Author: Lainey Morrow,
Direct quotations from  Interview with Melissa Stone at her office on October 6, 2016

Today, I was able to meet with Ms. Melissa Stone, Director of Disability Services (a Division of DHS). I gave her some comments from our group; she received your stories of your loved ones and how much they need this therapy. She said DDS intends to respond to all of your comments. I also took our questions, and I was able to get some explanation from Ms. Stone. We all seem to have similar questions, so hopefully this will help you. If nothing else, you may learn what some of the acronyms mean! It was a lengthy conversation, but it’s worth a read. I invite you to comment on the answers given because Ms. Stone has agreed to meet with me again next week. I’d like to take some of your comments back to her.

Kim Reynolds Rush asked, “Is this the only way? Who made this decision?”

Melissa: “This was brought to the division from a workgroup that was made of up representatives from the ARPTA ( Physical Therapy Association), AROTA (Arkansas Occupational Therapy Association), the CHMS (Child Health Management Services), DDTCS (Developmental Day Treatment Clinics), DDPA (a group of providers that provide waiver services), and Early Intervention Providers that provide services through our part C Federal grant. They have been meeting frequently to look at areas within DDS that are lacking in quality control devices, and this was brought to me as an idea of inserting a 90 minute threshold as a way to insert some quality control.”

I don’t have a quote on the context, but I’ll try to paraphrase Ms. Stone:
Cost savings in DHS is happening across the board with the elderly, mental health division, and the therapy services. The Stevens Group was hired to provide a report of many ways that the costs savings could be achieved. The division on aging came up with some internal quality controls to implement without having to involve the public, and the mental health division will see an improved plan next July. The Disability Services sector has proved to be more complicated, but this proposal is an attempt to work with professionals in all therapy fields (otherwise known as the workgroup) to come with realistic cost savings.

“So it seems like budget cuts have to happen, and you’re coming up with a plan to help reduce the budget. Correct?”

Melissa: “That word is going around a lot – the “cut” or “reduce” budget. When Cindy Gillespie got here as the DHS Director, that has not been her focus. Her focus has been about getting good quality services at the right time for the right people and doing more outcome measurements to ensure that what we’re providing works and getting people on services and back on their feet. And I know that doesn’t work specifically for my particular group of clients, the developmental disabled or delayed, but it does on a broader spectrum across DHS services. That has been where she has been trying to shift the focus since she got here. I think we do truly believe that if we offer efficient, early prevention services, that it will actually save us money in the long run. And that’s what we’re trying to focus on, but we also know that we’ve been operating without quality controls in place. This is an example of that – that right now we have a contract in place with AFMC that is a look-back at therapy, and if you look at the contract it’s a 3 month look-back. And what they are looking at is if a prescription is in a file, and if the therapy is in adherence for the past 3 months with that prescription. This 90 minute threshold per discipline per week is a way to better ensure that the prescriptions are being utilized correctly across the board.”

“How will this proposal eventually become a law?”

