Provider Manual Home Page
LifeWays is the Community Mental Health Services Program (CMHSP) for Hillsdale and Jackson counties. LifeWays is a member of the Mid-State Health Network Regional Entity (MSHN) and maintains a contract with MSHN regarding the administration of a comprehensive array of Medicaid services within its two-county area. LifeWays also maintains a contract directly with the Michigan Department of Health and Human Services (MDHHS) to administer services covered by the State General Fund. To fulfill the service array obligation outlined by the Michigan Mental Health Code, MDHHS and MSHN, LifeWays contracts with a panel of qualified service providers and agencies to provide specialty mental health services.
Services promote the best interests of the individual, are designed to increase independence, improve quality of life, support community integration and inclusion, and promote recovery.
LifeWays serves adults with mental illness, children and families, individuals with developmental disabilities and individuals with co-occurring mental health and substance use disorders. In addition, for residents of Jackson and Hillsdale counties, the LifeWays Access Center serves as a screening and entry point into the Substance Abuse service delivery system administered by Mid-State Health Network.
LifeWays’ Vision: We envision a fully integrated healthcare network that supports individuals in our community to reach their full potential.
LifeWays’ Mission: LifeWays Community Mental Health inspires hope and promotes life‐enhancing recovery.
LifeWays’ Strategic Plan has four strategic priority areas:
Link: Current Strategic Plan
The following section describes the major departments or teams within LifeWays. Providers may receive immediate assistance by contacting the subject-matter expert directly.
ADMINISTRATIVE SERVICES DIVISION
Maribeth Leonard, CEO
Agency Oversight; Policy and Executive Authority; Board Services; Human Resources Authority; Personnel & Financial Contracting Authority; Psychiatric Oversight; Legislative and State Relations; Legislative Tracking; Strategic Planning; Legal and Financial Risk Management; Succession Planning; Administrative Efficiencies.
Corporate Compliance; Risk Manager; HIPAA (Health Information Portability and Accountability Act), Privacy Officer.
Building Maintenance; Safety Management; Lease Management; OSHA (Office of Health and Safety Administration) Compliance; Tenant Relations; Custodial; Grounds Maintenance; owned Group Home Facilities Management.
CEO Communication, CEO Representation, Policy & Procedure Management and Monitoring, Board Relations, New Board Member Orientation, Board Manual, Governance Policies and Procedures, LifeWays' Intranet and Board Website Management, LifeWays Forms Management, Safety Management & Space Utilization Committee facilitation, Administrative Efficiencies, Records Retention, Request for Proposals Coordination, Freedom of Information Act (FOIA) Officer, Manage Compliance with Interlocal Agreements.
Recipient Rights Officer, Incident Report Monitoring and Complaint Investigation, Recipient Rights Advisory Committee, Incident Reports, Sentinel Events; Annual Recipient Rights Training (Staff, Provider Network employees, Board).
CLINICAL CARE SERVICES DIVISION
CLINICAL SERVICES OVERSIGHT
Access, Intensive Crisis Stabilization Services (ICSS) for children, Adult Mobile Crisis Team (MCT), Crisis R&R, Medical Services, Targeted Case Management, Supports Coordination, Peer Supports, Outpatient Therapy, EMR oversight
Welcoming, Triage, Brief Screens for CMH Eligibility, Crisis Intervention, Initial Evaluations for Services, Inpatient Pre-Screenings, Wait List oversight; SED Waiver Eligibility, CMH Eligibility Screenings for children in Foster Care; Autism (ASD) evaluations.
Crisis Intervention, Mobile Crisis Team for Adults, Intensive Crisis Stabilization Services (ICSS) for Children, Crisis R&R
Psychiatric Evaluations, Medication Reviews, Injection Services, Clozaril, Telemedicine, Integrated Health Assessments and Services
Aleksandra Wilanowski, M.D.
Psychiatrist; Advisor to CEO on all clinical policies and procedures.
Targeted Case Management, Supports Coordination, Certified Peer Support Specialists, Outpatient Therapy, TF-CBT, Jail Services.
Development and Implementation of a Comprehensive Prevention and Health Promotion Plan, including but not limited to wellness coaching, tobacco cessation, Mental Health Education to the Community, and Critical Incident Stress Management (CISM).
