks
Routine Preventative Care
Within five (5) weeks For infants under the age of six (6) months: Within two (2) weeks
Pregnant Woman Visits
1st Trimester: 2 weeks 2nd Trimester: 1 week 3rd Trimester: 3 days
Average Office Wait Time
Equal or less than one (1) hour
Provider Appointment
No more than six (6) scheduled per hour
After Hours
24/7 coverage (voicemail only not acceptable)
In addition to the above accessibility standards and in accordance to the requirements set forth by the Illinois Department of Healthcare and Family Services, a PCPs panel size may not exceed 600 IlliniCare Health members.
Appendix Volume 2, p. 330
49
TELEPHONE ARRANGEMENT STANDARDS
ΕΕAfter-hours, a provider must have arrangements
PCPs and Specialists must:
for:
ΕΕAnswer member telephone inquiries on a timely
••Access to a covering physician, ••An answering service, ••Triage service, or ••A voice message that provides a second phone
basis.
ΕΕPrioritize appointments. ΕΕSchedule a series of appointments and follow-up appointments as needed by a member.
ΕΕIdentify and reschedule no-show appointments. ΕΕIdentify special member needs while scheduling an appointment (e.g., wheelchair and interpretive linguistic needs, non-compliant individuals, or those people with cognitive impairments).
ΕΕAdhere to the following response time for telephone call-back waiting times:
••After-hours telephone care for non-emergent, symptomatic issues within 30 minutes.
••Same day for non-symptomatic concerns. ΕΕSchedule continuous availability and accessibility of professional, allied, and supportive personnel to provide covered services within normal working hours. Protocols shall be in place to provide coverage in the event of a provider’s absence.
ΕΕAfter-hours calls should be documented in a written format in either an after-hour call log or some other method, and then transferred to the member’s medical record. IlliniCare Health will monitor appointment and after hours availability on an on-going basis through its Quality Improvement Program (QIP).
COVERING PROVIDERS PCPs and specialty physicians must arrange for coverage with another IlliniCare Health network provider during scheduled or unscheduled time off. The covering provider must have an active Illinois Medicaid ID number and an active NPI number in order to receive payment. The covering physician is compensated in accordance with the terms of his/ her contractual agreement.
24-HOUR ACCESS IlliniCare Health’s PCPs and specialty physicians are required to maintain sufficient access to facilities and personnel to provide covered physician services and shall ensure that such services are accessible to members as needed 24-hours a day, 365 days a year as follows:
number that is answered.
ΕΕAny recorded message must be provided in English and Spanish. The selected method of 24-hour coverage chosen by the member must connect the caller to someone who can render a clinical decision or reach the PCP or specialist for a clinical decision. The PCP, specialty physician, or covering medical professional must return the call within 30 minutes of the initial contact. After-hours coverage must be accessible using the medical office’s daytime telephone number. IlliniCare Health will monitor providers’ offices through scheduled and unscheduled visits conducted by our Provider Relations staff.
MEMBER PANEL CAPACITY All PCPs reserve the right to limit the number of members they are willing to accept into their panel. IlliniCare Health DOES NOT guarantee that any provider will receive a certain number of members. If a PCP declares a specific capacity for their practice and wants to make a change to that capacity, the PCP must contact IlliniCare Health Provider Services. A PCP shall not refuse to treat members as long as the provider has not reached their requested panel size. Providers shall notify IlliniCare Health in writing at least 45 calendar days in advance of their inability to accept additional Medicaid covered persons under IlliniCare Health agreements. In no event shall any established patient who becomes a covered person be considered a new patient. IlliniCare Health prohibits all providers from intentionally segregating members from fair treatment and covered services provided to other non-Medicaid members.
ΕΕA provider’s office phone must be answered during normal business hours.
50
Appendix Volume 2, p. 331
Credentialing & Re-credentialing The credentialing and re-credentialing process exists to ensure that participating providers meet the criteria established by IlliniCare Health, as well as government regulations and standards of accrediting bodies. All providers who participate in the HealthChoice Illinois or MMAI products must also be a Medicaid provider in good standing.
ΕΕCopy of current unrestricted medical license to
NOTE: In order to maintain a current provider profile, providers are required to notify IlliniCare Health of any relevant changes to their credentialing information in a timely manner.
ΕΕSigned and dated release of information form not
CREDENTIALING Providers must submit at a minimum the following information when applying for participation with IlliniCare Health:
ΕΕComplete signed and dated Illinois Standardized Credentialing application or authorize IlliniCare Health access to the CAQH (Council for Affordable Quality Health Care) for the Illinois Standardized Credentialing application.
ΕΕSigned attestation of the correctness and completeness of the application, history of loss of license and/or clinical privileges, disciplinary actions, and/or felony convictions; lack of current illegal substance registration and/or alcohol abuse; mental and physical competence, and ability to perform the essential functions of the position, with or without accommodation.
ΕΕCopy of current malpractice insurance policy face sheet that includes expiration dates, amounts of coverage and provider’s name, or evidence of compliance with Illinois regulations regarding malpractice coverage.
ΕΕCopy of current Illinois Controlled Substance registration certificate, if applicable.
ΕΕCopy of current Drug Enforcement Administration (DEA) registration Certificate.
ΕΕCopy or original of completed Internal Revenue Service Form W-9.
ΕΕCopy of Educational Commission for Foreign Medical Graduates (ECFMG) certificate, if applicable.
practice in the state of Illinois.
ΕΕCurrent copy of specialty/board certification certificate, if applicable.
ΕΕCurriculum vitae listing, at minimum, a five (5) year work history (not required if work history is completed on the application). older than 120 calendar days.
ΕΕProof of highest level of education – copy of certificate or letter certifying formal postgraduate training.
ΕΕCopy of Clinical Laboratory Improvement Amendments (CLIA), if applicable. IlliniCare Health will verify the following information submitted for credentialing and/or re-credentialing:
ΕΕIllinois license through appropriate licensing agency.
ΕΕBoard certification, or residency training, or medical education.
ΕΕNational Practitioner Data Bank-Health Integrity Practitioner Data Bank (NPDB-HIPDB) for malpractice claims and license agency actions.
ΕΕHospital privileges in good standing at a participating IlliniCare Health hospital.
ΕΕReview five (5) year work history. ΕΕReview federal sanction activity including Medicare/ Medicaid services (OIG-Office of Inspector General and EPLS- Excluded Parties Listing).
ΕΕSite visits may be performed at practitioner offices within 60 calendar days of any member complaints related to physical accessibility, physical appearance, and adequacy of waiting and examining room space. If the practitioner’s site visit score is less than eighty percent (80%), the practitioner may be subject to termination and/ or continued review until compliance is achieved. A site review evaluates appearance, accessibility, record-keeping practices, and safety procedures.
Appendix Volume 2, p. 332
51
Once the application is completed, the IlliniCare Health Credentialing Committee will render a final decision on acceptance following its next regularly scheduled meeting. Providers must be credentialed prior to accepting or treating members. PCPs cannot accept member assignments until they are fully credentialed.
RE-CREDENTIALING To comply with accreditation standards, IlliniCare Health conducts the re-credentialing process for providers at least every three years, in compliance with the Illinois Register Department of Public Health, Section 965.300 Single Credentialing Cycle. The purpose of this process is to identify any changes in the practitioner’s licensure, sanctions, certification, competence, or health status which may affect the ability to perform services the provider is under contract to provide. This process includes all practitioners, primary care providers, specialists, and ancillary providers/facilities previously credentialed to practice within the IlliniCare Health network. In between credentialing cycles, IlliniCare Health conducts ongoing sanction monitoring activities on all network providers. This includes an inquiry to the appropriate Illinois state licensing agency, board, or commission for a review of newly-disciplined providers and providers with a negative change in their current licensure status. This monthly inquiry insures that providers are maintaining a current, active, unrestricted license to practice in between credentialing cycles. Additionally, IlliniCare Health reviews monthly reports released by the Office of Inspector General to review for any network providers who have been newly sanctioned or excluded from participation in Medicare and/or Medicaid programs. Additionally, between credentialing cycles, a provider may be requested to supply current proof of any credentials such as Illinois licensure, malpractice insurance, DEA registration, a copy of certificate of cultural competency training, etc. that have expiration dates prior to the next review process. A provider’s agreement may be terminated if at any time it is determined by the IlliniCare Health’s Board of Directors or the Credentialing Committee that credentialing requirements are no longer being met.
52
CREDENTIALING COMMITTEE The Credentialing Committee has the responsibility to establish and adopt as necessary, criteria for provider participation, termination, and direction of the credentialing procedures, including provider participation, denial, and termination. Committee meetings are held at least quarterly and more often as deemed necessary. NOTE: Failure of an applicant to adequately respond to a request for missing or expired information may result in termination of the application process prior to committee decision. Right to Review & Correct Information All providers participating within the IlliniCare Health network have the right to review information obtained by IlliniCare Health to evaluate their credentialing and/or re-credentialing application. This includes information obtained from any outside primary source such as the National Practitioner Data Bank-Healthcare Integrity and Protection Data Bank, malpractice insurance carriers and the State Licensing Agencies. This does not allow a provider to review references, personal recommendations, or other information that is peer review protected. Should a provider believe any of the information used in the credentialing/re-credentialing process to be erroneous, or should any information gathered as part of the primary source verification process differ from that submitted by a practitioner, they have the right to correct any erroneous information submitted by another party. To request release of such information, a written request must be submitted to the IlliniCare Health credentialing department. Upon receipt of this information, the provider will have 14 calendar days to provide a written explanation detailing the error or the difference in information to the IlliniCare Health. The IlliniCare Health Credentialing Committee will then include this information as part of the credentialing/ re-credentialing process. Right to Be Informed of Application Status All providers who have submitted an application to join IlliniCare Health have the right to be informed of the status of their application upon request. To obtain status, contact the IlliniCare Health Provider Relations department.
Appendix Volume 2, p. 333
Right to Appeal Adverse Credentialing Determinations Existing provider applicants who are declined for continued participation for reasons such as quality of care or liability claims issues have the right to appeal the decision in writing within 14 calendar days of formal notice of denial. All written requests should include additional supporting documentation in favor of the applicant’s reconsideration for participation in the IlliniCare Health network. Appeals will be reviewed by the Credentialing Committee at the next regularly scheduled meeting, but in no case later than 60 calendar days from the receipt of the additional documentation. The applicant will be sent a written response to his/her request within two weeks of the final decision.
Appendix Volume 2, p. 334
53
Disclosure of Ownership & Control Interest Statement The Enrollment Disclosure Statement Form (HFS form 1513 - http://www2.illinois.gov/ hfs/ SiteCollectionDocuments/hfs1513.pdf) is required documentation and verification of your eligibility to provide services. In addition, the federal regulations set forth in 42 CFR 455.105 require providers who are entering into or renewing a provider agreement to disclose to the U.S. Department of Health and Human Services, the state Medicaid agency, and to managed care organizations that contract with the state Medicaid agency certain business transactions. Failure to submit the accurate, complete information requested in a timely manner may lead to the termination or denial of enrollment into the network as specified in 42 CFR 455.416. 42 CFR 455.105 states in relevant part: “(a) Provider agreements. A Medicaid agency must enter into an agreement with each provider under which the provider agrees to furnish to it or to the Secretary on request, information related to business transactions in accordance with paragraph (b) of this section.
54
(b) Information that must be submitted. A provider must submit, within 35 days of the date on a request by the Secretary or the Medicaid agency, full and complete information about— (1) The ownership of any subcontractor with whom the provider has had business transactions totaling more than $25,000 during the 12-month period ending on the date of the request; and (2) Any significant business transactions between the provider and any wholly owned supplier, or between the provider and any subcontractor, during the 5-year period ending on the date of the request. (c) Denial of Federal financial participation (FFP). (1) FFP is not available in expenditures for services furnished by providers who fail to comply with a request made by the Secretary or the Medicaid agency under paragraph (b) of this section or under § 420.205 of this chapter (Medicare requirements for disclosure). (2) FFP will be denied in expenditures for services furnished during the period beginning on the day following the date the information was due to the Secretary or the Medicaid agency and ending on the day before the date on which the information was supplied.”
Appendix Volume 2, p. 335
Grievance & Appeals MEMBER GRIEVANCE IlliniCare Health Grievance System includes an informal complaints process and a formally structured grievance and appeals process. IlliniCare Health’s Grievance System is compliant with Section 45 of the Managed Care Reform and Patient Rights Act and 42 CFR Section 438 Subpart F, including procedures to ensure expedited decision making when a member’s health so necessitates. The filing of a grievance will not preclude the member from filing a complaint with the Illinois Department of Insurance (DOI), nor will it preclude DOI from investigating a complaint pursuant to its authority under Section 4-6 of the Health Maintenance Organization Act. A member grievance is defined as any expression of dissatisfaction by a member about any matter other than an Action. The grievance process allows the member, or the member’s appointed representative (guardian, caretaker, relative, PCP or other treating physician) acting on behalf of the member, to file a grievance either verbally or in writing or an appeal or request a State Fair Hearing. IlliniCare Health values its providers and will not retaliate in any way against providers who file a grievance on a member’s behalf. Acknowledgment IlliniCare Health shall acknowledge receipt of each grievance in writing. The IlliniCare Health staff member will document the substance of an oral grievance, and attempt to resolve it immediately. For informal complaints, defined as those received verbally and resolved immediately to the satisfaction of the member or appointed representative, the staff will document the resolution details. The Grievance and Appeals Coordinator will date stamp written grievances upon initial receipt and send an acknowledgment letter, which includes a description of the grievance procedures and resolution time frames, within two (2) business days of receipt.
Timeframe & Notice of Grievance Resolution Grievance investigation and review by the Grievance Committee (for those grievances not resolved informally) will occur as expeditiously as the member’s health condition requires, not to exceed fifteen (15) days from the receipt of all information or thirty (30) days from the date the grievance is received by IlliniCare Health. The determination by the Committee may be extended for a period not to exceed fourteen (14) days in the event of a delay in obtaining the documents or records necessary for the resolution of the grievance. Members have the right to attend and participate in the formal grievance proceedings and may be represented by a designated representative of his or her choice. Resolution is determined by majority vote. Any individuals who make a decision on grievances will not be involved in any previous level of review or decision making. In any case where the reason for the grievance involves clinical issues or relates to denial of expedited resolution of an appeal, IlliniCare Health shall ensure that the decision makers are healthcare professionals with the appropriate clinical expertise in treating the member’s condition or disease [see 42 CFR § 438.406]. Written notification of the grievance resolution will be made within five (5) days after the determination and will include the resolution and HFS requirements, including but not be limited to, the decision reached by IlliniCare Health, the reason(s) for the decision, the policies or procedures which provide the basis for the decision, and a clear explanation of any further rights available to the member. Grievances may be submitted verbally or in writing to: IlliniCare Health Attn: Grievance and Appeals P.O. Box 92050 Elk Grove Village, IL 60009-2050
Appendix Volume 2, p. 336
55
HealthChoice Illinois: 866-329-4701 MMAI: 877-941-0482
APPEALS An appeal is the request for review of a “Notice of Adverse Action”. A Notice of Adverse Action is the denial or limited authorization of a requested service, including the type or level of service; the reduction, suspension, or termination of a previously authorized service; the denial, in whole or part of payment for a service excluding technical reasons; the failure to render a decision within the required timeframes; or the denial of a member’s request to exercise his/her right under 42 CFR 438.52(b)(2) (ii) to obtain services outside the IlliniCare Health network. The review may be requested in writing or verbally within 60 days of the Notice of Adverse Action, however verbal requests for appeals must be followed by a written request. All appeals must be registered initially with IlliniCare Health and may be appealed to the Department of Healthcare and Family Services when IlliniCare Health’s process has been exhausted. IlliniCare Health will notify the filing party, within two (2) business days of receipt, of any additional information required to evaluate the appeal request. Appeals will be fully investigated without deference to the denial decision. The appeal will be reviewed by an appropriately licensed clinical peer who was not involved in any previous level of decision making regarding the request. IlliniCare Health will render a decision and provide written notification within 15 business days after receipt of required information, not to exceed 30 calendar days of receipt of the request. A member or an authorized representative may request a standard or expedited External Independent Review (EIR) of an adverse determination. Expedited Appeals Expedited appeals may be filed when either IlliniCare Health or the member’s provider determines that the time expended in a standard resolution could seriously jeopardize the member’s life or health or ability to attain, maintain, or regain maximum function. No punitive action will be taken against a provider that requests an expedited resolution or supports a member’s appeal. In instances where the member’s request for an expedited appeal is denied, the appeal must be transferred to the timeframe for standard resolution of appeals. IlliniCare Health will notify the filing party, within
56
24 hours of receipt, of any additional information required to evaluate the appeal request. IlliniCare Health will render a decision and provide notification within 24 hours after receipt of required information, not to exceed 72 hours of receipt of the initial request. IlliniCare Health will make reasonable efforts to provide the member, PCP and any healthcare provider who recommended the service with prompt verbal notice of the decision followed by written notice within three (3) calendar days after the initial verbal notification. Notice of Appeal Resolution Written appeal resolution notice shall include the following information:
ΕΕThe decision reached by IlliniCare Health; ΕΕThe date of decision; ΕΕFor appeals not resolved wholly in favor of the member the right to request a State fair hearing and information as to how to do so; and
ΕΕThe right to request to receive benefits while the hearing is pending and how to make the request, explaining that the member may be held liable for the cost of those services if the hearing decision upholds the IlliniCare Health decision. Appeals may be submitted verbally or in writing to: IlliniCare Health Attn: Grievance and Appeals PO Box 92050 Elk Grove Village, IL 60009-2050 HealthChoice Illinois: 866-329-4701 MMAI: 877-941-0482
STATE FAIR HEARING PROCESS Any adverse action or appeal that is not resolved wholly in favor of the member by IlliniCare Health may be appealed by the member or the member’s authorized representative to HFS for a Fair Hearing conducted in accordance with 42 CFR § 431 Subpart Please contact: Illinois Department of Healthcare and Family Services Bureau of Administrative Hearings 69 W. Washington Street 4th Floor Chicago, IL 60602 Toll-free: 855-418-4421 TTY: 800-526-5812
Appendix Volume 2, p. 337
Fax: 312-793-2005 IlliniCare Health is responsible for providing to the HFS an appeal summary describing the basis for the denial. IlliniCare Health will comply with HSM’s fair hearing decision.
REVERSED APPEAL RESOLUTION In accordance with 42 CFR §438.424, if IlliniCare Health or the state fair hearing decision reverses a decision to deny, limit, or delay services, where such services were not furnished while the appeal was pending, IlliniCare Health will authorize the disputed services promptly and as expeditiously as the member’s health condition requires. Additionally, in the event that services were continued while the appeal was pending, IlliniCare Health will provide reimbursement for those services in accordance with the terms of the final decision rendered by HFS and applicable regulations.
