r PB-217 222 Model Training Program Medical Services Administration, SRS ared for Medical Services Administration, SRS MARCH 1973 Distributed By: National Technical Information Service U. S. DEPARTMENT OF COMMERCE M IT? 3 PB 217 222 MODEL TRAINING PROGRAM FOR IMPLEMENTING THE MEDICAID MANAGEMENT INFORMATION SYSTEM I BIBLIOGRAPHIC DATA I SHEET 11. I'itle and Subtitle 1. Report No. SRS-73- 24711 Model Training Program 7. Author(s) Division of Management Systems 9. Performing Organization Name and Address Medical Services Administration, SRS Department of Health, Education and Welfare 301 C Street, S.W. Washington, D.C. 20201 J. Recipient's Accession No. 5. Report Date . Mar 15 , 1973 8. Performing Organization Rept. No. 10. Project/Task/Work Unit No. 11. Contract/Grant No. 2. Sponsoring Organization Name and Address same as (9) 13. Type of Report & Period Covered final 14. 15. Supplementary Notes 16. Abstracts This Model Training Program was designed for use in initiating and implementing the Medicaid Management Information System (MMIS). The purpose of this program is to serve as an aid to ensure that all personnel involved posses die knowledge and skill required to carry out the activities, and to use the system and reports effectively and efficiently. 17. Key Words and Document Analysis. 17o. Descriptors 17b. Identif iers/Opcn-Ended Terms 17c COSAT1 Field/Group 13. Availability Statement 19. Security Glass (This Report) UNCLA SSIFIED 20. Security Class ( This Page UNCLASSFFIfvD 21. Xo. of Pages ^7 22. Pi ice £ 5, H5 TABLE OF CONTENTS Page INTRODUCTION TO THE MANUAL , . . . 1 I. EXECUTIVE BRIEFING GUIDE ......... 6 1. Overview 6 2. Problems to be Addressed 7 3. Training Goals and Objectives 1 4. Session Development and Format ..... 7 5. Proposed Contents. . ....... . 8 Paper 1. "A Background and Summary Statement on the Medicaid Management Information System". . 9 Paper 2. "A Summary of the Implementation Steps for the Medicaid Management Information System". . „ 15 II. TRAINING MODULE FOR MMIS PROGRAM MANAGEMENT. ..... 28 1. Overview 28 2. Problems to be Addressed , . . . 28 3. Training Goals and Objectives 28 4. Session Development and Format. 29 5. Proposed Contents. « 38 III, TRAINING MODULE FOR MMIS CLERICAL PERSONNEL. ..... 46 1. Overview . 46 2. Problems to be Addressed 46 3. Training Goals and Objectives. 47 4. Session Development and Format .......... 47 5. Proposed Contents. ... ....... 61 Page IV. TRAINING MODULE FOR MMIS FINANCIAL PERSONNEL 76 1. Overview 76 2. Problems to be Addressed 76 3. Training Goals and Objectives 77 4. Session Development and Format 77 5. Proposed Contents . . . . , 81 V. TRAINING MODULE FOR DATA PROCESSING PERSONNEL . 104 1. Overview 104 2. Problems to be Addressed 104 3. Training Goals and Objectives ....... 105 4. Session Development and Format 105 5. Proposed Contents 108 VI. TRAINING MODULE FOR MMIS PROVIDERS 126 1. Overview 126 2. Problems to be Addressed 126 3. Training Goals and Objectives . . . . 127 4. Session Development and Format 127 5. Proposed Contents 131 Appendix A. "A Working Guide for the Development of the Current System Outline on Flow Chart Development" 136 ILLUSTRATIONS Page Figure I. 1. Project Management . . . . 18 2. System Design . . . . . 20 3- System Implementation 21 II. 1. MMIS Project Network 32 2. Model Medicaid Management Information System . . 41 III. 1. Processing Flowchart 49 2. Processing Flowchart ... ...... 50 3. Processing Flowchart ......... 51 4. Processing Flowchart ...... ... 52 5< Process Step Definition ............ 53 6. Process Step Definition ...... 54 7. Medicaid Claims Review Personnel Training Requirements ........... . . 58 8. Course Instruction Plan. Session One ..... 62 9. Course Instruction Plan, Session Two ..... 67 10, Course Instruction Plan. Session Three .... 69 11. Job Procedures 73 IV. 1. MMIS 83 2. Surveillance and Utilization Review Subsystem . 84 3. Management and Administration Reporting Subsystem , 86 4. Management Summary Report ........... 89 Page 5. Summary Profile Report. 93 6. Treatment Analysis Report 95 7. Claim Detail Report 96 8. Medical Assistance Financial Status 99 9. Financial Summary 100 10. Expenditure Analysis 102 V. 1. The Groups of Medicaid Participants 110 2. Recipients 112 3. Administration 113 4. MMIS Provides 114 5. The State Provides 115 6. Six Modular Subsystems 116 7. Receipient Subsystem 117 8. Provider Subsystem 119 9. Claims Processing Subsystem ..... 120 10. Reference File Subsystem 121 11. SUR Subsystem 122 12. MAR Subsystem 123 Charts I. 1. Component System Design 24 2. MMIS Installation Phases 25 3. A Time Line for Porgram Implementation (Optional) 26 1 INTRODUCTION TO THE MANUAL The installation of the Medicaid Management Information System will represent a major change in the management of programs now operated manually and will require modification in those programs now automated or partially automated. MMIS will affect not only the hundreds of state and privately employed personnel who administer the system, but also thousands of citizens eligible to receive Medicaid benefits. To meet MMIS objectives, employees must be familiarized with the new system and frequently trained in new skills. The purpose of this manual is to serve as a systematic guide to that training process. Its audience has been divided into six groups, determined according to the amount of information each needs for input into the system. Accord- ingly, the manual is divided into six modules, each of which addresses the training needs of a particular group. These groups are: Executives in state government, including the governor, governor's administrative aide, a legislative committee, and the director of the single state agency involved in administering Medicaid Title XIX program manager Clerical personnel Financial personnel Data processing personnel Providers While cne manual and the General System Design for Title XIX* represent a guide to content and methodology and contain sufficient material to accomplish training objectives of the six groups of MMIS- affected personnel, the "user," or trainer, will have to tailor the program detailed here to specific, local audiences. Eoth the manual and the system are designed for flexibility of use. This flexibility is reflected in the manual r s philosophy, which is "training by objectives." The user of this manual is urged to familiarize himself with this philosophy and format, and to modify the proposed session based on his assessment of the particular audience, the nature of the current state system being utilized and the training needs of the personnel involved. * Medicaid Management Information System, General System Design for Title XIX , U.S. Department of Health, Education, and Welfare, Social and Rehabilitative Service, Medical Services Administration, June 1, 1972. 2 Training by objectives calls for a basic five-step method in development: Articulate the problem to be addressed by training; State the general goal to be achieved by training; Identify specific objectives to be achieved by the training session; Outline the training method or methods to be used to achieve the objectives; Describe the content or materials to be used in the training or orientation session. Thus, each module is divided into five sections which generally follow these steps. The sections may be briefly outlined as follows: Section 1 - Overview of the module Section 2 - Articulation of the problems to be addressed Section 3 - Goals and objectives for training Section 4 - Session development and format Section 5 - Proposed contents Section 3, in which a statement of goals and objectives is developed, should be modified to accommodate particular variables in the local situation. The changes made in Section 3 of each module will, of course, determine modifications in Sections 4 and 5. There are a variety of ways in which both the trainer and the per- sonnel being trained can evaluate the success of the training effort, in other words, the achievement of objectives stated in Section 3 of each module. The choice of a method will depend on the local work situation and the nature of a particular state's training program. The following methods should be considered: Practice exercises done by the participants during the sessions. Such exercises provide performance data which indicate the ability of the participants to apply new information and concepts. 3 Evidence of openness in the sessions as indicated by comments and questions on the part of partici- pants Formal, written testing Assessment of on-the-job performance of the parti- cipants It is recommended that the trainer establish openness within the sessions to encourage immediate feedback, provide time for review/ discussion at the conclusion of the sessions, and work with super- visory personnel to establish means for measuring on-the-job perfor- mance . 4 MODULE I. EXECUTIVE BRIEFING GUIDE Page 1. Overview . 6 2. Problems to be Addressed 7 3. Training Goals and Objectives ..... 7 4. Session Development and Format . 7 5. Proposed Contents ..... 8 Paper 1. "A Background and Summary Statement on the Medicaid Management Information System 9 1. Development of MMIS 10 2. Benefits of the MMIS 10 3. Components of the MMIS 11 h > Implementation and Guides 13 Paper 2. "A Summary of the Implementation Steps for the Medicaid Management Information System" 15 1. Feasibility Study 16 2. Project Management Team 17 3. State Agency Review 17 4. System Design 19 5. System Implementation 19 6. System Evaluation 22 5 MODULE I. LIST OF FIGURES Page Figure 1, Project Management 18 Figure 2. System Design 20 Figure 3. System Implementation ............ 21 Chart 1. Componenet System Design 24 Chart 2. MMIS Installation Phases 25 Chart 3. A Time Line for Program Implementation (Optional) . ......... 26 6 I. EXECUTIVE BRIEFING GUIDE 1 . Overview The incorporation of the Medicaid Management Information System into the administrative functioning of a state government is a highly complex undertaking. It involves sanction and approval at several levels, as well as the ultimate mobilization of a large number of state personnel to bring about successful implementation. Such a large-scale effort must be undertaken at the behest of the. Governor and with the mandate of appropriate key decision makers within the state government. Each key level of policy makers must have sufficient information with which to make valid decisions and policies with respect to the MMIS. Varying levels of authority and policy roles dictate that the amount of information, and the focus of that information will vary to meet particular needs. As a result, this module for executives addresses the information needs of four executive levels; Governor, Administrative Aide to the Governor, Legislative Committee, and Director of the Single State Agency delegated to administer MMIS. The four executive levels mentioned above have several common characteristics that have been considered in determining the manner in which information about MMIS should be conveyed. First, they do not require large amounts of detail with respect to the MMIS in order to fulfill their decision-making obligations. Second, there are extensive demands on their time, thus restricting the amount of time allowable for an appropriate orientation to the MMIS. Finally, it should be pointed out that the basic objective of their orientation is to impart information. It is, in fact, the overall objective of a presentation to any of these executive officials to convince them that the MMIS should be strongly supported in their state. Executive approval and support is critical during the initial stages of the MMIS development effort, and it is strongly recommended that a briefing session be held at each appropriate level. Each of the subsequent areas of problems addressed, training goals, session development, and content are similar for the various executive levels. However, care should be taken to assure that each briefing module is tailored to the specific audience being addressed in terms of the con- tent and level of detail provided. 7 2. Problems to be Addressed The problems may be stated as follows: The Executive should be provided financial and personnel data upon which to make valid decisions with respect to the utilization of the MMIS. The Executive needs general information about the component functioning of the MMIS and its relationship to other levels of government. The Executive should be aware of the implica- tions of the MMIS utilization for state pro- viders , or recipients of Title XIX program funds. 3. Training Goals and Objectives The general goal of the briefing and orientation session is to pro- vide the Executive with adequate summary data on the operation of the MMIS and broad implications for implementation. The specific objec- tives for the session are: Ensure that the Executive is sufficiently informed about the human and financial objectives of MMIS Ensure that the Executive is conceptually aware of the broad component functions of MMIS Ensure that the Executive is aware of the imme- diate steps he should take and of the necessity for his continuing support of MMIS 4. Session Development a nd Format Keeping in mind the problems , goals, and objectives for the execu- tive brief, and also considering the time constraints and need for summary data, it is recommended that: a. The person responsible for the briefings should provide the Executive with two short papers on the MMIS several days in advance of the scheduled briefing. The papers, included in Section 5, are entitled, "A Background and Summary Statement on the Medicaid Management Information System", and "A Summary of the Implementation Steps for the Medicaid Management Informa- tion System 1 '. 8 b. A schedule be developed on an "as available" basis for briefing sessions. The following sequence of events is suggested for this briefing: Summarize the presentation about to be made Provide background information on MMIS and its component areas displaying charts 1 and 2 (optional). This is largely in support of the first paper referred to above. Provide summary information on the implementa- tion steps and a recommended time frame for each of the steps utilizing chart 3. Allow time for questions either at the end of the presentation or during the session. 5 . Proposed Contents The following documents and charts may be used in the Executive briefing session: Paper 1. "A Background and Summary Statement on the Medicaid Management Information System" Paper 2. "A Summary of the Implementation Steps for the Medicaid Management Information System" . Chart 1. A Component Flow Chart of MMIS. Chart 2. Outline of the Implementation Steps Chart 3. Sample Time Line for Implementation (optional) Appendix A. "A Working Guide for the Develop- ment of the Current System - Outline on Flow Chart Development"* Note - This Appendix is not intended for use by the Executive. It is a guide to the person doing the training on development of flow- chart type training aids . 9 aper 1. A BACKGROUND AND SUMMARY STATEMENT ON THE MEDICAID MANAGEMENT INFORMATION SYSTEM 10 1. Development of Medicaid Management Information System A Task Force on Medicaid and Related Programs was created by the U. S. Department of Health, Education, and Welfare to consider the related problems of rising costs in almost every area of medical delivery, the increased public demand for these ever more costly services, and public pressure to keep taxes paying for these services at a minimum. In 1969, the Task Force made its initial recommenda- tions. The recommendations fell into two broad categories: (1) There is a need to develop alternative methods of providing medical services to Medicaid clients; and (2) The administration of Medicaid and its control over Medicaid services should be made significantly more efficient . In response to the second imperative, a Management Systems Division was created within the Medical Services Administration, and mandated to produce a management approach or system that would improve the efficiency of each state's Medicaid program. This step resulted in the development of the MMIS. 2. Benefits of the MMIS The Medicaid Management Information System will assist the Executive or designated officials in several areas that are of major concern to the executive management of a state. As an agent of fiscal control, MMIS will help reduce the large backlog of payments to providers, and present a clearer picture of Medicaid's actual financial status. For instance, it makes impossible the payment of duplicate claims, and checks all claims for higher than usual charges. These features alone could save a state thousands of dollars per year. In addition, fiscal projection figures are generated by the Management and Administrative Reporting Subsystem to give a clear reading of the fiscal needs for the coming year. The MMIS can be used to analyze the claims for the care given to recipients to ensure that it is provided in a timely and expeditious manner. Through various management reports, those services which need expansion or suggest possibilities for alternative care options are presented. This allows the state to plan modification and growth in service in a controlled manner. * Task Force on Medicaid and Related Programs, HEW, Office of Secretary, June 29, 1970. 11 Concern over Medicaid costs is another area in which MMIS can play an important role. The Surveillance and Utilization Review Sub- system is designed to point out instances of misutilization of Medicaid that frequently attract public attention. Timely and accu- rate data from this system can be monitored to prevent budget over- runs and to ensure efficient state medical administration. In regard to the provider sector, quick and accurate claim payment will assist in maintaining confidence in the Medicaid structure and its admini- stration. In su m mary, the MMIS is designed to assist the Executive in his role as public policy maker by: Paying all valid claims quickly and accurately; Ensuring that only reasonable charges are accepted for payment; Keeping a constant watch for instances of Medicaid abuse by both providers and recipients ; Providing projections of Medicaid's future costs; Identifying areas of need within the Medicaid program. In short, MMIS combined with the strong backing of top-level management will provide more efficient administration for the Medicaid prcgram. 3, C omponents of the MMIS The Medicaid Management Information System, or MMIS, is a general- ized, computerized system for claims processing which provides infor- mation upon which management decisions can be made. It was conceived as a model design that each state could adapt to its particular needs and program. It is divided into six functional subsystems, each designed to solve one or more of Medicaid's current critical problems. These subsystems may be examined in detail in the five volumes of the General Systems Design for Title XIX.* Medicaid Management Information System, General System Design for Title XIX, U. S. Department of Health, Education, and Welfare, Social and Rehabilitative Service, Medical Services Administration, June 1, 1972. 