Case Study: Toney Health Insource Partnership Case Management
Toney Healthcare was engaged to provide our Case Management expertise and operational services via our Insource Partnership model for a large mission-driven health plan (over 2 million lives). Our focus was on instituting best practices, improving CMS and state compliance, and providing expert clinical leadership and nurse case manager resources to support the plan’s case management department.
Medicare Advantage: Dual Eligible cases: Support CMS audit readiness, meet compliance standards and assume responsibility for hundreds of previously unmanaged cases
Medicaid cases: Address a backlog of cases required to meet state Medicaid contract terms and audit compliance standards
1500 MA/Duals cases in 5 months
Unmanaged cases managed and brought into compliance
135 high risk
Caseload per clinician
>1000 Medicaid cases in 3 months
Backlogged cases brought into compliance
99.89%
catch up completion rate by target date
The Problems
The health plan's delegated CM vendor was underperforming and did not meet audit standards, requiring the health plan to assume responsibility for the cases.
The health plan had difficulty in addressing CMS and state Medicaid audit failures and mandated improvement plans due to: frequent management and supervisory turnover, inadequate staffing, and recruiting and training challenges.
Inconsistent policies and procedures (P&Ps), with frequent changes in attempts to address process and quality gaps, added issues that had to be resolved for future audits and for high quality program delivery.
The backlog grew to over 1000 cases identified over a two year period without outreach and engagement attempts.
The Solution
Through our Insource Partnership model, a dedicated, highly experienced Toney Healthcare Case Management team was deployed to address case management concerns in a SWAT-like manner, quantifying needs and gaps, and executing with flexibility as priorities changed. The team, led by Toney senior managers, was not delegated, but rather integrated within the plan's clinical operations. They worked on the health plan’s system, and followed and improved P&Ps, workflows and documentation requirements. Phase details follow.
Phase I: Medicare Advantage / Dual Eligible Cases
After failing a CMS audit, the client asked Toney Healthcare to step in to take over for a previously delegated entity. The goal was to bring all cases to passing standard within a five-month time frame. This included outreach, engagement, development of member-centric care plans, conducting Interdisciplinary Care Team meetings, and overall care coordination and management of approximately 1500 cases, none of which were previously outreached or managed. Given the complexity of the dual eligible population, the Toney Healthcare CM team successfully accomplished the tremendous task within the extremely tight timeline. The Toney Healthcare team successfully remediated the cases, completing 99.89% by a specified target date (the final case was completed shortly thereafter).
Throughout the project, the Toney CM team also participated in department staff meetings and process updates.Leadership provided advisory support by way of P&P improvements and training enhancements. They also supported planning for the integration of case management and disease management programs to meet NCQA standards as committed to by the client in their approved Model of Care (MOC).
Toney team managed nearly 1500 MA/Dual Eligible cases and over 1000 Medicaid cases.
Phase II: Medicaid Case Backlog
The Toney CM team seamlessly transitioned to the client’s Medicaid line of business where there was a backlog of over 1000 cases dating back a few years. Members had been identified for case management but had not been attempted for engagement. The team engaged and intervened with these members, all high risk and complex cases, following best clinical practices and compliance standards.
Initially, the team was assigned to remediate the backlog while the client’s own staff handled newly identified cases. However, due to performance challenges and need for high quality case management, the Toney Healthcare team was also asked to assume responsibility for all cases for a period of time to address the client’s shortfall in managing new cases in a timely manner. The design of the Insource Partnership model meant that Toney Healthcare handled all resourcing and performance management of the team, allowing the client to focus on other aspects of their healthcare services.
All Toney-managed cases were compliant and audit ready. The Toney team continues to provide best practices in the Medicaid line of business today.
Summary
Toney Healthcare was engaged by a large health plan serving over 2 million members across Medicaid, Medicare and Dual Eligible populations. The plan specifically needed case management advisory services and clinical operational support. Toney Healthcare provided significant expertise and best practices to the engagement, working nearly 2500 cases within an 8-month timeframe, and helping the plan to meet clinical assurance and compliance requirements in preparation for CMS and state Medicaid audits. Toney Healthcare leadership audited cases for all Toney case managers on a monthly basis and provided training and coaching as part of a plan to increase audit performance.
The Toney team was highly regarded and appreciated for their ability to apply their expertise to improve the health plan’s performance and attain a higher quality service level for members while meeting audit and regulatory compliance requirements.
The Toney Healthcare team subsequently managed a backlog of nearly 5000 Disease Management (DM) cases in support of the health plan’s aforementioned initiative to integrate the CM and DM programs to meet NCQA MOC standards.
