Mary Thornton & Associates, Inc

Mary Thornton & Associates, Inc
Medical Necessity Concept in Practice Mary Thornton & Associates, Inc

Medical Necessity: Who Cares?
What payers? What about accreditors? Even for rehab option? What about recovery programs and services? Isn’t this something only the doctor can determine? What about client choice? Mary Thornton & Associates, Inc

PAYERS Medicaid Medicare Champus/Tricare ODMH ODADAS Commercial insurers Mary Thornton & Associates, Inc

OIG’s Red Book 2002 Red Book once again cites MH: “the IG found that Medicare could save $685 million by reducing claims error rates for mental health services. (Error) Rates exceeded 34% suggesting numerous and widespread problems. The IG suggested CMS monitor cases of under-utilization, over-utilization, medical necessity and reasonableness.” Mary Thornton & Associates, Inc

OIG Audit of Medicare Part B Outpatient MH Services
May 2001 Release Review of core services, not partial hospital Review of 1998 services: $1.2 billion spent on mental health by Medicare –60% is outpatient Over half of services audited were to beneficiaries who are eligible because of disability, not age Mary Thornton & Associates, Inc

34% of individual therapy services inappropriate 50% of group therapy services inappropriate 40% of psych testing services inappropriate 16% of pharmacological services inappropriate Mary Thornton & Associates, Inc

41% billed inaccurately: wrong code, non-covered services, excessive billing 11% unqualified providers 65% poor documentation 23% medically unnecessary 22% receiving more services than necessary 8% not receiving enough services Mary Thornton & Associates, Inc

GAO Testimony on Medicaid Fraud (Nov 1999)
Three primary categories of fraud and abuse: Improper billing practices: upcoding, phantom TX, delivering more treatment than is necessary Misrepresenting qualifications: false credentials, performing outside the bounds of one’s license Improper business practices: kickbacks for referrals to a provider or product, anti-trust, cost reports issues, enhancement of profits by limiting care Mary Thornton & Associates, Inc

GAO and Medicaid This year for first time GAO adds Medicaid to list of programs at High Risk for fraud and abuse Cites schemes by states to leverage funds Waiver programs that increase costs Insufficient oversight to assure providers paid appropriately Mary Thornton & Associates, Inc

GAO and Medicaid January 30, 2003 Report Argues for more and more aggressive state Medicaid anti-fraud initiatives States are not collecting all they could for fraud efforts from feds because they would have to match - .01% being spent on payment safeguards Efforts to identify improper payments limited and modest in scope Mary Thornton & Associates, Inc

The OIG’s Work Plan: Other Medicaid Services
Waiver Programs Cost neutrality and costs effectiveness of Medicaid waiver programs being questioned 2 years ago Home and Community Based Waiver programs for the Mentally Retarded were cited Mary Thornton & Associates, Inc

What about accreditors? Medical necessity is a payment concept Medical necessity and quality of care are linked Treatment should be the least restrictive, considering the safety of the client and their current status (signs, symptoms, functioning) Mary Thornton & Associates, Inc

Even for rehab option? Rehab option services are either paid for by Medicaid or by state funds that follow the Medicaid model Medical necessity is a foundation concept Mary Thornton & Associates, Inc

What about recovery programs and services? Many services that are critical to a recovery-based model of care are being paid for through the rehab option, e.g. skill building, psychosocial rehab, residential support, and others Some recovery-focused services such as peer support and most recreational services are not paid for under rehab option and payment is not based on medical necessity Mary Thornton & Associates, Inc

Isn’t this something only a doctor can determine? No Diagnosing professionals Treatment planning signers Managers of care Once initial case made, continuing confirmation is found in progress notes and other documentation – the entire treatment team participates Mary Thornton & Associates, Inc

What about client choice? They can choose to receive services that are not medically necessary Those services must be paid for by the client or by alternate available resources Billing for non-medically necessary services is a problem Paybacks Potential for investigations, fines, etc. Mary Thornton & Associates, Inc

Productivity and Medical Necessity
Mary Thornton & Associates, Inc

Medical Necessity: What’s it mean?
Payer Acute Rehab Medicare Primarily Limited Medicaid X ODMH ODADAS Commercial Mary Thornton & Associates, Inc

Medical Necessity: What’s It Mean?
Starts with a qualified professional Assessment Clinical Formulation Diagnosis Determination of level of care Ordering treatment Scope of license issues Mary Thornton & Associates, Inc