12 Recipient Subsystem . The Recipient Subsystem is designed to maintain a file of all recipients certified for Medicaid. Recipient identification and associated demographic data may be updated frequently to ensure completeness and accuracy. Recipient identification cards, based on the current eligibility list, are issued monthly. Provider Subsystems . The Provider Subsystem performs two important functions. First, it analyzes the applications of new providers to enroll the provider into the Medicaid program. Second, it keeps an up-to-date list of all certified providers. Claims Processing Subsystem . Data provided by the Recipient Subsystem, the Provider Subsys- tem, and individual claims are brought together by the Claims Processing Subsystem to provide timely and accurate payment of claims. Eligi- bility of provider and recipient is verified; the amount of the claim is checked against the file of provider rates charged, and a voucher or request for payment is issued for valid claims. Invalid claims are suspended pending correction. In addition, the Claims Process- ing Subsystem feeds data on claims that have been adjudicated to the Reporting and Reference File Subsystems. Reference File Subsystem . This subsystem provides a generalized update facility, provides practitioners with usual and customary charge data and generates various listings of data pertaining to suspended claims. Surveillance and Utilization Review Subsystem . The Surveillance and Utilization Review Sub- system, referred to as SUR, is the key to accom- plishment of MMIS objectives or total Medicaid program control. It is based on an analysis of paid claims by a technique known as exception processing. Exception processing involves analyzing every claim paid to a given provider or on behalf of a given recipient against a 13 computer-established normative range for the participants' peer group. Only those partici- pants who fall outside this normative range are reported for review by the Medicaid staff and possible action. A wide variety of criteria are analyzed for each participant and a great deal of supporting documentation is available from the computer's data bank* In addition, the SUR is designed to allow management adjustment of these norms . Management and Administrative Reporting Sub- system . MARS reports show past and projected performance of expenditures against budgets. Levels of care being received by the various types of Medicaid eligibles and the performance of the MMIS itself are also given careful attention. One interesting aspect of MARS is the idea of reporting levels. Reports range from the very detailed analyses of providers' class groupings to the general budget vs. per- formance data for the entire Medicaid program. Decisions may be based on concise, meaningful summary reports with the assurance that detailed backup is available if necessary. 4 . Implementation and Gui des To test its effectiveness . the State of Ohio was chosen as a pilot project. The primary reasons for the selection of Ohio were: Size and demography of the state Ohio's willingness to accept the entire MMIS package Ohio's commitment to reorganize its medical services division to make effective use of the new system Ohio's commitment to assist other states in implementing the MMISc Detailed design and implementation of the Ohio system took approxi- mately two years. The system is now fully operational. 14 Concurrently, a scheme of Federal technical assistance was developed for use in and by other States. Included in this program are: (1) The MMIS General Systems Design - five volumes of MMIS design including sample in- puts, processing flows, and outputs. (2) The MMIS General Installation Guide - a one volume narrative of general suggestions to States seeking implementation of an MMIS- type system. (3) The User Training Manual - detailed design and explanation of clerical proce- dures to support MMIS. (4) SUR Publication - which show how to utilize the reports generated by the SUR Subsystem. (5) MARS Operational Techniques - which show how to utilize the reports generated by MARS. (6) MMIS Model Training Program -- a program for planned change for people impacted by MMIS. (7) Medicaid Operations Notes - which are a series of publications covering topics of interest to Medicaid Administrators. In addition to these documents, Federal personnel familiar with other states' problems are available to provide technical assistance. The technical assistance covers analysis of needs, suggestions for administrative organization, training, and help in solving implemen- tation difficulties. 15 Paper 2 . A SUMMARY OF THE IMPLEMENTATION STEPS FOR THE MEDICAID MANAGEMENT INFORMATION SYSTEM 16 Once the Executive, designated state official, agency director, or legislator has made a personal commitment to establish the MMIS in his State, he or she is responsible for allocating the necessary per- sonnel, facilities, and financial resources. This may require the hiring of additional staff, provision of overtime pay, or provision of a compensatory time arrangement for in-house personnel. Six steps, estimated to span a period of approximately two years, are involved in MMIS establishment. They are: Conduct of a feasibility study Establishment of a project management team Review of the state agency involved Development of the detailed system design Implementation of the system Evaluation of system operation Although these steps or phases of MMIS establishment are estimated to take about two years, the time period can be reduced if some of the activities are conducted concurrently. The amount of time between initiation of the feasibility study and completion of system evaluation will also be affected by the method chosen to perform the work (whether in-house or under contract). Let us now look at each of the steps in greater detail. 1. Feasibility Study The object of the feasibility study is to determine whether MMIS should be installed in a State. Those conducting the study must analyze: current operations and current operating costs, alternative administrative systems including the MMIS, and the cost-benefit relationship of alternatives in comparison with current methods of operation. These analyses will result in a recommendation, which will be supported by the findings. The feasibility study may have been performed by in-house resources, by utilizing support available for such a study from the Department of Health, Education, and Welfare, or by contracting the services of a consultant. 17 2 . Project Management Team Following a recommendation to proceed with the development of the MMIS, the Executive or designated state official, should then be pre- pared to establish a project management team responsible for organizing and carrying through implementation of the MMIS. Such a project team must operate under a formal organizational structure s so that each individual involved has a clear understanding of who is responsible for exactly what functions. This structure is especially important when an outside contractor is assisting the state agency in some capacity concerning the MMIS implementation. It is also imperative that the director of the project team have direct access to state agency top management in order that necessary decisions can be made on a timely basis. Only if this is so can a project of the complexity of MMIS proceed at a reasonable pace. To govern the activities of the project organization, a project plan must be developed that: Identifies each of the tasks to be performed dur- ing the course of the project Specifies responsibilities and scheduled dates of performance Establishes the project development schedule Figure I illustrates the organization of the project management team. The responsibilities of the team will cover review of the state agency, system design, and system development efforts, all of which are further discussed below. 3. State Agency Review The MMIS brings to zh.e state agency involved with the administra- tion of Medicaid an overall information processing system that is both streamlined and efficient, but the structure of the system imposes certain organizational requirements on the agency it serves. Thus, to create the best possible environment for installation of the MMIS, a review of the agency's organization, personnel policies and proce- dures must be conducted. This will determine whether these elements are organized in such a way as to support the MMIS. A thorough analy- sis of the agency will often reveal the need for adjustments in structure or operating procedures. These adjustments must be clearly identified and understood in order to embark upon the next phase, design of the system. 18 Figure 1. Project Management State Agency Contracto r Pro j ect Pro j ect Director Director Policy Coordinatin Committee Pro] ect Manager Support Systems Coord . EDP Operations Coord . Programming Coordinator Training Coordinator Technical Coordinator 19 4 . System Design The design efforts begin with an analysis of information require- ments in each organizational element of the state agency. This analy- sis identifies information that must be processed and specifies its form at various stages in the processing flow. To perform this analy- sis, system analysts work closely with agency personnel to ensure that all requirements are identified, and that the design will be based upon information derived through a process involving active user participation. Once the detailed requirements of the MMIS have been established, development of detailed systems specifications and implementation standards begin. Specifications are prepared for every element in the MMIS, including both automated and manual processes (see Figure 2). Detailed descriptions are prepared for all source documentation, system files, and specific outputs, including all reports. The result of the system design is a document completely describing the proposed MMIS at a level of detail that permits an accurate estimate of imple- mentation and operating costs, as well as sufficient technical detail to permit implementation to begin, (Refer to Appendix A for use of design documentation.) -> • System I m plemen tation The objective of the system implementation phase (see Figure 3) is to produce an efficiently operating MMIS based on the design pre- viously prepared. Planning for implementation is the critical first step in this complex and large-scale task. The plan must consider every activity to be performed during implementation, and organize and schedule those activities, Once the plan has been established, work will proceed on: Conversion of data from existing files for process- ing on the new system. Writing and preparation of programs for processing in the manner prescribed in the system design Development of forms and other paper materials to be used in the MMIS Development and documentation of manual procedures to be performed by clerical and other personnel interacting with the new system 20 Figure 2. System Design Recipient Subsystem St Surveillance and Utilization Review System Claims Processings- Subsystem Reference File [ Subsystem Provider Subsystem Management £ Administrative Reporting "P Subsystem Detailed Requirements Analysis Development of Detailed System Specification and Implementation Standards 21 G) •rl > O C id & id! c o ■H & CD > o o ro ■H Qi •H CO 0) p id •H ■p CD 1 !H io Gi *H tx > •Hi ■H P- p ?h i CD u 00 Eh ? Oh 0) Ph &j 1 6 CU P .3 o 0 OS co & 0) CD a. <-*\ ■P p rd CO H O w to rd •H & & G CD o rd a O o •H -P rd ■P CS (1) e o o p 6 0! -P CO >! 22 An extremely important activity during the implementation phase will be the training of various personnel regarding their new roles and specific duties. The staff should be made aware that their coop- eration with the effort to establish the MMIS will significantly enhance the efficiency of their agency's operation. A key activity during the implementation phase is the integrated system test which brings together each element under development to check the ability of the system to function as a whole in accordance with design speci- fications. Following successful completion of the system test, the system begins operation, initially with a back-up, and later as a fully operational system. 6 . System Evaluation Evaluating the success of a computerized/manual system is a diffi- cult job at best. There are, however, some yardsticks against which the success of MMIS may be measured. These include: Payment of all valid claims quickly and accu- rately ; Evidence that all reasonable charges are being accepted for payment; Exposure of Medicaid abuse by providers and recipients ; Projections of Medicaid future costs; Identification of areas of need within the Medicaid Program. Information which can be developed to provide such measurements include : Monthly costs of operation especially ratio of cost of service to cost of administration, include savings from SUR; Medicaid staff morale (rate of resignation) ; Provider response to new system; Turn- around time of claims being processed; Error frequency in incoming claims. 23 This system is designed to produce reports from which, together with provider and staff comments, provide a firm basis for system evaluation. 24 COMPONENT SYSTEM DESIGN Recipient Subsystem Surveillance and Utilization Review System Claims Processing Subsystem T Reference File Subsystem Provider Subsystem Management and Administrative Reporting Subsystem ° Detailed Requirements Analysis ° Development of Detailed System Specification and Implementation Standards Chart 1 25 MMI3 INSTALLATION PHASES ° Project Management ° Agency Review ° System Design 0 System Implementation Chart 2 26 A TIME LINE FOR PROGRAM IMPLEMENTATION (OPTIONAL) ■ Months Feasibility Analysis Review Training Installation Chart 3 27 MODULE II. TRAINING MODULE FOR MMIS PROGRAM MANAGEMENT Page 1. Overview . 28 2. Problems to be Addressed . « 28 3. Training Goals and Objectives. , 28 4. Session Development and Format 29 a. Schedule of Program Events . 29 b. Introduction of MMIS to Medicaid Staff 34 c. Staffing Patterns 36 d. Training Programs 37 5. Proposed Contents 38 LIST O F FIGURES Figure 1. MMIS Project Network 32 Figure 2. Model Medicaid Management Information System Functional Flow Diagram . . . 41 28 II. TRAINING MODULE FOR MMIS PROGRAM MANAGEMENT 1. Overview This module is intended for use by the program manager. Its focus will differ from the other five modules because of the role of the pro- gram manager. The program manager will have the overall responsibility for general installation as well as the training of MMIS related person- nel. Its major purposes are to provide a summary review of MMIS and to provide suggestions and guidance in implementing the training program for MMIS related personnel as part of the total MMIS installation plan. Thus, the information in this module, together with the information in the General Installation Guide , provide a framework for applying the other five modules in the training manual. Section 2 briefly discusses the training design and implementation related problems that the program manager will address. Section 3 articulates objectives; and Section 4 provides guidance in incorporating the training program, Modules I, III, IV, V, VI, into the specific systems installation plan for a particular state. Section 5 provides a summary of the subsystems operation of MMIS and is intended as a refer- ence for the program manager. It has been recommended that the State utilize a full-time train- ing coordinator to fulfill MMIS related training functions, and that this trainer be brought into the program at the earliest possible date. It is extremely important at this time for the program manager to review state policies and procedures to assure that these are current. Such a review will preclude numerous problems during the subsequent system implementation. 2. Problems to be Addressed The program manager will have the ultimate responsibility for the installation of the MMIS, for implementing and operating the program, and for incorporation of the training program for MMIS related personnel. The general problem addressed by this module is that the program manager needs a detailed plan for incorporating the training program into the installation plan. 3. Training Goals and Objectives The goal of this module is to provide a guide to the program manager for incorporating the training program for MMIS and to alert him to other 29 problems of system integration within the state's Medicaid program. The specific objectives for this module are as follows: Ensure that the program manager has a summary/ reference knowledge of the subsystem operation of the MMIS. Ensure that the program manager has a summary/ reference knowledge of the training and orien- tation modules for other MMIS related personnel. Ensure that the program manager is familiar with a suggested guide for incorporating the training program into the systems installation plan for his or her State. A . Session Development and Format Once established, the operations of the MMIS directly or indirectly involve the participation of many individuals inside and outside the Title XIX State Agency. Internally, personnel at different management levels and in different organizational elements will participate, both as users or beneficiaries of the system's capabilities and/or as sup- porters of the system's day-to-day operation. Top management personnel are concerned with the overall value and effectiveness of the MMIS in serving the public need. Mid-management and program analyst personnel directly utilize system outputs to monitor and control agency operations. Personnel at the operating level are engaged in system support functions, including input document processing, auditing , equipment operation, and output distribution. The successful operation of the state MMIS is critically dependent upon the qualit}/ of the participation of each of these categories of personnel. The quality of their participation is, in turn, dependent upon the training each receives regarding the MMIS and their involvement in the process of change, which accompanies the system implementation. It is hoped that the personnel involved in this change will be involved from the outset. A description of specific orientation and training activities essential to MMIS success and an approach for their accom- plishment follows: a. Schedule of Program Events The training of each group of MMIS related personnel must be considered an integral part of the overall MMIS installation effort. The logical, chronological sequence of events in the 30 overall MMIS development effort can be summarized as follows: (1) State Agency Review . The decision to adopt the MMIS is followed by a state agency review of its internal organization, personnel, policies, and procedures to ensure that these elements are properly structured to support the MMIS. The review should result in an organization plan that will become effective upon MMIS installation. A critical activity is a review of policies on provider agreements. The content of the plan serves as an essential source material to be used in preparation of MMIS training materials. (2) Detail System Design . Subsequently, the major effort of developing the detail system de- sign begins. Design specifications are prepared identifying and describing in detail the system's structure and all of the materials, processes, and standards required