Presentation to OVHA

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APS Healthcare, Inc.Maine Behavioral Health
Administrative Services Organization
October 2007
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Discussion Agenda

• Introductions
• Presentation Overview
• APS Overview
• Company Overview
• Operational Capacity
• Public Programs Division
• Maine Project Overview and Frequently Asked
  Questions
• APS CareConnection
• Conclusion and QA

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APS Introduction
APS Is A National Specialty Healthcare Company
Offering Market Leading Care Management And
Behavioral Health Services

• Broad offering of Care Management and Behavioral
  Health services
• Proven programs that improve healthcare delivery
• Customized to meet client needs
• Award-winning program design/delivery model
• Stand-alone and integrated programs
• Company tagline Healthy Together symbolizes
  vision of integrated care across the spectrum of
  health and partnering administrative
  organizations
• Diverse client mix covering over 20 million
  members
• 18 Medicaid agencies representing 40 of total
  U.S. Medicaid population
• 6 additional state employee or Medicaid managed
  care state programs
• 18 health plans
• 948 employers and employer groups
• Strong infrastructure/processes to support
  continual quality improvement

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Discussion Agenda

• Introductions
• Presentation Overview
• APS Overview
• Company Overview
• Operational Capacity
• Public Programs Division
• Maine Project Overview and Frequently Asked
  Questions
• APS CareConnection
• Conclusion and QA

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APS Service Overview
APS Program Portfolio
Care Management
Behavioral Health
Definition
Range of Services
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APS Overview Behavioral Health
Managed Behavioral Health
Employee Assistance Program

• Third-largest independent provider of MBH
  services
• 87 customers
• 3.4 million covered lives

• 870 customers
• 2.6 million covered lives
• 2002 and 2004 recipient of the Employee
  Assistance Professionals Association (EAPA)
  Quality Award for EAP excellence

Key Highlights

• Mix of customized services to meet client needs
• Full service programs
• National network of over 20,000 providers
• Strong focus and expertise in managing cost of
  care and providing high quality clinical programs
• Innovative approaches based on Care Management
  techniques

• Mix of customized services to meet client needs
• Full service programs
• High quality clinical programs
• Clinical first model
• 100 follow-up
• Comprehensive service offering
• National network of nearly 6,000 providers

Program Approach
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Discussion Agenda

• Introductions
• Presentation Overview
• APS Overview
• Company Overview
• Public Programs Division
• Maine Project Overview and Frequently Asked
  Questions
• APS CareConnection
• Conclusion and QA

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APS Overview Public Programs Management Team
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APS Public Programs Our State Contracts
Today, APS Serves 20 Medicaid Customers That
Provide Healthcare Coverage To Over 40 Of The
Medicaid Population
WA
ME
MT
VT
ND
OR
MN
NH
ID
MA
WI
NY
SD
MI
WY
RI
CT
PA
IA
NE
NJ
NV
OH
MD
UT
IN
DE
IL
CO
WV
CA
VA
2006 Additions
KS
MO
KY
OklahomaMissouriNew JerseyNew York
NC
TN
OK
AZ
NM
AR
SC
GA
AL
MS
2007 Additions
TX
LA
Vermont Georgia Alabama Tennessee Maine
Hawaii
FL
2007
PR
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APS Public Programs State of Maryland ASO

• 14.9 million program for the Maryland Public
  Mental Health System (PMHS)
• Services include prior authorization, utilization
  management, inspection of care
• 5 year contract (started in 2004) with two 1 year
  renewal options

Program Overview

• Serves behavioral health population carved out
  from Managed Care Organizations
• Extensive provider outreach and training
• Strong partnerships with local providers and
  community resources
• Includes claims processing through subcontractor
  ACS

Key Features

• Dedicated service center in Baltimore
• Staffed by Marylanders with behavioral health
  provider experience
• Member services, provider services, utilization
  management, quality improvement

Operating Model

• APS CareConnection
• Over 600,000 member records in system
• Auto-adjudication of gt50 of review request

Information System
Inducted as a Fellow into the Community
Behavioral Health Association of Maryland in
2005
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APS Public Programs West Virginia Behavioral
Health ASO

• Program for the West Virginia Department of
  Health and Human Resources
• Requirements include prior authorization,
  utilization management, member services, provider
  services, quality management
• Contract implemented in 2000 and extended through
  2008

Program Overview

• Serves behavioral health population
• Expanded to include Title XIX MR/DD Consumer
  Budgeting Model
• Consistent, high levels of provider satisfaction

Key Features

• Dedicated service center in Charleston, West
  Virginia
• Staffed by West Virginians with behavioral health
  experience
• Includes Consumer Advisory Committee

Operating Model

• APS CareConnection
• Internet-based no provider purchases required
• Auto-adjudication of review requests are enabled

Information System
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APS Public Programs Oklahoma Medicaid QIO

• Program for the Oklahoma Health Care Authority
• Requirements include prior authorization,
  continued stay review retrospective review of
  medical care, quality improvement
• Contract implemented in 2006 for three years