Ohio Medicaid: Services ordered are necessary for Dx or Tx of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort.”1 1 Ohio Adminstrative Code, 5101:3-1-01 Mary Thornton & Associates, Inc

Deconstructing Medical Necessity: “Services ordered are necessary for diagnosis” Initial assessments are usually covered unless internal transfer Reassessments should be done only if there is a need to update information E.g. Medicare pays for an assessment every three years or after any changes to level of care Psych testing should be done for diagnostic purposes only and then only if additional information is needed that cannot be obtained from an interview Consultations and other diagnostic work – e.g. labs, etc. may be covered in order to diagnose. Need clear link. 1 Mary Thornton & Associates, Inc

Deconstructing Medical Necessity: Services ordered are necessary for treatment of disease, illness, or injury Client must have a reimbursable diagnosis Mental health vs substance abuse DSM vs. ICD-9 Axis III/Medical Conditions important: Comorbidities may create additional complexity Mental retardation: limits mental health services Alzheimers and other forms of dementia Deafness and other communication problems Mary Thornton & Associates, Inc

Deconstructing Medical Necessity: “without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort.” Treatment can be focused on preventing backsliding Treatment can be focused on impairment of function Treatment can be focused on prevention of new morbidities, Mary Thornton & Associates, Inc

Ohio Medicaid: Medically necessary services are those that: Are not experimental and are generally accepted as effective for the problem being addressed Delivered at an appropriate intensity Provided at the appropriate level of care setting When used for diagnosing capable of providing “unique, essential and appropriate information” Mary Thornton & Associates, Inc

Ohio Medicaid: Medically necessary services are those that: Are not experimental and are generally accepted as effective for the problem being addressed Watch inappropriate psychotherapy Mary Thornton & Associates, Inc

Ohio Medicaid: Medically necessary services are those that: Delivered at an appropriate intensity Be concerned with too little and too much Meds only clients Frequent no shows Non-compliance Mary Thornton & Associates, Inc

Ohio Medicaid: Medically necessary services are those that: Provided at the appropriate level of care setting Do you have written levels of care that are accessible, well distributed, and being appropriately used by staff? Be concerned with appropriate and timely transfers and discharges Be also concerned with non-compliance with appropriate levels of care – good documentation to describe attempts to move clients Mary Thornton & Associates, Inc

Ohio Medicaid: Medically necessary services are those that: When used for diagnosing capable of providing “unique, essential and appropriate information” Additional diagnostic tests must be capable of providing information that is not available in other, less expensive ways. Mary Thornton & Associates, Inc

Criteria for Payment In addition to tests of medical necessity, Ohio Medicaid is looking for additional information before agreeing to pay Services must be voluntary and initiated by client Evidence of client choice of provider Eligible providers must render service Compliance with definition of service Service must be lowest cost service that effectively addresses client’s problem Mary Thornton & Associates, Inc

Additional Guidance for MH and SA
DSM IV or ICD 9 CM diagnosis Client must be active participant Sufficient cognitive ability to benefit Services must be: Provided according to an individualized service plan Least restrictive setting that is available and safe Developmentally appropriate for children Mary Thornton & Associates, Inc

DSM IV or ICD 9 CM diagnosis Dx alone is not enough Dx + Signs/Symptoms Dx + Functional Status Dx + Signs/Symptoms and Functional Status Current signs/symptoms and functional status is critical to medical necessity Acuity/other clinical information in 5th digit of ICD 9 Each service must be directed toward an appropriate diagnosis A second diagnosis may allow for additional services that might not otherwise be medically necessary. Mary Thornton & Associates, Inc

Client must be active participant Documentation must be clear about client’s participation in treatment Besides being present- what else? Non-compliance Catatonia and other diagnoses that may prevent participation Watch billing for these Signing treatment plans, progress notes Mary Thornton & Associates, Inc

Sufficient cognitive ability to benefit Watch for: Very young children Dementia – all kinds – fight if you think it is appropriate at early stages of disease Mental retardation – except for mild and sometimes moderate Autism Other clients who cannot benefit – e.g. intoxicated Mary Thornton & Associates, Inc

Services must be: Provided according to an individualized service plan Every service must be ordered Least restrictive setting that is available and safe Please note available Rehabilitation option services must be considered. Developmentally appropriate for children Mary Thornton & Associates, Inc