by the system. Manual as well as automated processes are designed. The manual-processing flow and the relationship of individual manual-processing steps to specific personnel positions are often included in the system's design documentation. This documenta- tion, like the organization plan mentioned above, is a basic source of instructional mate- rial in the MMIS training program. The initia- tion of the detail system design would be an appropriate point to begin training and orien- tation to the new policies and procedures for MMIS related personnel in order that they may provide necessary feedback to the system design. (3) Implementation Plan . During the development of the detail system design, the MMIS implementa- tion plan is started. Elements of design are analyzed to determine the specific tasks that must be performed to implement the system, the estimated effort required to perform each task, the logical relationship and sequence of imple- mentation tasks, and the standards to be used to evaluate the quality of work accomplished in each task. Major tasks that must be planned usually include programming, data collection, data conversion, new forms' production, system documentation, personnel training, system test- ing, final conversion phase-over, and system 31 monitoring. Implementation of the MMIS may also involve procurement, installation, testing, and acceptance of computer equipment required to sup- port the MMIS. The proper organization, staffing, and scheduling of these major tasks is critical to the installation of a successful MMIS. The MMIS project network shown in Figure 1 is illus- trative of the complexity of the overall MMIS implementation activity. A network diagram of this type is usually developed during the imple- mentation-planning phase. (See Appendix A). (4) Training and Integrated System Test , Once the implementation plan has been developed and approved, work proceeds on each implementation task in accordance with the schedule established in the plan. A detailed description of every implementation task is beyond the scope of this discussion. However, two tasks, job oriented training and the integrated system test , are of significant importance to the current dis- cussion. The content of these two tasks and their chronological relationship to other imple- mentation activities are outlined in the follow- ing paragraphs. Job training of MMIS related personnel is a key step in the overall MMIS implementation effort. Support personnel (e.g., clerical and data pro- cessing staff), user personnel (e.g., agency and state management) , and other interfacing persons or organizations (e.g., doctors s hospitals and other provider categories) require informa- tion and instruction relevant to the objectives and benefits of the MMIS and to any specific pro- cedures that may apply to their respective MMIS related roles. Required information and instruc- tion are disseminated through a carefully planned program of orientation and training activities. These activities are an integral part of the system- implementation process, and their sched- uling is dependent upon their logical relation- ship to other implementation events. Generally, decailed training of support personnel should be scheduled to occur after design activities have been completed and detailed manual-processing procedures have been defined, but before inte- grated system testing begins. Figure 1. MMIS Project Network ZS.P StfTilOlTiOM 33 Provider categories should receive instruction pertaining to their respective procedures for interacting with the Medicaid agency sufficiently in advance of system operations to permit them to prepare themselves and their staff personnel for the change-over and to allow valid provider suggestions to be incorporated, but not so early as to risk dissemination of information or in- structions that may be invalidated by later design modifications. Finally, user orientation to the new system may be scheduled relatively late in the MMIS installation period, but soon enough to ensure that optimum use is made of system outputs immediately upon initiation of MMIS operations. As each component of the MMIS is developed, it is tested to ensure that its performance is commensurate with the standards established in the detail system design specification. Individ- ual programs are tested as units; then related programs are grouped and tested as subsystems; and finally, all system components are tested as a completely integrated MMIS. An essential element in the integrated system test is the checkout of MMIS manual operations. This activity verifies the adequacy of MMIS manual processing procedures and the readiness of system personnel, primarily, or clerical per- sonnel, to perform these procedures. It is a test, therefore, of both the procedures' ade- quacy and performance. The manual procedures checkout should be con- ducted with a comprehensive set of test claims representative of as many different conditions as possible. The checkout should also be con- ducted with as full a complement cf clerical personnel as practical, and in an environment closely approximating actual operations. Ob- viously, the integrated system test must be preceded by the training of system personnel; consequently, the MMIS training schedule should be coordinated with the system test plan. 34 b. Introduction of MMIS to Medicaid Staff General . A significant factor in determining how smoothly the MMIS installation takes place and how efficiently it will operate is the thoroughness of the state agency train- ing program. Preparing all the various personnel involved in MMIS operations is a task of considerable magnitude. This section presents the objectives of the training pro- gram and outlines an approach for accomplishing these goals. State Agency MMIS Training Objectives . The general objec- tive of the state agency MMIS training program is to develop and maintain a level of competence in all MMIS related per- sonnel to ensure the successful installation and continuing operation of the system. This general objective can be expanded and expressed in terms of the specific categories of personnel who have MMIS related roles and the identifi- cation of the knowledge and skills each must have to com- petently act in those roles. These personnel categories constitute the target audiences of the. overall state agency training program. Descriptions of the target audi- ences and their respective roles follow: (1) Executive Policy and Decision Makers . Policy makers at the state administration level bear the overall responsibility for the administration of state welfare programs. Their concern for the Title XIX State Agency and the MMIS focuses on the effectiveness of the agency and the system in meeting the public need. As the ultimate recipients of manage- ment information, as generated by the MMIS through presentations and other communica- tions from agency representatives, executives should understand the agency operation and the significance of the MMIS. (2) Program and Supervisory Management . The program manager and key supervisory personnel in Title XIX State Agency direct and control the operation of the MMIS and are direct users of the system's products. As such, they must be both involved and committed supporters and users of the system. As supporters, they ensure the effective operation of the system by selecting, train- ing, organizing, and managing system support 35 personnel who directly perform the manual func- tions essential to MMIS operation. As users, program managers and supervisors are recipients of system outputs including data generated by The Surveillance and Utilization Review (SUR) Subsystem and the Management and Administrative Reporting Subsystem (MARS) . These system generated reports must be clearly understood by the program manager and supervisor if suc- cessful program operation is to be achieved. C3) Clerical Personnel . The clerical person- nel are those agency employees whose duties include MMIS input data preparation and other system related manual activities. The manual functions of the system's clerical staff inter- face directly with the automated functions of the MMIS, and it is this group of personnel, more than any other, upon which the day-to-day operation of the MMIS depends. It is important that MMIS clerical personnel understand the overall purpose of the MMIS as well as the specific skills required to perform individual duties . (4) Financial P erso nnel . Financial personnel aie responsible for collecting and summarizing financial data Co permit effective cost control in the Title XIX State Agency. In order to perform successfully, financial personnel should have a sound understanding of the overall purpose and operations of the MMIS, the nature and basis for financial input data, processing system 5 and the meaning and application of MMIS financial re- ports . (5) Data Proc essing P ersonnel . Data processing personnel are those state employees who work in the computer facility which supports the MMIS. Their duties include operation of the computer and the control and processing of system inputs and outputs. Often, their services are per- formed for several organizations, and they are not dedicated solely to the MMIS. In addition to knowing general operational procedures, data processing personnel must understand the overall purposes and operation of the MMIS and its spe- cific requirements for input conversion, control, processing, etc. 36 (6) Medical Service Providers . Providers include all persons who give services in accordance with the state plan. These include physicians, pharmacists, hospitals, ambulance services, clinics, and other individuals and organizations eligible to provide services and submit claims for Medicaid payments. The timely payment of valid claims to providers is a major objective of the MMIS. The success of the system in meeting this objective is depen- dent upon the degree to which providers under- stand the MMIS and, specifically those pro- cedures applicable to claims submissions and other interactions with the Medicaid agency. c. Staffing Patterns Various staffing patterns may be utilized to implement the MMIS at the state level. The program manager must assure that a project director within Medicaid has the responsibility for the MMIS design and implementation. The project director will serve as the primary point of interface between the con- tractor and the state agency at the program management level. The project director's efforts will ordinarily be completely consumed with the technical detail of the system operation, assuring that the information system runs smoothly. The pro- gram manager must assure that he. the project director and other key members of his staff, can identify implications of changes in processes and procedures for clerks, providers, recipients, and others. He must also assure that operational modifications and training are provided to accomodate such change. A key staff member in this process is the training coordinator . The training coordinator is a vital member of the MMIS imple- mentation team. He should be knowledgeable in all aspects of the MMIS concept, its objectives, and its design. He should understand the outputs of the system and their uses, partic- ularly the manual processing flow; and he should be familiar with documentation pertaining to specific manual procedures. The training coordinator should be a senior staff member, capable of interacting directly with state agency top manage- ment, as well as with supervisory operational personnel. 37 Specific functions of the training coordinator are to: Develop, jointly with the project manager, the detailed MMIS training plan based on the general training plan formulated at the project manage- ment level. The training coordinator may have participated in the formulation of the general plan. Identify and define the training requirements for each category of personnel. Establish a schedule for specific training activities and coordinate the schedule with appropriate management and supervisory person- nel, as required. Coordinate the preparation of specific instruc- tional material using subordinate personnel, other agency personnel, or contractor personnel, as appropriate. Conduct trairing activities. Evaluate training results and plan any additional training activities that may be required. d. Training Programs Modules III, IV, V and VI in this training manual contain model training program materials for state MMIS support personnel and medical services providers. The purnose of each model training program is to provide state training coordinators or training instructors with training objectives information, guidance, and sample materials to assist them in developing and conducting appropriate training for MMIS personnel in their states. Each of the modules is a self-contained unit that can be used with- out reference to other materials in the manual. This permits separate modules to be removed from the manual for use by individual instructors. A sum m ary of the contents of each module follows* Clerical Personnel Training Program (Module III) ♦ This module contains information, guidance, and sample materials for a training program appro- priate for currently employed clerical personnel and new staff anticipating assignment to positions 38 supporting the MMIS. It outlines the contents for a lecture/discussion and workshop activity to be used as a primary means of training clerical personnel. Guidance pertaining to the development of the Clerical Job Procedures Manual is also included. Financial Personnel Training Program (Module IV) . This module is intended to provide an overview of the MMIS for financial personnel involved with Medicaid payments. It emphasizes use of financial reports, as well as the support func- tions performed by financial personnel. Data Processing Personnel Training Program CModule V) . This module is designed to provide an overview of the MMIS with emphasis on the interrelationships between automated and non- automated elements of the system. The module contains information, guidance, and sample training material appropriate to the training requirements of this category of personnel. The program identifies and explains the use of contractor provided services and documentation relevant to MMIS data processing training and operations . Provider Indoctrination Program (Module. VI) . This module contains guidelines and sample materials for an indoctrination program appro- priate for providers of medical services. It features an outline of a briefing designed for presentation to provider groups explaining the new system and covering other items of interest to specific provider categories. Also presented is a design for booklets to be used for dissemi- nation of MMIS information to individual pro- viders in the State. 5. Proposed Contents The following review paper on the origin and nature of the MMIS can be utilized by the program manager for familiarizing personnel with the background and structure of the MMIS. 39 MMIS Overview The Medicaid Program was enacted in 1965 under Title XIX of the Social Security Act. Since that time, the program has been marked by rapid growth, not only in terms of its geographical coverage, but in its total annual expenditures of combined federal-state Medicaid funds. In the past six years, expenditures have increased from $1.7 billion to over $6 billion in Fiscal Year 1971. Concern over rapidly rising Medicaid costs and inflation in the health field, led to the establishment of a Task Force for Medicaid and Related Programs in 1969 to examine the deficiencies of these programs and make recommendations to the Secretary of the Department of Health, Education, and Welfare. The Task Force submitted its final recommendations in June 1970. One result was the organization of Manage- ment S3"stems Division (MSD) within the Medical Services Administration (MSA), Social and Rehabilitative Services (SRS). The MSD was charged with the design and delivery of a model information system for each State to improve the capability of the State to manage and control its Title XIX program. Following a study of the requirements cf the Title XIX agenc3 T in several of the States, a model system design con- cept was formulated , and a general system design specifica- tion for the HMIS prepared. The general system design cf the model MMIS orovides a basis for the development cf a detailed system design in each State. The overall objective of the Medicaid Management Informa- tion System in a State is to improve the capability of the Title XIX State Agency to administer its Medicaic Program more efficiently and effectively. To accomplish this , major attention must be focused on claims and provide for a collection of the necessary information for proper plan- ning and control of the Medicaid Program. Structure . The MMIS consists cf six integrated subsystems: Recipient Subsystem Provider Subsystem Claims' Processing Subsystem 40 Reference File Subsystem Surveillance and Utilization Review Subsystem Management and Administrative Reporting Subsystem The Recipient, Provider, Reference File, and Claims' Proces- sing Subsystems function as an integrated unit to process and pay each eligible provider for all valid claims of any eligible recipient. The Surveillance and Utilization Review (SUR) Subsystem consolidates, organizes, and reports selected data to reveal and facilitate investigation of potential mis- utilization or abuse of Medicaid. It also establishes statis- tical profiles of health care delivery and utilization pat- terns to support the continuing agency requirement to monitor and improve the quality of service provided under the Medi- caid program. The Management and Administrative Reporting Subsystem consolidates and organizes management information into a series of reports designed to meet the requirements of those individuals responsible for administration of Title XIX programs. The overall flow of information through the MMIS subsystems is pictured in Figure 2. Subsequent paragraphs summarize the functions of each subsystem. For more detailed information, see Medicaid Management Information System General Systems Design documentation or equivalent state MMIS design documen- tation. Summary of MMIS Recipient Subsystem Functions . The principal functions of the recipient subsystem are to: Maintain identification of all recipients eligible for Medicaid. Provide the mechanism for frequent and timely updates to all recipient eligibility files. Exercise control over data pertaining to recipient eligibility, including Medicare Part B Buy-in processing. Provide a computer file of all eligible recipients to support claims processing, Surveillance and Utilization Review activities, and Management Reporting. 