Program Overview

• Serves behavioral health population
• 24/7 Prior Authorization review for acute care
  for children
• Maintenance of open bed status list via
  www.SoonerPRO.com
• Implementation of prior authorizations for CMHCs
  in July 2007

Key Features

• Dedicated service center in Oklahoma City,
  Oklahoma
• Staffed by Oklahomans with behavioral health
  experience
• Inspection of Care onsite at hospitals and CMHCs

Operating Model

• APS CareConnection
• Internet-based no provider purchases required
• Auto-adjudication of review requests are enabled

Information System
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APS Public Programs Georgia External Review
Organization

• Program for the Department of Human Resources,
  Division of Mental Health, Developmental
  Disabilities, Addictive
• Requirements include provider training and
  technical assistance, on-site audits
• Flagship APS Behavioral Health program awarded in
  1999 and continuously extended

Program Overview

• Serves behavioral health population
• Both child and adult populations are included
• Addresses mental illness, addictive disease, and
  developmental disabilities

Key Features

• Dedicated service center in Atlanta, Georgia
• Staffed by Georgians with behavioral health
  experience
• Formal Quality Improvement process driven by
  members and their families, providers, and state
  policy makers.

Operating Model

• APS CareConnection
• Internet-based no provider purchases required
• Auto-adjudication of review requests are enabled

Information System
Since inception, increased people served by 12
each year, lowering expenditures to 1997 levels.
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A Sample of APS Best Practices and Lessons
Learned

• Provider Advisory Committee
• Systematic access to development of criteria,
  review processes, and provider support.
• Member Advisory Committee
• Ensuring member input into development of
  criteria, review processes, and provider
  feedback.
• Quality Improvement Opportunities
• Data driven, using information collected from
  service records, requests, claims, grievances,
  and member/provider priorities.
• Auto-adjudication
• Automated review of provider requests meeting
  DHHS criteria for automatic processing.
• Reduces provider burden, speeds approvals, MECMS
  updated with authorizations manually.

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Discussion Agenda

• Introductions
• Presentation Overview
• APS Overview
• Company Overview
• Operational Capacity
• Public Programs Division
• Maine Project Overview and Frequently Asked
  Questions
• APS CareConnection
• Conclusion and QA

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APS Public Programs Commitment to Maine Program

• Transparency
• Member and Provider Advisory Committees
  collaborates on all aspects of operations.
• APS CareConnection enhances transparency of
  review process and status of reviews for
  providers and MaineCare.
• Shared Results
• Between stakeholders in Maine, including
  MaineCare, providers, associations, and members
  resiliency, recovery, community integration.
• Between programs, bring best practices and
  lessons learned to Maine from APS programs in
  other states.
• Flexibility
• Listen and learn from all stakeholders.
• Adapt and evolve a hallmark of APS.
• Full Service ASO
• Member services, Provider Representatives,
  Consumer Liaison, Utilization Reviewers, Quality
  Management staff.
• Person-centered focused on the individual and
  working to promote quality of life and safe
  integration with community.
• Collaboration
• MaineCares partner at the table to plan and
  assist.
• Local service center is integral to the
  community Maine citizens working for Maine

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APS Public Programs Maine Behavioral Health ASO

• Program for the Maine Department of Health and
  Human Services
• Requirements include prior authorization,
  utilization management, member services, provider
  services, quality management
• 23 month contract started September 1, 2007 with
  possibility of two 1 year renewals

Program Overview

• Serves behavioral health population
• Extensive provider outreach and training
• Strong partnerships with local providers and
  community resources
• Includes data entry into MECMS for provider
  authorizations

Key Features

• Dedicated service center in Portland, Maine
• Staffed by Mainers with behavioral health
  experience
• Member Advisory Committee, Provider Advisory
  Committee, Consumer Liaison

Operating Model

• APS CareConnection
• Internet-based no provider purchases required
• Auto-adjudication of review requests will be
  enabled
• Telephone review requests supported (fax is
  supported but not preferred)

Information System
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APS Public Programs Overview of Maine Program

• Prior Authorization
• 11 Services require prior authorization by APS.
• Acute services not subject to prior
  authorization.
• 24/7 Availability of reviewers for provider and
  member access.
• Utilization Management
• All 28 Services or Service Groupings require
  continued stay review.
• 65MN Services
• No changes in requirements.
• DHHS will support until transition to ASO
• Provider Services
• Provider Services Manager and Reps provide
  support and respond to questions.
• Regional training conducted annually.
• Member Services
• Information available on website and through call
  center.
• Quality Management
• Quality assurance and improvement functions.
• Grievance and appeal support.

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APS Public Programs Services to be Reviewed
Maine ASO
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APS Public Programs Services to be Reviewed
Maine ASO
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APS Public Programs Services to be Reviewed
Maine ASO
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APS Public Programs Services to be Reviewed
Maine ASO
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APS Public Programs Services to be Reviewed
Maine ASO
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Overview of Maine Review Process
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APS Proposed Local Service Center In Maine, For
Maine
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Operations for Maine ASO Where do we start?