Appendix Volume 2, p. 338
57
Provider Complaint IlliniCare Health has established a provider complaint system that allows a provider to dispute the policies, procedures, or any aspect of the administrative function, including the proposed action. NOTE: The process for appeals of medical necessity decisions (actions) is outlined above in the Member Appeals Section of this Manual. Providers may submit a complaint via telephone, written mail, electronic mail or in person. IlliniCare Health has designated a Provider Complaints Coordinator (PCC) to process provider complaints. Provider complaints will be thoroughly investigated using applicable statutory, regulatory, contractual and provider contract provisions, collecting all pertinent facts from all parties and applying IlliniCare Health’ written policies and procedures. After the complete review of the provider complaint, the PCC will provide a written notice of resolution to the Provider within thirty (30) days from the date of the decision. Provider Complaints may be submitted verbally or in writing to: IlliniCare Health Attn: Provider Complaints PO Box 92050 Elk Grove Village, IL 60009-2050 HealthChoice Illinois: 866-329-4701 MMAI: 877-941-0482 In addition to communicating the provider complaint process through this Manual, IlliniCare Health communicates the provider complaint process during provider orientation and on its website.
58
Appendix Volume 2, p. 339
Fraud, Waste, & Abuse IlliniCare Health takes the detection, investigation, and prosecution of fraud and abuse very seriously, and has a fraud, waste and abuse (FWA) program that complies with the State of Illinois and federal laws. To report FWA, call Provider Services at 866-329-4701 or our Fraud and Abuse hotline at 866-685-8664. IlliniCare Health, in conjunction with its management company, Centene, successfully operates a Special Investigation Unite (SIU) that manages the review and investigation of reported concerns. IlliniCare Health performs front and back end audits to ensure compliance with billing regulations. Our sophisticated code editing software performs systematic audits during the claims payment process. To better understand this system; please review the Billing and Claims section of this manual. SIU performs back end audits which in some cases may result in taking the appropriate actions against those who, individually or as a practice, commit fraud, waste and/or abuse, including but not limited to:
ΕΕRemedial education and/or training around eliminating the egregious action;
ΕΕMore stringent utilization review; ΕΕRecoupment of previously paid monies; ΕΕTermination of provider agreement or other contractual arrangement;
ΕΕCivil and/or criminal prosecution; and ΕΕAny other remedies available to rectify.
ΕΕConflicts of Interest; ΕΕSelf-Referrals; and ΕΕAccepting gifts from a company, for example a DME company or pharmaceutical company, in exchange for directing your Medicare and Medicaid patients to use those companies If you suspect or witness a provider inappropriately billing or a member receiving inappropriate services, please call our free anonymous and confidential hotline at 866-685-8664. IlliniCare Health and Centene take all reports of potential fraud, waste and/or abuse very seriously and investigate all reported issues. IlliniCare Health and Centene has a no retaliation policy for anyone reporting a concern. Authority & Responsibility IlliniCare Health’s Vice President of Compliance and Regulatory Affairs has overall responsibility and authority for carrying out the provisions of IlliniCare Health’s compliance program. IlliniCare Health is committed to identifying, investigating, sanctioning and prosecuting suspected fraud and abuse. The IlliniCare Health provider network will cooperate fully in making personnel and/or subcontractor personnel available in person for interviews, consultation, grand jury proceedings, pre-trial conferences, hearings, trials and in any other process, including investigations.
Some of the most common FWA issues include:
ΕΕUnbundling of codes; ΕΕUp-coding; ΕΕAdd-on codes without primary CPT; ΕΕDiagnosis and/or procedure code not consistent with the member’s age/gender;
ΕΕUse of exclusion codes; ΕΕExcessive use of units; ΕΕMisuse of benefits; ΕΕClaims for services not rendered;
Appendix Volume 2, p. 340
59
Critical Incidents IlliniCare Health adheres to a systematic approach to promote the identification of any potential critical incident(s). Any concerns identified as a potential critical incident must be promptly reported, reviewed, investigated, and appropriate corrective actions must be taken as necessary. The primary focus is to identify and report instances that have the potential for harm to a member. IlliniCare Health requires affiliated providers to be proactive in critical incident reporting to promote the safety of members. Retaliatory action is prohibited against the reporting personnel by the affiliated provider, an employee, and/or other person affiliated with IlliniCare Health. Identification of potential critical incidents is the key action to reducing the risk of harm to members. Examples of critical incidents include, but are not limited to:
ΕΕAbuse, neglect, exploitation or any incident that has the potential to place a member or a member’s services at risk including those which do not rise to the level of abuse, neglect, or exploitation.
ΕΕSuicide attempts. ΕΕWillful infliction of injury. ΕΕFinancial misconduct: Misuse or withholding of a person’s resources.
ΕΕFailure to notify a health care professional when needed; failure to provide or arrange necessary services to avoid physical or psychological harm.
ΕΕInappropriate use of restraints in the Long Term Care setting. All suspected critical incidents should be reported to:
ΕΕIlliniCare Health Provider Services: 866-329-4701 ΕΕThe Illinois Office of the Inspector General: 1-800368-1463 or http://www.state.il.us/agency/oig/ reportfraud.asp All information is kept private and confidential.
60
Appendix Volume 2, p. 341
Cultural, Linguistic, & Disability Competency CULTURAL COMPETENCY Studies have found that culturally and linguistically diverse groups, those with limited English proficiency, and people with disabilities experience less adequate access to care, lower quality of care and poorer health status outcomes. Cultural competency within IlliniCare Health is defined as “the willingness and ability of a system to value the importance of culture in the delivery of services to all segments of the population. It is the use of a systems perspective which values differences and is responsive to diversity at all levels in an organization. Cultural competency is developmental, community focused and family oriented. In particular, it is the promotion of quality services to understand, racial and ethnic groups through the valuing of differences and integration of cultural attitudes, beliefs and practices into diagnostic and treatment methods and throughout the healthcare system to support the delivery of culturally relevant and competent care. It is also the development and continued promotion of skills and practices important in clinical practice, crosscultural interactions and systems practices among providers and staff to ensure that services are delivered in a culturally competent manner.” Cultural competency is a set of interpersonal skills that allow individuals to increase their understanding, appreciation, acceptance and respect for cultural differences and similarities within, among and between groups, and the sensitivity to know how these differences influence relations with members. It includes a set of complimentary behaviors, attitudes and policies that help professionals work effectively with people of different cultures. Cultural competency helps professionals work effectively with culturally diverse members, including, but not limited to:
ΕΕImmigrants and refugees. ΕΕRace and ethnicity.
ΕΕSocioeconomic status and social class. ΕΕSexual orientation. ΕΕDisability. There are five skills associated with becoming culturally competent. They are: 1. Self-Awareness: Not treating people differently based on assumptions; 2. Understanding: Remembering that some of your patients have experienced discrimination, lack of quality health care, and successful treatment with nontraditional medical approaches; 3. Awareness of Others: Remembering that some patients speak to you based on a large number of cultural beliefs and expectations; 4. Reflectiveness: Critically examining and continuously monitoring your own beliefs and assumptions; and 5. 5Lifelong Learning: Developing skills necessary for working with people of different cultures and backgrounds. Similarly, when communicating across cultures, we should:
ΕΕMaintain formality; ΕΕShow respect; ΕΕCommunicate clearly; and ΕΕValue diversity. LINGUISTIC COMPETENCY Linguistic competency is also fundamental to ensuring effective communication with patients who have limited English proficiency or are deaf, hard of hearing, or speech disabled. Effective communication between patients and providers is a crucial component to ensuring better health status outcomes.
Appendix Volume 2, p. 342
61
When working with an interpreter, providers should:
ΕΕUse professional interpreters rather than family and friends;
ΕΕAllocate additional time for interpretation; ΕΕSpeak directly to the patient not to the interpreter; ΕΕAvoid jargon or technical terms; ΕΕKeep sentences short and pause to allow time for interpretation;
ΕΕAsk only one question at a time; ΕΕBe prepared to repeat yourself or re-phrase yourself if the message is not understood; and
ΕΕCheck with the patient to ensure that the message was understood correctly. To facilitate effective communication, providers must ensure patients have access to medical interpreters, signers, and TTY/TDD Services at no cost to the patients. Therefore, IlliniCare Health provides the following services:
ΕΕLanguage Line Services, in 140 languages, 24 hours a day, 7 days a week;
ΕΕInformation in other formats in Spanish, Russian, Audio, and Braille;
ΕΕTDD/TTY access; and ΕΕTranslators in your office or hospital (all at no cost). If you need translation services at any time, contact Member Services.
ACCOMMODATING PEOPLE WITH DISABILITIES It is equally important to maintain “Disability Awareness”. The Americans with Disabilities Act (ADA) defines a person with a disability as: A person who has a physical or mental impairment that substantially limits one or more major life activities, and includes people who have a record of impairment, even if they do not currently have a disability, and individuals who do not have a disability, but are regarded as having a disability. Under the ADA, Section 504 of the Rehabilitation Act, and other state and federal laws and regulations, it is unlawful to discriminate against persons with disabilities or to discriminate against a person based on that person’s association with a person with a disability. People with disabilities are entitled, by law, to fair and equal opportunities in all aspects of life. ADA standards assist in meeting the needs and requirements for persons with disabilities
62
by governing accommodations and accessibility requirements for “programs of the public entities” (including government-run healthcare facilities) and “places of accommodation.” Accommodations for people with disabilities include, but are not limited to:
ΕΕPhysical accessibility; ΕΕEffective communication; ΕΕPolicy modification; ΕΕAccessible medical equipment; and ΕΕTrained staff. In addition to providing sufficient accommodations, to successfully meet the demands for “disability awareness”, you must “know your patients”. This includes capturing information about accommodations that may be required, recording information in patient’s charts or electronic health records, and if making referrals to other providers, communicating with the receiving provider regarding any necessary accommodations that may be required. Moreover, empowering people with disabilities is a vital component of providing them with healthcare services. It is important that providers acknowledge prejudices, help combat discrimination, and encourage empowerment. Providers can do this by focusing on person centered planning and selfdetermination. This means that providers support members’ freedom to choose a meaningful life in the community, grant them the authority to control the resources they need to build that life, and support the member in selecting services and supports best suited to their individual needs. This enables the member to take responsibility for their lives, and confirms that the member plays an important role in designing or re-designing their system of care. Ultimately, this is the difference between treating patients with disabilities under the “Medical Model,” as opposed to the “Independent Living Model.”
Medical Model Decisions made by the rehabilitation professional
Independent Living Model Decisions made by the individual
Focus is on problems or Focus is on social and deficiencies/disabilities attitudinal barriers
Appendix Volume 2, p. 343
Having a disability is Having a disability is perceived as being a natural, common unnatural and a tragedy experience in life When communicating with people with disabilities, using “Person-First” language is key way to modify prejudice, discrimination, and stigma since it puts the person first and the disability second. Similarly, make sure to treat them with respect rather than using demeaning terms. Examples include:
ΕΕDisabled rather than Handicapped; ΕΕAccessible Parking rather than Handicapped Parking; ΕΕHas a disability rather than Stricken/Victim/Suffering From; ΕΕCognitive of Intellectual Impairment rather than Retarded; ΕΕUses a Wheelchair rather than Wheelchair Bound; ΕΕPerson with a Communication Disorder or Person who is Deaf rather than Deaf or Mute; and ΕΕPerson who is blind rather than blind. When interacting with people with disabilities, it is equally as important to treat them with respect and to not make assumptions. Helpful interaction tips include: Mobility Impairments
Don't push, touch, or lean on someone's wheelchair. When possible, bring yourself to their level to speak with them.
Visually Impaired
Identify yourself, do not touch or distract the guide dog who is working.
Person who is Deaf or Hard of Hearing
Speak directly to the person not the interpreter, do not assume they can read lips, do not obscure your face in any way.
Person with a Speech Impairment
Do not finish their sentences; if you do not understand, ask the person to repeat or you can repeat to make sure you understood.
Seizure Disorder
Do not interfere with the seizure, protect their head during the event, do not assume they need you to call 911.
Respiratory Distress Disorder (MCS)
Do not wear perfumes, do not use or spray chemicals, maintain good ventilation.
Developmental Disabilities
Speak clearly using simple words, do not talk down to the person, do not assume they cannot make their own decisions unless you have been told otherwise.
In summary, IlliniCare Health is committed to the development, strengthening, and sustaining of healthy provider/ member relationships. Members are entitled to dignified, appropriate, and quality care. However, when healthcare services are delivered without regard for cultural differences, members are at risk for sub-optimal care. They may be unable or unwilling to communicate their healthcare needs in an insensitive environment, reducing effectiveness of the entire healthcare process. Therefore, IlliniCare Health evaluates the cultural competency level of its network providers and is dedicated to providing training and tool kits to assist providers in continually developing and enhancing their culturally competent and culturally proficient practices.
Appendix Volume 2, p. 344
63
Quality Improvement Program IlliniCare Health culture, systems, and processes are structured around its mission to improve the health of all enrolled members. The Quality Assessment and Performance Improvement Program (QAPI Program) utilizes a systematic approach to quality using reliable and valid methods of monitoring, analysis, evaluation and improvement in the delivery of the healthcare provided to all members, including those with special needs. This system provides a continuous cycle for assessing the quality of care and service among plan initiatives including preventive health, acute and chronic care, behavioral health, over- and underutilization, continuity and coordination of care, patient safety, and administrative and network services. This includes the implementation of appropriate interventions and designation of adequate resources to support the interventions. IlliniCare Health recognizes its legal and ethical obligation to provide members with a level of care that meets recognized professional standards and is delivered in the safest, most appropriate settings. To that end, IlliniCare Health will provide for the delivery of quality care with the primary goal of improving the health status of its members.
PROGRAM STRUCTURE IlliniCare Health’s Board of Directors (BOD) has the ultimate authority and accountability for the oversight of the quality of care and service provided to members. The BOD delegates ongoing oversight of the QAPI program to Quality Improvement Committee (QIC) and has established various standing and ad-hoc committees to monitor and support it. The QIC is a senior management committee with physician representation that is directly accountable to the BOD. The purpose of the QIC is to promote a system-wide approach to Quality Assurance, provide oversight and direction in assessing the appropriateness of care and services delivered, encourage Provider participation, and to continuously enhance and improve the quality of care and services provided to members. In addition, the QIC has the responsibility for developing and implementing the QAPI program. This will be accomplished
64
through a comprehensive, plan-wide system of ongoing, objective, and systematic monitoring; the identification, evaluation, and resolution of process problems; the identification of opportunities to improve member outcomes; and the education of the member, Providers and staff regarding the QA, UM, and Credentialing programs. The following sub-committees report directly to the QIC:
ΕΕCredentialing Committee ΕΕPharmacy and Therapeutics Committee ΕΕUtilization Management Committee ΕΕGrievance and Appeal Committee ΕΕDelegation Oversight Committee ΕΕPeer Review Committee (Ad Hoc Committee) PRACTITIONER INVOLVEMENT IlliniCare Health, recognizing the integral role practitioner involvement plays in the success of its quality improvement program, encourages provider representation in various levels of the process. The QIC consists of a cross representation of all types of Providers, including PCPs, specialists, dentists and long term care representatives from IlliniCare Health network and across the service area. IlliniCare Health encourages PCP, behavioral health, specialty, and OB/GYN representation on key quality committees such as, but not limited to, the QIC, Credentialing Committee, Peer Review Committee, Pharmacy and Therapeutics Committee, and select ad-hoc committees.
QUALITY ASSESSMENT & PERFORMANCE IMPROVEMENT PROGRAM (QAPI) The scope of IlliniCare Health’s QAPI Program addresses both the quality of clinical care and the quality of services provided to members and providers. IlliniCare Health QA activities encompass all demographic groups, benefits and care settings; and, address all services, including medical and behavioral healthcare, preventive, emergency, primary, and specialty care; as well, as acute care, short-term care,
Appendix Volume 2, p. 345
long-term care, home care, pharmacy and ancillary services. Areas subject to quality oversight include:
ΕΕAcute and chronic care management and disease management.
ΕΕAdoption and compliance with preventive health and clinical practice guidelines.
ΕΕBehavioral healthcare management and coordination with medical practitioners.
ΕΕContinuity and coordination of care. ΕΕDelegated entity oversight. ΕΕDepartment performance and service. ΕΕEmployee and provider cultural competency. ΕΕEmployee and provider linguistic competency. ΕΕDisparities in care. ΕΕMember Grievance and Appeals. ΕΕMember satisfaction. ΕΕHealth education and promotion. ΕΕNetwork accessibility and appointment availability, including specialty practitioners.
ΕΕCompliance with disability guidelines and care oversight.
ΕΕPatient safety including appropriateness and quality of healthcare services.
ΕΕProvider satisfaction. ΕΕSelection and retention of skilled, quality-oriented practitioners and facilities (credentialing and recredentialing).
ΕΕUtilization Management, including under and over utilization.
ΕΕCompliance with preventive health and practice guidelines. Performance Improvement Process IlliniCare Health QIC reviews and adopts an annual QAPI program and QAPI work plan based on managed care Medicaid appropriate industry standards. The QAPI adopts traditional quality/risk/utilization management approaches to problem identification with the objective of identifying improvement opportunities. Most often, initiatives are selected based on data that indicates the need for improvement in a particular clinical or non- clinical area, relevance to our member populations, and includes targeted interventions that have the greatest potential for improving health outcomes or services. Performance improvement projects, focused studies and other quality improvement initiatives are designed and implemented in accordance with principles of
sound research design and appropriate statistical analysis. Results of these studies are used to evaluate the appropriateness and quality of care and services delivered against established standards and guidelines for the provision of that care or service. Each quality improvement initiative is also designed to allow IlliniCare Health to monitor improvement over time. Annually, IlliniCare Health develops a Quality Assessment Performance Improvement (QAPI) Work Plan for the upcoming year. The QAPI work plan serves as a working document to guide quality improvement efforts on a continuous basis. The work plan integrates quality improvement activities, reporting and studies from all areas of the organization (clinical and service), accountabilities, and includes timelines for completion and reporting to the QIC as well as requirements for external reporting. Studies and other performance measurement activities and issues to be tracked over time are scheduled in the QAPI work plan. IlliniCare Health communicates activities and outcomes of its quality improvement program to both members and providers through avenues such as the member newsletter, provider newsletter, and the IlliniCare Health web portal. At any time, IlliniCare Health providers may request additional information on the health plan programs including a description of the QAPI program and a report on the IlliniCare Health progress in meeting the QAPI program goals by contacting IlliniCare Health Quality Improvement department.
HEALTHCARE EFFECTIVENESS DATA & INFORMATION SET (HEDIS) HEDIS is a set of standardized performance measures developed by the National Committee for Quality Assurance (NCQA) which allows comparison across health plans. HEDIS gives purchasers and consumers the ability to distinguish between health plans based on comparative quality instead of simply cost differences. HEDIS reporting is a required part of NCQA Health Plan Accreditation and IlliniCare Health’s contract with the Department of Healthcare and Family Services for the provision of coordinated care services within our products. HEDIS rates are becoming increasingly important, not only to the health plan, but to the individual provider as well. IlliniCare Health purchasers of healthcare use the aggregated HEDIS rates to evaluate the effectiveness of a Health Insurance Company’s ability to demonstrate an improvement in preventive health outreach to its members.