Oversight of: Centralized Scheduling, Customer Services and Advisory Councils, Information Technology, Public Relations, Quality Improvement, and Utilization Management.
Centralized Scheduling; Customer Services, Complaints, Disputes and Appeals; Information; Advisory Councils.
COMMUNICATIONS & OUTREACH
(formerly Strategic Relations)
Liaison for all community agencies to LifeWays; community partners’ collaboration, partnerships with mutual consumer service agencies.
CENTRAL MICHIGAN 211
Information & Referral; Call Center Staffing; Database Administration; Navigation Services.
Development and Implementation of a Comprehensive Prevention and Health Promotion Plan, including but not limited to anti-stigma marketing efforts and LifeWays’ Branding efforts.
Ongoing assessment of need; System compliance User Access and Security; Technical Assistance and Support; and Information/Data Integrity; Information security; IT Help Desk; Network Administration; Data Security Officer.
Quality Improvement Plan and Annual Review, Quality Process Facilitation & Continuous Improvement; Audit and Accreditation Readiness; EMR Systems Administration; Data Analysis; Primary Health Care Integration Grant Project Management.
Utilization Management Criteria, LifeWays Treatment Algorithms, Service Descriptions and Eligibility Criteria, The Level of Care Evaluation Parameters, Length of Stay Protocols, Service Authorizations, Clinical Case Reviews, Utilization Review, Reconsiderations and Treatment Disputes, Self-Determination
BUSINESS OPERATIONS DIVISION
FINANCIAL SERVICES ADMINISTRATION
Budgeting; Financial reporting to the LifeWays Board; Fiscal Audit and Financial Reporting Compliance; Claims and Billing; Accounting; Accounts Receivable/Payable; Payroll; Financial Reporting to Regional, State, and Federal agencies as required; Ability-to-Pay Determination; and Financial Contract Monitoring.
Hiring, Orientation, Performance Evaluation, Job Descriptions, Discipline, Terminations, Employee Retention, Staff Development & Training, Cultural Competence, Unemployment, Worker’s Comp, Salary Structure, HR Policies and Procedures, Employee Relations, Time and Attendance Management, Benefit Management, Personnel Law Compliance.
Network Management; Contract Management; Credentialing; Certification; Billing Verification; Provider Relations, Education and Technical Assistance; Contractual Issues, Accreditation, Customer Satisfaction.
The Chief Executive Officer is appointed by the Board to execute and administer the program through general policy guidelines established by the Board, in accordance with the approved plan for services and budget, applicable County regulations, the provisions of the Mental Health Code, Administrative Rules and the Master Contracts with the Department of Health and Human Services and Mid-State Health Network (our regional entity and Prepaid Inpatient Health Plan). The execution and administration of the program is evaluated by the Board in seven broad categories: Fiscal Management, Personnel Management, Program/Clinical Management, Systems Management and Standards Compliance, Local Government/ Community Relationships, Funding Source/Licensing Body Relationships, and Board Relationships.
The Chief Executive Officer is the sole employee of the Board. Authorization to hire, terminate employees, and/or contracted services is solely vested in the Chief Executive Officer.
The Chief Executive Officer is responsible for the execution of the Board’s Strategic Plan. LifeWays’ strategic planning is implemented on an ongoing basis through a continuous improvement process. The Quality Improvement Department is responsible for initial facilitation and coordination of the plan’s development. Preparation for the strategic plan includes: 1) assessment of the state of the organization’s successes, current activities and future activities; 2) assessment of the organization's strengths, weaknesses, opportunities and threats; and, 3) environmental assessment. The assessment process is completed through input obtained from all major stakeholder groups. Strategic planning results in the following:
Public Policy Analysis
The Chief Executive Officer or designee seeks to analyze health care policy documents that have national, state, or regional implications and provide a summary with recommendations to the Board of Directors, and providers as appropriate. The summary includes a brief overview of the policy statement, its impact on LifeWays and its provider network, and recommendations for actions that need to take place to ensure compliance with the policy.
The Chief Executive Officer/designee maintains regular contact with state and federal legislators, to establish and maintain information on the status of legislation to provide ongoing analysis and updates to Board members and interested providers. In addition, the CEO promotes effective advocacy to address issues that arise.