• Go Live will be December 1, 2007
• Specific Program Requirements and Operational
  Details will be provided in November 2007.
• Provider Training will also be offered in
  November 2007
• Regional on-site training in 4 locations in
  Maine.
• Web-based Training will be offered through
  November and December relative to go live
  questions and support.
• Provider Services Representatives will be
  available for telephone support.
• Extensive feedback and clinical support available
  to providers after go-live to ensure continuity
  of services and claims processing.
• Five data entry staff dedicated to claims in
  addition to review staff.

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APS Public Programs Collaboration Is The Way We
Work

• APS is reaching out in communications, meetings
  and calls to Maine providers and consumers and
  other stakeholders to
• Develop and maintain collaborative working
  relationships with all stakeholders
• Explain our approach to utilization management
  and review.
• Discuss various methods for collaboration
  including participation in meetings, joint
  communications and participation in APS Advisory
  Committees.
• Ensure that the implementation of the ASO is
  successful for all stakeholders

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Maine Behavioral Health ASO - FAQs

• What is APS philosophy of utilization review?
• APS works with providers and members to approve
  the right services, in the right setting, to
  promote member recovery and ability to live in
  the community.
• Why should providers use APS CareConnection to
  submit registration and review data?
• Reduces administrative burden for providers both
  for clinical review process and for billing,
  compared to other review methods.
• Much more secure than faxing
• For some services, CareConnection allows
  auto-adjudication that streamlines the review
  process significantly
• What has been APS's experience in using
  Residential Treatment Centers or facilities in
  other states?
• APS works with Residential Treatment Centers
  (RTCs)/Residential Treatment Facilities (RTFs)
  in several states Arkansas, Oklahoma, Georgia,
  Maryland, West Virginia which provide similar
  services as Private Non-Medical Institutions in
  Maine.

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Maine Behavioral Health ASO - FAQs

• How has managed care worked in other states for
  treatment foster care and for residential care?
• In some cases TFC and PNMI care is prior
  authorized in others only continued stays are
  reviewed.
• APS conducts review the same way for these
  facilities as it does other providers reviewing
  Individual Service Plans and approving medically
  necessary services based on criteria that is
  approved by the State Agency with input from
  affected providers.
• Will APS work from an outcome performance
  perspective and if so, how does that work?
• We are interested in both individual and system
  level outcomes.
• Individual outcomes include, for example
• Reduction in hospitalizations and readmissions.
• Continuity of treatment.
• Ambulatory follow-up after hospitalization.
• Reduction in Emergency Department visits.
• Avoidance of justice system involvement.

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Maine Behavioral Health ASO - FAQs

• Will APS work from an outcome performance
  perspective and if so, how does that work?
  (Continued)
• We are interested in both individual and system
  level outcomes.
• System level outcomes include, for example
• Development and spread of successful models, such
  as Peer Support.
• Member and provider satisfaction with access to,
  and quality of, services.
• Identification and adoption of best practices.
• How does APS evaluate the quality of service
  delivery?
• APS works with Provider and Member Advisory
  Committees to identify specific performance
  measures for the system dashboard.
• APS uses utilization, eligibility, and
  provider-reported data to create dashboard
  measures measures that stakeholders can use to
  determine if were going in the right direction.
• APS publishes the dashboards on a quarterly,
  semi-annual, or annual basis so that stakeholders
  can see for themselves if quality is improving.
• APS and the community will identify and conduct
  projects to improve the quality of services
  evidence-based, safe, effective, efficient,
  person-centered, equitable.

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Discussion Agenda

• Introductions
• Presentation Overview
• APS Overview
• Company Overview
• Operational Capacity
• Public Programs Division
• Maine Project Overview and Frequently Asked
  Questions
• APS CareConnection
• Conclusion and QA

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APS CareConnection - Overview

• APS CareConnection is a healthcare management
  system...
• developed by APS to support its utilization
  review, care management, and disease management
  applications.
• Web-based no special software or hardware
  required for desktop access.
• Base application is configured for use in local
  service centers.
• Creates a transparent environment for APS,
  clients, providers, and members to share
  information.
• HIPAA compliant and secure
• Currently in use for 13 programs in 12 states.

APS CareConnection Applications
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Discussion Agenda

• Introductions
• Presentation Overview
• APS Overview
• Company Overview
• Operational Capacity
• Public Programs Division
• Maine Project Overview and Frequently Asked
  Questions
• APS CareConnection
• Conclusion and QA

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Contact Information

• Full information to reach APS Healthcares Maine
  ASO program will be distributed as soon as
  available.
• This information will include staff names, phone
  numbers, fax numbers and email addresses.
• In the meantime, if you have any questions,
  please contact Kelly Bickmore, Provider Relations
  Manager at
• kbickmore_at_apshealthcare.com