ATTENTION:
If you have any questions / comments / concerns about the Budget Cut issues we are currently
dealing with, and you don't currently see it listed on this page, please send an email to
BudgetCutFAQ@smokymountaincenter.com and include as much information as you can so we can
answer your request.
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Q: Are respite services being cut?
A: There will be no authorizations for hourly respite for NEW consumers. (see SMC’s “IMPORTANT MESSAGE RE AUTHORIZATION OF DEVELOPMENTAL DISABILITY SERVICES” communication dated 10/8/09). A “new” consumer is defined as a person without an SMC authorization for Hourly Respite in effect on 10-8-2009.
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Q: Will the rate changes create a need to amend contracts?
A: No, for those services that SMC pays at the Medicaid rate, the contract language in Attachment A stipulates “paid at current Medicaid rate less any applicable co pay.”
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Q: When a current consumer receiving DT/PA/Hourly Respite changes providers will the consumer be considered a “new” consumer?
A: No (see SMC’s “IMPORTANT MESSAGE RE AUTHORIZATION OF DEVELOPMENTAL DISABILITY SERVICES” communication dated 10/8/09). A “new” consumer is defined as a person without an SMC authorization for DT/PA/Hourly Respite in effect on 10-8-2009.
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Q: How does the LME define new consumer?
A: Per SMC’s “IMPORTANT MESSAGE RE AUTHORIZATION OF DEVELOPMENTAL DISABILITY SERVICES” communication dated 10/8/09, a “new” consumer is defined as a person without an SMC authorization for DT/PA/Hourly Respite in effect on 10-8-2009.
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Q: How will families be notified of cuts in services? (ANSWER REVISED 10/13/09)
A: It is the provider’s responsibility to explain this information to consumers and families. SMC received information from the Division of MH/DD/SAS stating that a decrease in services as a result of the LME’s loss of State funding is, in fact, appealable by a consumer or his/her guardian. More information will be presented to providers about this at the upcoming Quarterly Provider Meetings over the next week.
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Q: If reduction in an authorization for a service may jeopardize an individual’s residential placement, will SMC reconsider?
A: Please note this information in the authorization request when submitting to SMC as SMC will listen to this request but can in no way guarantee that services will not be reduced.
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Q: When can we expect SMC's new state funded fee schedule, particularly rates for DT?
A: At this time, SMC is not changing the rate for Developmental Therapy.
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Q: In the new level of care guidelines posted by SMC, for Level of Care B there are no listed services for MR/MI Family Living or Supervised Living Levels 2-6. Is this an oversight or have these services been eliminated for those individuals?
A: Those residential services are in the current and in earlier versions of the SMC Level of Care Guidelines only for consumers in LOC C & D because such higher level services are generally not necessary for consumers at LOC A or B.
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Q: Will the rates for DT, PA, Respite, & Case Management be reduced as of 10/1/09 as the Medicaid fee schedule states? What will the new rates be?
A: At this time, the rates for DT, PA, and Respite are not changing as these are not Medicaid-funded services. The rate paid for IPRS consumers for case management will mirror the Medicaid rate for TCM ($17.67 per 15 minute unit as of 10/1/09).
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Q: What causes delays in getting authorizations approved?
A: The Division’s and Smoky’s standard for routine authorization request turn around time is 14 calendar days. We track requests received & waiting decisions daily, and our reports indicate that this standard is met about 99% of the time. If someone does not receive a response within that timeframe, we request that they contact a Care Manager to inquire about the status of the request. If that does not resolve the issue, please contact Steve Puckett with case specific information & he will investigate.
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Q: Why are there inter-rater reliability problems with plan review, and what is SMC’s internal QA process to ensure as much inter-rater reliability as possible?
A: Inter-rater reliability in reviewing PCPs and in making authorization decisions is an ongoing challenge that we are very mindful of. We work continuously at achieving good inter-rater reliability among Care Managers, but do not claim that we are as good at this as we want to become. Several months ago we implemented standardized criteria for PCP review/approval and for review of medical necessity that we believe are very helpful in standardizing reviews across Care Managers, although there remains an element of clinical judgment in determining whether a service is necessary and in what amount. If someone has examples in which it appears that our inter-rater reliability is low in reviewing PCPs and authorizing services, we would appreciate hearing about those specific situations. Please contact Steve Puckett with such information.
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Q: What is a provider’s recourse when it believes that plan review is at a level that is much too “picky”?
A: Smoky has established uniform guidelines for reviewing plans and for rendering medical necessity decisions for authorization requests (see our review tool posted on SMC’s website: (http://www.smokymountaincenter.com/documents/providers/authinfo/SMC_RoutineAuthRequestReview.pdf). If someone has examples in which it appears that Care Managers have deviated from these standards, please let us know and provide examples to Steve Puckett.
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