Melissa: “Public comment ends on October 14 at midnight, and we will take all of the comments, and we’ll group them because a lot of them are kind of similar. And then we’ll give formalized written responses to them, and we’ll put that up on the website. And people have been asking if we’ll directly send them a copy. I don’t think we’ll directly send a copy, but what I’m going to ask is from those sign-in sheets from last night. I’m going to make an email file like a group, and we’ll send out a notice that says they’re up on this website, and this is the link, and this is how you pull them down.”
Lainey: “So that is the response to the Public Comment. Then what?”
Melissa: “Then the way that the state of Arkansas probligation process works is that we go before the legislative committee of public health, which I don’t know if you know this, but Senator Cecille Bledsoe, who was the very attractive woman on the front row, is the chairman of public health. So I was glad that she was there sitting on the front row yesterday. So she and her committee will review the rule. And then there’s a second committee that actually has to review, vote, and pass the rule after that. And that will happen, and I think we’re trying to meet at the very end of October for public health, and then in November, if it’s on track, it will go before that (legislative) committee. Once it does that, because it’s a state plan, it will be a state plan amendment. We actually have to send it to the federal government for the last approval. And they say yay or nay. But I’ll tell you, you’re in the public comment period, and I meant this when I said this yesterday, we’ll look at all of this, and if there’s a substantial change to what we’ve put out the notice of rule makings – if there’s a substantial change to the 90 minutes per discipline per week and say we do something different, it almost stops the clock and starts back over, and then we’ll go through it again. So it could be a long process.”
Lainey: “So some of these questions are hard to answer because you haven’t come to that part in the process. The thing that would concern me is that this (working) group would – like we’re having public comment now – but what about when you’ve kind of come to more decisions?  You know, for example, what if you all come to the decision that the return time on an authorization would be a month? What if the public didn’t like it? What’s their option?”
Melissa: “So there’s a lot of options. So say this rule passes, and everything is ready to go on this. It’s on the books and ready to go July 1. There’s still a whole other process of putting a contractor in place to do the PA (prior authorization) process. That process is just like this process. You have to put the RFP out for public comment, you ask for bids, people bid on it, it goes over to the legislature, the legislature hears about it, reviews it, and has to vote on it. So this whole thing with the PA process will go through almost an identical process on its own next spring.”
Lainey: “And that’s when you’ll determine the time?”
Melissa: “Yes. It’ll be all laid out in the contract. And the legislature votes on our contracts. So we do a lot of checks and balances with them. We really do. I don’t think the general public realizes how much say their state rep and state senator have over how we operate.
Other DDS Representative present: “Yeah, in the RFP, they would put in the required timeframe, and the vendor would have to turn around within, and that would be a performance measure in their contract.”
Lainey: “And if they can’t do it then?”
Melissa: “Then we would usually withhold money or cancel or…”
DDS Rep: “We would have the right to financially punish them or cancel.”
Lainey: “So this question is what tools will these individuals be using to determine that this person is qualified to do that? That would be during this process?”
Melissa: “All of the qualifications will be laid out in the contract.”
Lainey: “So this working group would help to determine the qualifications? And they’re all qualified people themselves, so?”
Melissa: “Right. They’re all clinicians.”

Suzy, a therapy provider, asked, “It has been proven that pre-approvals didn’t work in the past when they were eliminated. What would you change to make it work this time?

Melissa: “Well it was eliminated for the contract that made reference to the AFMC retrospective 3-month look-back. And it was eliminated because there were problems with it. And I think rather than, and I wasn’t here at that time, but rather than fixing those problems, they just went a different route. A lot of the people, a lot of the women, who are on this work group were here when that PA process was in place. In fact, one of the men on that group said, ‘I have that whole PA process on floppy disc drives.’  And we all kind of laughed like, ‘Well, how are we going to get it off?’ And someone said, ‘No, I’ve had them all burned to a disc.’ And I said, ‘Oh, thank goodness.’ So they said we can tell you what worked and what didn’t work. We remember. We were here. And so that group is pulling out that disc, and going through it, and they’re presenting that as part of their proposal when they hand that to us.”

Marcie Lyn Johnson posted several questions in our Facebook group:

“Who will be deciding what services my child is qualified for and how much time she needs to achieve her goals?”

Melissa: “So nothing is going to change in terms of how it currently works. I think we use something called the, and this is a Medicaid form, the DMS640 form, and we have not made any changes to that. So if you look at the manuals that have changed, it said that you are allowed 4 units of OT, 4 units of Speech, 4 units of PT per day. That has really been striked through, and now it says 6 units of each per week. Nothing else about how this process worked is changed. So when you hit this 6 units per week, if you need more than that, then it’ll be a prior authorization. And that is the process that this clinical team that I mentioned, the work group, is working on the specs that will be utilized for the third party outside contractor that will do that. We have outside contractors that do that right now for other Medicaid state plan services. So this PA process is not a new concept. It’s used by a lot of states, and it’s used by our own state in other aspects. But we are committed to making people feel a little bit more comfortable with this. And the workgroup has said that we really would like clinicians looking at this paperwork, and we agree. If you have people saying whether or not something meets medical necessity on a document in review, they need to be qualified to make that determination.