42 Summary of MMIS Provider Subsystem Functions . The principal functions of the Provider Subsystem are to: Process and enroll providers in the Medicaid program upon their agreement to comply with Title XIX rules and regulations. Ensure that only qualified providers are paid by Title XIX for services rendered. Create and maintain a computer file of all eligible providers to support claims processing, Surveillance and Utilization Review activities, and Management Reporting. Summary of MMIS Claims Processing Subsystem Functions . The principal functions performed by the claims processing sub- system are to: Ensure that all claims and related transactions are accurately entered into the system at the earliest possible time. Establish strict system controls to ensure that all transactions are processed completely and promptly and that all claim discrepancies are resolved expeditiously. Verify the eligibility of both the recipient and the providers. Reject claims that do not meet control specifi- cations for "reasonableness" of information. Ensure that correct payment is made to providers on a timely basis. Create a computer file of adjudicated claims to support Surveillance and Utilization Review activities and Management Reporting. Summary of MMIS Reference File Subsystem Functions . The principal functions of the reference file subsystem are to: Provide a generalized update facility for various reference files (e.g., procedures, diagnosis, formulary files) used in claims' processing. 43 Provide practitioners' usual and customary charge data. Generate various listing of data pertaining to suspended claims. Summary of MMIS Surveillance and Utilization Review Subsystem Functions . The principal functions of the Surveillance and Utilization Review Subsystem (SUR) are to: Develop a comprehensive statistical profile of health care delivery and utilization patterns. Reveal suspected instances of fraud or abuse of the Medicaid program by individual patterns. Provide information indicating the existance of any potential defects in the level of care or quality of service provided under the Medi- caid program. Summary of MMIS Management and Administration Reporting . The principal functions of the Management and Administrative Re- porting Subsystem are to: Furnish the state agency with information to support the management review, evaluation, and planning /decision making process. Provide management with financial data for proper fiscal planning and control. Provide management with information to assist in the development of improved medical assis- tance program policies and regulations. Monitor the progress of claims processing operations « including the status of provider payments . Analyze provider performance in terms of the extent and adequacy of participation. Provide the necessary data to support federal reporting requirements. 44 MODULE III. TRAINING MODULE FOR MMIS CLERICAL PERSONNEL P age 1. Overview 46 2. Problems to be Addressed 46 3. Training Goals and Objectives 47 4. Session Development and Format 47 a. Prerequisite Activities 48 b. Developing the Training Program 55 5. Proposed Contents 61 a. Instruction Plan 61 b. Clerical Job Procedures Manual 61 LIST OF FIGURES Figure 1. Processing Flowchart 49 Figure 2. Processing Flowchart 50 Figure 3. Processing Flowchart . . , . 51 Figure 4. Processing Flowchart 52 Figure 5. Process Step Definition 53 Figure 6. Process Step Definition 54 Figure 7. Medicaid Claims Review Personnel Training Requirements 58 45 LIST OF FIGURES (con't. ) Figure 8. Course Instruction Plan. Session One. Figure 9. Course Instruction Plan. Session Two. Figure 10. Course Instruction Plan. Session Three. Figure 11. Job Procedures. ............ 46 III. TRAINING MODULE FOR MMIS CLERICAL PERSONNEL 1. Overview The Medicaid Management Information System provides for the utili- zation of a computerized system to accomplish monitoring and management functions currently performed on a manual basis in some States. The utilization of a conceptual, mechanical system does not, however, elim- inate the need for a great deal of human effort in the installation and operation of the system. The training of new personnel and the reorien- tation of existing personnel to their roles and functions under the MMIS system is vital. Clerical, financial, and data processing personnel must be thoroughly prepared for the new system, or the system will fall short of its objectives. The general goal of this module is to assist the state MMIS training coordinator in developing and implementing a training program for MMIS clerical personnel and their supervisors. The model clerical training program and sample instructional materials presented in Section 3 are in outline form only, and are based on the General Systems' Design of the model MMIS developed by the U.S. Department of Health, Education, and Welfare in 1971. The applicability of these materials to the clerical training activity in each State will be largely dependent upon the degree to which the actual design of the state MMIS matches that of the model. Clerical personnel structures and specific clerical procedures can be expected to vary from State to State. It is suggested that the training coordinator review Section 4 to compare the suggested training outline against the actual training requirements in his State; modify these materials, as required; and develop detailed instructional material appropriate for the particular clerical procedures that are to be used in his State. The identification of specific training requirements for a large number of clerical personnel can be a difficult task. It is suggested that the trainer may follow the processes prescribed in Sections 1 and 2 to develop a general view of the training requirements. In addition, an examination of the job descriptions under the MMIS for clerical personnel should be made. Training requirements may then be developed. 2. Problems to be Addressed The general problem of training of clerical personnel assigned to 47 carry out certain functions within the MMIS may be stated as follows: Clerical personnel need to know of the manual activities required to operate the MMIS. Clerical personnel must understand the rela- tionship between manual and mechanical func- tions. Clerical personnel must understand the rela- tionships between the subsystem of the MMIS and the role of clerical functions in the system. Clerical personnel under the MMIS may lack the requisite skills and/or experience to perform the clerical functions of the sub- system. 3. Training Goals and Objectives The general goal of the clerical training module is to familiarize the clerical staff with the operation of the MMIS and prepare them to begin work under the system. Specifically, the objectives of this training are to: Ensure that the clerical staff understands MMIS and its functional relationship to the current system. Ensure that the clerical staff understands how to use the MMIS Clerical Job Procedures Manual . Provide clerical personnel practice in the use of the MMIS Clerical Job Procedures Manual. 4. Session Development and Format This section presents guidance for developing the clerical training program to ensure that a competent staff is ready when MMIS operations are scheduled to begin. The discussion focuses primarily on preliminary activities in the claims' processing area, which constitutes the largest part of clerical activities within the MMIS. Guidance is applicable 48 however, to all the MMIS clerical functions and the MMIS training coor- dinator should make certain that every clerical .position in the state agency is considered during development of the clerical training program. a. Prerequisite Activities Before the development of the clerical training program can begin, the design and development of the MMIS must have pro- ceeded to such a point that the activities described below have been accomplished. In most States, these activities will be the responsibility of the program manager or the system contractor. Agency Organization . The decision to imple- ment the MMIS in any State must involve the agency personnel in the planning of the change process if it is to be effective. The decision must be followed by an effort on the part of the state agency to review its internal organ- ization and personnel functions to make sure that these elements are properly structured to support the MMIS. The review should result in a recommended reorganization plan that will become effective as the MMIS becomes operation- al. The reorganization will require substantial changes in the structure and functions of clerical positions. Prior to developing the clerical training program, the training coordina- tor must ensure that the new organizational structure of the state agency has been formulated and that he has complete information pertaining to related clerical personnel structure since understanding the effect the reorganization will have on individuals personally will provide a key stimulus for training. Manual Processing Procedures . Development of the MMIS clerical training program is also dependent upon the prior definition of MMIS manual process- ing procedures. This information is generally contained in system design documentation provided by the contractor. At a minimum, this documenta- tion should include a set of manual processing flow diagrams with accompanying narrative describ- ing the manual steps required to process infor- mation through the MMIS. Sample diagrams and narrative are shown in Figure 1 through 6 on the following pages. 49 50 LU _J Q O 3 LU CL 13 Q_ LU I- CO > LO DO ZD to CO CO LU 8 a: CL cn 5 LU \— CO >- co CD co Q CD CO CO en — 1 — 1 LU < h- i LU O Q h- LU a: Q_ LU 2 o CO o CO C£ Q LU - ►-. <_) O i-H Q I LU O _X H QC 2CJ 3 O -It- D- >— « i— >- LCI O _ 2 H O < ~ < O h- a. z 2 LU I- O z o LU O LU Z o o < M Z CO < LU Z Q X -I < LU LU Z _J LU I — o LU Q O LU (- LU a. 3 CL LU h- CO >- LO CO 00 00 LO LU Q. 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Prior to development of the training program, there must also be established clerical job procedures giving a detailed breakdown of MMIS manual processing procedures, staff patterns, and narratives that describe the step-by-step sequence of operations for each clerical position. Doc- umentation containing this information should be provided by the system contractor, In the event that detailed clerical procedures are not defined by the contractor, the MMIS train- ing coordinator will require assistance from appropriate state system analysts and agency staff personnel in identifying- or perhaps even formulating, the specific procedures re- quired for each clerical position. Specifi- cations for the clerical job procedures manual are presented in Section 5b. Forms . Data entry and manual system control forms and other system, documents must be de- signed and copies made available for use in the training effort. Instructions for the preparation or checking of data on system documents must also be formulated, including specifications for appropriate codes and legal data values, where applicable. b . Developin g the Training Program Development of the clerical training program is the responsi- bility of the MMIS training coordinator. Performance of this responsibility involves the following four tasks; (1) define specific training requirements; (2) select a training method; (3) schedule the training activity; and (.4) prepare training materials. Determine Trainin g Requ irement s. The basic objective of the clerical training program is to provide clerical personnel with the essen- tial knowledge and skill to enable them to effectively perform their individual system- related tasks when the MMIS is operational . Meeting this basic objective requires a train- ing program which will develop a general under- standing of the overall MMIS design and system 56 information flow, develop a detailed under- standing of and ability to use the MMIS Clerical Job Procedures Manual , and create a positive attitude regarding the MMIS to dispel concern over organizational and oper- ational changes that will accompany MMIS installation. Development of an effective training program requires that specific training standards be defined to identify the instruction which must be presented and to identify the person- nel for whom the instruction applies. This information is derived from review and analy- sis of documentation resulting from the pre- requisite activities discussed above; that is, the state agency reorganization plan (or the current organization if no reorganization is contemplated) , the MMIS manual procedures design documentation, and the MMIS Clerical Job Procedures Manual . If the Clerical Job Procedures Manual is complete and well orga- nized, identifying instructions to be presented is relatively simple and straightforward. Simply stated, the task of defining clerical training requirements involves compiling a list of clerical job positions and, for each position, listing items which the incumbent must know and be able to do in order for the MMIS to operate smoothly. Such a list shows clearly who is to be trained and what training is needed. In compiling the list, job positions which are identical or similar may be combined and a total shown to indicate the number of positions in that set (e.g., Claims Receiving Clerk, 4). The principal training items to be listed for each position are, of course, the manual pro- cedures for which the position's incumbent is responsible (e.g., sorting and logging all the incoming documents). In addition, consideration should be given to other items designed to pro- vide perspective of the total MMIS and to answer personal concerns which clerical personnel may 57 have about the new system. In this regard, training items listed for each job position should include a system overview and a dis- cussion of the system's impact on the agency. Figure 7 presents sample training requirement statements for two typical categories of MMIS clerical personnel. Select a Training Method . Following determin- ation of the clerical training requirements, the training coordinator should select a method for fulfilling these requirements. Factors which should be considered when making this selection include time and manpower available for preparation of the training program, number and diversity of personnel to be trained, and availability of cirri cal personnel for off-the- job training. Several methods are available to the training coordinator but each requires the development of the appropriate resources necessary to meet the unique requirements of the particular form of presentation. They include ; (1) Lecture. This method is suitable for providing infomation to large groups of people. Ordinarily, by itself, this is the least effective mode of communi- cation. It requires an adequate amount of preparation on the lecturer's part, and demands a fair amount of verbal skill to be effective. Time must be allocated to permit time provided off the job to attend the lecture(s). (2) Workshop . Workshops are suitable for small groups. It is necessary for the workshop leader to be well prepared and to have the workshop objectives and content clearly in mind in order to pro- vide effective direction. Workshops are highly effective in reinforcing both knowledge and work habits (especially with reference to reporting functions). Workshops require time off the job for participants . 58 Figure 7 . Medicaid Claims Review Personnel Train inp Requirements Sample Entries POSITION (S) NUMBER REQUIREMENT 1. Claims Receiving 4 1. MMIS Overview 2. System Impact on Agency 3. General Claims Processing Flow 4. SDecific Claims Rereivinp Procedures a. Mail sorting proce- dures b. Microfilming proce- dures c. Distribution proce- dures d. Log maintenance pro- cedures L. Claims Control z 1 . MMIS Overview 2. System Impact on Agency 3. General Claims Processing Flow 4. Specific Claims Process- ing Procedures a. Input document pro- cessing b. Output distribution procedures c . Ettot rmrppti on V — • 1 — 1 J_ -V- V — 1- \ 1 — 1 X- X. * — * — 1 J— Kj LI. procedures d. Batch Control Log procedures 59 C3) Self-Study of Booklet: Material . The self-study method requires careful preparation of study materials since there is no direct contact between the student and instructor. Particularly suited for individual training, this method has the advantage of providing trainees with a continuous reference source as well as a training document. No travel time or scheduled time off the job is necessary, and the partici- pant can proceed at his own pace in learning. (4) Programmed Instruction . This method is suitable for individual training, but requires considerable preparation and testing. It effective- ly reinforces learning in certain types of subjects;, bat is not considered espe- cially effective in teaching team skills. (5) Formal On- The- Job Training . This method is suitable for individual train- ing. It requires a considerable amount of preparation s but little off-job study time. C6) Informal On-The-Job Trainin g. This method is suitable for individual train- ing. It requires no preparation or off- job study time. It is generally less effective than formal on-job training. A combination of the lecture-discussion and workshop methods ma37 prove adaptable to the training situation in most states. The lecture-discussion method is an effec- tive technique for providing a general orientation to the MMIS to a relatively large group of clerical personnel. A properly structured workshop activity affords a good environment for presenting detailed instruction to the clerical group while allowing , at the same time , individ- ual members in tne. group to concentrate on specific areas which are directly related 60 to their individual requirements. For this reason, this approach is recommended, and is the basis for the model training program in Section C. Schedule Training Activity . The training program presented in Section C is organized for presenta- tion in three sessions of approximately one-half day each. The training could be accomplished, for example, in three consecutive mornings possibly permitting clerks to spend the afternoons catching up with a portion of the work that has backlogged in their offices during their absence. Considera- tion must be given to permitting overtime or tem- porary additional staff where such training has a critical effect on the work flow. The first two sessions are a lecture-discussion activity; the third session is a workshop activity. Scheduling of the training sessions should be coordinated with the overall MMIS implementation plan. A key activity which clerical training must precede is the integrated system test phase. Clerical per- sonnel will be expected to participate in this phase in order to test manual system procedures. Clerical training should be scheduled so that the training is accomplished approximately two to four weeks prior to the integrated system test. Prepare Training Materials . The Clerical Training Course outlined in Section 5 should be reviewed, modified, and details added by the training coor- dinator. Reference documents cited in the outline should contain adequate source material for the training coordinator to use in preparing detailed instruction for Sessions One and Two. Model MMIS references should be used only in the absence of adequate state MMIS documentation. Handouts or vu-graphs must be prepared to outline or highlight the instruction. Use of either of these techniques ensures a higher degree of atten- tion on the part of the participants, and assists them in understanding the materials presented. 