LifeWays employs a Corporate Compliance/Risk Management Officer and maintains a Corporate Compliance Committee. The Compliance Committee, acting through the Compliance Officer, is empowered to investigate, evaluate, and report facts, and make recommendations to the Chief Executive Officer and the Board of Directors of possible responses or initiatives, including disciplinary or other adverse action for misconduct by Organization employees and or members of the network, i.e., provider agencies/staff, doctors, contractors. However, the presence and authority of the LifeWays Corporate Compliance Committee and Program does not circumvent network members from maintaining their own committee/program as their own risk management of a covered entity as designated by the Health Information Portability and Accountability Act (HIPAA) and other federal laws and regulations.
Each network provider is required to have a designated Corporate Compliance Officer, Corporate Compliance Plan and a means of analyzing and assuring the effectiveness of its individual effectiveness. Each Corporate Compliance and a means of analyzing and assuring the effectiveness of their individual effectiveness. Each Corporate Compliance Plan must include the required Seven Essential Elements:
LIFEWAYS CMH CORPORATE COMPLIANCE HOTLINE
MID-STATE HEALTH NETWORK COMPLIANCE HOTLINE
Anyone is able to file a complaint to the Corporate Compliance Program. The Corporate Compliance Hotline is an essential component of the program to be utilized as a resource for not only reporting potential wrong doing but also for seeking help and guidance. All complaints will be treated in a confidential manner. A complaint may be filed anonymously. Anyone filing a complaint is able to do so without fear of retribution or retaliation. Complaints will be addressed in a timely and consistent manner. Complaint form to mail or fax.
The Corporate Compliance Officer provides technical assistance regarding compliance requirements to the Chief Executive Officer, staff, the Board of Directors, and providers to monitor and coordinate consistent systems to identify potential legal risk.
Areas of risk that may be reported to the Corporate Compliance Officer include:
Under the leadership of the CEO, the Jackson County Facilities Director oversees safety management, lease and tenant management, environmental and emergency safety procedures, security, utilities maintenance and repair, Jackson County Building Authority inspections.
LifeWays' Safety Manager is Ric Scheele, Director of Facilities, Jackson County Government (517) 768-6662.
The Board, a Community Mental Health Authority, is established pursuant to Public Act 258 of 1974, as amended by Public Act 290 of 1996. The members, collectively, are charged with assessing County needs for behavioral health services, establishing plans to meet those needs, reviewing and approving the annual plan and budget, securing funds to help support the program, reviewing and evaluating the quality, effectiveness and efficiency of services, appointing a Chief Executive Officer, and establishing policy guidelines for the Chief Executive Officer to execute the behavioral health program.
Under the leadership of the Governance Director, the Governance Department maintains the Board meeting process in compliance with the Michigan Open Meetings Act. The Governance Director is the Freedom of Information Act (FOIA) Officer; is responsible to ensure Board composition in alignment with the Mental Health Code requirements; conducts New Board Member orientation; manages the annual review of Policy & Procedures; coordinates the Records Retention Process, and serves as on-site liaison to the Jackson County Facilities Director.
Governance incorporates the Board of Directors and the Chief Executive Officer. The 12-member Board includes four Hillsdale County residents and eight Jackson County residents, in accordance with each county’s population. Members are appointed by each County’s Board of Commissioners, for three-year staggered terms, from April 1 of the year of appointment. Every effort is made to assure the ethnic and cultural diversity of the Board. The Mental Health Code requires one third of the Board members to be composed of either primary consumers or family members of primary consumers, and of this number, at least two of the members must be primary consumers. Board meetings are held monthly and are open to the public (alternating between Jackson and Hillsdale locations).
The Office of Recipient Rights, led by the Recipient Rights Officer, works closely with the CEO, and is a member of the Administrative Services Division.
The Office of Recipient Rights is responsible for protecting the rights of recipients of services in compliance with the Mental Health Code, Administrative Rules, and the mandatory reporting provisions of the Children and Adult Protective Services Acts, and for the following activities.
The Clinical Services Division is led by the Chief Clinical & Quality Officer (CCQO) who works closely with the CEO and Medical Director, and is responsible for oversight of all LifeWays directly provided services. The CCQO also works with other LifeWays departments to develop evidenced based practices, a trauma informed service delivery, and a philosophy of resilience and recovery.
