Special Notice / Hearing: None__
Vote Required: Majority
To: Honorable Board of Supervisors
From: Louise F. Rogers, Chief, San Mateo County Health
Chester J. Kunnappilly, MD, Chief Executive Officer, San Mateo Medical Center
Subject: Amendment to the Agreement with Ankura Consulting Group, LLC to Provide Independent Review Organization Services
RECOMMENDATION:
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Adopt a resolution authorizing an amendment to the agreement with Ankura Consulting Group, LLC to provide independent review organization services, and increasing the amount of the agreement by $350,000, to an amount not to exceed $700,000, with no changes to the term.
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BACKGROUND:
In July 2021, the County of San Mateo and San Mateo Medical Center (SMMC) entered into a financial settlement with the Department of Justice on behalf of the Office of the Inspector General of the Department of Health and Human Services (OIG). As a result of the settlement, SMMC entered into a five-year Corporate Integrity Agreement (CIA) with the OIG. One requirement of the CIA is that SMMC must select an Independent Review Organization (IRO) to perform an annual medical necessity review of 100 paid claims, for each year of the CIA. SMMC must select and engage an IRO within 120 days of the CIA’s effective date of July 29, 2021, which is November 26, 2021.
Through referrals and inquiries, SMMC selected and interviewed five vendors for the IRO role. SMMC’s Compliance Officer and County Attorney participated in the interview process. SMMC received proposals from four vendors, which included a summary of experience, references, and estimated quotes. SMMC’s Compliance Officer contacted references for the top two vendors, which were selected based on experience in medical necessity clinical review. After thorough review of each vendor and review of experience, references and quotes, Ankura Consulting Group, LLC (Ankura) was selected due to their experience in both medical necessity reviews and as an IRO for other organizations. On December 7, 2021, this Board approved an agreement with Ankura for the term from October 25, 2021, through December 31, 2026, in an amount not to exceed $350,000.
DISCUSSION:
SMMC utilized a greater number of senior managing director hours than initially expected. There were many accounts where the auditor questioned SMMC’s medical necessity determination and therefore required sending accounts to be reviewed by Ankura’s physician advisor (who worked at the Senior Managing Director level). SMMC also asked for additional physician advisor review regarding findings submitted to the OG. The use of this process varies every year, and the last two years have required SMMC to have the physician advisor properly review numerous accounts and provide detailed responses to SMMC’s questions.
County Attorney has reviewed and approved the resolution and amendment as to form.
The resolution contains the County’s standard provisions allowing amendment of the County fiscal obligations by a maximum of $25,000 (in aggregate).
It is anticipated that 100% of SMMC’s required reports will be completed and submitted to SMMC’s Compliance Officer to meet the CIA’s deadlines.
PERFORMANCE MEASURE:
|
Measure |
FY 2024-25 Estimated |
FY 2025-26 Projected |
|
Percentage of SMMC’s required reports that are completed and submitted to SMMC’s Compliance Officer to meet the CIA’s deadlines |
100% |
100% |
EQUITY IMPACT:
Ankura’s continued IRO services do not directly impact equitable health outcomes. However, the IRO services agreement does ensure that SMMC maintains compliance with the CIA, which supports SMMC’s mission to serve County patients. SMMC’s patients span a wide spectrum of races, ethnicities, gender, and gender-identities. Within the past 18 months the largest cohorts of specialty care patients at SMMC were female (52%), Hispanic or Latino (63%), and primarily Spanish speaking (55%). SMMC strives to eliminate bias in the medical profession by providing culturally competent training to its employees and by following up with patients to ensure that they continue to have access to care.
FISCAL IMPACT:
The term of the amended agreement is October 25, 2021 through December 31, 2026. The amendment increases the amount payable under the agreement by $350,000 to an amount not to exceed $700,000 for the 62-months term. Funds in the amount of $87,500 are included in the SMMC FY 2024-25 Adopted Budget. Funds in the amount of $175,000 are included in the SMMC FY 2025-26 Recommended Budget. Similar arrangements will be made for future years.
Expenses at SMMC are covered by fees for services or third-party payors whenever possible. The portion of expenses for services provided to the medically indigent or to those covered by programs that do not meet the full costs of care is covered by the County’s General Fund contribution to SMMC and is within the existing annual appropriation.