Appendix Volume 2, p. 346
65
How are HEDIS rates calculated? HEDIS rates may be calculated using two methodologies: administrative data methodology or hybrid methodology. Administrative data methodology is calculated from claims or encounter data submitted to the health plan. Measures typically calculated using administrative data methodology include: annual mammogram, annual chlamydia screening, appropriate treatment of asthma, antidepressant medication management, access to PCP services, and utilization of acute and mental health services. Hybrid methodology consists of both administrative data and a sample of medical records. Hybrid methodology requires review of a random sample of member medical records to obtain documentation of services rendered but that were not reported to the health plan through claims/encounter data. Accurate and timely claim/encounter data and submission of appropriate CPT II codes can reduce the necessity of medical record reviews. Measures typically requiring medical record review include: diabetic HgA1c, LDL, eye exam and nephropathy, controlling high-blood pressure, and prenatal care and postpartum care. Who will be conducting the medical record reviews (MRR) for HEDIS? IlliniCare Health conducts internal collection of medical record reviews to increase efficiency, accuracy, and reduce provider abrasion. Medical record review audits for HEDIS are usually conducted March through May each year. At that time, providers may receive a call from an IlliniCare Health representative if any of your patients are selected into HEDIS samples. Prompt cooperation with these requests is greatly needed and appreciated. Providers who may be interested in reducing disruptions are encouraged to contact us to arrange remote access to medical records. What can be done to improve HEDIS scores?
ΕΕUnderstand the specifications established for each HEDIS measure.
ΕΕSubmit claim/encounter data for each and every service rendered. All providers must bill (or report by encounter submission) for services delivered, regardless of contract status. Claim/encounter data is the most clean and efficient way to report HEDIS. If services are not billed or not billed accurately they are not included in the calculation. Accurate and timely submission of claim/ encounter data will positively reduce the number of medical record reviews required for HEDIS rate calculation.
66
ΕΕEnsure chart documentation reflects all services
provided.
Ε Bill CPT codes related to HEDIS measures such as diabetes, eye exam, and blood pressure. If you have any questions, comments, or concerns related to the annual HEDIS project or the medical record reviews, please contact the IlliniCare Health Quality Improvement department. We offer on-site education and assistance to help you close any gaps in care and improve overall HEDIS performance.
PROVIDER SATISFACTION SURVEY At least annually, IlliniCare Health conducts a provider satisfaction survey which includes questions to evaluate provider satisfaction with our services such as claims, communications, utilization management, and provider services. The survey is conducted by an external vendor. Participants are randomly selected by the vendor, meeting specific requirements outlined by IlliniCare Health, and the participants are kept anonymous. We encourage you to respond in a timely manner to the survey as the results of the survey are analyzed and used as a basis for forming provider related quality improvement initiatives.
CONSUMER ASSESSMENT OF HEALTHCARE PROVIDER SYSTEMS (CAHPS) SURVEY The CAHPS survey is a member satisfaction survey that is included as a part of HEDIS and NCQA accreditation. It is a standardized survey administered annually to members by an NCQA certified survey vendor. The survey provides information on the experiences of IlliniCare Health members with the health plan and practitioner services and gives a general indication of how well we are meeting the members’ expectations. Member responses to the CAHPS survey are used in various aspects of the quality program including monitoring of practitioner access and availability.
PROVIDER PROFILING In recent years, it has been nationally recognized that pay-for-performance and other incentive and/ or bonus programs, which include provider profiling, have emerged as a promising strategy to improve the quality and cost-effectiveness of care. IlliniCare Health has implemented a physician profiling as a tool to encourage providers to promote appropriate care and services for IlliniCare Health members which have been shown to lead to better health outcomes. Provider profiling promotes efforts that are consistent with the Institute of Medicine’s aims for advancing quality (safe, beneficial, timely, patient-centered, efficient and equitable) as well as recommendations from other national agencies such as the CMS-AMA
Appendix Volume 2, p. 347
Physician Consortium, NCQA, and NQF. Additionally, that the program encourages accurate and timely submission of preventive health and disease monitoring services in accordance with evidencebased clinical practice guidelines. Physicians, who meet a minimum panel threshold will receive a quarterly profile report with an individual score for each measure. Scores will be benchmarked per individual measure and compositely to the IlliniCare Health network average and as applicable, to the then available NCQA Medicaid mean. Provider profile indicator data is not risk adjusted and scoring is based on provider performance within the service area range. PCPs who meet or exceed established performance goals and who demonstrate continued excellence or significant improvement over time may be recognized by IlliniCare Health in publications such as newsletters, bulletins, press releases, and recognition in our provider directories.
Appendix Volume 2, p. 348
67
Medical Records Review IlliniCare Health providers must keep accurate and complete medical records. Such records will enable providers to render the highest quality healthcare service to members. To ensure the member’s privacy, medical records should be kept in a secure location.
REQUIRED INFORMATION Medical record is defined as the complete, comprehensive member records including, but not limited to, x-rays, laboratory tests, results, examinations and notes, accessible at the site of the member’s participating primary care physician or provider, that document all medical services received by the member, including inpatient, ambulatory, ancillary, and emergency care, prepared in accordance with all applicable state rules and regulations, and signed by the medical professional rendering the services. Providers must maintain complete medical records for members in accordance with the following standards:
ΕΕMember’s name, and/or medical record number on all chart pages.
ΕΕPersonal/biographical data is present (i.e., employer, home telephone number, spouse, next of kin, legal guardianship, primary language, etc.).
ΕΕProminent notation of any spoken language translation or communication assistance.
ΕΕAll entries must be legible and maintained in detail.
ΕΕAll entries must be dated and signed, or dictated by the provider rendering the care is documented in the history and physical.
ΕΕPast medical history (for members seen three or more times) is easily identified and includes any serious accidents, operations and/or illnesses, discharge summaries, and ER encounters; for children and adolescents (18 years and younger) past medical history relating to prenatal care, birth, any operations and/or childhood illnesses.
ΕΕTreatment plan is appropriate for diagnosis. ΕΕDocumented treatment prescribed, therapy prescribed and drug administered or dispensed including instructions to the member.
ΕΕDocumentation of prenatal risk assessment for pregnant women or infant risk assessment for newborns.
ΕΕSigned and dated required consent forms. ΕΕUnresolved problems from previous visits are addressed in subsequent visits.
ΕΕLaboratory and other studies ordered as appropriate.
ΕΕAbnormal lab and imaging study results have explicit notations in the record for follow up plans; all entries should be initialed by the primary care provider (PCP) to signify review.
ΕΕReferrals to specialists and ancillary providers are documented including follow up of outcomes and summaries of treatment rendered elsewhere including family planning services, preventive services and services for the treatment of sexually transmitted diseases.
ΕΕHealth teaching and/or counseling is documented. ΕΕFor members ten (10) years and over, appropriate notations concerning use of tobacco, alcohol and substance use (for members seen three or more times substance abuse history should be queried).
ΕΕDocumentation of failure to keep an appointment. ΕΕEncounter forms or notes have a notation, when indicated, regarding follow-up care calls or visits. The specific time of return should be noted as weeks, months or as needed.
ΕΕEvidence that the member is not placed at inappropriate risk by a diagnostic or therapeutic problem.
ΕΕConfidentiality of member information and records protected.
ΕΕEvidence that an advance directive has been offered to adults 18 years of age and older.
ΕΕWorking diagnosis is consistent with findings. 68
Appendix Volume 2, p. 349
MEDICAL RECORDS RELEASE All member medical records shall be confidential and shall not be released without the written authorization of the covered person or a responsible covered person’s legal guardian. When the release of medical records is appropriate, the extent of that release should be based upon medical necessity or on a need to know basis.
MEDICAL RECORDS TRANSFER FOR NEW MEMBERS All PCPs are required to document in the member’s medical record attempts to obtain historical medical records for all newly assigned IlliniCare Health members. If the member or member’s guardian is unable to remember where they obtained medical care, or they are unable to provide addresses of the previous providers then this should also be noted in the medical record.
MEDICAL RECORD AUDITS IlliniCare Health will conduct random medical record audits as part of its QAPI Program to monitor compliance with the medical record documentation standards noted above. The coordination of care and services provided to members, including over/under utilization of specialists, as well as the outcome of such services also may be assessed during a medical record audit. IlliniCare Health will provide verbal or written notice prior to conducting a medical record review.
Appendix Volume 2, p. 350
69
Our Approach IlliniCare Health strives to work with the provider community to ensure members’ individual needs are met leveraging our care coordination approach. This approach includes:
ΕΕFocus on early identification before condition worsens.
ΕΕFacilitate communication and coordination of services across medical and behavioral health specialties.
ΕΕIdentify and engage high-risk consumers. ΕΕIdentify barriers to adherence with current treatment plans and goals.
ΕΕCoordinate with consumer, their support system, and physicians to a customize plan of care.
ΕΕHolistic model: Care coordination can link to local community resources such as shelter/ housing, clothing, utilities assistance, and domestic violence agencies. To reach the Medical Director or Vice President of Medical Management for additional information on our approach, please contact: Clinical Management HealthChoice Illinois: 866-329-4701 MMAI: 877-941-0482
MODEL OF CARE Model of Care defines the management, procedures and operational systems that provide access, coordination and structure needed to provide services and care to IlliniCare Health members. IlliniCare Health’s Model of Care includes the following elements:
ΕΕMeasurable goals ΕΕStaff structure and care management roles ΕΕInterdisciplinary care team ΕΕProvider network having special expertise and use of clinical practice guidelines
ΕΕModel of care training ΕΕHealth risk assessment ΕΕIndividualized Care Plan ΕΕCommunication network ΕΕCare Management ΕΕPerformance and health outcome measurements IlliniCare Health ensures all of our members have:
ΕΕAccess to essential available services such as medical, behavioral and social services
ΕΕAccess to affordable care ΕΕCare coordination through an identified point of contact
ΕΕSeamless transitions of care ΕΕImproved access to preventive health services ΕΕAppropriate utilization of healthcare services ΕΕOverall improved health outcomes
70
Appendix Volume 2, p. 351
Health Risk Screening (HRS) Completed by all new members within 60 days of enrollment to identify those with unmet or ongoing needs. The HRS allows us to assess:
ΕΕFunctional Abilities ΕΕPhysical and Behavioral Health Conditions ΕΕSocial, Environmental, and Cultural Issues ΕΕAbility to Live Independently ΕΕMobility ΕΕEconomic Self-sufficiency ΕΕMedications ΕΕOther needs that form the basis of our care plans For high risk members, a more comprehensive Health Risk Assessment (HRA) will be conducted, either in-person or over the phone, and an individualized plan of care will be developed within 90 days of enrollment. Member Outreach
ΕΕExplain benefits, provide health education, including how to access care (i.e., appropriate Emergency Room utilization).
ΕΕParticipate in community events and establish partnerships with local community agencies, churches, and high volume provider offices to promote healthy living and preventive care.
ΕΕInfluence consumers’ beliefs and behaviors because they are hired from within the community.
ΕΕIdentify and engage high-risk consumers. ΕΕFacilitate communication across medical and behavioral health specialties.
Appendix Volume 2, p. 352
71
Provider Resources IlliniCare Health is dedicated to providing the tools and support providers need to deliver the best quality of care to our members. Below are a few resources providers can utilize.
ILLINICARE HEALTH WEBSITE Providers should use IlliniCare.com as their main source of information related to our plan and products. Providers can access the following information at IlliniCare.com:
ΕΕProvider Manual and Billing Manual. ΕΕMember Handbook and benefit information. ΕΕPrior Authorization Check Tool. ΕΕClinical Guidelines. ΕΕProvider Forms. ΕΕPolicies and Procedures. ΕΕQuarterly Newsletters and other IlliniCare Health news.
ΕΕAnd more!
Please contact your Provider Relations representative for a tutorial on the Provider Portal.
INTERACTIVE VOICE RESPONSE (IVR) SYSTEM What’s great about the IVR system? It’s free and easy to use! The IVR provides you with greater access to information. Through the IVR you can:
ΕΕCheck member eligibility. ΕΕCheck claims status. ΕΕAccess IlliniCare Health information 24 hours a day, seven days a week, 365 days a year.
We are continually updating our website with the latest news and information, so save IlliniCare.com to your Internet “Favorites” list and check our site often!
PROVIDER PORTAL IlliniCare Health Provider Portal allows providers to check member eligibility and benefits, submit and check status of claims, request authorizations, and send/receive messages to communicate with IlliniCare Health staff. IlliniCare Health’s contracted providers and their office staff have the opportunity to register for our Provider Portal in just four easy steps. The Provider Portal offers tools which make obtaining and sharing information easy! It’s simple and secure! Go to Provider.IlliniCare.com to get started. Through the Provider Portal, you can:
ΕΕView the PCP panel (patient list); 72
ΕΕView and submit claims and adjustments; ΕΕView and submit authorizations; ΕΕView payment history; ΕΕView member gaps in care; ΕΕView quality scorecard; ΕΕCheck member eligibility; and ΕΕContact us securely and confidentially.
PROVIDER SERVICES Provider Services are providers’ first point of contact at IlliniCare Health. This department works with all other departments to ensure that providers and their support staff receive the necessary assistance and information. If you have questions about IlliniCare Health’s operations, benefits, policies, and/or procedures; contact the Provider Services department.
PROVIDER RELATIONS IlliniCare Health’s Provider Relations department is designed around the concept of making your experience a positive one by being your advocate within IlliniCare Health. The Provider Relations department is responsible for providing the services listed below which include but are not limited to: Contracting.
Ε Maintenance of existing IlliniCare Health Provider Manual.
Appendix Volume 2, p. 353
ΕΕDevelopment of alternative reimbursement strategies.
ΕΕResearching of trends in claims inquiries to IlliniCare Health.
ΕΕPool settlement updates/status. ΕΕNetwork performance profiling. ΕΕIndividual physician performance profiling. ΕΕPhysician and office staff orientation. ΕΕHospital and ancillary staff orientation. ΕΕOngoing provider education, updates, and
The goal of this department is to furnish you and your staff with the necessary tools to provide the highest quality of healthcare to IlliniCare Health enrolled membership. To contact the Provider Relations representative for your area by phone, please call the Provider Services toll free help line. If you prefer to send an email, please include your name, call-back phone number, and provider Tax ID with your inquiry to ProviderRelations_IL@centene.com.
training.
Top 10 Reasons to Contact your PR Representative
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
To report any change to your practice (i.e., practice TIN, name, phone numbers, fax numbers, address, and addition or termination of providers, or patient acceptance).
Initiate credentialing of new providers.
To schedule an in-service training for new staff.
To conduct ongoing education for existing staff.
To obtain clarification of policies and procedures.
To obtain clarification of a provider contract.
To request fee schedule information.
To obtain responses to membership list questions.
To obtain responses to claims questions.
To learn how to use electronic solutions on web authorizations, claims submissions, and check eligibility.
Appendix Volume 2, p. 354
73
IlliniCare.com
74
Appendix Volume 2, p. 355
Exhibit 11
Appendix Volume 2, p. 356
9/11/2019
Care Manager I (RN)
Who We Are
Why We're Different
Products & Services
Careers Why Centene? Investors
Benefits
News
Students
Contact
Continued Learning
Applicant Resources
Returning Applicants
Clinical & Nursing Jobs
Search Our Jobs KEYWORD
Enter Keyword LOCATION Fairborn, OH RADIUS 50 miles
Search
Appendix Volume 2, p. 357
https://jobs.centene.com/job/skokie/care-manager-i-rn/17169/12912339
1/10
9/11/2019
Care Manager I (RN)
Care Manager I (RN) ILLINICARE HEALTH PLAN
Skokie, Illinois
Apply Now
As a member of the Centene Medical Management/Health Services team, you’ll help innovate and execute strategies that redefine the industry standard for improving the lives and health of people. We’re a team of skilled physicians, nurses, pharmacists, social workers and health service experts who use our advanced clinical analytics to implement award winning programs, develop care, deliver partnerships, and work directly with our members to achieve outcomes that set us apart as industry leaders. Together, we’re transforming the health of communities, one person at a time.
What does it take? What are the qualities that will help you achieve success in this role at Centene?
Appendix Volume 2, p. 358
https://jobs.centene.com/job/skokie/care-manager-i-rn/17169/12912339
2/10
9/11/2019
Care Manager I (RN)
Success Profile
Our Medical Roles
Appendix Volume 2, p. 359
https://jobs.centene.com/job/skokie/care-manager-i-rn/17169/12912339
3/10
9/11/2019
Care Manager I (RN)
Clinical & Nursing Opportunities at Centene Our Clinical team is at the forefront of our purpose-driven work. Learn more about how you can help transform the health of our communities, one person at a time.
Responsibilities Job ID 1150654 Category Clinical & Nursing Schedule Full-time Description: Position Purpose: Perform care management duties to assess, plan and coordinate all aspects of medical and supporting services across the continuum of care for select members to promote quality, cost effective care Develop, assess and adjust, as necessary, the care plan and promote desired outcome Assess the member's current health status, resource utilization, past and present treatment plan and services, prognosis, short and long term goals, treatment and provider options Coordinate services between Primary Care Physician (PCP), specialists, medical providers, and non-medical staff as necessary to meet the complete medical socio economic needs of clients Develop plan of care based upon assessment with specific objectives, goals and interventions designed to meet member's needs Provide patient and provider education Facilitate member access to community based services Monitor referrals made to community based organizations, medical care and other services to support the members’ overall care management plan Actively participate in integrated team care management rounds Identify related risk management quality concerns and report these scenarios to the appropriate resources Enter and maintain assessments, authorizations, and pertinent clinical information into various medical management systems For LTSS - 30% travel to perform home visits to members For New Hampshire, Massachuse s, & Michigan Complete Health - home visits required
Appendix Volume 2, p. 360
https://jobs.centene.com/job/skokie/care-manager-i-rn/17169/12912339
4/10
9/11/2019
Care Manager I (RN)
Qualifications: Education/Experience: Graduate from an Accredited School of Nursing. Bachelor’s degree in Nursing preferred. 2+ years of clinical nursing experience in a clinical, acute care, or community se ing. Knowledge of healthcare and managed care preferred. Licenses/Certifications: Current state’s RN license. LTC or nursing home experience preferred. LTSS Requirements: Valid driver’s license and proof of car insurance.
