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The North Carolina Gold Star Provider Monitoring Process for LME/MCOs
The DHHS Gold Star Provider Monitoring Tools have been revised and automated for statewide implementation. These tools were adopted from the original Gold Star tools developed by Cardinal Innovations Healthcare Solutions (formerly known as Piedmont Behavioral Health). The tools have been updated and standardized for use by all LME/MCOs participating in the 1915(b)(c) waiver pursuant to Session Law 2011-264 (HB 916).
The revision of these tools was done under the auspices of the Gold Star Monitoring Work Group which included representation from Cardinal Innovations, the Division of Medical Assistance, the Division of Health Service Regulation and the Division of Mental Health, Developmental Disabilities and Substance Abuse Services. Numerous subject matter experts across the divisions provided technical assistance and feedback in the refinement of these tools. In addition to collaboration with staff from Cardinal Innovations during all phases of the process, representatives from various LME/MCOs provided feedback by participating in an independent peer review of the tools or by participation in special focus groups to help fine-tune the tools to facilitate replication statewide.
Gold Star Provider Monitoring includes the tools and guidance for monitoring licensed independent practitioners (LIPs) and provider agencies with provisional, routine or advanced placement status. Specialized tools (e.g., tools for entry into the network, for the addition of a new service as well as a tool for monitoring non-contract providers). The tools for conducting post-payment reviews. In addition to a generic post-payment review tool, special post-payment review tools are included for the Innovations Waiver, Outpatient Opioid Treatment, Diagnostic Assessment, Residential Providers (excluding PRTF), Day Treatment, Psychiatric Residential Treatment Facilities (PRTF) and for Licensed Independent Practitioners.
The DHHS Gold Star Tools are completely automated for the purpose of tool administration, documentation, scoring, and generation of reports. The automation of these tools is in direct response to Session Law 2009-451 (SB 202) which directed the Department to explore and implement procedures to reduce the administrative burden on LMEs and providers in demonstrating compliance to state requirements. Instructions for completing the tools are included in the workbooks.
The following presentation provides a discussion of the legislative and federal mandates which pertain to the LME/MCO's responsibility for monitoring providers, a description of the process by which the tool revisions occurred, as well as an overview of the Gold Star process and the results of the collaboration engaged in to bring this phase of the project to fruition. This presentation is bookmarked to allow easy navigation to specific topics of interest.
The transition from a fee-for-service model of service delivery to a managed care model carries inherent risks and an increased level of accountability by the LME/MCO for quality of care, positive outcomes, and financial viability. Consequently, the LME/MCO's approach to monitoring the performance of its provider network in a managed care environment takes on special significance.
The above presentation is supplemented by the following document which discusses how the Gold Star provider monitoring process measures provider performance from both a quantitative and a qualitative perspective.
Please send any questions or comments about the new tools or the Gold Star Provider Monitoring Process to the following mailbox:
gold.star.provider.monitoring@dhhs.nc.gov
or to
provider.monitoring@dhhs.nc.gov