61 The importance of the role of the clerical per- sonnel in the new system must be communicated to each participant. Once the function is identi- fied as critical, training will be a much simpler task. The most important reference document and training aid to be used is the state MMIS Clerical Job Procedures Manual . Sufficient copies of this document should be available for use during session Three. A minimum of one manual for every two or three trainees should be on hand. As discussed under "Clerical Job Procedures", this manual should be produced as a part of the system user documen- tation package of the system contractor. In the event that this is not provided or prepared in a format suitable for training purposes, the train- ing coordinator may wish to prepare a procedures manual following the guidelines presented in Section 5. * Proposed Contents This section contains a plan of instruction for a three-session clerical training course and an outline and sacaple materials for a Ciericai Job Procedures Ma nual. a. Instructi on Plan Figure 8 covers the course instruction plan for Session One; Figure 9 for Session Two; and Figure 10 for Session Three. b . Clerical Job Procedures Manual The state MMIS C leri cal Job Procedures Msr i ual contains de- tailed instructions for clerical personnel pertaining to the specific functions which must be performed at each clerical position. The Man ual serves as a basic training document and a reference. manual during day-to-day operations. The following is a specification for this manual. This specifi- cation may be incorporated in the requirements for system documentation to be provided by the MMIS contractor, or may be used, in lieu of such contractor support, by the state agency to prepare the manual internally. 62 Figure 8. Course Instruction Plan. Session One. CLERICAL TRAINING COURSE SESSION OBJECTIVE: This session is structured to refresh clerical personnel understanding of current agency operations and its problems, to explain the rationale for adopting the MMIS, to provide a general overview of the MMIS, and to foster a positive attitude toward the MMIS and new role of clerical personnel in the MMIS. SESSION LENGTH: Approximately hours . REFERENCE DOCUMENTS; TRAINING AIDS: Ref. 1. Model MMIS General System Design , Vol. I Ref. 2. State MMIS Design Documentation Ref. 3. State Agency Reoganization Plan Ref. 4. Recent State Medicaid Program Surveys, if any Handout: Session One Outline Handout: State MMIS Functional Flow Diagram Vu-graphs : Session One Outline Segments (optional) COURSE OF INSTRUCTION: The following topics are to be covered in Session One. Purpose and Overview of Clerical Training Course (15 min.) State objectives and evaluate criteria for the training course. Distribute course 63 outline -and discuss each topic heading briefly. Introduce and state objective of Session One. Preliminary Overview of MMIS (5 min. ) State briefly what MMIS means, what it is, when it will become operational, and generally, why it is being developed. Review of Existing State A gency Operations (60 min.) Refresh clerical personnel understanding of current operations and problems by dis- cussing the topics listed. Illustrate with actual or hypothetical cases where practical. a. Current Operations (1) Agency Objectives (2) Organization (3) Existing ADP Configuration (4) General Processing Flow (5) Major Existing Data Files b. Operational Problems (as appropriate) (1) Timeliness (2) Validity of Claims (3) Maintenance of Audit Trails 64 (4) Accuracy of Records (5) Retrieval of Information (6) Other Problems c. Problems Causes (as appropriate) (1) Agency Interrelationships (2) Overall Agency Workload (3) Non-systematic Numbering Systems (4) Cross-jurisdictional (geographic factors) (5) Inadequate Data Collection (6) Limitations of Manual Filing and Retrieval (7) Unintentional Human Errors (8) Intentional Abuse (9) Other Causes d. Summary Point: The current operation has many areas in which improvement is desirable . 4 . General Description of MMIS (60 min.) Describe the general purpose and physical components of the system by discussing the topics listed below. Supplement presenta- tion with graphic materials, if available. a. MMIS Objectives (1) Improvement of Existing Operations Through Systems Approach and Automation 65 (2) Advantages of Automation (a) Volume (b) Speed (c) Accuracy (d) Flexible Retrieval Components of the System (1) Computer Center (a) Location (b) Role (2) Data Terminals (a) Description (b) Location(s) (c) Role (3) Microfilm Equipment (a) Description (b) Locations (c) Role (4) Forms (a) Types (general) (b) Use (collectively (5) Support Personnel (a) General Impact of MMIS on Agency Organization (b) Clerical Job Positions and Organizational Relationships 66 (6) System Documentation (a) Summary of Applicable Docu- mentation (b) Clerical Job Procedures Manual (purpose) 5 . Summary (10 min. ) a. Review of Session One b. Preview of Sessions Two and Three 67 Figure 9. .Course Instruction Plan. Session Two. CLERICAL TRAINING COURSE SESSION OBJECTIVE: This session introduces the MMIS Clerical Job Procedures Manual to clerical personnel, familiarizes them with its organization and content, and instructs them in its use. SESSION LENGTH: Approximately hours. REFERENCE DOCUMENTS: Ref. 1. State MMIS Design Documentation Ref . 2 . MMIS Clerical Job Procedures Manual TRAINING AIDS: Sufficient copies of MMIS Clerical Job Procedures Manual . COURSE OF INSTRUCTION: The following topics are to be covered in Session Two. 1 . Review of Sessi o n One (5 min. ) 2 . Objecti ve a nd O v erview of Session Two ' (5 min. ) 3 . Introduction to Clerical Job Procedures Manual (20 min. ) Distribute copies of Clerical Job Pro- c edures Manual and discuss its overall purpose and organization, as follows: a. Training purpose b. Reference Purpose c. Organization and General Content d. Validity of the Current Edition 68 4 . Use of Clerical Job Procedures Manual (60 min. ) a. Flow Diagram Conventions b. Overall Manual Processing Flow (1) Tracing Inputs through the System (demonstrate) (2) Job Interfaces c. Individual Job Narratives (1) Locating the Narrative (2) Applying the Narrative 5 . Preview of Session Three and Integrated System Test (10 min. ) a. Session Three Preview b. Integrated System Test (1) Purpose and Schedule (2) Clerical Personnel Participation 6 . Session Review and Questions (Open ) 69 Figure 10. Course Instruction Plan. Session Three. CLERICAL TRAINING COURSE SESSION OBJECTIVE: This session reinforces personnel understand- ing of the instructions in the MMIS Clerical Job Procedures Manual by exercising clerical procedures in a workshop environment . Trainees are not expected to memorize pro- cedures, but are expected to demonstrate the ability to accurately use the Clerical Job Procedures Manual . SESSION LENGTH: Open REFERENCE DOCUMENTS: MMIS Clerical Job Procedures Manual TRAINING AIDS: Sufficient copies of MMIS Clerical Job Pro- cedures Manual ; Prepared Input Documents; Blank Processing Forms; Tables or Desks; In-Out Desk Trays. WORKSHOP INSTRUCTIONS: The workshop is structured to simulate the environment of an operation MMIS of a typical working day . Tables should be arranged and designated to represent clerical processing units which will exist in the reorganized state agency. Clerical personnel assigned to each unit should be seated at the appropriate table(s). Workshop assignments should match anticipated actual assignments, if known. Tables should be equipped with one or more in-out trays, as needed. Each table should also have a supply of blank MMIS form3, logs, j 70 folders, envelopes, and other materials as appropriate for the unit, which the table represents. The instructor (s) will be required to simulate a variety of external elements such as the mail room, computer center, manage- ment, and certain external agencies, institu- tions, and individuals. Additional tables should be designated and materials prepared for this purpose. Prior to the workshop session, simulated input documents (e.g., claims from various types of providers, provider applications, provider change forms, and provider cost reports) must be prepared. Any computer outputs which might be required during the course of the simulation activity should be anticipated and improvised in advance. Also, a variety of recipient, provider, and management inquiries should be prepared as written scripts to be entered during the course of the simulation. The preparation of these materials requires extremely careful planning in order for the simulation to be realistic and effective. Also, as a precautionary note, all simulated documents should be clearly marked "simulation" to avoid the embarrassing possibility of work- shop material inadvertantly being picked up and processed by the real system. 71 At the start of the simulation activity, the various P. 0. boxes of the simulated mail room are loaded with previously prepared simulated inputs. In addition, some partially processed materials can be predistributed to in- or out- trays at appropriate clerical positions (simulating in-process work carried over from the previous day) . The simulation begins with each clerk perform- ing his assigned duties using the MMIS Cleri- cal Job Procedures Manual as his guide. Dur- ing the course of the activity, materials will move from unit to unit, and in and out of the simulated computer center and other simu- lated elements . The activity continues until such time as the "day's" work is completed or the instructors call a halt. The simulation activity should be followed by a critique. The critique is an important element in the learning process which provides j an opportunity for all participants to discuss the operation and the specific problems and solutions discovered. It also serves the secondary purpose of identifying any deficien- cies which may exist in the MMIS Clerical Job Procedures Manual , thus permitting corrections to be made prior to the final installation of MMIS . 72 At a minimum, the MMIS Clerical Job Procedures Manual should contain the following items: Introduction Overall MMIS Manual Processing Flow. A graphic and narrative summary of MMIS manual process- ing describing the flow of information through the system. Descriptions of Input Documents. Samples of forms and instructions pertaining to its com- pletion. Description of Control Documents. Samples of control sheets and logs with narrative describ- ing the use of each document and instructions pertaining to its completion. Descriptions of Clerical Job Procedures. Nar- rative describing, for each clerical position the step-by-step procedures associated with each MMIS-related job performed at the position. In both size and importance, the most significant part of the manual is the section explaining the clerical job procedures. A narrative should be included for every Medicaid agency clerical position which has one or more MMIS-related jobs to perform, since it is to serve as the primary guide to clerical duties. Each narrative must provide precise step-by-step instructions, with sufficient detail to enable the individual clerk to correctly perform his tasks. Narratives must be specific, presented in a standard, easy-to-read format with each step in the job procedure clearly identified, and arranged in an appropriate and logical sequence. Exceptions to pro- cedures should be explained. A sample of clerical job procedures prepared in a form appro- priate in both style and level of detail is presented in Figure 11. 73 Figure 11. System Medicaid Drug Claims Processing Job Numb»r Froquoncy Job Nom« Batch Control For First Audit RESPONSIBILITY ACTION B. Control Clark 1 , Receive batches of Drug Claim documents in travel- ing folders from the Mail Clerk. 2. Verify the type of Drug Claim documents in each folder with the code shown on the Traveling Folder Slip. 3. Verify the count of pages in each Folder with the number indicated on the Traveling Folder Slip. 4. Record from the Traveling Folder Slip onto the Folder Control Register the following: a. Folder number. b. Type of claim document. c. Date received. d. Number of pages in the Folder. 5. Send all Adjustment batches to the Senior Clerk 6. Place all remaining folders in the Open Work File for distribution to the First Audit, insuring that Folders with the earliest dates are distributed first. 7. Upon issuing a Folder to the First Audit, enter that auditor's initials in the appropriate column of the Folder Control Register. 74 MODULE IV. TRAINING MODULE FOR MMIS FINANCIAL PERSONNEL Page 1. Overview 76 2. Problems to be Addressed 76 3. Training Goals and Objectives . 77 4. Session Development and Format 77 a. Identify Personnel and Functions 78 b. Determine Training Requirements 78 c. Select Training Methods 79 d. Schedule Training Activity 80 e. Prepare Training Materials 81 5. Proposed Contents 81 a. Narrative and Figures 81 b. Introductory Briefing Handouts 85 c. MARS Reporting Levels 97 75 MODULE IV. LIST OF FIGURES Page Figure 1. MMIS ................ 83 Figure 2. Surveillance and Utilization Review Subsystem 84 Figure 3. Management and Administrative Reporting Subsystem ................... 86 Figure 4. Management Summary Report . . . . . . . . » . 89 Figure 5. Summary Profile Report . . . 93 Figure 6. Treatment Analysis Report .......... 95 Figure 7. Claim Detail Report „..,... 96 Figure 3. Medical Assistance Financial Status . . . . . 99 Figure 9. Financial Summary . . ....... 100 Figure 10. Expenditure Analysis . ....... 102 76 IV. TRAINING MODULE FOR MMIS FINANCIAL PERSONNEL 1. Overview The module is intended to provide financial personnel with a basic introduction to the operation of the MMIS and to explain how it will facilitate their work. Section 4, "Session Development and Format," suggests ways for the training coordinator to define the audience for the module and how to develop an effective training program for this audience. Section 5, "Proposed Contents", describes and presents sample material which may be used in preparing the training program. The information contained in the module was derived from the General Systems Design of the MMIS and other Federal material, thus substantial modification may be necessary at the State level to accomodate varia- tions in detail design. The relationship between "financial personnel" and other people in the Medicaid program may vary widely from State to State. As a conse- quence, their involvement in MMIS could range from quite limited to very extensive. It should be noted, however, that regardless of the degree of their involvement in claims processing functions, they form an inte- gral part of any successful MMIS effort. 2. Problems to be Addressed The work roles of financial personnel in MMIS may vary greatly from State to State and, as a result, the first general problem is to identify specific needs based on local data. There are, however, several general problems that all financial personnel must deal with, regardless of the nature of the system or the specific role. These general problems include : Financial personnel need a knowledge of the sub- system operation and relationships. Financial personnel require a specific knowledge of fiscal functions within the subsystem. Financial personnel must be aware of the financial policies and procedures affecting other groups within MMIS. 77 3. Training Goals and Objectives The general goal for the training and orientation of financial per- sonnel is to provide them with a general understanding of the subsystem operation of MMIS. The specific objectives are as follows: Ensure that financial personnel are able to use the MMIS outputs for financial and Medicaid utilization control. Ensure that during the system design phase, financial personnel are able to provide feed- back to the design staff about their specific information requirements from MMIS. Ensure that financial personnel are familiar with the data processing methods by which re- ports (outputs) are compiled. 4. Session Development and Format This section contains a discussion or the development of a training program for financial personnel and suggests ways of identifying train- ing requirements * There are five basic steps in the development, of a successful financial training program. Identify the personnel involved in financial affairs and their functions. Determine the training requirement for these people. Develop a training schedule. Select the method most suitable for their training. Prepare the training materials to be used. Each of these points will be considered carefully. 78 I a. Identify Personnel and Functions Within each state Medicaid agency, there is usually a hierar- chy of financial personnel which closely parallels that of program oriented personnel. Financial personnel who influ- ence Medicaid workings may also be found outside the state agency itself; for example, a state auditor. It is important that the training coordinator be able to distinguish separate groups of financial personnel. (Auditors may not be interested in the same things as the chief of fiscal affairs, for instance.) b. Determine Training Requirements Once groups of individuals with similar functions have been identified, the training coordinator must determine the appro- priate requirement for each group. An outline should be pre- pared for each group stating exactly in what areas which group will be trained. For example: Category Number Scope of Training Chief of Fiscal Affairs and immediate staff Orientation to Medicaid situation. Introduction to MMIS, MARS and SUR opera- tion. Reports of interest to fiscal affairs. Auditor 10 Brief orientation to Medicaid. Introduction to MMIS. SUR operation. Reports on misutiliza- tion and what they mean. 79 After the scope of training has been determined for each per- sonnel category, it is necessary to select appropriate train- ing methods. c. Selection of Training Methods Some of the factors to consider in selecting a training method are: Manpower available for program preparation and implementation* Time limits imposed by design and implementation dates . Availability of time off from work for partici- pants . The choice of anyone of the following methods will, plainly, be affected to some extent by these factors. Alternative training methods include: (-i) L ecture . This method is suitable for providing information to large group? of people. Ordinarily by itself, this is the least effective mode of communication. It requires an adequate amount of preparation on the lecturer's part, and demands a fair amount of verbal skill to be effective. Time off the job must be allocated to permit lecture attendance. C2) Seminar . The seminar method requires a substantial amount of preparation and knowledge on the part of the leader and participants. Since it is based on dis- cussions, this method may have more fruit- ful results because the participants must •assume more responsibility for their own learning. (3) Workshop . Workshops are suitable for small groups. It is necessary for the work- shop leader to be well prepared and to have the workshop objectives clearly in mind to provide effective direction. Workshops are highly effective in reinforcing knowledge 80 (especially with reference to reporting functions) . Workshops require time off the job for participants. (4) Self-Study of Booklet Material . The self-study method requires careful prepara- tion of study materials since there is no direct contact between student and instruc- tor. Particularly suited for individual training, this method has the advantage of providing trainees with a continuous refer- ence source as well as a training document. No travel time or scheduled time off the job is necessary, and the participant can proceed at his own pace in learning. Of these four methods, the first two are generally most effec- tive in training financial personnel. Lecture presentations acquainting people with the overall design of the system should be followed by discussion regarding the effect of MMIS on the financial area. This is especially important when the utili- zation of system outputs is a primary topic of concern. It is axiomatic that unless the user feels totally comfortable with the output, it will not be utilized. Time off work is required for both of these methods. Never- theless, the benefits in terms of efficient operation far outweigh the time lost from normal work. Reference materials to support the seminars are available from the Management Systems Division of SRS/DHEW for both the SUR and MARS subsystems. These manuals provide interpretation of the facts presented by MARS and SUR reports, and an in-depth presentation of the rationale behind each one. d. Schedule Training Activity Financial personnel should be included early enough in the im- plementation schedule that they can influence the detail sys- tem design. Often, those who are currently involved in activ- ities such as SUR and Claims Processing are able to identify system improvements which data processors tend to overlook. 