The Clinical Care Services Division encompasses Access, Crisis Services (Mobile Crisis, Crisis R&R), Outpatient Services (Targeted Case Management, Supports Coordination, Peer Supports, and Therapy), and Medical Services.
Clinical Consultation/Technical Assistance
The Chief Clinical & Quality Officer works in collaboration with the Medical Director, Utilization Management Supervisor, and Chief Operating Officer (COO) to resolve complex and high risk clinical cases.
Improving Practices/Change Agent Leadership Teams
The CCQO works with LifeWays departments and provider network agencies on ad hoc committees called the Improving Practices Leadership Team to develop system wide processes that impact service delivery as well as program specific development, and implementation of Evidenced Based or Best practices.
The functions of Access are to provide a No Wrong Door philosophy to provide consumers access to needed behavioral health services. The key functions of our access system are to:
Mobile Crisis Services and ICSS provide short-term crisis services in the least restrictive environment for individuals who are eligible for community mental health services but are at risk of inpatient placement. Mobile Crisis and ICSS provide short-term services to safely manage a crisis situation by de-escalating the crisis and helping the consumer return to his or her regular life as quickly as possible. After the crisis is resolved, the individual will continue with previous services or, if new to LifeWays, will be connected with the appropriate mental health services. The Crisis R&R is a living room model program where individuals may come to relax and de-escalate from a crisis. The Crisis R&R is staffed by a clinician and peers whose goal is to provide a welcoming environment that supports recovery.
Medical Services provide psychiatric evaluations to consumers, medication reviews as well as integrated nursing assessments. The Medical Services also has a Clozaril program and injection service.
Integrated Care Services
Medical Services has a care manager and medical assistant funded by our PBHCI grant to support integrated health. Their role is to work with the consumer and treatment team to treat the whole person.
Case Management and Support Coordination
Case management and supports coordination services encompass a range of consumer-centered services that link consumers with health care, psychosocial, and other services. The goal is to ensure timely and coordinated access to medically appropriate levels of health and support services, and continuity of care, through ongoing assessment of the consumer’s and other key family members’ needs and personal support systems.
Our outpatient services currently offers therapy in our Hillsdale location. Clinicians focus on solution focused therapy and have training in Trauma Focused Cognitive Behavior Therapy (TF-CBT).
LifeWays provides a full time clinician in both our Jackson and Hillsdale jails to provide crisis services, brief therapy, and linkage to programs in preparation for release back into the community.
Peers that work in our outpatient department are focused on being an additional support for the consumer to ensure they engage in services and provide a focus on recovery.
LifeWays’ Prevention and Wellness staff lead and implement key prevention activities related to behavioral and integrated health initiatives and works collaboratively with key community partners to create prevention plans and outcomes that improves the behavioral health status of community residents.
Key prevention initiatives coordinated or implemented directly by LifeWays include
Critical Incident Stress Management (CISM)
The Clinical Services Team coordinates response to requests from the community to provide Critical Incident Stress Debriefing services following community disasters, traumatic incidents, or terrorist attacks. Coordination includes identifying the response team based on individual competencies necessary to address the incident and determining the number of debriefings needed and the location. Additional service needs and appropriate referrals are made for participants if needed. Follow-up occurs to determine satisfaction and identify additional needs following the debriefing. The Prevention and Wellness Coordinator participates in community disaster planning exercises and provides technical assistance to the LifeWays Network regarding community disaster response guidelines.
Mental Health First Aid (MHFA)
The goal of Mental Health First Aid is to increase mental health literacy. Like CPR training helps a non-medical professional assist an individual following a heart attack, Mental Health First Aid training helps an individual who doesn’t have clinical training assist someone experiencing a mental health crisis. In both situations, the goal is to help support an individual until appropriate professional help arrives, with the added underlying intention to promote health literacy.
Mental Health First Aiders learn to apply a single strategy in helping someone through a panic attack, engaging with someone who may be suicidal, supporting a person experiencing psychosis and helping an individual who has overdosed. In practicing the intervention strategy, Mental Health First Aiders learn the risk factors and warning signs of specific illnesses such as anxiety, depression, psychosis and addiction; engage in experiential activities that build understanding of the impact of illness; and learn information about evidence-based treatment and support - ultimately building participants' mental health 'literacy.'