Centene is an equal opportunity employer that is commi ed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Apply Now
Share this job
Check out this location See what's near our Skokie location. Vi
M
Appendix Volume 2, p. 361
https://jobs.centene.com/job/skokie/care-manager-i-rn/17169/12912339
5/10
9/11/2019
Care Manager I (RN)
Who We Are
Why We're Different
Products & Services
Careers Why Centene? Investors
Benefits
News
Students
Contact
Continued Learning
Applicant Resources
Returning Applicants
Clinical & Nursing Jobs
Search Our Jobs KEYWORD
Enter Keyword LOCATION Fairborn, OH RADIUS 50 miles
Search
Appendix Volume 2, p. 362
https://jobs.centene.com/job/kankakee/care-manager-i-rn/17169/12763447
1/10
9/11/2019
Care Manager I (RN)
Care Manager I (RN) ILLINICARE HEALTH PLAN
Kankakee, Illinois
Apply Now
As a member of the Centene Medical Management/Health Services team, you’ll help innovate and execute strategies that redefine the industry standard for improving the lives and health of people. We’re a team of skilled physicians, nurses, pharmacists, social workers and health service experts who use our advanced clinical analytics to implement award winning programs, develop care, deliver partnerships, and work directly with our members to achieve outcomes that set us apart as industry leaders. Together, we’re transforming the health of communities, one person at a time.
What does it take? What are the qualities that will help you achieve success in this role at Centene?
Appendix Volume 2, p. 363
https://jobs.centene.com/job/kankakee/care-manager-i-rn/17169/12763447
2/10
9/11/2019
Care Manager I (RN)
Success Profile
Our Medical Roles
Appendix Volume 2, p. 364
https://jobs.centene.com/job/kankakee/care-manager-i-rn/17169/12763447
3/10
9/11/2019
Care Manager I (RN)
Clinical & Nursing Opportunities at Centene Our Clinical team is at the forefront of our purpose-driven work. Learn more about how you can help transform the health of our communities, one person at a time.
Responsibilities Job ID 1150652 Category Clinical & Nursing Schedule Full-time Description: Position Purpose: Perform care management duties to assess, plan and coordinate all aspects of medical and supporting services across the continuum of care for select members to promote quality, cost effective care Develop, assess and adjust, as necessary, the care plan and promote desired outcome Assess the member's current health status, resource utilization, past and present treatment plan and services, prognosis, short and long term goals, treatment and provider options Coordinate services between Primary Care Physician (PCP), specialists, medical providers, and non-medical staff as necessary to meet the complete medical socio economic needs of clients Develop plan of care based upon assessment with specific objectives, goals and interventions designed to meet member's needs Provide patient and provider education Facilitate member access to community based services Monitor referrals made to community based organizations, medical care and other services to support the members’ overall care management plan Actively participate in integrated team care management rounds Identify related risk management quality concerns and report these scenarios to the appropriate resources Enter and maintain assessments, authorizations, and pertinent clinical information into various medical management systems For LTSS - 30% travel to perform home visits to members For New Hampshire, Massachuse s, & Michigan Complete Health - home visits required
Appendix Volume 2, p. 365
https://jobs.centene.com/job/kankakee/care-manager-i-rn/17169/12763447
4/10
9/11/2019
Care Manager I (RN)
Qualifications: Education/Experience: Graduate from an Accredited School of Nursing. Bachelor’s degree in Nursing preferred. 2+ years of clinical nursing experience in a clinical, acute care, or community se ing. Knowledge of healthcare and managed care preferred. Licenses/Certifications: Current state’s RN license. LTC or nursing home experience preferred. LTSS Requirements: Valid driver’s license and proof of car insurance.
Centene is an equal opportunity employer that is commi ed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Apply Now
Share this job
Check out this location See what's near our Kankakee location. View Map
Appendix Volume 2, p. 366
https://jobs.centene.com/job/kankakee/care-manager-i-rn/17169/12763447
5/10
9/11/2019
Care Manager I (RN)
Who We Are
Why We're Different
Products & Services
Careers Why Centene? Investors
Benefits
News
Students
Contact
Continued Learning
Applicant Resources
Returning Applicants
Clinical & Nursing Jobs
Search Our Jobs KEYWORD
Enter Keyword LOCATION Fairborn, OH RADIUS 50 miles
Search
Appendix Volume 2, p. 367
https://jobs.centene.com/job/westmont/care-manager-i-rn/17169/12819227
1/10
9/11/2019
Care Manager I (RN)
Care Manager I (RN) ILLINICARE HEALTH PLAN
Westmont, Illinois
Apply Now
As a member of the Centene Medical Management/Health Services team, you’ll help innovate and execute strategies that redefine the industry standard for improving the lives and health of people. We’re a team of skilled physicians, nurses, pharmacists, social workers and health service experts who use our advanced clinical analytics to implement award winning programs, develop care, deliver partnerships, and work directly with our members to achieve outcomes that set us apart as industry leaders. Together, we’re transforming the health of communities, one person at a time.
What does it take? What are the qualities that will help you achieve success in this role at Centene?
Appendix Volume 2, p. 368
https://jobs.centene.com/job/westmont/care-manager-i-rn/17169/12819227
2/10
9/11/2019
Care Manager I (RN)
Success Profile
Our Medical Roles
Appendix Volume 2, p. 369
https://jobs.centene.com/job/westmont/care-manager-i-rn/17169/12819227
3/10
9/11/2019
Care Manager I (RN)
Clinical & Nursing Opportunities at Centene Our Clinical team is at the forefront of our purpose-driven work. Learn more about how you can help transform the health of our communities, one person at a time.
Responsibilities Job ID 1153056 Category Clinical & Nursing Schedule Full-time Description: Position Purpose: Perform care management duties to assess, plan and coordinate all aspects of medical and supporting services across the continuum of care for select members to promote quality, cost effective care Develop, assess and adjust, as necessary, the care plan and promote desired outcome Assess the member's current health status, resource utilization, past and present treatment plan and services, prognosis, short and long term goals, treatment and provider options Coordinate services between Primary Care Physician (PCP), specialists, medical providers, and non-medical staff as necessary to meet the complete medical socio economic needs of clients Develop plan of care based upon assessment with specific objectives, goals and interventions designed to meet member's needs Provide patient and provider education Facilitate member access to community based services Monitor referrals made to community based organizations, medical care and other services to support the members’ overall care management plan Actively participate in integrated team care management rounds Identify related risk management quality concerns and report these scenarios to the appropriate resources Enter and maintain assessments, authorizations, and pertinent clinical information into various medical management systems For LTSS - 30% travel to perform home visits to members For New Hampshire, Massachuse s, & Michigan Complete Health - home visits required
Appendix Volume 2, p. 370
https://jobs.centene.com/job/westmont/care-manager-i-rn/17169/12819227
4/10
9/11/2019
Care Manager I (RN)
Qualifications: Education/Experience: Graduate from an Accredited School of Nursing. Bachelor’s degree in Nursing preferred. 2+ years of clinical nursing experience in a clinical, acute care, or community se ing. Knowledge of healthcare and managed care preferred. Licenses/Certifications: Current state’s RN license.
Centene is an equal opportunity employer that is commi ed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Apply Now
Share this job
Check out this location See what's near our Westmont location. View Map
Appendix Volume 2, p. 371
https://jobs.centene.com/job/westmont/care-manager-i-rn/17169/12819227
5/10
9/11/2019
Care Manager I (RN)
Who We Are
Why We're Different
Products & Services
Careers Why Centene? Investors
Benefits
News
Students
Contact
Continued Learning
Applicant Resources
Returning Applicants
Clinical & Nursing Jobs
Search Our Jobs KEYWORD
Enter Keyword LOCATION Fairborn, OH RADIUS 50 miles
Search
Appendix Volume 2, p. 372
https://jobs.centene.com/job/danville/care-manager-i-rn/17169/12812697
1/10
9/11/2019
Care Manager I (RN)
Care Manager I (RN) ILLINICARE HEALTH PLAN
Danville, Illinois
Apply Now
As a member of the Centene Medical Management/Health Services team, you’ll help innovate and execute strategies that redefine the industry standard for improving the lives and health of people. We’re a team of skilled physicians, nurses, pharmacists, social workers and health service experts who use our advanced clinical analytics to implement award winning programs, develop care, deliver partnerships, and work directly with our members to achieve outcomes that set us apart as industry leaders. Together, we’re transforming the health of communities, one person at a time.
What does it take? What are the qualities that will help you achieve success in this role at Centene?
Appendix Volume 2, p. 373
https://jobs.centene.com/job/danville/care-manager-i-rn/17169/12812697
2/10
9/11/2019
Care Manager I (RN)
Success Profile
Our Medical Roles
Appendix Volume 2, p. 374
https://jobs.centene.com/job/danville/care-manager-i-rn/17169/12812697
3/10
9/11/2019
Care Manager I (RN)
Clinical & Nursing Opportunities at Centene Our Clinical team is at the forefront of our purpose-driven work. Learn more about how you can help transform the health of our communities, one person at a time.
Responsibilities Job ID 1144166 Category Clinical & Nursing Schedule Full-time Description: Position Purpose: Perform care management duties to assess, plan and coordinate all aspects of medical and supporting services across the continuum of care for select members to promote quality, cost effective care Develop, assess and adjust, as necessary, the care plan and promote desired outcome Assess the member's current health status, resource utilization, past and present treatment plan and services, prognosis, short and long term goals, treatment and provider options Coordinate services between Primary Care Physician (PCP), specialists, medical providers, and non-medical staff as necessary to meet the complete medical socio economic needs of clients Develop plan of care based upon assessment with specific objectives, goals and interventions designed to meet member's needs Provide patient and provider education Facilitate member access to community based services Monitor referrals made to community based organizations, medical care and other services to support the members’ overall care management plan Actively participate in integrated team care management rounds Identify related risk management quality concerns and report these scenarios to the appropriate resources Enter and maintain assessments, authorizations, and pertinent clinical information into various medical management systems For LTSS - 30% travel to perform home visits to members For New Hampshire, Massachuse s, & Michigan Complete Health - home visits required
Appendix Volume 2, p. 375
https://jobs.centene.com/job/danville/care-manager-i-rn/17169/12812697
4/10
9/11/2019
Care Manager I (RN)
Qualifications: Education/Experience: Graduate from an Accredited School of Nursing. Bachelor’s degree in Nursing preferred. 2+ years of clinical nursing experience in a clinical, acute care, or community se ing. Knowledge of healthcare and managed care preferred. Licenses/Certifications: Current state’s RN license.
LTSS Requirements: Valid driver’s license and proof of car insurance. LTC or nursing home experience preferred. This position will cover both Vermillion and Iroquois Counties.
Centene is an equal opportunity employer that is commi ed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Apply Now
Share this job
Check out this location See what's near our Danville location.
Appendix Volume 2, p. 376
https://jobs.centene.com/job/danville/care-manager-i-rn/17169/12812697
5/10
9/12/2019
Care Manager I (RN)
Who We Are
Why We're Different
Products & Services
Careers Why Centene? Investors
Benefits
News
Students
Contact
Continued Learning
Applicant Resources
Returning Applicants
Clinical & Nursing Jobs
Search Our Jobs KEYWORD
Enter Keyword LOCATION Fairborn, OH RADIUS 50 miles
Search
Appendix Volume 2, p. 377
https://jobs.centene.com/job/peoria/care-manager-i-rn/17169/12544746
1/10
9/12/2019
Care Manager I (RN)
Care Manager I (RN) ILLINICARE HEALTH PLAN
Peoria, Illinois
Apply Now
As a member of the Centene Medical Management/Health Services team, you’ll help innovate and execute strategies that redefine the industry standard for improving the lives and health of people. We’re a team of skilled physicians, nurses, pharmacists, social workers and health service experts who use our advanced clinical analytics to implement award winning programs, develop care, deliver partnerships, and work directly with our members to achieve outcomes that set us apart as industry leaders. Together, we’re transforming the health of communities, one person at a time.
What does it take? What are the qualities that will help you achieve success in this role at Centene?
Appendix Volume 2, p. 378
https://jobs.centene.com/job/peoria/care-manager-i-rn/17169/12544746
2/10
9/12/2019
Care Manager I (RN)
Success Profile
Our Medical Roles
Appendix Volume 2, p. 379
https://jobs.centene.com/job/peoria/care-manager-i-rn/17169/12544746
3/10
9/12/2019
Care Manager I (RN)
Clinical & Nursing Opportunities at Centene Our Clinical team is at the forefront of our purpose-driven work. Learn more about how you can help communities, one person at a time.
Responsibilities Job ID 1144173 Category Clinical & Nursing Schedule Full-time Description: Position Purpose: Perform care management duties to assess, plan and coordinate all aspects of medical and supporting services across the continuum of care for select members to promote quality, cost effective care Develop, assess and adjust, as necessary, the care plan and promote desired outcome Assess the member's current health status, resource utilization, past and present treatment plan and services, prognosis, short and long term goals, treatment and provider options Coordinate services between Primary Care Physician (PCP), specialists, medical providers, and non-medical staff as necessary to meet the complete medical socio economic needs of clients Develop plan of care based upon assessment with specific objectives, goals and interventions designed to meet member's needs Provide patient and provider education Facilitate member access to community based services Monitor referrals made to community based organizations, medical care and other services to support the members’ overall care management plan Actively participate in integrated team care management rounds Identify related risk management quality concerns and report these scenarios to the appropriate
Appendix Volume 2, p. 380
https://jobs.centene.com/job/peoria/care-manager-i-rn/17169/12544746
4/10
9/12/2019
Care Manager I (RN)
resources Enter and maintain assessments, authorizations, and pertinent clinical information into various medical management systems For LTSS - 30% travel to perform home visits to members For New Hampshire, Massachuse s, & Michigan Complete Health - home visits required Qualifications: Education/Experience: Graduate from an Accredited School of Nursing. Bachelor’s degree in Nursing preferred. 2+ years of clinical nursing experience in a clinical, acute care, or community se ing. Knowledge of healthcare and managed care preferred. Licenses/Certifications: Current state’s RN license.
LTC or nursing home experience preferred.
LTSS Requirements: Valid driver’s license and proof of car insurance.
Centene is an equal opportunity employer that is commi ed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Apply Now
Share this job
Appendix Volume 2, p. 381
https://jobs.centene.com/job/peoria/care-manager-i-rn/17169/12544746
5/10
Exhibit 12
Appendix Volume 2, p. 382
9/12/2019
Care Manager I (RN)
Care Manager I (RN) CENTENE CORPORATION
Edwardsville, Illinois
Apply Now
As a member of the Centene Medical Management/Health Services team, you’ll help innovate and execute strategies that redefine the industry standard for improving the lives and health of people. We’re a team of skilled physicians, nurses, pharmacists, social workers and health service experts who use our advanced clinical analytics to implement award winning programs, develop care, deliver partnerships, and work directly with our members to achieve outcomes that set us apart as industry leaders. Together, we’re transforming the health of communities, one person at a time.
What does it take? What are the qualities that will help you achieve success in this role at Centene?
Appendix Volume 2, p. 383
https://jobs.centene.com/job/edwardsville/care-manager-i-rn/17169/12098246
2/10
9/12/2019
Care Manager I (RN)
Success Profile
Our Medical Roles
Appendix Volume 2, p. 384
https://jobs.centene.com/job/edwardsville/care-manager-i-rn/17169/12098246
3/10
9/12/2019
Care Manager I (RN)
Clinical & Nursing Opportunities at Centene Our Clinical team is at the forefront of our purpose-driven work. Learn more about how you can help communities, one person at a time.
Responsibilities Job ID 009KO Category Clinical & Nursing Schedule Full-time Description: Position Purpose: Perform care management duties to assess, plan and coordinate all aspects of medical and supporting services across the continuum of care for select members to promote quality, cost effective care Education/Experience: Graduate from an Accredited School of Nursing. Bachelor’s degree in Nursing preferred. 2+ years of clinical nursing experience in a clinical, acute care, or community se ing. Knowledge of healthcare and managed care preferred. Licenses/Certifications: Current state’s RN license. LTSS Requirements: Valid driver’s license and proof of car insurance.
Qualifications:
Appendix Volume 2, p. 385
https://jobs.centene.com/job/edwardsville/care-manager-i-rn/17169/12098246
4/10
9/12/2019
Care Manager I (RN)
Develop, assess and adjust, as necessary, the care plan and promote desired outcome Assess the member's current health status, resource utilization, past and present treatment plan and services, prognosis, short and long term goals, treatment and provider options Coordinate services between Primary Care Physician (PCP), specialists, medical providers, and non-medical staff as necessary to meet the complete medical socio economic needs of clients Develop plan of care based upon assessment with specific objectives, goals and interventions designed to meet member's needs Provide patient and provider education Facilitate member access to community based services Monitor referrals made to community based organizations, medical care and other services to support the members’ overall care management plan Actively participate in integrated team care management rounds Identify related risk management quality concerns and report these scenarios to the appropriate resources Enter and maintain assessments, authorizations, and pertinent clinical information into various medical management systems Apply Now
Share this job
Check out this location See what's near our Edwardsville location. View Map
Appendix Volume 2, p. 386
https://jobs.centene.com/job/edwardsville/care-manager-i-rn/17169/12098246
5/10
9/12/2019
Care Manager I (RN)
Care Manager I (RN) CENTENE CORPORATION
Galesburg, Illinois
Apply Now
As a member of the Centene Medical Management/Health Services team, you’ll help innovate and execute strategies that redefine the industry standard for improving the lives and health of people. We’re a team of skilled physicians, nurses, pharmacists, social workers and health service experts who use our advanced clinical analytics to implement award winning programs, develop care, deliver partnerships, and work directly with our members to achieve outcomes that set us apart as industry leaders. Together, we’re transforming the health of communities, one person at a time.
What does it take? What are the qualities that will help you achieve success in this role at Centene?
Appendix Volume 2, p. 387
https://jobs.centene.com/job/galesburg/care-manager-i-rn/17169/12098247
2/10
9/12/2019
Care Manager I (RN)
Success Profile
Our Medical Roles
Appendix Volume 2, p. 388
https://jobs.centene.com/job/galesburg/care-manager-i-rn/17169/12098247
3/10
9/12/2019
Care Manager I (RN)
Clinical & Nursing Opportunities at Centene Our Clinical team is at the forefront of our purpose-driven work. Learn more about how you can help communities, one person at a time.
Responsibilities Job ID 009KQ Category Clinical & Nursing Schedule Full-time Description: Position Purpose: Perform care management duties to assess, plan and coordinate all aspects of medical and supporting services across the continuum of care for select members to promote quality, cost effective care Education/Experience: Graduate from an Accredited School of Nursing. Bachelor’s degree in Nursing preferred. 2+ years of clinical nursing experience in a clinical, acute care, or community se ing. Knowledge of healthcare and managed care preferred. Licenses/Certifications: Current state’s RN license. LTSS Requirements: Valid driver’s license and proof of car insurance.