“What time delay will there be with determining the above? What tools will these individuals be using  to determine if she is qualified?”

[See previous process and contract implementation discussion above.]

“If extra time is requested beyond the cap of 90 minutes, what is the process to get that extension, on the parents, the therapist, and the school where she attends?”

[See previous process discussion for context to the following statements.]
Lainey: “At this point in the process, you haven’t determined that. When would that be?”
Melissa: “The contract leg of that. And that’s kind of in here. It’s very similar to what we already do for PA process for other therapies.”
Lainey: “But it’s a whole other, the public will get to comment of that particular?”
Melissa: “The contract. Yes.”

“What amount will truly be saved by going through this process and possibly contracting out to a third party?”

Melissa: “So in the public notice that ran in the newspaper, we were legally required to put a savings amount. So there’s a number in the newspaper article of what we estimate this would save the state of Arkansas to implement the process. That was the public notice.”
Lainey, reading: “It says, ‘total estimated annual savings $56,235,645.'”
Melissa: “That was the estimation at the time from our Chief Financial Office here at DHS.”
Lainey: “So that is simply by eliminating people who shouldn’t be referring a kid to a center that they don’t really need to go to. That is all that will save this money. (I was referring to abuse that was mentioned at the public meeting.)”
Melissa: “I don’t really want to, I just don’t feel qualified to speak to how they came up with the data on this money. I mean that is some of the stuff that we’ve talked about, but this was projections of the savings that would accrue by inserting a 90 minute threshold and taking an account a percentage of approved PAs based on the current use.”

Dorothy Graves asked, “What does the governor mean by saying if DDS/DHS can’t come up with a solution we will end up with ‘managed care for the oversight and management of therapy for children and adults with special needs? Is this a threat?”

Melissa: “They’re asking me what the Governor means… on a statement I’m not sure he said. I’m going to pass on that one.”
Lainey: “Umm. I can understand that.”
Melissa: “Managed care was a hot topic in the past. It was recommended by the Stevens group. It was a way for them to achieve the savings. It was voted on in the legislature, and it failed. During a special session. The 2017 legislation starts in January, so there’s speculation that managed care will come up again. And that’s probably where that’s coming from.”
Lainey: … “So this was in the Stephens report, and that’s probably where this discussion came from… but right now that’s not necessarily what you’re discussing.”
Melissa: “I think the provider networks, some of them are worried that if they don’t help us come up with a cost saving ideas, that that would be a next step. I think that is spreading amongst the provider network from things I’ve been hearing.”
Lainey: “But there is that question. If you can’t cut enough money, what happens?”
Melissa: “We are coming up with best practices that hopefully also will save taxpayer dollars the best we can without interrupting needed services.

“Also, what is the population that is abusing therapy services now and recommending them only for profit?”

Melissa: “I wouldn’t say ‘abusing the system.’ I would say that we really modeled this after what a lot of other states are doing. We looked at other state plans. We’re in the minority of not having a quality control mechanism in place when it comes to therapy. So for example, Alaska, which they actually do really good work in the DD arena is what I’m hearing. They’re using a prescreening tool that was highly recommended to us by CMS, but Alaska for PT, OT, for children with development disabilities under the age of 21, is only allowed through medical necessity and a prior authorization. There’s other models that are completely 100% of PT, OT, Speech are prior authorized, and there was suggestions, and there’s been a lot of talk about that we should really model some of the Medicaid services just like what state employee insurance provides. And state employee insurance provides 12 sessions a year, and everything else gets prior authorized. So there was a lot of discussion of things, and I felt like the 90 minutes was a good balance. It brought the quality devices that we were looking for, but it wasn’t too restrictive. And if we can do the PA process as quickly as we are hoping, there should not be detrimental effect.”