Under the leadership of the Communications & Outreach Director, the areas of Marketing/Public Relations, Services Central Michigan 2-1-1 comprise the Communications & Outreach Division. The Communications & Outreach Director functions as liaison to community agencies including schools, law enforcement, courts, and human service agencies.
The Communications & Outreach Department:
Central Michigan 2-1-1 is a partnership between LifeWays and 8 Michigan County United Ways to provide single point access to information and referral services.
The Public Relations Coordinator, a member of the Strategic Relations Division, is responsible for organizing events, marketing and public relations duties. When necessary, to assist in the completion of these tasks, additional LifeWays staff may be recruited based on their position in the agency, skill sets, and/or interest in helping achieve the Committee's goals and objectives.
LifeWays' Public Relations Coordinator is responsible for organizing LifeWays’ Anti Stigma efforts, with a focus on changing the perception of multiple stakeholders toward persons with mental illness. The desired outcome is a reduction of negative stereotypes of persons with mental illness held by community members, service delivery professionals and other stakeholder groups.
LifeWays utilizes print, radio and television media to ensure that promotion of its network services reaches a wide audience in the community.
LifeWays’ Annual Report, the LifeWays Handbook, and other printed materials are reviewed/approved by the Public Relations Coordinator as to form and sufficiency, for standardization of LifeWays publications.
Public Relations Workgroup
Public Relations staff is assigned to participate in this statewide Community Mental Health Association of Michigan’s Public Relations Workgroup. This workgroup meets monthly to share marketing and public relations materials, develop a state-wide anti-stigma campaign, and organize events to increase mental health awareness and outcomes for all persons statewide.
Customer Services is a function of the Operations Division. Customer Services is responsible for responding to questions and concerns from the community, consumers, and providers, and to also oversee the disputes and appeals process. The Customer Services Specialist is knowledgeable about all aspects of LifeWays including access, benefits, eligibility, claims, protocols, and the dispute and appeal process. The Customer Services Specialist serves as an important link between the internal and external customers. Internal customers include LifeWays staff. External customers include consumers, providers and other community stakeholders.
Complaints, Disputes and Appeals: In cases where a Customer Services Specialist cannot resolve concerns s/he will assist the caller in filing a formal dispute/appeal. The dispute/appeal will be forwarded to the appropriate department, and the Customer Services Specialist will monitor timeliness and outcome
To ensure consumers have a clear understanding of their condition, eligibility for service, access to service, benefits, and process for payment and recipient rights, they receive current and ongoing information. Information is provided in a variety of formats including writing, audio and Spanish. This is accomplished through the following methods:
LifeWays has long recognized the value of advisory councils. The LifeWays advisory councils provide a vehicle for consumer/stakeholders input of an advisory nature to assist in quality program development and to assist the Chief Executive Officer, and Board in its policy-making role. Information is received from two councils: the LifeWays Consumer Advisory Council and the Recipient Rights Advisory Council.
Customer Services facilitates the Agency's Advisory Council for individuals who receive services to review processes and plans and provide feedback on the potential impact to recipients. Examples of items that have been presented to the Advisory Council are: Revisions to the treatment planning process, strategic planning.
If you are uncertain as to who can be of assistance in resolving your issue or if you need to file a complaint, Customer Services should be your first point of contact at (517) 780-3332 or 1-866-630-3690.
LifeWays Customer Services
Fax: (517) 789-1276
TTD: (517) 789-2492
LifeWays Medical Services
1200 N. West Avenue 25 Care Drive
Jackson, MI 49202 Hillsdale, MI 49242
(517) 796-4540 (517) 439-9327
Fax: (517) 796-4517 Fax: (517) 439-3339
LifeWays Office of Recipient Rights
1200 N. West Avenue
Jackson, MI 49202
Fax: (517) 789-7564
1200 N. West Avenue 25 Care Drive
Jackson, MI 49202 Hillsdale, MI 49242
(517) 789-1200 (517) 439-2641
Fax: (517) 796-4575 Fax: (517) 439-3339
Henry Ford Allegiance Health Hillsdale Hospital
(After-Hours Access in Jackson) (After-Hours Access in Hillsdale)
205 N. East Ave 168 S. Howell Street, 3rd Floor
Jackson, MI 49201 Hillsdale, MI 49242
(517) 789-5971 (517) 437-5363
Fax: (517) 788-4701 Fax: (517) 437-5368
The Information Technology Team supports LifeWays’ IT infrastructure to ensure reliable, secure access to network resources and data. The focus of the IT Team is limited to the agency side of the data network. Members of the Provider Network are responsible for the proper design, implementation and maintenance of their computer systems.