Qualifications:
Appendix Volume 2, p. 389
https://jobs.centene.com/job/galesburg/care-manager-i-rn/17169/12098247
4/10
9/12/2019
Care Manager I (RN)
Develop, assess and adjust, as necessary, the care plan and promote desired outcome Assess the member's current health status, resource utilization, past and present treatment plan and services, prognosis, short and long term goals, treatment and provider options Coordinate services between Primary Care Physician (PCP), specialists, medical providers, and non-medical staff as necessary to meet the complete medical socio economic needs of clients Develop plan of care based upon assessment with specific objectives, goals and interventions designed to meet member's needs Provide patient and provider education Facilitate member access to community based services Monitor referrals made to community based organizations, medical care and other services to support the members’ overall care management plan Actively participate in integrated team care management rounds Identify related risk management quality concerns and report these scenarios to the appropriate resources Enter and maintain assessments, authorizations, and pertinent clinical information into various medical management systems Apply Now
Share this job
Check out this location See what's near our Galesburg location. View Map
Appendix Volume 2, p. 390
https://jobs.centene.com/job/galesburg/care-manager-i-rn/17169/12098247
5/10
9/12/2019
Care Manager I (RN)
Who We Are
Why We're Different
Products & Services
Careers Why Centene? Investors
Benefits
News
Students
Contact
Continued Learning
Applicant Resources
Returning Applicants
Clinical & Nursing Jobs
Search Our Jobs KEYWORD
Enter Keyword LOCATION Fairborn, OH RADIUS 50 miles
Search
Appendix Volume 2, p. 391
https://jobs.centene.com/job/galesburg/care-manager-i-rn/17169/12098247
1/10
9/12/2019
Care Manager I (RN)
Success Profile
Our Medical Roles
Appendix Volume 2, p. 392
https://jobs.centene.com/job/galesburg/care-manager-i-rn/17169/12098247
3/10
9/12/2019
Care Manager I (RN)
Clinical & Nursing Opportunities at Centene Our Clinical team is at the forefront of our purpose-driven work. Learn more about how you can help communities, one person at a time.
Responsibilities Job ID 009KQ Category Clinical & Nursing Schedule Full-time Description: Position Purpose: Perform care management duties to assess, plan and coordinate all aspects of medical and supporting services across the continuum of care for select members to promote quality, cost effective care Education/Experience: Graduate from an Accredited School of Nursing. Bachelor’s degree in Nursing preferred. 2+ years of clinical nursing experience in a clinical, acute care, or community se ing. Knowledge of healthcare and managed care preferred. Licenses/Certifications: Current state’s RN license. LTSS Requirements: Valid driver’s license and proof of car insurance.
Qualifications:
Appendix Volume 2, p. 393
https://jobs.centene.com/job/galesburg/care-manager-i-rn/17169/12098247
4/10
9/12/2019
Care Manager I (RN)
Develop, assess and adjust, as necessary, the care plan and promote desired outcome Assess the member's current health status, resource utilization, past and present treatment plan and services, prognosis, short and long term goals, treatment and provider options Coordinate services between Primary Care Physician (PCP), specialists, medical providers, and non-medical staff as necessary to meet the complete medical socio economic needs of clients Develop plan of care based upon assessment with specific objectives, goals and interventions designed to meet member's needs Provide patient and provider education Facilitate member access to community based services Monitor referrals made to community based organizations, medical care and other services to support the members’ overall care management plan Actively participate in integrated team care management rounds Identify related risk management quality concerns and report these scenarios to the appropriate resources Enter and maintain assessments, authorizations, and pertinent clinical information into various medical management systems Apply Now
Share this job
Check out this location See what's near our Galesburg location. View Map
Appendix Volume 2, p. 394
https://jobs.centene.com/job/galesburg/care-manager-i-rn/17169/12098247
5/10
9/12/2019
Care Manager I (RN)
Who We Are
Why We're Different
Products & Services
Careers Why Centene? Investors
Benefits
News
Students
Contact
Continued Learning
Applicant Resources
Returning Applicants
Clinical & Nursing Jobs
Search Our Jobs KEYWORD
Enter Keyword LOCATION Fairborn, OH RADIUS 50 miles
Search
Appendix Volume 2, p. 395
https://jobs.centene.com/job/galesburg/care-manager-i-rn/17169/12098247
1/10
9/12/2019
Care Manager I (RN)
Success Profile
Our Medical Roles
Appendix Volume 2, p. 396
https://jobs.centene.com/job/galesburg/care-manager-i-rn/17169/12098247
3/10
9/12/2019
Care Manager I (RN)
Clinical & Nursing Opportunities at Centene Our Clinical team is at the forefront of our purpose-driven work. Learn more about how you can help communities, one person at a time.
Responsibilities Job ID 009KQ Category Clinical & Nursing Schedule Full-time Description: Position Purpose: Perform care management duties to assess, plan and coordinate all aspects of medical and supporting services across the continuum of care for select members to promote quality, cost effective care Education/Experience: Graduate from an Accredited School of Nursing. Bachelor’s degree in Nursing preferred. 2+ years of clinical nursing experience in a clinical, acute care, or community se ing. Knowledge of healthcare and managed care preferred. Licenses/Certifications: Current state’s RN license. LTSS Requirements: Valid driver’s license and proof of car insurance.
Qualifications:
Appendix Volume 2, p. 397
https://jobs.centene.com/job/galesburg/care-manager-i-rn/17169/12098247
4/10
9/12/2019
Care Manager I (RN)
Develop, assess and adjust, as necessary, the care plan and promote desired outcome Assess the member's current health status, resource utilization, past and present treatment plan and services, prognosis, short and long term goals, treatment and provider options Coordinate services between Primary Care Physician (PCP), specialists, medical providers, and non-medical staff as necessary to meet the complete medical socio economic needs of clients Develop plan of care based upon assessment with specific objectives, goals and interventions designed to meet member's needs Provide patient and provider education Facilitate member access to community based services Monitor referrals made to community based organizations, medical care and other services to support the members’ overall care management plan Actively participate in integrated team care management rounds Identify related risk management quality concerns and report these scenarios to the appropriate resources Enter and maintain assessments, authorizations, and pertinent clinical information into various medical management systems Apply Now
Share this job
Check out this location See what's near our Galesburg location. View Map
Appendix Volume 2, p. 398
https://jobs.centene.com/job/galesburg/care-manager-i-rn/17169/12098247
5/10
Exhibit 13
Appendix Volume 2, p. 399
9/12/2019
Care Manager I (RN)
Who We Are
Why We're Different
Products & Services
Careers Why Centene? Investors
Benefits
News
Students
Contact
Continued Learning
Applicant Resources
Returning Applicants
Clinical & Nursing Jobs
Search Our Jobs KEYWORD
Enter Keyword LOCATION Fairborn, OH RADIUS 50 miles
Search
Appendix Volume 2, p. 400
https://jobs.centene.com/job/jackson/care-manager-i-rn/17169/12535836
1/10
9/12/2019
Care Manager I (RN)
Care Manager I (RN) MAGNOLIA HEALTH PLAN
Jackson, Mississippi, Mississippi Apply Now
As a member of the Centene Medical Management/Health Services team, you’ll help innovate and execute strategies that redefine the industry standard for improving the lives and health of people. We’re a team of skilled physicians, nurses, pharmacists, social workers and health service experts who use our advanced clinical analytics to implement award winning programs, develop care, deliver partnerships, and work directly with our members to achieve outcomes that set us apart as industry leaders. Together, we’re transforming the health of communities, one person at a time.
What does it take? What are the qualities that will help you achieve success in this role at Centene?
Appendix Volume 2, p. 401
https://jobs.centene.com/job/jackson/care-manager-i-rn/17169/12535836
2/10
9/12/2019
Care Manager I (RN)
Success Profile
Our Medical Roles
Appendix Volume 2, p. 402
https://jobs.centene.com/job/jackson/care-manager-i-rn/17169/12535836
3/10
9/12/2019
Care Manager I (RN)
Clinical & Nursing Opportunities at Centene Our Clinical team is at the forefront of our purpose-driven work. Learn more about how you can help communities, one person at a time.
Responsibilities Job ID 1149375 Additional Locations USA,Mississippi,US Category Clinical & Nursing Schedule Full-time Description: Position Purpose: Perform care management duties to assess, plan and coordinate all aspects of medical and supporting services across the continuum of care for select members to promote quality, cost effective care Develop, assess and adjust, as necessary, the care plan and promote desired outcome Assess the member's current health status, resource utilization, past and present treatment plan and services, prognosis, short and long term goals, treatment and provider options Coordinate services between Primary Care Physician (PCP), specialists, medical providers, and non-medical staff as necessary to meet the complete medical socio economic needs of clients Develop plan of care based upon assessment with specific objectives, goals and interventions designed to meet member's needs Provide patient and provider education Facilitate member access to community based services Monitor referrals made to community based organizations, medical care and other services to support the members’ overall care management plan Actively participate in integrated team care management rounds Identify related risk management quality concerns and report these scenarios to the appropriate
Appendix Volume 2, p. 403
https://jobs.centene.com/job/jackson/care-manager-i-rn/17169/12535836
4/10
9/12/2019
Care Manager I (RN)
resources Enter and maintain assessments, authorizations, and pertinent clinical information into various medical management systems For LTSS - 30% travel to perform home visits to members For New Hampshire, Massachuse s, & Michigan Complete Health - home visits required Qualifications: Education/Experience: Graduate from an Accredited School of Nursing. Bachelor’s degree in Nursing preferred. 2+ years of clinical nursing experience in a clinical, acute care, or community se ing. Knowledge of healthcare and managed care preferred. Licenses/Certifications: Current state’s RN license. For New Hampshire and Massachuse s: Candidates with RN license in good standing in other states than NH, must obtain a NH RN within 90 days of hire. Active driver’s license in good standing preferred. For Arizona Complete Health - Complete Care Plan: Obstetrics (OB) assignments requires RN experience in OB (clinical, acute care, community) Pediatric assignments require RN experience in pediatrics (clinical, acute care, community) For Michigan Complete Health: Licensed RN; licensed nurse practitioner, licensed physician's assistant. Valid driver's license required. LTSS Requirements: Valid driver’s license and proof of car insurance.
Centene is an equal opportunity employer that is commi ed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Apply Now
Appendix Volume 2, p. 404
https://jobs.centene.com/job/jackson/care-manager-i-rn/17169/12535836
5/10
Exhibit 14
Appendix Volume 2, p. 405
9/10/2019
Care Manager II (RN)
Care Manager II (RN)
SUNSHINE STATE HEALTH PLAN
Sunrise, Florida
Apply Now
As a member of the Centene Medical Management/Health Services team, you’ll help innovate and execute strategies that redefine the industry standard for improving the lives and health of people. We’re a team of skilled physicians, nurses, pharmacists, social workers and health service experts who use our advanced clinical analytics to implement award winning programs, develop care, deliver partnerships, and work directly with our members to achieve outcomes that set us apart as industry leaders. Together, we’re transforming the health of communities, one person at a time.
What does it take? What are the qualities that will help you achieve success in this role at Centene?
Appendix Volume 2, p. 406
https://jobs.centene.com/job/sunrise/care-manager-ii-rn/17169/13147515
2/11
9/10/2019
Care Manager II (RN)
Success Profile
Our Medical Roles
Appendix Volume 2, p. 407
https://jobs.centene.com/job/sunrise/care-manager-ii-rn/17169/13147515
3/11
9/10/2019
Care Manager II (RN)
Clinical & Nursing Opportunities at Centene Our Clinical team is at the forefront of our purpose-driven work. Learn more about how you can help transform the health of our communities, one person at a time.
Responsibilities Job ID 1154823 Category Clinical & Nursing Schedule Full-time Description: Position Purpose: Perform care management duties to assess, plan and coordinate all aspects of medical and supporting services across the continuum of care for select members to promote quality, cost effective care. Assess the member's current health status, resource utilization, past and present treatment plan and services, prognosis, short and long term goals, treatment and provider options Utilize assessment skills and discretionary judgment to develop plan of care based upon assessment with specific objectives, goals and interventions designed to meet member's needs and promote desired outcomes Coordinate services between Primary Care Physician (PCP), specialists, medical providers, and non-medical staff as necessary to meet the complete medical socio economic needs of clients Provide patient and provider education Facilitate member access to community based services Monitor referrals made to community based organizations, medical care and other services to support the members’ overall care management plan Actively participate in integrated team care management rounds Identify related risk management quality concerns and report these scenarios to the appropriate resources. Case load will reflect heavier weighting of complex cases than Care Manager I, commensurate with experience
Appendix Volume 2, p. 408
https://jobs.centene.com/job/sunrise/care-manager-ii-rn/17169/13147515
4/11
9/10/2019
Care Manager II (RN)
Enter and maintain assessments, authorizations, and pertinent clinical information into various medical management systems Direct care to participating network providers Perform duties independently, demonstrating advanced understanding of complex care management principles. Participate in case management commi ees and work on special projects related to case management as needed For New Hampshire, Massachuse s, & Michigan Complete Health - home visits required Qualifications: Education/Experience: Graduate from an Accredited School of Nursing. Bachelor’s degree in Nursing preferred. 2+ years of clinical nursing experience in a clinical, acute care, or community se ing and 1+ years of case management experience in a managed care se ing. Knowledge of utilization management principles and healthcare managed care. Experience with medical decision support tools (i.e. Interqual, NCCN) and government sponsored managed care programs. Licenses/Certifications: Current state’s RN license. Texas Requirements: Education/Experience: Graduate from an Accredited School of Nursing. Bachelor’s degree in Nursing preferred. 2+ years of clinical nursing or case management experience in a clinical, acute care, managed care or community se ing. 2+ years experience working with people with disabilities and vulnerable populations who have chronic or complex conditions in a managed care environment. Experience with medical decision support tools (i.e. Interqual, NCCN) and government sponsored managed care programs. Other state specific requirements may apply. Licenses/Certifications: Current state’s RN license. For New Hampshire Healthy Families: Candidates with active RN license in good standing in other states than NH, must obtain the NH RN equi within 90 days of hire. Active driver’s license in good standing preferred. CCM preferred. For Arizona Complete Health - Complete Care plan: Pediatrics assignments require 2+ years’ RN experience in pediatrics (clinical acute care, community or managed care se ing) and 1+ year experience in care management Obstetrics (OB) assignments require 2+ years’ RN experience in OB (clinical, acute, community or
Appendix Volume 2, p. 409
https://jobs.centene.com/job/sunrise/care-manager-ii-rn/17169/13147515
5/11
9/10/2019
Care Manager II (RN)
managed care se ing) and 1+ year experience in care management Licenses/Certifications: Current state’s RN license.
For Buckeye Community Health Plan: Education/Experience: Graduate from an Accredited School of Nursing. Bachelor’s degree in Nursing preferred. 2+ years of clinical nursing experience in a clinical, acute care, or community se ing and 1+ years of case management or utilization experience in a managed care se ing. Knowledge of utilization management principles and healthcare managed care. Experience with medical decision support tools (i.e. Interqual, NCCN) and government sponsored managed care programs. Licenses/Certifications: Current state’s RN license. For Michigan Complete Health: Licensed registered nurse; licensed nurse practitioner; licensed physician's assistant. Valid driver's license required.
Centene is an equal opportunity employer that is commi ed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Apply Now
Share this job
Check out this location See what's near our Sunrise location.
Appendix Volume 2, p. 410
https://jobs.centene.com/job/sunrise/care-manager-ii-rn/17169/13147515
6/11
Exhibit 15
Appendix Volume 2, p. 411
9/20/2020
(7) Care Manager I (RN) | Centene Corporation | LinkedIn
1
Search
6
Travis, land your dream job by learning n skills.
Care Manager I (RN)
Centene Corporation • United States No longer accepting applications
Position Purpose: Perform care management duties to assess, plan and coordinate all aspects of medical and supporting services across the continuum of care for select members to promote quality, cost effective care Develop, assess and adjust, as necessary, the care plan and promote desired outcome Assess the member's current health status, resource utilization, past and present treatment plan and services, prognosis, short and long term goals, treatment and provider options Coordinate services between Primary Care Physician (PCP), specialists, medical providers, and non-medical staff as necessary to meet the complete medical socio economic needs of clients Develop plan of care based upon assessment with specific objectives, goals and interventions designed to meet member's needs Provide patient and provider education Facilitate member access to community based services Monitor referrals made to community based organizations, medical care and other services to support the membersʼ overall care management plan Actively participate in integrated team care management rounds Identify related risk management quality concerns and report these scenarios to the appropriate resources Enter and maintain assessments, authorizations, and pertinent clinical information into various medical management systems
Contact the job poster
See my courses
Rob Allen Talent Acquisition Leader Saint Louis, Missouri
PROFINDER
Looking for talent? Post a job
Send InMail Industry Health, Wellness & Fitness , Hospital & Health Care Employment Type Full-time Job Functions Health Care Provider , Management
Messaging Search messages Connections to Centene Corporation
Harrison Barnes
CEO of BCG Attorney Search - #1 Law
Qualifications Education/Experience: Associateʼs degree in Nursing. Bachelorʼs degree in Nursing preferred. 2+ years of clinical nursing experience in an acute care setting. Knowledge of healthcare and managed care preferred. Abraham Rubinsky Licenses/Certifications: Current stateʼs RN license. Well....then get to it and good luck with Previous care management experience preferred. Intermediate to Expert that! level computer skills preferred. Travis Hedgpeth • 2 59 PM Thanks--just shoot me over some that work for you for lunch over Centene is an equal opportunity employer that is committed to diversity, dates next few weeks. Or, I can do the and values the ways in which we are different. All qualified applicants will the I just figure your schedule is receive consideration for employment without regard to race, color, same, probably religion, sex, sexual orientation, gender identity, national origin, disability, meetings.less flexible with board veteran status, or other characteristic protected by applicable law.
See less
COURSE 32,048 viewers
The New Rules of Work
Hana Kismetovic
Employee Health Nurse at BayCare H View all Messages
Abraham Rubinsky
You: Thanks--just shoot me over …
Rob Adams
Sponsored • UT Austin Alu… 1
Anna Clayton, MA, LMFT
InMail • We have talked before - …
Rebekah J. Hiltman
InMail • Hi Travis! Quick Question..
Courtney McLellan
Courtney: Hello, We have several …
Write a message…
John Tarr
John: Travis - I hope this messag…
Send
Nina Shock
InMail • Partner Opportunity with…
Appendix Volume 2, p. 412
https://www.linkedin.com/jobs/view/care-manager-i-%28rn%29-at-centene-corporation-103843387/
1/3
9/20/2020
(7) Care Manager I (RN) | Centene Corporation | LinkedIn
Put your best foot forward with your application Search
1
Travis Hedgpeth
Hire a resume writer
6
Partner at The Hedgpeth Law …
Get a resume review
Weʼre waiting on more data to deliver Competitive intelligence
Insights will only be displayed when there are 3 or more applicants
An inside look at Centene Corporation and its employees
Hiring trends over the last 2 years 16,650
28%
Total employees
Company-wide 2y growth
22%
Health Care Provider 2y growth
20,000
10,000
Sep 2018
Mar 2019
Sep 2019
Mar 2020
Sep 2020
Median tenure ∙ 2.9 years Centene Corporation talent sources Centene Corporation hired 39 people from University of Southern California. See all Health Care Provider hires at Centene Corporation came from these companies and more
Health Care Provider hires at Centene Corporation came from these schools and more
Messaging Search messages Connections to Centene Corporation
Harrison Barnes
CEO of BCG Attorney Search - #1 Law
Hana Kismetovic
See more companies
See more schools
Abraham Rubinsky See more company insights
Well....then get to it and good luck with that!