81 e. Prepare Training Materials In preparing the training material included in the next section, it was necessary to be general and to follow the General Sys- tems Design of the MMIS . As a result, the typical reports referenced here may not parallel reports produced in a particular State. It is therefore the responsibility of the training coordinator to ensure that representative financial reports from the state system and their explanations replace these typical examples. 5. Proposed Contents This section contains sample materials for achieving training ob- jectives for MMIS financial personnel, including a proposed narrative accompanied by figures and introductory handouts designed to familiar- ize financial personnel with MMIS reports. It is suggested that the trainer distribute the summary papers recommended for utilization in Module I to financial personnel at the conclusion of the orientation session. While the session focuses on specific aspects of the system related to financial personnel, the summary documents may be useful as references. a. Narrative and Figures There is little disagreement about the value of the Medicaid Program; that the nation's poor should not be denied good medical care because of inability to pay for it. However, the increase in costs for this service has been alarming, as shown in the figures below: Year Amount (in millions of dollars) 1966 1967 1968 1969 1970 1971 $ 372 1944 3266 4107 4794 6148 The major area of controversy, about Medicaid concerns its costs which have been much higher than anticipated since 82 the program's inception. As can be seen, the cost of Medicaid rose from 372 million dollars at its inception in 1966, to almost 6.15 billion by 1971. The 6.15 billion in funds spent represents about a 30 percent increase over 1970 spending levels. Officials at all levels of government felt that something had to be done to be certain that these increases were at least justified by increased services to the poor. Problems in Medicaid reporting and ad- ministration had reached the crisis level. Areas of major spending for Medicaid in 1971 included: In response to this crisis, the Medical Services Administra- tion of the Department of Health, Education, and Welfare developed a generalized administrative system for Medicaid which could be modified to fit any state with a Medicaid Program. This system was named the Medicaid Management In- formation System, or MMIS for short. The design of the MMIS permits handling of management and review functions by separate computerized modules as shown in Figure 1. Detection of misutilization by provider and recipient is the function of the Surveillance and Utiliza- tion Review module, known as the SUR. Management reporting is done by the Management and Administrative Reporting Sub- systems or MARS. The Surveillance and Utilization Review module uses paid claims as a basis for developing a statistical profile of utilization according to norms developed by the system and modified by the state as shown in Figure 2. Significant deviation from these norms causes the computer to generate a report containing comparative information on the partici- pant and a history of his utilization of Medicaid for the preceding five quarters. Service Amount (in millions of dollars) In-Patient Hospital Care Nursing Home Care Physician Services Prescribed Drugs Dental Care $2,228 1,674 717 473 181 83 Figure 1. MMIS 84 Figure 2. Surveillance and Utilization Review Subsystem 85 Additional reports are available to provide a more detailed review of the participant's pattern of Medicaid claims. The Management and Administrative Reporting Subsystem also uses files of paid claims as well as budget data supplied by financial officials to report on how well the Medicaid pro- gram is meeting expectations by providing multilevel finan- cial management reports as shown in Figure 3. The provision of very broad executive su mm aries down to the detailed county-by- county breakdowns helps administrators at all levels predict their ongoing performance and correct par- ticular problems. The financial reports generated by MARS and the documentation of misutilization of SUR is discussed in some detail in the package entitled "Financial Reports and their Significance" which are now being handed out. (Hand out packages.) b . Introductory Briefing Handouts These handouts are designed to acquaint the financial people with the types of reports which MMIS will provide for them, and to provide the basis upon which an intelligent seminar may be conducted. A discussion of the contents of the hand- out is contained in the following paragraphs. This handout is designed to acquaint financial people with the reports from the Medicaid Management Information System which may have a direct impact upon their jobs. As mentioned in the introductory presentation, these reports are generated by two functional subsystems of the MMIS, the SUR and MARS. Each of these will be discussed in turn. The principal functions performed in the Surveillance and Utilization Review subsystem are to: Develop a comprehensive statistical profile of health care delivery and utilization patterns . Reveal suspected instances of fraud or abuse of the Medicaid Program by individual pro- viders and recipients. Provide information indicating the existence of any potential defects in the level of care or quality of service provided under the Medi- caid program. 86 Figure 3. Management and Administrative Reporting Subsystem B7 The principal source of information for SUR is in the file of adjudicated claims which the MMIS maintains. MMIS also applies certain demographic and identification data on individual pro- viders and recipients. All participants, providers and recipients, are classified into homogeneous groupings according to their particular char- acteristics. A statistical profile is developed of each such group and also of each individual participant. Individual participant profiles are then measured against the appropriate group profile and all participants deviating significantly from this group norm are displayed for review. The partici- pants who are expected should be investigated in detail by a multilevel investigative staff ranging from SUR specialists to peer group reviewers, to the state attorney general, if necessary, to confirm suspected misutilization, Appropriate corrective action is initiated against proven misutilizers in accordance with the nature and severity of the improper activity or practice that was detected. The computer system accomplishes all operations required to identify the exceptions to the norms of participant perfor- mance. To assist in the subsequent investigative process of confirming misutilization , the computer system provides access to claims data. The user car', select and print only the claims data that are of potential value in making a determination of misutilization. Five major groups of reports are produced by the subsystem. A general description of these reports is provided below: Management Summary Reports present a statistical profile on each of the peer group classifications defined by the user. The content of these reports corresponds to that of the Summary Profile and Treatment Analysis Reports described below. These reports will communicate to management the group norms developed by the system, and will assist him in determining whatever modifications may be required to tailor these norms to his needs. Summary Profile Reports present, for each individ- ual Medicaid participant, an interrelated set of statistical report items which have been carefully selected to reveal common types of misutilization subject to detection by statistical reporting techniques. Data on these reports are presented 88 in such a manner that long term trends in utili- zation patterns may be easily recognized without compromising the need to recognize potential misutilization at the soonest possible moment. Treatment Analysis Reports are available to facilitate, to the extent possible, an analysis of the level and quality of care rendered by individual providers of physicial and in-patient hospital services. Data on these reports are organized to show specific services rendered in response to specific diagnoses. Claim Detail Reports are available to support the investigation of misutilization by indivdual participants. These reports permit a high level of user selectivity in displaying essential data from each adjudicated claim. Special Reports may be requested from the system. The content and format of these reports is speci- fied by the user. Any data contained in the MMIS data base may be selected and printed, in order to satisfy requirements for information not met by the standard reports mentioned above. Figure 4 contains a Management Summary Report sample. It reflects exactly the same information as the Summary Profile Report for class groupings rather than for individual participants. This report is to be used by management with ad- vice from financial planners to adjust the compu- ter-determined levels at which the exception cri- teria should be set. Like the Management Summary Report , the Summary Profile Report (Figure 5) is divided into five sections. The identification section presents all facts relevant to establishing who the par- ticipant is and where he fits into the Medicaid establishment. Section Bl, the second section, is concerned with volume-oriented data. It is important to note that high volume which may cause exceptions and consequent generation of a report does not 89 1 S9 i erf I w I H I erf o I JH\DO(a\nr^i01SiOMSrOI^l m cr- cn i— 1 cn CO CM *st 00 00 cn CM m cn -3- oo cn rH S. rH m cn or 3> CO •o- - CM X r> cn cn cn CM cn rH Si Si C"\ CT\ r— 1 cn cn H CM rH H C7 CM a H !--- < I I 00 I rH I 33 H P I— < X g M rl u CM r-> Si CM o S. CM r-» CM m cn cn rH «s un 1S. \D O H 3'. 00 00 vD H CM r>« 00 CM CM vO cn ^0 H r-~ m in CM CM ci in VC r-. sj lO n CM cn X3. \o CM H rH VJD in oo rH ^ cn iH rH m CN CM cn vO CM H m s ■Xj S. cn m —i CM rH cn cn C 1 s> cr i-> rH S C CM cn H C cn cn CO cn cn rH CM rH rH .-- vO cn N CM rH H m rH H — 1 rH rH m -.o CO CO 00 — ; r> - rH r-* CM VC H vC cn X cn VO X i — i X m r» in Si CM rH cn s. 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CM <• CO vO CO CO vc ■>* co >. rH VO CM -T fS 00 c CO vO ft - : 0> CO CO CM CO CO CM ro <■ ci «tf — vO H rH O -* ■SC * * rH CO CO vO 1—: - CN <* 00 VC CO r~ vO IS. CM CO #1 vC 00 m X r- CM in LT 00 rH H - C : r" CO IT) rH m CP CTi H «C CM X VO CM CM •a rH r>. CM H vO H Cd H Ph M OJ X! Pi 2 P P5 Cd Pi Cd rJ Cd Cm id Ph H z I < Pi Cd id fd Cd § Pi Pi o (d Pi M O 00 o o>i> z < < Id g Cd O PS L3 x H H H H O Z Z Z S Z Cd Cd Cd Cd U O U O X a Cd PM 3 [§ rH H U H ■ z o Cd Z OictisJDiOOBSO Cd Cd Cd Cd > Pi Pi Pi Pi <: Cd > cm <3 i-iNci-*invONcoaMSH lS-'S.lSTS-TS'S.CS-T3-lStrH rH 94 by itself indicate misutilization. The final three sections with their summaries and per- centages are the areas where misutilization is most often picked up. Trend rates which are abnormally high (or low) may also be excellent indicators of the need for further investigation. As in other reports, those indicators which caused the exception are circled and starred. Treatment Analysis Reports (Figure 6) are also produced on an exception basis. This allows the Medicaid staff to pick up suspicious diag- nosis/ treatment /prescribing practices even if billing procedures seem to fit into the pattern of the participants peers. This report is in- tended as either a supplement to the summary profile report or as an initiator from which additional reports may be requested. Its pri- mary function in either case is medical rather than financial, and it is included here pri- marily for reference. Claim Detail Reports (Figure 7) are also pro- vided when requested to support documentation of a case of suspected misutilization. These serve merely as checks for the auditor's guidance in matching invoices with records for the particular participant. For any given par- ticipant, a Claim Detail Report should be a complete list of all claims paid to or for that participant. Special Reports are available to satisfy infor- mation requirements not covered by standard SUR reports. Any data, financial or medical, con- tained in the history file (see below) may be selected, sequenced, summarized, and used for computation in order to produce the desired special report. The following data are con- tained in the claim history file. Definition of these data elements within each state will provide a uniform nationwide base of information. - Transaction control number - Category of service 95 u •H p4 uj ui a: o < > I ui o 0* UJ — up u/ z c O « o 1 15 CP UJ 1 • ar m u 1 Cj "~" 1 Z vi — ~> UJ or C 1 o z UJ C 1 > o JO o i < z UJ u. a O 3 1 c Q 1 u >- or or o UJ o *v L5 O wl UJ VI u « o H- < > X UJ Ui < -. 1 L/~< U> u o (/I „ u O *' « z a > 1 < p- Ui or * LU ■ < n UI c •_> LJ 2 _ ! (9 w or 1- 1 > 3 ui < VI 3 a. a (/i ui PJ oc a e X or o UJ o UJ z vj" PJ z . 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X X DATE SPENS V, >. -s. in on •< — i CM Z i/> O tn in in •O %0 o o o i • z pi It* rr\ r- i— i a i or CI m m in m 1 UJ *» >* m o * in UJ Z f- f- i- or z *1 CO or a. *»• -4- CD CO u Kf> IS) CM CM -* r- co o UJ > HJIrl o OC X »0 * CM o Z UJ a a f- CM CI < o O o o o o o a O CM —I z t- <_) z uj IM ^ — z CO CM IM z . m •* m t- . f~ cc —> CD o o *»*t O 3 UJ « c ■e> 1 •c o 1 1 CM — i 1 I- CI CO c* CM "- Cl Z i/i or m •o m •0 •* o _l r+ >0 CM X 1- m in in •a o 1 1 1 Z O -< 5z •» * •* o> or * Ifl o> f*- 3 -> * or o .XI «v CO p» 00 Z 1- in * in t- i_) CM O CI IM < z - r o z or r- o z CD UJ z <» c Uj UJ 00 uj or r-4 >- •uj Z J — a in m or CO a • * CM 97 - Transaction code - Recipient ID number - Recipient county code -- Recipient aid category - Primary diagnosis code - Provider number - Payment amount - Third party liability action - Third party payment amount - Procedure code - Drug code - Refill indicator - Beginning date of service - Ending date of service - Prescription number - Patient status - Procedure charge - Drug charge - Place of service - Units of service - Date of adjudication - Adjudication status - Type of service c. MARS Reporting Levels In lieu of presuming a typical Medicaid organization within the State 5 the MARS reports are broken down into four func- tional areas « These area groupings extend from summaries of concise data reflecting the status of the Title XIX program at the highest reporting level to detailed information at the 98 lowest reporting level. Between these levels are two addl tional reporting levels of information which support super visory and staff functions. The groupings consist of: Level 1 - Status reports . Concise summary data which provides management with a com- posite overview of the current status of the Medicaid program. Level 2 - Summary reports . Consolidated manage- ment information which expands upon Level 1 reports and supports the plan- ning and evaluation functions within each functional area. Level 3 - Analysis reports and SUR profile reports . Information which permits an indepth review and analysis of a functional area in order to identify problems. Level 4 - Detail reports . The lowest level of in- formation distribution containing spe- cific detailed information generated for use by a given functional area. These reports are generated within the other subsystems and are not included in MARS reports in this section (see SUR reports) . Status Reports . This example of a medical assis- tance financial status report (Figure 8) lists expenditures and budgets for the entire Medicaid program, broken down by broad categories of ser- vice. It is intended for the use at the highest management levels in order to analyze general trends and compare current and previous years' figures. Summary Report . This example of a financial summary report (Figure 9) is intended for use by Level 2 management and/ or as a supplement to the management summary report mentioned above. The financial summary takes one of the catego- ries of service mentioned in the management summary report and breaks it down with a more detailed analysis. 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The second section of the report presents essentially the same data for all categories of service so that the two may be compared (i.e. , this program vs. all Medicaid programs). Analysis Report . This example, an expenditure analysis report (Figure 10) , presents expendi- ture data by aid category of service. Like the financial summary, each report concentrates on a single category of service, but includes a section on equivalent data for the entire Medicaid program. Trends rates, which are indicators not tied to volume, are the best means of determining if a particular section of a program is ad- vancing too rapidly. 102 o H a IM O 1 O' M _^ •a ml »- -j (M M pg CO f\J IN < « «e p- • ♦ • • • (i • o m f*. fl*l o I. r» © CD pg • o P- o O *n 1 g\ • © mi m o ff\ *>« rg o o mi UJ o o o o o ec • • • • 8 1— ♦ ♦ z • X w (J- o h- eo o < (SI (S! • - a> • rsi «0 • o h- p- o • CO O o P- o m eo z «SI >-« mi o o IU O O o o o o o • • • • • • • 4 ♦ 4 * IA u • o >> IM m o m < < •0 (SI (M ml > & • <1" • • <*> • o IT « tt p- ■4- (SJ f\J mi i— * f> z O 4 o a i/s O U1 -o Q- (M c** z t— i pmi IU IU o O o o o o o a • IU i- w 4 4 so a; < < _J mi o m-i o 3 u < o o Csj •■5 •0 • m • 1- o 0 r~ p- m 1? Q < -* 59 a ft O mi m 6-- z < a o UJ O o o o IU 0j£ • * p- <> 4 + a. Q « < o I — oc >• o |U < UJ i/> a of > UJ UJ I- u> Ul Z UJ (J UJ ■ M «- or > a c a — o uj o uj 1/1 uj j- ee < " ■ u. oe — x >/> o uj u ee a — _l < o«> Z 1/1 4 _J UJ >. I- -J ~ 0C I c 5 z a. k o 3 — i- or uia v) < o — »- »- O < — -I > uj jz < ec eo w 3 t- uj o o >S> O k- z p- UJ z — X — >- o _l < 4 _J O O 103 MODULE V. TRAINING MODULE FOR DATA PROCESSING PERSONNEL Page 1. Overview 104 2. Problems to be Addressed 104 3. Training Goals and Objectives 105 4. Session Development and Format 105 5. Proposed Contents . . . . 