It was similarly asked, “Why wouldn’t it be more effective to put in place a process to evaluate the rule breakers?”

Bobbi LeAnn Hydrick asked, “Will pediatricians have to have more classes or professional development on diagnosing speech/language, occupational and physical delays?”

Melissa: “No. Just based on feedback we’ve received, and standard practice nationally, we think it would be beneficial to insert an ‘ages and stages’ screening. It’s used a lot by Pediatricians already in our state. It’s another tool that can help pediatricians recognize developmental delays in referring children for services.”

Dena Pate Wilson asked for clarification, “Will TEFRA be included in these new therapy limits, or do these new limits specifically apply to Medicaid?”

Melissa: “Yes. TEFRA is Medicaid. It’s just you privately pay into it.”

Rebecca Bryan asked, “How many hoops will we have to jump through if our kids do end up needing more than 90 minutes of one or more discipline?”

Shana Wells similarly asked, “What does this mean for kids that need all the therapy allotted plus more and what does this mean we need to do to qualify for more?”

Melissa: “I don’t know the specifics right now. [See process of the law above.] I am hopeful based on the clinicians we have putting together the process that it will not be a burden on people.”
Lainey: “It sounds like the parents aren’t necessarily having to do anything, it’s the…”
Melissa: “No, so PCPs and physicians that bill private insurance are very familiar with this. They do that every day to get children that are on private insurance therapy above their 12 sessions a year. That’s very standard. So it’ll be pediatricians and therapists who are also familiar with that process who run businesses making those requests.”
Lainey: “Somebody that I talked to today called this an administrative nightmare. So it’s not going to be as bad as they’re thinking paperwork-wise?”
Melissa: “We have to remember, this is going to be a third party vendor. I’m not talking about DHS employees reviewing PAs. We’re going to have them under a very tightly written contract with performance measures. If they don’t meet them, there will be contractual implications such as withholding their money up to cancellation.”
Lainey: “So how long will it take for you to make that decision that they’re not performing well?”
Melissa: “So lucky for us, the general assembly inserted a lot more contracting parameters, so we do these things called vendor performance reports every three months on every single one of our vendors. So every contract we have in place, we evaluate them every three months.”
Lainey: “So this is all on the therapists. If they need more therapy, there’s going to be a pretty clear process in place, once you get to that stage, on how to get the kid more therapy?”
Melissa: “Yes.”
Lainey: “But (as previously discussed) you can’t talk about right now how much time that will take. Is it correct that the 90 minute, or therapy beginning will not be delayed? People are very concerned about the time turn around.”
Melissa: “Oh the timeframe will be in there (the contract).”

Lindsay Hoelzeman asked, “With these new changes, will therapists still be able to refer children to their PCPs and request a prescription to do a full evaluation?”

Melissa: “We’re not changing anything regarding evaluations.”

Many of us have wondered, “How will someone who doesn’t know my child be able to evaluate him/her well and truly decide his/her needs?”

Melissa: “It will be your same therapist doing the comprehensive evaluations if that’s what your child gets.”
Lainey: “And then the third party, you all will determine…”
Melissa: “the credentials for those people and the turn-around time for when they have to respond.”
Lainey: “And that’s a sticking point where are people are afraid that these people are going to say No because they don’t know the kid, whereas these therapists are with them personally.”
Melissa: “The therapist is writing the documentation that will be turned in. It’s a document review. So it’ll depend on the documentation submitted by the therapist. And I’ll just say, the ones that do private insurance billing, if the child qualifies, the child qualifies. If it’s not written correctly in the evaluation, and they get denied for some reason, there will be an appeal process, and we’ll be able to correct it. So it’s going to depend on how that therapist writes up the documentation that’s being turned in for review. But I have faith that these professionals know how to do that.”
Lainey: “So the appeals process will be also be written in to the turn-around time?”
Melissa: “Yes.”

So if you’ve made it this far, then you’re ready to get some more comments in before the Public comment period ends on October 14. Your comments are helping! Please send them.