About the company Centene Corporation 101,656 followers
Hospital & Health Care • 10,001+ employees • 16,650 on LinkedIn
Travis Hedgpeth • 2 59 PM Thanks--just shoot me over some dates that work for you for lunchFollow over the next few weeks. Or, I can do the same, I just figure your schedule is probably less flexible with board meetings.
Centene Corporation is a leading multi-line healthcare enterprise that provides programs and related services to Write a message… individuals receiving benefits under Medicaid, including the State Children's Health Insurance Program (SCHIP), as well as Aged, Blind, or Disabled (ABD), Foster Care, Long-Term Care and Medicare (Special Needs Plans). The more …show Send
Employee Health Nurse at BayCare H View all Messages
Abraham Rubinsky
You: Thanks--just shoot me over …
Rob Adams
Sponsored • UT Austin Alu… 1
Anna Clayton, MA, LMFT
InMail • We have talked before - …
Rebekah J. Hiltman
InMail • Hi Travis! Quick Question..
Courtney McLellan
Courtney: Hello, We have several …
John Tarr
John: Travis - I hope this messag…
Nina Shock
InMail • Partner Opportunity with…
Appendix Volume 2, p. 413
https://www.linkedin.com/jobs/view/care-manager-i-%28rn%29-at-centene-corporation-103843387/
2/3
9/20/2020
(7) Care Manager I (RN) | Centene Corporation | LinkedIn
See more
Search
About Community Guidelines Privacy & Terms Sales Solutions Safety Center LinkedIn Corporation © 2020
Accessibility Careers Ad Choices Mobile
1
Talent Solutions Marketing Solutions Advertising Small Business
Questions?
Visit our Help Center.
Manage your account and privacy
6
Select Language English (English)
Go to your Settings.
Messaging Search messages Connections to Centene Corporation
Harrison Barnes
CEO of BCG Attorney Search - #1 Law
Hana Kismetovic
Abraham Rubinsky Well....then get to it and good luck with that! Travis Hedgpeth • 2 59 PM Thanks--just shoot me over some dates that work for you for lunch over the next few weeks. Or, I can do the same, I just figure your schedule is probably less flexible with board meetings.
Employee Health Nurse at BayCare H View all Messages
Abraham Rubinsky
You: Thanks--just shoot me over …
Rob Adams
Sponsored • UT Austin Alu… 1
Anna Clayton, MA, LMFT
InMail • We have talked before - …
Rebekah J. Hiltman
InMail • Hi Travis! Quick Question..
Courtney McLellan
Courtney: Hello, We have several …
Write a message…
John Tarr
John: Travis - I hope this messag…
Send
Nina Shock
InMail • Partner Opportunity with…
Appendix Volume 2, p. 414
https://www.linkedin.com/jobs/view/care-manager-i-%28rn%29-at-centene-corporation-103843387/
3/3
Exhibit 16
Appendix Volume 2, p. 415
9/12/2019
Supervisor, Care Management
Who We Are
Why We're Different
Products & Services
Careers Why Centene? Investors
Benefits
News
Students
Contact
Continued Learning
Applicant Resources
Returning Applicants
Clinical & Nursing Jobs
Search Our Jobs KEYWORD
Enter Keyword LOCATION Fairborn, OH RADIUS 50 miles
Search
Appendix Volume 2, p. 416
https://jobs.centene.com/job/burr-ridge/supervisor-care-management/17169/13277609
1/10
9/12/2019
Supervisor, Care Management
Supervisor, Care Management ILLINICARE HEALTH PLAN
Burr Ridge, Illinois
Apply Now
As a member of the Centene Medical Management/Health Services team, you’ll help innovate and execute strategies that redefine the industry standard for improving the lives and health of people. We’re a team of skilled physicians, nurses, pharmacists, social workers and health service experts who use our advanced clinical analytics to implement award winning programs, develop care, deliver partnerships, and work directly with our members to achieve outcomes that set us apart as industry leaders. Together, we’re transforming the health of communities, one person at a time.
What does it take? What are the qualities that will help you achieve success in this role at Centene?
Appendix Volume 2, p. 417
https://jobs.centene.com/job/burr-ridge/supervisor-care-management/17169/13277609
2/10
9/12/2019
Supervisor, Care Management
Success Profile
Our Medical Roles
Appendix Volume 2, p. 418
https://jobs.centene.com/job/burr-ridge/supervisor-care-management/17169/13277609
3/10
9/12/2019
Supervisor, Care Management
Clinical & Nursing Opportunities at Centene Our Clinical team is at the forefront of our purpose-driven work. Learn more about how you can help time.
Responsibilities Job ID 1156418 Category Clinical & Nursing Schedule Full-time Description: Position Purpose: Responsible for day-to-day oversight of the Integrated Care Managers and coordination of necessary resources for members. This may include adequate clinical, behavioral, acute/chronic, and social care services. Ensure staff is able to facilitate member and provider needs through entire care management cycle. Partner with internal staff on key initiatives and outreach for members as needed. Coordinate and communicate on access issues, assessments, internal protocols. Implement policies and procedures through oversight for complex cases and present to management Assist in recruitment efforts in accordance to the staff to member ratio
Appendix Volume 2, p. 419
https://jobs.centene.com/job/burr-ridge/supervisor-care-management/17169/13277609
4/10
9/12/2019
Supervisor, Care Management
Coordinate the training of care management staff Facilitate on-going communication between care management staff and providers Assign cases and oversee care management caseloads including service care plan approval and member case file reviews Maintain compliance with federal and state regulations and contractual agreements Supervise the daily activities of staff to promote quality improvement and efficient methods For Arizona Complete Health - Complete Care Plan: Compile and review multiple reports for statistical and financial tracking purposes to identify case management trends and assist in financial forecasting. Qualifications: Education/Experience: Bachelor’s degree in Nursing, Social Work, Health Care Administration, related field or equivalent experience. 4+ years of social work, healthcare administration, patient/community advocacy, care management , or combined care management and clinical nursing experience. Previous experience as a lead in a functional area or managing cross functional teams on large scale projects. Licenses/Certifications: Licensed Clinical Social Worker (LCSW), Licensed Marriage & Family Therapist (LMFT), Licensed Behavioral Health Medical Practitioner, Licensed Professional Counselor, Licensed Substance Abuse Counselor, Licensed Psychologist, or Registered Nurse preferred. For Arizona Complete Health - Complete Care Plan: Education/Experience: Bachelor’s degree in Nursing or equivalent experience, or Master’s Degree in Behavioral Health related field. 4+ years of social work, healthcare administration, patient/community advocacy, care management , or combined care management and clinical nursing experience. Previous experience as a lead in a functional area or managing cross functional teams on large scale projects. Licenses/Certifications: Licensed Clinical Social Worker (LCSW), Licensed Master Social Worker (LMSW), Licensed Marriage & Family Therapist (LMFT), Licensed Professional Counselor (LPC), Licensed Associate Marriage & Family Therapist (LAMFT), Licensed Associate Counselor (LAC), Licensed Associate Master Social Worker (LAMSW) or Registered Nurse Pediatric team - must have experience working with children who have chronic or complex conditions Obstetrics (OB) team - OB experience is preferred
Appendix Volume 2, p. 420
https://jobs.centene.com/job/burr-ridge/supervisor-care-management/17169/13277609
5/10
9/12/2019
Supervisor, Care Management
Centene is an equal opportunity employer that is commi ed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Apply Now
Share this job
Check out this location See what's near our Burr Ridge location. View Map
Appendix Volume 2, p. 421
https://jobs.centene.com/job/burr-ridge/supervisor-care-management/17169/13277609
6/10
Exhibit 17
Appendix Volume 2, p. 422
Case: 18-60746
Document: 00514875241
Page: 1
Date Filed: 03/15/2019
_________________ Case No. 18-60746 _________________ IN THE UNITED STATES COURT OF APPEALS FOR THE FIFTH CIRCUIT United States of America, ex rel. GWENDOLYN PORTER, Relator, Plaintiff-Appellant, v. MAGNOLIA HEALTH PLAN, INCORPORATED, Defendant-Appellee. ____________________________________ Appeal from the United States District Court for the Southern District of Mississippi ____________________________________
BRIEF OF DEFENDANT-APPELLEE MAGNOLIA HEALTH PLAN, INCORPORATED
John B. Howell III WATKINS & E AGER PLLC 106 Madison Plaza, Suite C Hattiesburg, Mississippi 39402 601.264.4499 Timothy L. Sensing WATKINS & E AGER PLLC 400 East Capitol Street Jackson, Mississippi 39201 601.965.1900
Appendix Volume 2, p. 423
Case: 18-60746
Document: 00514875241
Page: 2
Date Filed: 03/15/2019
_________________ Case No. 18-60746 _________________ IN THE UNITED STATES COURT OF APPEALS FOR THE FIFTH CIRCUIT United States of America, ex rel. GWENDOLYN PORTER, Relator, Plaintiff-Appellant, v. MAGNOLIA HEALTH PLAN, INCORPORATED, Defendant-Appellee.
Certificate of Interested Persons The undersigned counsel of record certifies that the following persons and entities as described in the fourth sentence of Rule 28.2.1 have an interest in the outcome of this case. These representations are made in order that the judges of this court may evaluate possible disqualification or recusal. 1. Magnolia Health Plan, Incorporated................................. Defendant-Appellee 2. John B. Howell III Timothy L. Sensing Watkins & Eager PLLC ................................ Counsel for Defendant-Appellee 3. Gwendolyn Porter ............................................................... Plaintiff-Appellant 4. United States of America ................................................. Real party in interest ii
Appendix Volume 2, p. 424
Case: 18-60746
Document: 00514875241
Page: 3
Date Filed: 03/15/2019
5. C.W. Walker III C.W. Walker III, LLC..................................... Counsel for Plaintiff-Appellant 6. Derrick Simmons Simmons & Simmons, PLLC ......................... Counsel for Plaintiff-Appellant 7. Centene Corporation ...................... Parent corporation of Defendant-Appellee
Corporate Disclosure Statement Defendant-Appellee Magnolia Health Plan, Incorporated, is a wholly-owned subsidiary of Centene Corporation, which is a publicly-traded company.
/s/John B. Howell III John B. Howell III Attorney of record for Defendant-Appellee Magnolia Health Plan, Incorporated
iii
Appendix Volume 2, p. 425
Case: 18-60746
Document: 00514875241
Page: 4
Date Filed: 03/15/2019
Statement Regarding Oral Argument Oral argument is not warranted because the issues presented for review involve routine application of settled law.
iv
Appendix Volume 2, p. 426
Case: 18-60746
Document: 00514875241
Page: 5
Date Filed: 03/15/2019
Table of Contents Table of Authorities ............................................................................................... vi Statement of the Issues Presented for Review .......................................................1 Statement of the Case ..............................................................................................1 A. Facts Alleged in the Amended Complaint ................................................... 2 B. Procedural History and Rulings Presented for Review................................ 7 Summary of the Argument .....................................................................................9 Argument ................................................................................................................10 A. Standard of Review ................................................................................... 10 B. The False Claims Act, Materiality, and Escobar.......................................11 C. The amended complaint did not plead any facts that suggest Magnolia’s alleged false representations about the staffing of its case management positions were material to the government’s decision to pay. ..........................................................................................13 D. The district court appropriately determined Exhibits I, J, K, M, N, and O were irrelevant to materiality. .................................................... 21 E. The district court did not err in concluding Porter’s proposal to re-amend the complaint to include Mississippi statutes and regulations concerning nursing practice would have been futile. ............. 24 Conclusion...............................................................................................................27 Certificate of Service..............................................................................................29 Certificate of Compliance with Rule 32(a) ..........................................................30
v
Appendix Volume 2, p. 427
Case: 18-60746
Document: 00514875241
Page: 6
Date Filed: 03/15/2019
Table of Authorities Cases Abbott v. BP Exploration & Production, Inc., 851 F.3d 384 (5th Cir. 2017) ...12, 22 Ashcroft v. Iqbal, 556 U.S. 662 (2009) ..............................................................10, 11 Celanese Corp. v. Martin K. Eby Construction Co., 620 F.3d 529 (5th Cir. 2010) ................................................................................................ 25 Christiana Trust v. Riddle, 911 F.3d 799 (5th Cir. 2018) ....................................... 10 City of Clinton, Ark. v. Pilgrim’s Pride Corp., 632 F.3d 148 (5th Cir. 2010) ........ 11 Coyne v. Amgen, Inc., 717 F. App’x 26 (2d Cir. 2017) ........................................... 16 D’Agostino v. ev3, Inc., 845 F.3d 1 (1st Cir. 2016) ...........................................16, 21 Guilfoile v. Shields, 913 F.3d 178 (1st Cir. 2019) ................................................... 12 Mississippi True v. Dzielak, 25CH1:18-cv-00557, Order, dkt. 96 (Hinds Cnty. Chan. Ct. Sept. 28, 2018) ...............................................8, 14, 15 Murchison Capital Partners, L.P. v. Nuance Communications, Inc., 625 F. App’x 617 (5th Cir. 2015) .............................................................. 8, 15 Ruiz v. Brennan, 851 F.3d 464 (5th Cir. 2017)........................................................ 10 Thomas v. Chevron U.S.A., Inc., 832 F.3d 586 (5th Cir. 2016) .............................. 25 United States ex rel. Campie v. Gilead Sciences, Inc., 862 F.3d 890 (9th Cir. 2017) ..........................................................................................15, 16 United States ex rel. Escobar v. Universal Health Services, Inc., 842 F.3d 103 (1st Cir. 2016) ..............................................................18, 19, 20 United States ex rel. Harman v. Trinity Industries, Inc., 872 F.3d 645 (5th Cir. 2017) ................................................................................................ 17
vi
Appendix Volume 2, p. 428
Case: 18-60746
Document: 00514875241
Page: 7
Date Filed: 03/15/2019
United States ex rel. Longhi v. United States, 575 F.3d 458 (5th Cir. 2009) .......... 12 United States ex rel. McBride v. Halliburton Co., 848 F.3d 1027 (D.C. Cir. 2017) ............................................................................................. 17 United States ex rel. Miller v. Weston Educational, Inc., 840 F.3d 494 (8th Cir. 2016) ................................................................................................ 12 United States ex rel. Petratos v. Genentech Inc., 855 F.3d 481 (3d Cir. 2017) ...........................................................................................16, 21 United States ex rel. Shupe v. Cisco Systems, Inc., 759 F.3d 379 (5th Cir. 2014) ................................................................................................ 11 United States ex rel. Stephenson v. Archer Western Contractors, LLC, 548 F. App’x 135 (5th Cir. 2013) .................................................................. 17 Universal Health Services, Inc. v. United States ex rel. Escobar, 136 S. Ct. 1989 (2016) ............................................................................passim Statutes 31 United States Code Section 3729........................................................................12 Mississippi Code Annotated Section 73-15-5 .........................................................26 Regulations Code of Arkansas Regulations Section 016.06.10-213.480 .................................... 21 22 California Code of Regulations Section 51272 .................................................. 21 Code of Mississippi Regulations Section 30-18-2830............................................. 26 Vermont Administrative Code Section 12-7-74:7412 ............................................. 21
vii
Appendix Volume 2, p. 429
Case: 18-60746
Document: 00514875241
Page: 8
Date Filed: 03/15/2019
Statement of the Issues Presented for Review 1.
In its 2016 Escobar decision, the Supreme Court clarified that the
rigorous materiality element of a claim arising under the False Claims Act requires a falsehood to be so important that it is likely to influence the government’s payment decision. Plaintiff-Appellant Gwendolyn Porter’s amended complaint did not plead any facts suggesting Defendant-Appellee Magnolia Health Plan, Inc.’s alleged false representations were capable of influencing the government’s payments. Did the district court err in granting Defendant-Appellee Magnolia Health Plan, Inc.’s motion to dismiss the amended complaint for failure to state a claim upon which relief can be granted? 2.
Did the district court err in denying Porter leave to re-amend her
complaint because her proposed amendment was not indicative of materiality and thus would have been futile? Statement of the Case Before filing this qui tam action, Plaintiff-Appellant and Relator Gwendolyn Porter informed the federal government through the United States Attorney of the underlying “false claims and their nature” and provided supporting “documents and other material evidence.” (ROA.327; R.E. Tab 1.) On March 1, 2016, Porter filed her original complaint against Defendant-Appellee Magnolia Health Plan, Inc. and Centene Management Company, LLC, asserting two claims arising under the False 1
Appendix Volume 2, p. 430
Case: 18-60746
Document: 00514875241
Page: 9
Date Filed: 03/15/2019
Claims Act (FCA) and several others based on common law. (ROA.9, ROA.35 through ROA.40.)
A couple of weeks later, she amended the complaint by
substituting Centene Corporation for Centene Management Company, LLC and tacking on additional exhibits that resulted in a 523-page pleading. (ROA.293 through ROA.815.) A. Facts Alleged in the Amended Complaint Per the amended complaint, Magnolia is a coordinated care organization that, beginning in 2010 and on several occasions since, contracted with the Mississippi Division of Medicaid to co-administer1 a portion of the State’s Medicaid program, commonly known as MississippiCAN. (ROA.298, ROA.299, ROA.302, ROA.353, ROA.450.) As of 2015, the annual value of Magnolia’s MississippiCAN contract was in the hundreds of millions of dollars.
(ROA.297, ROA.301, ROA.350,
ROA.351.) A large component of those funds come from the federal government. (ROA.298, ROA.300 through ROA.301, ROA.320.) Porter is a registered nurse who worked for Magnolia as a case manager from February 2011 until September 2012. (ROA.297; R.E. Tab 1.) As an in-house case manager, she provided almost exclusively telephonic services to Medicaid enrollees,
1
UnitedHealthcare Community Plan, Inc. was the only other coordinated care organization co-administering the MississippiCAN program. (ROA.299.) After leaving her job with Magnolia, Porter went to work as a case manager for United. (Appellant’s Br. 20.) She brought a similar qui tam action against United shortly after filing this action; that case is stayed pending disposition of this appeal. (Id. at 22–23.) 2
Appendix Volume 2, p. 431
Case: 18-60746
Document: 00514875241
Page: 10
Date Filed: 03/15/2019
such as patient education, encouragement regarding lifestyle changes, and coordination of services. (ROA.312, ROA.809 through ROA.810; R.E. Tabs 1, 5.) After a few months of employment with Magnolia, Porter wrote two whistleblower letters to the Mississippi Division of Medicaid, claiming that Magnolia was––improperly, in her view––staffing case manager positions with licensed practical nurses (LPNs) rather than registered nurses (RNs). (ROA.297, ROA.811; R.E. Tabs 1, 5.) To preserve her anonymity, Porter “drove to Jackson to mail the letters” and wore “cloth gloves while handling the letters so as to leave no fingerprints.” (ROA.297, ROA.811; R.E. Tabs 1, 5.) The Division of Medicaid did not take any action against Magnolia after receiving the letters.