LifeWays' on-site Safety Officer is Amon Hodge (Executive Director of Information Systems).
LifeWays’ Quality Improvement Team, under the leadership of the Chief Clinical and Quality Officer, is an ongoing function of LifeWays and its Provider Network. It is driven by a commitment to the provision of quality care that produces functional outcomes for consumers of LifeWays services. LifeWays’ Quality Improvement model integrates philosophies and practices of quality assurance, quality planning and continuous improvement. LifeWays’ Quality Improvement Program reflects the expectations and standards of the Michigan Department of Health and Human Services (MDHHS), Mid-State Health Network expectations, and the Commission on Accreditation for Rehabilitation Facilities (CARF). The purpose of LifeWays’ Quality Improvement Program is to implement and maintain a Quality Improvement Plan that facilitates good process design and systematically measures, assesses, and improves organizational performances to produce good customer outcomes and satisfaction through the effective and efficient use of LifeWays resources.
Electronic Medical Record (EMR)
The QI Team will collaborate with Providers’ IT support personnel to facilitate timely, secure access to LEO, the Electronic Medical Records (EMR) system. LifeWays will provide a LEO license to Providers/Provider Groups generating more than 20 claims per month. Providers requiring additional licenses will be required to cover the license and maintenance costs. LifeWays will only pay for one (1) license fee and maintenance fee per Provider. Services will be provided in a professional, responsive and user-friendly manner.
LEO is a browser-based Electronic Medical Records system. Internet Explorer is certified for use with LEO. Java plug-in is required for most peripherals that integrate with LEO. Such peripherals as document scanners and signature pads are integral for inputting information into the LEO system.
All LifeWays staff and members of the Provider Network require user credentials before access can be gained to the LEO. For security reasons, procedures are in place requiring users change their passwords on a regular basis.
The Quality Improvement team continuously strives toward efficient delivery and retrieval of data within our EMR system. The Quality Improvement team is responsible for defining agency reports and assuring information reliability.
LifeWays' EMR Administrator is Alexis Shapiro.
The Utilization Management Team is responsible for designing and implementing processes that promote cost-effective, well-coordinated services for each consumer. The key functions of the Utilization Management Team include:
Utilization Management Criteria
Utilization Management Criteria refers to a variety of tools, documents, and publications that are used to determine whether a service or services array represents the appropriate services in the appropriate amount for an individual consumer, such as: 1) Medical Necessity; 2) Service Descriptions, Qualifications, and Eligibility Criteria; 3) Level of Care Grid; 4) Services Available by Funding Source; 5) Level of Care (LOC) Evaluation Parameters for Assessment of Service Needs; and 6) Length of Stay Protocols. (See Section III. Accessing/Authorizing Services)
Service Descriptions and Eligibility Criteria
Service Descriptions and Eligibility Criteria are another basis for Utilization Management decision-making. Service Descriptions are developed based on what the service is meant to do, differentiating it from other similar services, and providing detail as necessary so that a service may be chosen that is likely to meet needs. This is called Scope of Service. Eligibility requirements specify criteria that describe a consumer and their medical symptoms that are likely to benefit from service. Eligibility criteria are also designed to reduce duplication of services and promote use of the right service for that consumer.
The Level of Care Evaluation Parameters
The Level of Care (LOC) assessment is used to determine a score representative of overall consumer functioning level. This score is often used in the eligibility criteria to ensure that consumers receive the appropriate INTENSITY of services to meet their needs. Treatment providers utilize this tool and enter it into the consumer’s clinical record. Utilization Management reviews this score as a component of eligibility and necessity for a treatment request. Current LOC tools include the CAFAS, PECFAS, LOCUS, and SIS.