108 a. Narrative , 109 LIST OF FIGURES Figure I. The Groups of Medicaid Participants 110 Figure 2. Recipients 112 Figure 3. Administration 113 Figure 4. MMIS Provides 114 Figure 5. The State Provides . 115 Figure 6. Six Modular Subsystem 116 Figure 7. Recipient Subsystem ...... 117 Figure 8. Provider Subsystem ... 119 Figure 9. Claims Processing Subsystem 120 Figure 10. Reference File Subsystem 121 Figure 11. SUR Subsystem 122 Figure 12. MAR Subsystem 123 104 V. TRAINING MODULE FOR DATA PROCESSING PERSONNEL 1. Overview This module is designed to give systems and computer ~oriented per- sonnel an overview of the Medicaid program and the Medicaid Management Information System. Because it is the joint responsibility of the com- puter equipment vendor (s) and the designer of the detail system to be used in a State to provide detailed operational training, the module is not detailed and covers only the general system design. This module may be used to develop an overview of both Medicaid and MMIS for data processing personnel. The information is drawn from the General System Design for Title XIX* and from other material available at the national level. The training coordinator will probably wish to develop material along similar lines for his own state situation. Section 5, "Proposed Contents," may be used as is to present the general design of MMIS, or may be modified to reflect the state's detail design. The section can be used to set a positive tone for the develop- ment work before it has begun, since all personnel concerned with the design of the system should have at least this much knowledge of its operation. Individuals who will actually be involved in the design of their state's system should be thoroughly familiar with the "Contents" material. 2. Problems to be Addressed There is a tendency for data processing personnel involved in large projects having a heavy emphasis on computer usage (such as MMIS) to become isolated from other aspeccs of the program. However, since data processing personnel will be heavily involved in the total systems design, it is important that they understand the nature of the subsystems func- tioning. The general problem to be addressed s then s is that data pro- cessing personnel need to understand the general subsystems operation. The specific problems are as follows: Data processing personnel are isolated by the nature of their function from the rest of the Medicaid Program. Data processing personnel lack a knowledge of the goals of the MMIS system and subsystem operations. ^Medicaid Management Information System, General System Design for Title XIX , U.S. Department of Health, Education and Welfare Social and Rehabilitative Service, Medical Services Administration, June 1, 1972. 105 Data processing personnel are unaware of the nature and extent of the task involved in installing the system. 3 . Training Goals and Objectives The general goal of the training and orientation of data processing personnel is to provide them with an understanding of the Medicaid Pro- gram and the functions of MMIS. The specific objectives of the train- ing are as follows : Ensure that data processing personnel under- stand that they have an important part to play in the total effort to improve the functioning of the Medicaid Program. Ensure that data processing personnel under- stand the objectives of MMIS and the subsystems operation. Ensure that data processing personnel are aware of the scope of and the major steps involved in installing the MMIS , Initially, the training coordinator must break the "data processing group" into homogenous groupings for training purposes. Then each cat- egory can be analyzed, and an outline prepared of the particular train- ing necessary, if specific procedures for operating the system have been defined, these should be worked into the outline. Any training to be done by equipment manufacturers should also be included in the out- line. If the purpose of the training is simply to acquaint people with the new MMIS, a simpler outline will suffice. A sample of each type of outline follows: 4. Session Development an d Form at Category PEE --DESIGN TRAINING Number to be Trained Scope of Traini ng Programmer 5 1. Orientation to Medi- caid . 2. Introduction to MMIS. 3. Interaction between subsystems . 4. Timing for development. 106 Category POST-DESIGN TRAINING Number to be Trained Scope of Training Data Entry Clerk 15 1, Orientation to Medicaid. 2. Introduction to MMIS. 3. How to utilize data entry equip- ment. 4. Specific Medicaid procedures for document handling. After the training requirement has been determined, the training coordinator should select a method or methods to fulfill this require- ment. Some of the factors that enter into this decision are: Manpower available for program preparation and implementation. Time limits imposed by design and implemen- tation dates. Availability of time off from work for the trainees. Several training methods are available that place varying emphasis on the limitation mentioned above. These include: (1) Lectures . This method is suitable for providing information to large groups. Ordinarily, by itself, this is the least effective mode of communication. It re- quires an adequate amount of preparation on the lecturer's part, and a fair amount of verbal skill to be effective. Time off the job must be allocated to permit lecture attendance. (2) Seminar . The seminar method requires a substantial amount of preparation and 107 knowledge on the part of leader and par- ticipants. Since it is based on discussion, this method may have more fruitful results because the participants must assume more responsibility for their own learning. (3) Workshop . Workshops are suitable for small groups. It is necessary for the work- shop leader to be well prepared and to have the workshop objectives clearly in mind to provide effective direction. Workshops are effective in reinforcing knowledge (espe- cially with reference to reporting functions) . Workshops require time off the job for participants . C4) Self -Study of Booklet Material . The self-study method requires careful prepara- tion of study materials since there is no direct contact between the student and the instructor. Particularly suited for individ- ual training, this method has the advantage of providing trainees with a reference source as well as a training document. No travel time or scheduled time off the job is neces- sary, and the participant can proceed at his own pace in learning. Of these four methods 5 a combination of lectures, seminar, and self- study of booklet material are most suitable for operating personnel; and a combination of lectures and seminar are best for systems and program- ming personnel. Time off the job, a significant factor in the first three methods, is well spent if people can be made to accept the necessity for the change and learn their part in it. Workshops can be developed in conjunction with the integrated systems' test to minimize wasted time, while lectures may be scheduled to coincide with normally slack periods. A seminar approach to training higher level data processing people not only gives an opportunity for them to thrash out the new system, but may provide valuable input to the system designers. Some sort of a reference manual should be available for each level of data processing personnel. The training coordinator must see that this type of material is made available (generally from the equipment vendor and detail designer) for ready reference. 108 The scheduling of the data processing training should depend on the purpose of the activity. If the event is designed to simply acquaint and inform people of the new system, it should be scheduled soon after the decision to go ahead with implementation is made. If operation training is conducted, it is wise to schedule it close enough to the system implementation date that people will not forget their new learning; but far enough in advance that any problems can be worked out. 5. Proposed Contents This sample presentation of an overview of MMIS may be modified to reflect the implementation plan of the particular State. If some of the subsystems are not to be used, the training coordinator will, of course, wish to delete them from the presentation. This will leave room for an expansion of those subsystems which do apply. This training should be applicable to both long-time employees and new staff in the data processing department. Each will have different levels of experience, a factor that will require the training coordina- tor to integrate those materials presented here with the operational techniques of the computing equipment and the detail design. It is imperative that every employee concerned with data processing have the system presented to him in at least as much detail as the sample train- ing material. A second factor concerning the training material is the level of involvement of the data processing department in the detail design and programming of the system to be actually used. If a contractor is doing the entire detail design, an early overview of the system being develop- ed is sufficient until it is installed. If, on the other hand, the state data processing department is partially responsible for the detail design, thorough understanding of the system must be developed through additional training. This sample outline of presentation material, including supporting visual displays suitable for flip chart/vu-graph reproduction, covers: Current status of Medicaid nationally. Rationale for MMIS development. Effect of MMIS on persons concerned with Medicaid. 109 Explanation of MMIS in terms of data processing. The outline is provided below: a. Narrative . The phenomenal grox^th of the Medicaid program through its first five years can be seen in the following table, which traces expenditures. Note that the cost of Medicaid rose from 372 million dollars at its inception to almost 6.15 billion by 1971. This represents a 30 percent increase in one year, and there is no end in sight. Needless to say, cost conscious people who are concerned by the rapid rise are asking, "Where can we look to reduce, expenditures . " There are three groups of Medicaid participants who can effectively influence costs as indicated in Figure 1; pro- viders of services; recipients of services; and Medicaid administration. To develop a method of controlling costs in all the areas mentioned above, the U.S. Department of Health, Education, and Welfare developed a comprehensive management information and control system for the states called the Medicaid Manage- ment Information System. MMIS ties the three categories of participants together, providing benefits to each, while en- suring tight control over the total Medicaid program. Providers are given faster and more accurate claim payment, quicker response to questions, and a more uniform enrollment procedure. At the same time, statistics are kept by MMIS to effect continuous monitoring of each provider's charges, volume of service, and treatment methods. The system builds and maintains a computerized data file to be used for invoice processing, administrative reporting, and Surveillance and Utilization Review. Year Amount (in millions of dollars) 1966 1967 1968 1969 1970 1971 $ 372 1,944 3,266 4,107 4,794 6,148 110 Figure 1. The Groups of Medicaid Participants PROVIDERS ADMINISTRATION RECIPIENTS Ill Recipients are assured of wider provider acceptance of Medi- caid and care that closely approximates that available to non- Medicaid individuals as shown in Figure 2. Like providers, recipients are monitored with respect to any abuse of Medicaid. The state Medicaid administration can be assured that the pro- gram is being continuously monitored for misutilization through the use of MM1S as indicated in Figure 3. More data about health care patterns will be made available to administrators than ever before. MMIS provides many levels of reports that help management plan for the future. Additionally, the ad- vanced automation of MMIS helps eliminate many of the manual procedures of claim processing and eligibility checking that burden the administrators. Figure 4 describes how the MMIS is designed to accomplish these functions and what is required to accomplish its imple- mentation. The Department of Health, Education and Welfare has written a General Systems' Design for MMIS that is appli- cable in total or in part to all states providing Medicaid services. The General Systems' Design includes specifications for Input elements, suggested reports, and a means of connecting the two. Clerical and automatic data processing functions are included ia the general design as well as designs for all re- quired computer files. Additionally, DHEW has made technical assistance available for project management assistance in modification of design to fit the state's needs. Figure 5 describes the state's responsibilities to assure the system is initiated and operates effectively. A state is responsible for carefully reviewing its requirements with regard to Medicaid policy, procedures, and personnel, as well as the program-by-program design of the actual system that will operate in the state. The MMIS is comprised of the six modular subsystems for ease of programming shown in Figure 6. Each performs a specific unique function within the system, which we will explore next . The Recipient Subsystem, shown in Figure 7, serves to collect data on all eligible Medicaid recipients. Its basic func- tion is to provide an edited, cross-referenced master list of recipients to the Claims Processing Subsystem. 112 Figure 2. Recipients RECIPIENTS MMIS: 1. MAINTAINS A FILE OF ALL PERSONS ELIGIBLE FOR MEDICAID 2. UPDATES AND CONTROLS ALL DATA APPLICABLE TO ELIGIBILITY, INCLUDING MEDICARE PART B, BUY-IN 3. INTERFACES AND PROVIDES A DATA-BASE FOR CLAIMS PROCESSING, SURVEILLANCE AND UTILIZATION REVIEW, AND MANAGEMENT REPORTING 113 'Jj' 1 !'': 2 Admin is tr at ion MMIS: 1. INSURES RAPID MOVEMENT OF CLAIM INFORMATION WHILE PROVIDING MAXIMUM ACCURACY 2. PROVIDES EXCEPTION REPORTING IN THE AREAS OF USUAL AND CUSTOMARY PRACTICE,, AND CHARGES TO REVEAL MISUTILIZATION BY PROVIDERS 3. DEVELOPS AND REPORTS A COMPREHENSIVE STATIS- TICAL PROFILE OF UTILIZATION AND HEALTH CARE DELIVERY PATTERNS 4. REPORTS FISCAL DATA NECESSARY FOR SOUND ADMIN- ISTRATIVE PLANNING 114 Figure 4. MMIS Provides X 7 MMIS PROVIDES*. V A MODULAR, GENERAL SYSTEM DESIGN INCORPORATING: A. STRUCTURAL AND FUNCTIONAL SYSTEM REQUIREMENTS B. PROCESSING FLOW WITH CLERICAL AND ADP FUNCTIONS TO SUPPORT IT C. INPUT, OUTPUT, AND DATA ELEMENT SPECIFICATIONS D. REQUIREMENTS FOR FILE DESIGN E. TECHNICAL ASSISTANCE IN DETAIL SYSTEMS DESIGN 115 Figure 5. The State Provides THE STATE PROVIDES: A. MODIFICATION OF THE SYSTEM TO MEET YOUR STATE'S SPECIAL NEEDS B. DETAIL DESIGN AND PROGRAMMING C. ORGANIZATIONAL AND OPERATIONAL ANALYSIS OF PERSONNEL, PROCEDURES, AND COMPUTER EQUIPMENT 116 Figure 6. Six Modular Subsystems 118 The Provider Subsystem, shown in Figure 8, performs essentially the same tasks for providers as does the Recipient Subsystem for recipients. New providers are certified by this subsystem as they are enrolled. The Provider and Recipient Subsystems and claims-to-be paid serve as input to the Claims Processing Subsystem shown in Figure 9. The subsystem checks eligibility of the provider and recipient and the reasonableness of the charge. If the claim is accepted for payment, it is added to the list of pay- ables for that provider. At specified intervals, the subsystem issues checks for these lists. If the claim is not accepted, it is held in the subsystem until the error that caused the exception is corrected. The provider is notified of any error not caused by bad data preparation, and is also given a state- ment of claims paid and suspended with each check. As soon as a given claim is adjudicated, it is placed into the adjudicated claim file. The Reference File Subsystem shown in Figure 10 serves to main- tain and update the files of reasonable and customary charges, and the procedure, diagnosis, and formulary file. These files are used during claims processing to determine if a claim charged is within reasonable limits; and if the diagnosis is reasonably consistent with the treatment. The adjudicated claims file produced by claims processing, along with the provider and recipient eligibility master files are used by the Surveillance and Utilization Review (SUR) Sub- system shown in Figure 11 to detect patterns of misutilization of Medicaid by individual providers and recipients. This is accomplished by developing norms of utilization for similar groups of providers or recipients , then checking each monthly statement against these norms. The degree of abnormality necessary to except a claim may be set at whatever level the state wishes, and only excepted claims are subjected to manual review. If an exception cannot be resolved, several levels of reports can be requested by the reviewer. These include a range of reports, from highly generalized summaries to individ- ual claims and analyses of treatment patterns used. The Management and Administrative Reporting Subsystem uses in- formation collected on the operation of MMIS as well as the files used in SUR activities (see Figure 12) to produce a series of multilevel management reports. These range from one page summaries of the current financial and program status to comprehensive reports on county-level utilization. The types 119 Figure 8. Provider Subsystem 120 Figure 9. Claims Processing Subsystem 121 Figure 10. Reference File Subsystem 122 Figure 11. SUR Subsy stem 123 Figure 12. MAR Subsystem 124 of errors entering the system are categorized and presented by frequency, and statistics on provider claim filing habits are accumulated. In summary, MMIS is a modular, integrated management infor- mation system. Once implemented, it will control the Medi- caid payment procedure and help provide a means to monitor the payment process. 125 MODULE VI. TRAINING MODULE FOR MMIS PROVIDERS Page 1. Overview 126 2. Problems to be Addressed ..... 126 3. Training Goals and Objectives 127 4. Session Development and Format . 127 a. Determine Training Requirement 128 b. Select Training Materials 129 c. Schedule Training Activity 131 d. Prepare Training Materials 131 5. Proposed Contents . 