(ROA.297,
ROA.812; R.E. Tabs 1, 5.) On the contrary, after receiving Porter’s letters, the Division of Medicaid renewed or renegotiated the MississippiCAN contract twice. (ROA.302, ROA.551, ROA.588, ROA.736; R.E. Tabs 1, 3, 4.) In the contracts, Magnolia agreed to administer the provision of “covered services” to Medicaid enrollees, which consist mainly of clinical health services including inpatient care, physician office visits, emergency hospital care, physical therapy, mental health services, dental care, prescription drugs, and durable medical equipment. (ROA.301, ROA.387 through ROA.389, ROA.490 through ROA.491, ROA.621 through ROA.626.)
Magnolia represented that “all covered
services…will meet the quality management standards of the Division” and that it 3
Appendix Volume 2, p. 432
Case: 18-60746
would
“comply
Document: 00514875241
with
all
applicable
Page: 11
policies
and
Date Filed: 03/15/2019
procedures
of
the
Division…applicable to each category of Covered Services.” (ROA.356, ROA.360, ROA.457, ROA.463, ROA.592, ROA.598 (emphases added).) Magnolia also agreed to provide “case [or care] management services” to enrollees, which fall outside the umbrella of “covered services.” (ROA.394 through ROA.396, ROA.497 through ROA.498, ROA.670 through ROA.676; R.E. Tabs 2, 3, 4.) Although the two earliest contracts do not define “case management,” the third refers to “care management” as “[a] set of Member-centered, goal-oriented, culturally relevant, and logical steps to assure that a Member receives needed services in a supportive, effective, efficient, timely and cost-effective manner.” (ROA.603, R.E. Tab 4.) Unlike covered services, care management services are not clinically-based; rather, they are almost exclusively provided telephonically by inhouse personnel at Magnolia, and include items such as scheduling, referrals, documentation of services provided, discharge planning, risk assessments, patient education, encouragement regarding lifestyle changes, and coordination of services. (ROA.307 through ROA.312, ROA.394 through ROA.396, ROA.497 through ROA.498, ROA.671 through ROA.676, ROA.809 through ROA.810; R.E. Tabs 1, 2, 3, 4, 5.) Although the contracts contain specific licensing requirements for positions such as Magnolia’s medical director and providers of covered services (ROA.362, 4
Appendix Volume 2, p. 433
Case: 18-60746
Document: 00514875241
Page: 12
Date Filed: 03/15/2019
ROA.404, ROA.465, ROA.506, ROA.599, ROA.658), there are no such particular requirements for case managers. Quantitatively, the most the dense contracts say about case manager jobs is that “staffing shall be at a level that is sufficient to perform all necessary medical assessments and to meet all Mississippi Medicaid enrollees’ case management needs at all times.” (ROA.361, ROA.464, ROA.601; R.E. Tabs 2, 3, 4.) Qualitatively, they generally state that case management staffing should be “adequate” and that “[a]ll staff must be qualified by training and experience.” (ROA.361, ROA.464. ROA.599; R.E. Tabs 2, 3, 4.) In boilerplate in all three contracts, Magnolia agreed it would comply with “all applicable federal and state law (statutory and case law), regulations and standards, as have been or may hereinafter be established, specifically including without limitation, the policies, rules, and regulations of the Division.” (ROA.354, ROA.456, ROA.590.)
There is no contractual provision explicitly requiring
Magnolia to use RNs to fill case management positions.
(ROA.352 through
ROA.805; Appellant’s Br. 39.) Several documents that were neither part of the contracts nor presented to the Division of Medicaid or the federal government were attached to the amended complaint as Exhibits I, J, K, M, N, and O. One is a page from Magnolia’s 2011 policy and procedure manual defining the term “case management.” (ROA.806.) Another is a 2010 internal policy from Magnolia that indicates an “RN case 5
Appendix Volume 2, p. 434
Case: 18-60746
Document: 00514875241
Page: 13
Date Filed: 03/15/2019
manager” is one of several members of the “Integrated Care Team.” (ROA.807.) A 2016 employment advertisement from Centene (not Magnolia) for a “Supervisor, Case Management” position states “RN Required.” (ROA.808.) A page from Magnolia’s enrollee handbook says “[o]ur care managers are registered nurses or social workers.” (ROA.814.) And a 2013 Magnolia PowerPoint slide indicates “Case Managers are registered nurses.” (ROA.815.) The only quasi-legal provision mentioned in the amended complaint that purports to limit case managers to RNs comes from a telenursing frequently asked question published on the website of the Mississippi Board of Nursing: “case management (on site and telephonic) [is] not within the scope of practice of the licensed practice nurse in Mississippi. They are within the scope of practice of the registered nurse.” (ROA.313, ROA.813; R.E. Tabs 1, 6.) Apparently believing that provision to carry the force of law, Porter alleges Magnolia’s staffing of case manager slots with LPNs “violat[es] state law” and, by extension, the MississippiCAN contracts. (ROA.313 through ROA.317; R.E. Tab 1.) (The statutes and regulations Porter now relies on in her Brief were not included in the Amended Complaint.) She then surmises that, because “one who possesses an RN degree commands a greater salary, as a rule, than one who possesses only an LPN degree,” the capitated rate payments (a significant portion of which derives from federal dollars) the 6
Appendix Volume 2, p. 435
Case: 18-60746
Document: 00514875241
Page: 14
Date Filed: 03/15/2019
Division of Medicaid negotiated with and paid to Magnolia were “fraudulently inflated” inasmuch as the Division presumed Magnolia would be using RNs to provide case management services.
(ROA.298, ROA.318 through ROA.320.)
Therefore, says Porter, all of the capitated rate payments Magnolia received since February 2011 are false claims under the False Claims Act because “the underlying data…was fraudulently inflated.” (ROA.320.) Alternatively, she asserts that every capitated rate payment for an enrollee who was served by an LPN case manager is a false claim. (ROA.320 through ROA.321.) The amended complaint says nothing about whether Magnolia’s allegedly false statements and presentments regarding case management staffing were material to––i.e., so central as to be capable of influencing––the government’s decision to pay money. (ROA.293 through ROA.815.) B. Procedural History and Rulings Presented for Review Just over a year after the complaint was filed, the United States declined to intervene. (ROA.816 through ROA.817.) After the case was unsealed and service was effectuated, Centene filed a motion to dismiss the amended complaint for failure to state a claim upon which relief can be granted. (ROA.845.) Porter confessed the motion, and Centene was dismissed. (ROA.861 through ROA.864.) Magnolia also filed a Rule 12(b)(6) motion. (ROA.833.) Concerning the two claims under the FCA, Magnolia argued Porter had failed to plead facts supportive 7
Appendix Volume 2, p. 436
Case: 18-60746
Document: 00514875241
Page: 15
Date Filed: 03/15/2019
of the essential element of materiality. (ROA.839 through ROA.841, ROA.900 through ROA.903.) In her response, Porter withdrew all of her common law claims but opposed dismissal of the two claims under the Act.
(ROA.868 through
ROA.869.) In footnotes 32 and 33, Porter in passing requested leave to amend the amended complaint to refer to statutory and regulatory provisions of Mississippi law concerning nursing practice. (ROA.884; R.E. Tab 7.) While its motion to dismiss was pending, Magnolia was awarded the MississippiCAN contract a fourth time in July 2018.2 A couple of months later, the district court granted the motion, concluding that Porter had failed to plead facts showing Magnolia’s alleged false representations concerning the staffing of its case management positions were material to the government’s decision to pay. (ROA.919 through ROA.920.) The court also denied Porter’s footnoted requests for leave to amend her amended complaint to include Mississippi statutes and regulations concerning the practice of nursing, finding such an amendment would be futile. (ROA.920 through ROA.921.) A final judgment was entered, from which Porter appeals.
(ROA.923,
ROA.924.)
2
Mississippi True v. Dzielak, 25CH1:18-cv-00557, Order, dkt. 96 at 3, 10 (Hinds Cnty. Chan. Ct. Sept. 28, 2018). This Court can take judicial notice of that Order because it is a public record. Murchison Capital Partners, L.P. v. Nuance Commc’ns, Inc., 625 F. App’x 617, 618 n.1 (5th Cir. 2015). 8
Appendix Volume 2, p. 437
Case: 18-60746
Document: 00514875241
Page: 16
Date Filed: 03/15/2019
Summary of the Argument In its recent Escobar decision, the Supreme Court re-calibrated the materiality element of claims arising under the False Claims Act.
Now materiality is a
“demanding” and “rigorous” standard, even at the pleading stage, such that the government’s mere act of labeling compliance with a legal or contractual provision a condition of payment is not dispositive. Neither can materiality “be found where noncompliance is minor or insubstantial,” but rather only where a misrepresentation was “so central to” or “went to the very essence of the bargain” that it was likely to influence the government’s payment decision. As the district court correctly held, Porter’s amended complaint fails to allege any facts that would suggest Magnolia’s allegedly improper staffing of non-clinical, mainly telephonic case manager positions with LPNs was material to the government’s payments of hundreds of millions of dollars annually for a wide array of clinical healthcare services under the MississippiCAN contracts. On the contrary, Porter alleges the Division of Medicaid and the federal government were aware of Magnolia’s supposed infractions but continued renewing the contracts and paying Magnolia anyway. Escobar calls that “strong evidence” of immateriality. Under such circumstances and where scant allegations are otherwise made respecting materiality, cases from other circuits applying Escobar (that this Court has cited with approval) have almost uniformly found dismissal appropriate. In sum, because the 9
Appendix Volume 2, p. 438
Case: 18-60746
Document: 00514875241
Page: 17
Date Filed: 03/15/2019
only facts pleaded on the subject of materiality point to its absence, under Rules 8 and 9(b) the amended complaint fails to state a claim for which relief may be granted. In two footnotes in her district court briefing, Porter asked for leave to amend the amended complaint to include Mississippi nursing practice statutes and regulations that supposedly exclude LPNs from case management activities. Because those provisions do not remotely suggest staffing case management positions with RNs was the essence of the bargain of the MississippiCAN contracts and thus influenced the government’s payments, the district court rightly determined the proposed amendment would be futile and denied Porter leave to so amend. The judgment of the district court should be affirmed. Argument A. Standard of Review This Court reviews the dismissal of a complaint for failure to state a claim de novo. Christiana Trust v. Riddle, 911 F.3d 799, 802 (5th Cir. 2018). The complaint itself, any attachments thereto, and matters of public record subject to judicial notice can be considered in evaluating a Rule 12(b)(6) motion. Ruiz v. Brennan, 851 F.3d 464, 468 (5th Cir. 2017). To survive a motion to dismiss for failure to state a claim upon which relief can be granted, “a complaint must contain sufficient factual matter, accepted as true, to ‘state a claim to relief that is plausible on its face.’” Ashcroft v. Iqbal, 556 U.S. 10
Appendix Volume 2, p. 439
Case: 18-60746
Document: 00514875241
Page: 18
Date Filed: 03/15/2019
662, 678 (2009) (quoting Bell Atl. Corp. v. Twombly, 550 U.S. 544, 570 (2007)). “A claim has facial plausibility when the plaintiff pleads factual content that allows the court to draw the reasonable inference that the defendant is liable for the misconduct alleged.” Id. “A complaint is insufficient if it offers only labels and conclusions, or a formulaic recitation of the elements of a cause of action.” Id. (quotation marks omitted). In order to “plead[] facts to support allegations of materiality” as required under the False Claims Act, a plaintiff must satisfy not only the plausibility standard of Rule 8, but also the particularity standard of Rule 9(b). Universal Health Servs., Inc. v. United States ex rel. Escobar, 136 S. Ct. 1989, 2004 n.6 (2016) (hereinafter Escobar). That means, at a minimum, the plaintiff must set forth the “who, what, when, where, and how” of the alleged fraud. United States ex rel. Shupe v. Cisco Sys., Inc., 759 F.3d 379, 382 (5th Cir. 2014) (quotation marks and citation omitted). With respect to the district court’s denial of Porter’s request for leave to amend, because the decision was based on futility “a de novo standard of review identical, in practice, to the standard used for reviewing a dismissal under Rule 12(b)(6)” applies. City of Clinton, Ark. v. Pilgrim’s Pride Corp., 632 F.3d 148, 152 (5th Cir. 2010). B. The False Claims Act, Materiality, and Escobar There are four elements to a False Claims Act claim: “(1) whether there was 11
Appendix Volume 2, p. 440
Case: 18-60746
Document: 00514875241
Page: 19
Date Filed: 03/15/2019
a false statement or fraudulent course of conduct; (2) made or carried out with the requisite scienter; (3) that was material; and (4) that caused the government to pay out money or to forfeit moneys due (i.e., that involved a claim).” Abbott v. BP Expl. & Prod., Inc., 851 F.3d 384, 387 (5th Cir. 2017).
Materiality is a required
component of both the fraudulent presentment and false statement FCA claims asserted by Porter under 31 U.S.C. Sections 3729(a)(1)(A) and (B). Guilfoile v. Shields, 913 F.3d 178, 187 n.7 (1st Cir. 2019) (§ 3729(a)(1)(A)); United States ex rel. Miller v. Weston Educ., Inc., 840 F.3d 494, 504 n.3 (8th Cir. 2016) (§ 3729(a)(1)(B)); see Escobar, 136 S. Ct. at 2002 (declining to decide whether materiality requirement of Section 3729(a)(1)(A) derives from common law or statute). Well before this suit was filed, this Court had recognized the FCA’s materiality element means “hav[ing] the potential to influence the government’s decisions.” United States ex rel. Longhi v. United States, 575 F.3d 458, 470 (5th Cir. 2009). That was consistent with the Act’s definition of “having a natural tendency to influence, or be capable of influencing, the payment or receipt of money or property.” 31 U.S.C. § 3729(b)(4). Then, shortly after this case was filed, the Supreme Court in Escobar confirmed those understandings but expounded on how the materiality requirement should be enforced. 136 S. Ct. 1989. In Escobar, the Court emphasized the materiality standard is “rigorous” and 12
Appendix Volume 2, p. 441
Case: 18-60746
Document: 00514875241
Page: 20
Date Filed: 03/15/2019
“demanding.” Id. at 2002–03. The strictness of that element is consistent with the Act’s circumscribed focus: “The False Claims Act is not an all-purpose antifraud statute or a vehicle for punishing garden-variety breaches of contract or regulatory violations.” Id. at 2003 (quotation marks and citation omitted). Materiality is not established by the government’s mere act of labeling compliance with a given provision a condition of payment, nor is it enough that the government can decline payment if it learns of noncompliance. Id. Neither can materiality “be found where noncompliance is minor or insubstantial,” but rather only where a misrepresentation was “so central to” or “went to the very essence of the bargain” that it was likely to influence the government’s payment. Id. at 2002, 2003 & n.5, 2004. C. The amended complaint did not plead any facts that suggest Magnolia’s alleged false representations about the staffing of its case management positions were material to the government’s decision to pay. i. Escobar’s instructions and application Escobar identified a couple of non-dispositive hallmarks of materiality: (1) the government’s express conditioning of payment upon compliance with a legal or contractual provision; and (2) the government’s consistent refusal to pay claims when a certain provision is not complied with. Id. at 2003. By the same token, said the Court, the following are “strong evidence” of immateriality: (1) where the government regularly pays a certain claim despite knowing a requirement was violated; (2) where the government regularly pays a certain type of claim despite 13
Appendix Volume 2, p. 442
Case: 18-60746
Document: 00514875241
Page: 21
Date Filed: 03/15/2019
knowing a requirement was violated, and has not signaled a change in position. Id. at 2003–04. Here, the amended complaint does not identify any provision (much less one pertaining to staffing of case manager positions) that Magnolia must comply with if the government is to pay. Nor does Porter allege the government consistently refuses to pay if case manager jobs are staffed by persons who are not RNs. Moreover, the amended complaint says nothing explicitly or even inferentially about the probable effect of LPN-staffing of case management spots on the government’s payment decision. On the other hand, the amended complaint does plead that after Porter informed the Division of Medicaid in 2011 via two letters that Magnolia was using LPNs instead of RNs, no action was taken except continuance of payments and reawarding the MississippiCAN contract to Magnolia twice. (ROA.297, ROA.302, ROA.811 through ROA.812; R.E. Tabs 1, 5.) Porter also says that before filing the original complaint in March 2016, she informed the federal government through the United States Attorney of “the false claims and their nature” and provided it with substantiating “material evidence.” (ROA.327; R.E. Tab 1.) Yet the government declined intervention (ROA.816 through ROA.817), and after the case was unsealed and the motion to dismiss was pending, Magnolia was awarded the MississippiCAN contract a fourth time. Mississippi True v. Dzielak, 25CH1:18-cv-00557, Order, dkt. 14
Appendix Volume 2, p. 443
Case: 18-60746
Document: 00514875241
Page: 22
Date Filed: 03/15/2019
96 at 3, 10 (Hinds Cnty. Chan. Ct. Sept. 28, 2018).3 Per Escobar, those facts strongly indicate that Magnolia’s case management staffing representations were not material to the government’s decision to pay. ii. Escobar’s application by the courts of appeals Porter attempts to backtrack, saying a course of continued payments is of diminished importance at the pleading phase per the Ninth Circuit’s opinion in United States ex rel. Campie v. Gilead Sciences, Inc., 862 F.3d 890 (9th Cir. 2017), where the court reversed dismissal of a qui tam complaint. (Appellant’s Br. 43–51.) There are several flaws with that argument. First, unlike Campie where there was a lack of clarity concerning the government’s awareness of the defendant’s regulatory violations, there is no such doubt here because Porter sent two whistleblower letters to the Division of Medicaid in 2011 and informed the federal government of “the false claims and their nature” before March 1, 2016. (ROA.297, ROA.327, ROA.811; R.E. Tabs 1, 5.) Yet payments and contract renewals have continued unabated. (ROA. 302, ROA.551, ROA.588, ROA.736, ROA.812; R.E. Tabs 1, 3, 4, 5; Mississippi True, 25CH1:18cv-00557, Order, dkt. 96 at 3, 10.)