Length of Stay Protocols
Length of Stay Protocols are clinical source data, LifeWays consumer data, and other population data as available, used to determine appropriate duration of services for individuals with different level of care scores and different disorders. The purpose of these protocols is to provide a benchmark for ensuring the most effective duration of services for each consumer based on their individual presentation.
Utilization Managers authorize requested services that are in accordance with Utilization Management Criteria. Services outside of Utilization Management Criteria require clinical specialist review before authorization. If services are requested for a consumer not meeting eligibility criteria for service, or who has exclusion criteria present, service will be denied unless clear rationale for the request is presented. In cases where rationale is present, the Utilization Manager(s) will present the case for specialist review and when needed will consult with the Chief Clinical & Quality Officer and Medical Director.
Providers request authorization for services using the Electronic Health Record. Initial service requests and requests for re-authorization are managed by the assigned Utilization Manager. Utilization Managers who have clinical competency in required areas make service authorization decisions based on Utilization Management Criteria. Review begins within 3 days and all requests are authorized or denied within 14 days. (See Section III. Accessing/Authorizing: Authorization Process)
Clinical Case Reviews
The UM department completes clinical record reviews. The UM department completes clinical record reviews. Concurrent reviews are used for approval of medically necessary treatments or services. However, concurrent reviews happen during active treatment of psychopathology. The focus of concurrent review is to ensure that the consumer is getting the most appropriate level of care suited to
condition, in the most cost-effective way. The retrospective review involves the review of medical/behavioral health documents following a treatment episode. Once reviewed, utilization management will determine the efficacy of treatment, and if it were medically necessary. The other function of retrospective review is the approval of treatments that normally require precertification but were done without prior approval.
Utilization Review is a collaborative, dynamic process through which specific questions are asked about populations served by LifeWays. Utilization review is done on an aggregate as well as an individualized basis as needs are identified. The purpose of the analysis is to determine if there are patterns of over or under utilization, as well as identifying any service needs or protocol changes. Utilization review is an ongoing process administered by the Utilization Management team. Specific reports are reviewed by individual Utilization Mangers and discussed at Utilization Management staff meetings. The team analyzes the findings and compiles recommendations and reports. These are then presented at the Quality Improvement Council meeting as needed via the Utilization Review Committee.
Reconsiderations and Treatment Disputes
Reconsiderations are forwarded to the Supervisor of the Utilization Management department once they are received from the hospital requesting payment. Reconsiderations are distributed to Utilization Management designees for review of clinical information, protocols and standards. Once a decision is made Customer Service is notified so that the provider can be notified. In cases where prior authorization is not received for hospitalization, the provider must coordinate with the assigned contract manager. If the contract manager agrees to make an exception Customer Service will be notified and request a retroactive review from Utilization Management.
Treatment disputes that are regarding authorization decisions are distributed to the Supervisor of Utilization Management via Customer Services - who are the first point for the treatment disputes process. The Director of Utilization Management reviews the dispute and determines which Utilization Manger should review and compile clinical information. This decision is based on competency areas and with consideration to not assign it to the Utilization Manager that made the decision or reviewed the request. An objective “third” party shall review the dispute. Upon completion of the dispute, the Director of Utilization Management will review it and it will then be sent back to Customer Services to be given to the consumer.
The LifeWays Self-Determination Program is based on the value that consumers should be able to define what they need in terms of the life they seek, should have access to meaningful choices, and control over their lives. Customer Services and Utilization Management provides consultation to consumers and providers regarding self-determination. Self-Determination is based on four principles:
The Utilization Management (UM) Staff are responsible for 1) educating other LifeWays Divisions, LifeWays Board of Directors, LifeWays’ Provider Network, consumers, family members of consumers, Community Partners, and stakeholders on the referral process and eligibility criteria for LifeWays’ clinical practices; 2) understanding how the practices align with EBP, PP, and BP standards/guidelines and the expected recovery/quality of life outcomes of these programs; and 3) providing technical assistance and training to LifeWays’ Provider Network Staff to ensure clinical excellence in the delivery of LifeWays’ Clinical Practices.