131 126 VI. TRAINING MODULE FOR MMIS PROVIDERS 1. Overview The provider training module is designed to assist the training coordinator in developing a training program for providers of Medicaid services. Providers include physicians, hospitals, clinics, labora- tories, pharmacists, and all those providing services under the State Medicaid Plan. The module is a flexible framework that recognizes the diversity of provider functions. The material presented in this module is derived from two sources: the Medicaid Management Information System, General Systems Design , and the experience of the State of Ohio in implementing this system in detail. Not all of the material presented may be relevant to the situation in any given State. The training coordinator should examine this training program against the detailed design of MMIS to be imple- mented in his state to determine its applicability. The coordinator should also (in conjunction with Medicaid management) analyze the particular relationship of his State's Medicaid Agency to both pro- viders and associations to determine the best method of program development . Insofar as the MMIS will influence programmatic aspects of Medicaid, (deadline dates, payment criteria, etc.), it will be necessary to develop a clear and concise explanation of differences between the current system and MMIS requirements. This should be included in the reference material presented to the providers. It should be noted that providers may have a significant influence upon the functioning of MMIS and should be "consulted" concerning issues, rather than simply informed of policy decisions. Consulting those persons closest to the actual delivery of medical care will help avoid embarrassing and costly errors in system design and implementation. 2 . Problems to be Addressed The provider category presents a somewhat different set of problems to be addressed than the groups dealt with in previous modules. Pro- viders are privately employed, and related only contractually to the system. In addition, their orientation and training requires that they take time from their jobs (a factor frequently necessitating the sanction of their employers). 127 Although the providers are, in a sense, removed from the system, their functions are as critical to its success as those of other groups. The general problem to be addressed by this module, then, is that providers are not aware of the general objectives and functioning of the MMIS to the degree necessary to fulfill their roles within the system. More specifically, the problems are as follows? Providers should be aware of the MMIS subsystem functions and relationships. Providers should be familiar with their roles and responsibilities within the system. Providers should be familiar with the Provider Manual for MMIS. Providers should be aware of the advantages for them under MMIS. 3. Training Goals and Objectives The general goals of an orientation program for providers are to provide them with an understanding and gain their acceptance of MMIS. More specifically, the objectives are as follows: Ensure that providers understand the purpose of MMIS and the advantage of the system for them* Ensure that providers are familiar with MMIS sub- system functions of the MMIS and their responsi- bilities in relating to those functions under the system. Ensure that providers are thoroughly familiar with the Provider Manual and the instructions for procedures contained therein. 4. Session Development and Format Gaining provider acceptance and approval of the new Medicaid pay- ments system is crucial to the smooth change over and continued success of MMIS. Like any new system, MMIS will require changes by diverse groups of people. Of these, the providers are the most independent and consequently the most difficult to control. For this reason, careful consideration of the needs of providers by the training coordinator and his supervisors must be an integral part of development of the new system. 128 Below are four basic steps that the training coordinator should undertake to develop and implement a provider training program: Determine the training requirement Select one of more training methods Schedule training activities Prepare training material Each of these steps will be considered in turn. a. Determine Training Requirement The first step in developing a training program is to decide who will need training and what training will be needed. Within each State, there will be several groupings of pro- viders by type of practice (e.g., hospitals, physicians, ambulance drivers, etc.). Each will need specialized train- ing dictated by its interrelationship with the Medicaid pro- gram. Ambulance operators do not need the same training as physicians or pharmacy staffs. It should be noted, however, that there may be instances where providers who perform radically different functions have virtually identical train- ing needs. An example might be physical therapists and optometrists. Both frequently require prior authorization to perform on a Medicaid patient. Both may have substantial expenditures for medical supplies and neither is usually a medical doctor. It is the function of the training coordinator to divide pro- viders into meaningful groups for training purposes. A sample breakout (based on internal organization and the "handbooks" prepared by Ohio Department of Public Welfare) is included below. While it is most important to aave trained individual providers, it must also be recognized that provider associations play an important role in the medical care patterns of any State. As a result, associations as well as individual Medicaid providers should be informed about MMIS in as positive a manner as possible. Needless to say, the political situation within the State and the relationship between the provider associations and the legislative and executive branches of state government will largely dictate the scope and the content of contact with 129 provider associations. For this reason, the broad discussion of training material is to be particularized by the training coordinator in conjunction with other state officials; again, the responsibility for identifying target associations and for selecting appropriate material for these associations must rest with the state. For each category of provider or each association defined, an outline covering the scope of training should be developed that indicates generally what is to be covered (or specifi- cally avoided). An example of this type of outline follows. _ Number in Scope of Training a egory Medicaid Physicians (MD's and DDS), 9,876 Purpose of MMIS Surgeons, and DO's Changes in Medicaid policy Effective date of changes Completion of new forms and filling them out New systems outputs and how to interpret them or for an association: State Medicaid Association 6,543 Purpose of MMIS Why changes? Policy changes are related to current problems Effective dates of changes Effect of change on associa- tion members as a group . Initial determination of the training requirements and the development of the training requirement outlines provide the basis on which the other three developmental steps may proceed. b . Select Training Materia ls Following determination of the MMIS training requirements, the training coordinator selects a method or methods for fulfilling the requirements. Several factors should be considered in making this selection: Manpower available for preparation of the program. 130 Time limitations imposed by design. and implementation dates Logistics (cost and timing of mailing, print- ing, and travel) Provider attitude toward training Several training methods are available to the coordinator. These may be used singly or in combination within the para- meters imposed above. (1) Lecture Method . This method is suitable for providing information to large groups of people. It requires an adequate amount of preparation and verbal skill to be effective. Time spent off the job and traveling to the lecture site is required of the providers. (2) Workshop . Workshops are suitable for small groups. It is necessary for the work- shop leader to be well prepared and to have the workshop objectives clearly in mind to provide effective direction. Workshops are highly effective in reinforcing knowledge (especially with reference to reporting functions). Workshops require time off the job for participants. (3) Self-Study of Booklet Material . The self- study method requires careful preparation of study materials since there is no direct con- tact between providers and the instructor. Particularly suited for individual training, this method has the advantage of providing trainees with a continuous reference source as well as a training document. No travel time or scheduled time off the job is necessary, and the provider can proceed at his own pace in learning. Casette tapes may be employed effectively with this group. All three methods offer feasible alternatives for training Medi caid providers and provider associations. The booklet method is an excellent means of informing individual providers scat- tered throughout the state of changes in policy, forms, and deadlines that will affect each particular provider type. 131 The section on training materials contains an outline of a "typical" provider booklet. Also suggested is an outline of a lecture type presentation appropriate to state medical societies and other provider associations. The workshop materials suggested are useful as either take-home handouts from the lecture or as mail-outs, either with the booklets or as a separate package. c. Schedule Training Activity Scheduling of the training sessions should be dictated by two factors: the stage of development of the MMIS detailed design, and the extent to which providers are likely to resist change- over to the new system. It is essential the provider handbooks be sent out well before the system goes into operation and that any associated work- shop material be sent to providers after basic design require- ments for the MMIS have been completed. All provider docu- ments must be finalized well before the system is scheduled to go into operation. (See MMIS Installation Guide , Exhibit 3.) State provider professional association briefings and related activities are also suggested by the guide and by the schedule in Module II of the model training system. d . Prepa re. Training Materials As mentioned above, the training coordinator should review the material presented in Section 5 of this module and pre- pare documentation to support the training. Perhaps the most difficult task of the training coordinator is to pull together all Medicaid policy decisions that affect providers into a coherent reference and training booklet. It is suggested that a policy statement be signed by all involved persons to avoid conflicts of interpretation. 5 . Proposed Con t ents This section contains an outline for a presentation to be given state provider associations and suggested material to be included in the Provider Handbook. 132 The outline has been developed with presentation to a large meet- ing in mind, but the topics it treats are equally transferable to small group sessions or as the subject of mail-outs. . Consideration should be given to the possibility of allowing informed and committed providers to deliver instruction to their peers on the overall impact of MMIS. In any case, face-to-face contact with providers is the best way to obtain accurate feedback. The outline of the Provider Handbook represents the type of "ready reference" document which must be distributed to each provider's office before new forms and procedures can be implemented. 133 Outline of Session with Provider Association I. Agenda Discussion A, Purpose of meeting (stressing need for provider involve- ment in successful implementation of a new system) B. Outline of the session II. A short history of Medicaid development in the state and U, S. (refer to Paper 1, "A Background and Summary Statement on the Medicaid Management Information System") III. Problems that have developed as a result of rapid growth of medicaid (provider point of view) A. Slow payment of claims (cash flow) B. Loss of claims in processing C. Positive identification of recipients D. Relationship to Medicaid and third party claim E. Poor statements and irregular claims payment F. Slow response to inquiries G. Unreasonable fee schedules H. Poor administrative climate degrades Medicaid program in legislative and public eye IV, What is MMIS? A computer system which is designed to simplify and speed up all a*spects of the Medicaid operation. V. How will MMIS affect solutions to the problems which we have outlined above? Let's consider this, problem by problem. (Explain state system affect on problems listed in III.) VI. Development • of new forms to expedite the change to MMIS. (Show forms and explain differences.) VII. Recap inportance of new system to providers VIII. Questions 134 Provider Handbook I. Program Overview A. Authority for program B. Participation requirement for providers (1) Payment provisions (2) Maintenance of records of services rendered (3) Non-discrimination C. Recipient eligibility (1) Requirements (2) Identification (3) Purchase limitations D. Administrative Procedures (1) Relationship to other programs (2) Obtaining and replenishing forms and manuals E. Third party liability (1) Coverage procedures (2) Procedures for ascertaining third party coverages (3) Overpayment procedures II. Physician Services A. Eligibility (1) Physicians credentials (2) Services covered (3) Non-covered services (4) Limitations 135 B. Other services (1) Surgical expenses (2) Resident and intern (3) Anesthstic (4) Radioligists (5) Pathologists (6) Multiple Surgery (7) Assistance at Surgery (8) Relationship to Medicare C. Drugs and supplies (1) Prescription requirements (2) Listing by type and limitation (3) Non-prescription drugs (4) Medical supplies and prosthetic devices (5) Rules as related to physicians dispensing III. Billing A. Reporting requirements (1) Sample forms (2) Procedures for completing (3) Submission requirements B. Remittance statement (1) Payment procedure (2) Claims in process (3) Correction of invoices 136 Appendix A, A WORKING GUIDE FOR THE DEVELOPMENT OF THE CURRENT SYSTEM OUTLINE ON FLOW CHART DEVELOPMENT 137 UTILIZATION OF FLOW CHART INFORMATION It is essential that the Program Manager, who is responsible for assuring that each element critical to MMIS development is initiated and monitored, has a clear understanding of the various organizational and process display techniques which will be utilized to describe current and projected Medicaid operation. Since individuals with vary- ing background will be assuming the management role in different states, it is difficult to provide suggestions which will be useful to each user. However, there are basic management considerations which should be developed from the information obtained through such displays. These considerations are discussed in the following paragraphs. Regardless of the types of graphic conventions utilized for con- tent display purposes, the intent of a functional or organizational flow is to track program activity and define the structure within which such activity occurs. A frequent problem encountered when deal- ing with flows such as Figure 1, Page 32, Model Medicaid Management Information System is that the graphics are overpowering, often dis- couraging examination because of this evident complexity. This reaction stems from attempting to develop some '"overall response 3 ' from the flow diagram. It is important when working with such displays to "begin", that is, to start at a beginning point and follow the logic path. Once this approach has been followed to its conclusion, the flow chart elements are easily understood. Although rules cannot be developed which cover all types of flow charting since it has become rather "free form" artj we may arbitrarily divide flow charts into three categories. (1) Those which provide an operating overview. (2) Those which attempt to schedule through interrelation of critical events. (3) Those which follow the path of an input such as a form or an individual. It bears reiteration that formal graphic conventions have been documented for the development of such techniques as PERT networks and GANTT charts.* Where this form of graphics is provided, adequate docu- mentation is readily available to explain in detail the conventions *PERT - a technique used for planning and scheduling projects which consist of numerous activities having uncertain but interdependent completion time, GANTT - a graphic method for depicting time, task, and completion relationships without specifying interrelationships of tasks. 138 utilized. More often, however, the output of such efforts as feasi- bility studies conducted within the state will provide more "free form" displays. The Program Manager must utilize such documentation in con- junction with the basic MMIS system documentation to make determina- tions about: (1) What subsystems operate and will be affected by the installation of MMIS. (2) What critical path implications are there in the interrelationships of subsystems, i.e., what events must be started or completed before another activity can begin. (3) What are the implications of this organiza- tional and fucntional activity on the detailed operational day-to-day processes. Stating the problem in this fashion, the relationship between the types of figures utilized and the determinations to be made is evident : (1) An operational overview for identification of tne system affected. (2) Critical path description for timing and priority considerations. (3) Detailed input tracking for identifying and documenting day-to-day processes. Such information must be developed and assembled from two primary sources : (1) The MMIS description provided in the basic system documentation. (2) State feasibility study results which relate the existing operation to the proposed system. At this point the type and effectiveness of the feasibility study which has been conducted becomes critical. The study results must: (1) Lay out the operational overview for the state operation and compare schematically that operation to the model. 139 (2) Incorporate basic state unique elements relating to hardware configurations, and software and organizational/operational factors which impinge on system development. (3) Define basic critical path considerations. If this activity is contracted and completed properly, the basic model provided in Figure 1 can be used as a checklist for each sub- system to determine where procedures in the local operation differ and, more importantly, why they differ. Each element and, in some cases, entire subsystems may not apply to individual operations but where this is true it is essential that the rationale for these differences be clearly understood by the Program Manager. Such information will be most readily available and in a useful form if the results of the feasibility study have been organized to reflect a functional flow diagram which may be compared to the basic MMIS model. Where tnis has not been done, such a flow can be constructed from the feasibility report. It is essential that the differences between the model and operation be identified, basic critical path elements established and local constraints/restrictions identified before the system design is contracted by the state. Requirements for the system design may be viewed as stemming from the basic MMIS model as modified by local configuration ele- ments. During the conduct of the system design the documentation developed will complete the critical path consideration outlined in the feasibility study and develop the detailed input tracking necessary for each element of the system. The Program Manager must by this time be sufficiently familiar with the graphic technique to ensure he is able to utilize this blueprint for operation, and critique the proposed system design in necessary areas. GPC 936-863