Moreover, in Campie, government
reimbursement for the defendant’s medications was contingent upon continued FDA
3
This Court can take judicial notice of that Order because it is a public record. Murchison Capital Partners, 625 F. App’x at 618 n.1. 15
Appendix Volume 2, p. 444
Case: 18-60746
Document: 00514875241
Page: 23
Date Filed: 03/15/2019
approval, which the defendant was said to have fraudulently obtained. 862 F.3d at 905. There is no such condition here. Also, in Campie there were alternative reasons for the FDA’s continued approval of the noncompliant medications, and the government’s continued payments after the defendant became compliant had far less significance than if payments had been made during noncompliance. 862 F.3d at 906. Neither circumstance is alleged here. Second, in contrast with Campie, cases from this Court and other circuits demonstrate that, even at the pleading stage, the government’s continuance of payments while aware of mere allegations of fraud strongly suggests immateriality. In other words, completion of a full-blown government investigation is not a prerequisite for continuing payments to be indicative of a lack of materiality. In D’Agostino v. ev3, Inc., 845 F.3d 1, 7 (1st Cir. 2016), in affirming the dismissal of a complaint the First Circuit held that the “fact that [the government] has not denied reimbursement for [the defendant] in the wake of [the relator’s] allegations casts serious doubt on the materiality of the fraudulent representations.” (Emphasis added.) In concluding materiality had not been pleaded, the Third Circuit found important the government’s continued payments to and lack of action (and intervention) against the defendant after the alleged misinformation had been disclosed to the government. United States ex rel. Petratos v. Genentech Inc., 855 F.3d 481, 490 (3d Cir. 2017). And in Coyne v. Amgen, Inc., 717 F. App’x 26, 29– 16
Appendix Volume 2, p. 445
Case: 18-60746
Document: 00514875241
Page: 24
Date Filed: 03/15/2019
30 (2d Cir. 2017), the Second Circuit held the government’s continued reimbursements after awareness of potentially inaccurate information demonstrated immateriality. In United States ex rel. Harman v. Trinity Industries, Inc., 872 F.3d 645, 662– 63 (5th Cir. 2017), although reviewing a jury verdict, this Court drew from the “wellconsidered opinions” of D’Agostino and Petratos “the lesson” that “continued payment by the federal government after it learns of the alleged fraud substantially increases the burden on the relator in establishing materiality.”4 (Emphasis added.) And although predating Escobar, in United States ex rel. Stephenson v. Archer Western Contractors, LLC, 548 F. App’x 135, 138–39 (5th Cir. 2013), this Court held materiality was not established where the government continued paying even though it was aware of the defendants’ noncompliance. Third, even if all of those cases were ignored and the Division of Medicaid and federal government’s continued contract renewals and payments despite awareness of Porter’s allegations were discounted, that would, at best, negate strong inferences of immateriality; it would not go the opposite direction and suggest materiality.
4
Harman also looked to United States ex rel. McBride v. Halliburton Co., 848 F.3d 1027, 1034 (D.C. Cir. 2017), a summary judgment case where the District of Columbia Circuit found it noteworthy that, before the government’s investigation, the defendant continued receiving an award fee for exceptional performance “even after the Government learned of the allegations.” (Emphasis added.) 17
Appendix Volume 2, p. 446
Case: 18-60746
Document: 00514875241
Page: 25
Date Filed: 03/15/2019
iii. Escobar II Porter insists that because the First Circuit on remand in United States ex rel. Escobar v. Universal Health Services, Inc., 842 F.3d 103 (1st Cir. 2016) (hereinafter Escobar II) concluded sufficient facts had been pleaded respecting materiality, the district court’s decision here was erroneous. (Appellant’s Br. 36–38.) The facts of Escobar II are quite egregious and, in any event, poles apart from those Porter has pleaded. There, MassHealth (the Massachusetts Medicaid program) had passed regulations specifically requiring clinical mental health positions like psychiatrists, psychologists, and social workers to hold certain licenses and possess particular levels of education. 842 F.3d at 107. Compliance with MassHealth’s regulatory regime was an express condition of payment. Id. at 110. Four of the five staff members who treated the Relators’ decedent lacked the specified qualifications. Id. at 108. Two were counselors who had no licenses; another held herself out as a psychologist with a Ph.D., but actually had received instruction from an unaccredited internet college and had her licensure application denied by the state; and the fourth was a nurse posing as a psychiatrist and prescribing medicine. Id. The Relators’ daughter died from a seizure as a result. Id. One of the unlicensed counselors and 22 other employees of the defendant had fraudulently obtained and used National Provider Identification numbers that were used to submit Medicaid reimbursement 18
Appendix Volume 2, p. 447
Case: 18-60746
Document: 00514875241
Page: 26
Date Filed: 03/15/2019
claims. Id. The First Circuit determined materiality had been adequately pleaded for the following reasons. First, and unlike here, payment was expressly conditioned upon compliance with MassHealth’s licensing regulations. Id. at 111. Second, unlike the general nursing practice statutes and regulations Porter belatedly discusses in her Brief (but that were not included in her amended complaint), those regulations were adopted by the Massachusetts Medicaid agency to apply to clinical Medicaid providers and to explicitly require those providers to have certain credentials. Id. That fact, said the court, “strongly counsels in favor of a finding that compliance with these regulations is central to the state’s Medicaid program and thus material to the government’s payment decision.”
Id.
By contrast, as discussed below, the
Mississippi regulations Porter now attempts to rely on were not promulgated by the Division of Medicaid and do not specify that any case managers (much less Magnolia’s non-clinical ones) must have an RN degree. Last, and also contra here, there was no allegation MassHealth continued paying the defendant’s claims after learning of its noncompliance, which would have been strongly indicative of immateriality. Id. at 112. Because of its marked dissimilarity from the facts pleaded by Porter, Escobar II is of no aid to her. iv. Porter’s resort to intuition Against the background of a complaint devoid of any suggestion the 19
Appendix Volume 2, p. 448
Case: 18-60746
Document: 00514875241
Page: 27
Date Filed: 03/15/2019
government’s payment was subject to influence by Magnolia’s alleged noncompliance (but on the contrary alleging the government was aware and continued to pay and re-up the contracts), Porter appeals to intuition, asking in the context of “health care services for those who cannot afford them” where lack of qualifications “could be harmful–even fatal”: “What could be more material to a decision to pay someone for a medical assessment or diagnosis, or come up with a plan for treatment” than that the person be minimally qualified? (Appellant’s Br. 41, 42.) But no court has ever drawn such a bright line. The Supreme Court had the perfect opportunity in Escobar, which involved the lack of licensure in the clinical healthcare (not the non-clinical administrative, as here) Medicaid context. It did not do so, holding instead that the demanding materiality standard is about “likely behavior,” not labels. 136 S. Ct. at 2002. As just discussed, neither did the First Circuit on remand in Escobar II, instead basing its conclusion on the plaintiffs’ pleading (contra here) of (1) the express conditioning of payment on (2) compliance with regulations enacted by the Medicaid agency (3) that explicitly required certain licenses for specific clinical positions. 842 F.3d at 110–11. Also unlike here, the state Medicaid agency did not continue making payments to and contracting with the defendant after learning of noncompliance. Id. at 112. Moreover, in some states, LPNs can serve as case managers for Medicaid
20
Appendix Volume 2, p. 449
Case: 18-60746
Document: 00514875241
Page: 28
Date Filed: 03/15/2019
enrollees.5 It is implausible that the government’s payment decisions respecting Mississippi’s Medicaid program could turn on the provision of case management services by those qualified, vel non, as RNs while LPNs render case management services to Medicaid enrollees in other states. By Porter’s reasoning, surely failing to adequately train physicians on the use of materials used in brain surgery and not reporting defective batches of those devices to the FDA would be so important to the government’s decision to pay as to be material, right? Not so. D’Agostino, 845 F.3d at 7. How about suppressing data about a cancer drug’s severe adverse side effects? No. Petratos, 855 F.3d at 485– 86, 490. Those cases illustrate the point quite well: compliance requirements that may subjectively appear important to the beholder may not be the basis of the bargain for the government payer. Such outcomes should not be surprising; indeed, they both implement and bear witness to Escobar’s ratcheting of materiality to a “rigorous” and “demanding” standard. 136 S. Ct. at 2002, 2003. D. The district court appropriately determined Exhibits I, J, K, M, N, and O were irrelevant to materiality. Porter contends the district court failed to give due regard to Exhibits I, J, K,
5
See, e.g., CODE ARK. R. § 016.06.10-213.480 (“qualified case managers…shall be licensed in the state of Arkansas as a Social Worker, Registered Nurse or Licensed Practical Nurse”) (emphasis added); 22 CAL. CODE REGS. § 51272 (case managers for “high-risk persons” enrolled in state’s Medicaid program include persons “certified as a…Licensed Vocation Nurse”); VT. ADMIN. CODE § 12-7-74:7412.1(a) (nursing care management for enrollees with complex needs “shall be provided by a Registered Nurse or Licensed Practical Nurse”) (emphasis added). 21
Appendix Volume 2, p. 450
Case: 18-60746
Document: 00514875241
Page: 29
Date Filed: 03/15/2019
M, N, and O to the amended complaint. (Appellant’s Br. 51–58.) Though she does not dispute the district court’s point that none were part of the MississippiCAN contracts, Porter believes each is an “admission against interest” and suggestive of materiality. (Appellant’s Br. 52.)
But because she does not allege any of those
items were ever presented the Division of Medicaid or the federal government (via contractual promise or otherwise), they cannot constitute predicate false claims or statements that caused the government to pay money. Abbott, 851 F.3d at 387 (falsehoods must have “caused the government to pay out money or to forfeit moneys due”). In any event, none of the exhibits are germane to materiality. Exhibit I was a page from Magnolia’s 2011 policy and procedure manual that defines the term “case management” as “a coordinated set of activities conducted for individual patient management of serious, complicated, protracted, or other health conditions.” (ROA.806) (emphasis added). The document also discusses a plan of care the case manager will develop. (ROA.806.) It is unclear how the plan of care and Magnolia’s internal (and quite broad) definition of case management could be indicative of the centrality, vel non, of case management staffing to the contracts and thus likely to influence the government’s payment decision. Ditto for Exhibit J, a 2010 internal policy from Magnolia stating that an “RN case manager” is one of several members of the “Integrated Care Team.” 22
Appendix Volume 2, p. 451
Case: 18-60746
Document: 00514875241
Page: 30
Date Filed: 03/15/2019
(ROA.807.) That document at most shows Magnolia undertook (whether voluntarily or contractually) to staff some case manager spots with RNs. But it simply has no bearing on whether staffing of the positions with RNs went to the very essence of the bargain underlying the MississippiCAN contracts. Exhibit K is a 2016 employment advertisement from Centene (not Magnolia) for a “Supervisor, Case Management” position that indicates “RN Required.” (ROA.808.) Even if it were a Magnolia document, at best it shows the company recruited RNs as case manager supervisors. Even assuming that desire derived from the contracts or legal provisions, that would go to Magnolia’s knowledge. But it is not indicative of whether RN case management staffing was so important as to be capable of influencing the government’s decision to pay. Exhibit N is an excerpt from Magnolia’s enrollee handbook indicating that “[o]ur care managers are registered nurses or social workers.”
(ROA.814.)
Similarly, a 2013 PowerPoint slide from Magnolia stating “Case Managers are registered nurses” was Exhibit O. (ROA.815.) Again, as with the other exhibits just discussed, Porter does not allege those statements were made to the government or the Division of Medicaid. Perhaps they have relevance to the scienter element, but they do not speak one way or the other as to whether the supposed requirement that RNs be case managers would have potentially affected the government’s payments. Exhibit M is a telenursing frequently asked question from the Mississippi 23
Appendix Volume 2, p. 452
Case: 18-60746
Document: 00514875241
Page: 31
Date Filed: 03/15/2019
Board of Nursing’s website that says “case management (on site and telephonic) [is] not within the scope of practice of the licensed practice nurse in Mississippi. They are within the scope of practice of the registered nurse.” (ROA.313, ROA.813; R.E. Tabs 1, 6.) There is no indication this statement has legal effect or that it was derived from statutes and regulations the Board of Nursing has the authority to interpret and promulgate.
Although Porter says the provision “condenses the statutes and
regulations regarding standards of practice between the RN and the LPN” (Appellant’s Br. 55), nowhere in the amended complaint does she identify the purportedly underlying statutes and regulations. Regardless, assuming arguendo the FAQ carries the force of law, that would go the falsity element, not materiality. As the Supreme Court recognized in Escobar, “billing parties are often subject to thousands of complex statutory and regulatory provisions,” but the materiality of compliance with each such provision is a separate, exacting inquiry. 136 S. Ct at 2002. The mere facts the FAQ exists and Magnolia allegedly did not comply with it say nothing about their importance to, and potential influence on, the government. In sum, because none of these exhibits pertain to materiality, the district court appropriately did not include them in its decisional calculus. E. The district court did not err in concluding Porter’s proposal to re-amend the complaint to include Mississippi statutes and regulations concerning nursing practice would have been futile. Footnotes 32 and 33 of her response opposing the motion to dismiss were the 24
Appendix Volume 2, p. 453
Case: 18-60746
Document: 00514875241
Page: 32
Date Filed: 03/15/2019
only instances where Porter asked for leave to re-amend the complaint should Magnolia’s motion be granted. (ROA.884; R.E. Tab 7.) And those requests were limited to the Mississippi nursing practice statutes (MISS. CODE ANN. §§ 73-15-1, et seq.) and two chapters of the Board of Nursing’s regulations (CODE MISS. R. §§ 3018-2830:1–2).6 (ROA.884; R.E. Tab 7.) Porter did not seek leave in the district court to include the Position Statement (discussed on pages 17–18 of her Brief) or anything else beyond the aforementioned statutes and regulations, so she has waived those issues.7 Celanese Corp. v. Martin K. Eby Const. Co., 620 F.3d 529, 531 (5th Cir. 2010) (arguments not raised in district court are waived and not considered on appeal); Thomas v. Chevron U.S.A., Inc., 832 F.3d 586, 590 (5th Cir. 2016) (“A movant is required to give the court some notice of the nature of his or her proposed amendments.”). Adding the nursing practice statute and regulations would not have enabled Porter to plead materiality. One statute differentiates an RN’s practice from an LPN’s mainly by looking to the level of knowledge of “biological, physical, behavioral, psychological and sociological sciences” involved. MISS. CODE ANN. §
6
Porter says she would have pleaded these authorities had Escobar been handed down before she filed her original and amended complaints. But she does not explain why she did not seek leave to so amend in the 11 months between Escobar (June 2016) and her issuance and service of the summons (May 2017). (ROA.4.) 7
Even if waiver were not found, Porter does not say nor is it apparent that the Position Statement from the Board of Nursing would have been legally binding on Magnolia. In any event, like the statutes and regulations Porter now mentions, it is not indicative of materiality. 25
Appendix Volume 2, p. 454
Case: 18-60746
73-15-5(2), (5).
Document: 00514875241
Page: 33
Date Filed: 03/15/2019
The RN’s knowledge of those items is characterized as
“substantial,” while an LPN’s is “basic.” Id. Porter contends that because the RN’s practice, unlike the LPN’s, includes “assessment, diagnosis, planning, intervention, and evaluation,” “LPNs cannot legally perform them.” Id.; Appellant’s Br. 14. The regulations are similar, although LPNs are permitted to assist RNs with “[c]onducting focused nursing assessments” and otherwise “[p]eform[] nursing procedures and activities” for which they have “the necessary degree of knowledge, skill, and judgment.” CODE MISS. R. § 30-18-2830:1.2(F); Id. § 30-18-2830:2.3(D), (E). Under the contracts, the non-clinical case management services to be performed telephonically by in-house personnel at Magnolia include scheduling, referrals, documentation of services provided, discharge planning, risk assessments, patient education, encouragement regarding lifestyle changes, and coordination of services. (ROA.307 through ROA.312, ROA.394 through ROA.396, ROA.497 through ROA.498, ROA.671 through ROA.676, ROA.809 through ROA.810; R.E. Tabs 1, 2, 3, 4, 5.) There is no indication diagnostic or intervention services were job duties. Under the regulations, LPNs are permitted to perform assessments with appropriate supervision, as well as any other activities for which they possess adequate knowledge, skill, and judgment. And under the statutes, while LPNs may not have substantial knowledge of the stated sciences, they do have basic knowledge. 26
Appendix Volume 2, p. 455
Case: 18-60746
Document: 00514875241
Page: 34
Date Filed: 03/15/2019
Scheduling appointments, coordinating referrals, documentation and coordination of services, and like tasks hardly connote more than a modicum of requisite knowledge. Porter even admits that such tasks “could be performed by anyone.” (Appellant’s Br. 11.) So even if Magnolia employed LPNs as case managers to render some services for which they were qualified but others for which they were insufficiently qualified, any non-compliance was a matter of degree rather than outright. For that reason, the “guns that don’t shoot analogy” from Escobar, which actually addressed scienter rather than materiality, misses the mark. But assuming Porter’s reading of those provisions is correct and that LPNs were legally incapable of many performing case management tasks, nothing changes. At best, the statutes and regulations are germane to the falsity element. They give no insight about whether staffing of non-clinical, mainly telephonic case management positions was the heart of the bargain of the MississippiCAN contracts for clinical healthcare services that had an annual value in the hundreds of millions of dollars, and thus whether the government’s payments may have been influenced. Accordingly, the district court did not err in concluding Porter’s proposed amendment would have been futile. Conclusion For the foregoing reasons, the district court’s judgment should be affirmed.
27
Appendix Volume 2, p. 456
Case: 18-60746
Document: 00514875241
Date: March 15, 2019
Page: 35
Date Filed: 03/15/2019
Respectfully submitted, MAGNOLIA HEALTH PLAN, INCORPORATED Defendant-Appellee
By:
/s/John B. Howell III John B. Howell III WATKINS & E AGER PLLC 106 Madison Plaza, Suite C Hattiesburg, Mississippi 39402 601.264.4499 jhowell@watkinseager.com Timothy L. Sensing WATKINS & E AGER PLLC 400 East Capitol Street Jackson, Mississippi 39201 601.965.1900 tsensing@watkinseager.com
28
Appendix Volume 2, p. 457
Case: 18-60746
Document: 00514875241
Page: 36
Date Filed: 03/15/2019
Certificate of Service I certify that today I filed the foregoing Brief of Defendant-Appellee Magnolia Health Plan, Incorporated with the Court’s CM/ECF system, which sent notice of the filing to all counsel of record and interested persons registered to receive service. Date: March 15, 2019
/s/John B. Howell III John B. Howell III
29
Appendix Volume 2, p. 458
Case: 18-60746
Document: 00514875241
Page: 37
Date Filed: 03/15/2019
Certificate of Compliance with Rule 32(a) Certificate of Compliance with Type-Volume Limitation, Typeface Requirements, and Type Style Requirements 1.
2.
This brief complies with the type-volume limitation of Federal Rule of Appellate Procedure 32(a)(7)(B) because: x
this brief contains 6,282 words, excluding parts of the brief exempted by Federal Rule of Appellate Procedure 32(a)(7)(B)(iii), or
â–Ą
this brief uses a monospaced typeface and contains ___ lines of text, excluding the parts of the brief exempted by Federal Rule of Appellate Procedure 32(a)(7)(B)(iii).
This brief complies with the typeface requirements of Federal Rule of Appellate Procedure 32(a)(5) and the type style requirements of Federal Rule of Appellate Procedure 32(a)(6) because: x
this brief has been prepared in a proportionally spaced typeface using Microsoft Word Version 14.0 in Times New Roman 14, or
â–Ą
this brief has been prepared in a monospaced typeface using Microsoft Word, Version 14.0 with ___ characters per inch and Times New Roman.
Date: March 15, 2019
/s/John B. Howell III John B. Howell III
30
Appendix Volume 2, p. 459