Under the leadership of the Contracts and Provider Network Management Director and as a member of the Operations Division, the Contracts and Provider Network Management Team supports LifeWays’ Provider Network with the provision of professional, expedient, valid and comprehensive business functions in a flexible, highly secure manner.
Personnel responsible for contract management coordinate overall contracting functions for revenue and expenditure contracts in collaboration with other LifeWays teams. This includes credentialing functions, recommended contract language, rate setting, recommended payment method, monitoring of financial performance and review, integration and reporting of other contract performance related issues. It also includes review of provider accounting records to ensure compliance with Federal and State regulations regarding Federal Block Grants and LifeWays standards.
LifeWays maintains a credentialing process, which is applied to all independent practitioners and organizational providers seeking membership in LifeWays' Provider Network. A more detailed description of this process can be found under the "Credentialing" section of this manual.
Standard Setting and Interpretation
The Contracts and Provider Network Management Director develops and maintains a set of contract standards designed to promote consistent implementation of policy across network providers and within LifeWays. These Standards can be found under the “Standards and Best Practice Guidelines” section in this manual.
Audit/Accreditation Readiness and Facilitation
The audit coordination, certification and accreditation function facilitates efficient and effective review of LifeWays’ Network Provider performance to assure consistent achievement of regulatory, accrediting, governing and standards. The Contracts and Provider Network Management Staff/Director coordinates internal and external performance audits, and prepares applications for accreditation/certification for specialized services. The Contracts and Provider Network Management Director develops and maintains mechanisms to organize and integrate all audit functions, including pre-audit planning, concurrent audit assistance, and post-audit follow-up (requests for improvement and/or corrective action responses) and monitoring corrective action implementation.
Providers are required to cooperate with all internal and external reviews (Michigan Department of Health and Human Services, CARF, Joint Commission on Accreditation of Healthcare Organizations, Department of Consumer and Industry Services, etc.). All providers are subject to onsite reviews by the Contracts and Provider Network Management Director/Designee at any time.
Contracts and Provider Network Management staff oversee the procurement process, which includes development and distribution of Requests for Proposals, development of scoring criteria, and facilitation of the selection committee. In addition, staff is responsible for recruiting new providers when a need is documented by the Network Capacity Evaluation plan and/or the Credentialing Committee.
Under the direction of the Chief Financial Officer, the Finance Director and Outpatient Billing/Reimbursement Supervisor oversee the Finance Team. These positions direct, manage, supervise and coordinate the activities and operations of Finance; and coordinates assigned activities with other LifeWays Departments. The Chief Financial Officer provides highly responsible and complex leadership support to the Chief Executive Officer for the overall benefit of LifeWays.
The Finance Team has four major functional areas: claims and billing, accounting and reporting, budgeting, and other business-related functions.
The claims and billing function include claims adjudication, claims dispute review, review of billing statements, first and third-party billing, posting of cash receipts to consumer accounts, and coordination of ability-to-pay determinations.
Business functions include accounts payable, purchasing and payroll. Recording and depositing of cash receipts, maintenance of the accounting records, billing and monitoring of Federal Block Grants and other earned contracts, preparation and analysis of financial statements, budgeting and coordination of all external financial audits are elements of the accounting and reporting function.
The Human Resources Executive Director, a member of the Business Services Division, works under the direction of the CFO to develop personnel policies, programs and services related to employment, compensation, employee benefits, performance evaluation, employee relations, employee recruiting, selection and retention, and compliance with applicable federal, state and local HR laws. The Human Resources Executive Director works closely with the CEO and Governance Executive Director on strategic human resource planning and goals. The Human Resources Department promotes and advances a workplace environment consistent with LifeWays’ mission and strategic objectives.
The HR Executive Department also facilitates the annual LifeWays training process to ensure up-to-date knowledge of LifeWays employees.
LifeWays has an organizational chart, which establishes clear lines of authority, responsibility and accountability.
Links: Functional organization chart | LifeWays' organization chart with position titles
The Committees noted below assist ensuring quality services at LifeWays. These committees are described in more detail under the Quality section of this manual.
LifeWays directly provides access services, crisis services, certified peer support, case management/supports coordination, and physician services. Additionally, through our provider network a full range of services are available. The consumer handbook provides a description of all services. Refer to consumer handbook for descriptions of each of these services.
Link: Guide to Services Handbook