Rehabilitation Option
Federal Definition: “Any medical or remedial services (provided in facility, home or other settings) recommended by a physician or other licensed practitioner of the healing arts, within the scope of their practice under state law, for the maximum reduction of physical or mental disability and restoration of the individual to the best possible functional level.” Mary Thornton & Associates, Inc

IAPSRS Definition of Rehabilitation Model: “Focuses on the functioning of the individual in the normal, day to day environment, and looks at the strengths and skills people bring to the rehabilitation process and supports in the community. “ Mary Thornton & Associates, Inc

IAPSRS Definition of Rehabilitation Model continued: “Although an individual may still be symptomatic, the rehabilitation process helps a person learn ways to compensate for the effects of the mental illness thorough environmental supports and coping skills. The person with the mental illness becomes the the expert in managing the disability.” Mary Thornton & Associates, Inc

Why is Rehab Option so important to the payer?
Research has demonstrated that rehabilitation leads to: shorter hospitalizations improved social functioning greater satisfaction higher productivity and integration in community Mary Thornton & Associates, Inc

Rehabilitation Option Services
Specifically referenced as rehab option covered services in Ohio: Basic/Daily Skills training Social Skills training Residential services Employment related services Social/Recreational services Family Education Services Mary Thornton & Associates, Inc

Rehabilitation Option Services
Social/Recreational – Medical Necessity Criteria still very clear “Services may not be for the exclusive purpose of social or recreational activity but must evidence a clear therapeutic objective specifically identified in the individual’s service plan….” Mary Thornton & Associates, Inc

Rehab Option Model Community Support Services: Restoration of basic or daily living skills Restoration of social or personal skills Residential Support Illness Management Others: Pre-voc/ed Medication and Somatic Treatment Individual and Group Psychotherapy Other Acute Services: ACT, Partial Hospital, IOP Peer, Recreational, Employment, Vocational Mary Thornton & Associates, Inc

Documenting Medical Necessity
Documentation: Primary means or determining whether claims should be paid. Making the case for current and for on-going medical necessity: Assessment; Treatment plans; Progress notes; and, Related lab and other diagnostic work Mary Thornton & Associates, Inc

Florida Outpatient Center
Management did not act to promote integrity, efficiency and accountability Billed for ineligible clients ( did not meet GAF requirement) Destroyed audit trail by shredding service tickets. $4.2 mm payback in cash and services Mary Thornton & Associates, Inc

Tx plans incomplete, sometimes not there at all, or no signature or date of signature Geriatric Day Tx usually had no prior certification Physicians did not always sign treatment plans Physicians did not always participate in development of treatment plans or their review Mary Thornton & Associates, Inc

Interns and other students billed w/out sufficient or evidence of supervision Dual billing of Medicaid and contracts No evidence of efforts to reduce level of care based on impact of Tx Tx Plans reflected maximum allowable under Medicaid not goals and needs of patients Mary Thornton & Associates, Inc

Documenting the Medical Necessity of Rehabilitation
Service focus is on teaching not providing – cueing, reminding, training, overcoming barriers “Medical necessity” based on functional criteria. Community Support is not case management Mary Thornton & Associates, Inc

Documenting the Recovery Philosophy
Consumer choice: treatment planning Empowerment: focus on strengths based skills development Non-coercion and self-determination: engaging the consumer in their own recovery Protection of rights: privacy, choice, complain, to choose their provider, and so forth Responsibility for managing one’s own health: treatment planning, provider choice, skills and resource development Mary Thornton & Associates, Inc

Rehabilitation Services
Skills development for restoration to maximum functional state Organized approach to development of new or redevelopment of old competencies Can use curriculum in community support too Implies that a baseline has been established Not clinically focused although clinical services may play an integral or supportive role in treatment Symptom reduction is not the focus – symptom and disability management is Mary Thornton & Associates, Inc

Rehabilitation Services - Examples
Basic Skills: Food planning and preparation Maintenance of living environment Community awareness and mobility skills Economic issues: bill paying, budgeting, etc. Personal hygiene Medication self-administration Mary Thornton & Associates, Inc

Social Skills: Those necessary for working, getting along with neighbors and landlords, social contacts and development of social network Problem solving, conflict resolution Management of stress Relationship building Mary Thornton & Associates, Inc

Disability management Identification and management of symptoms Effects of medication Vulnerability to stress Effects of drugs and alcohol Early recognition of warning signs of illness Development of skills for coping with deficits resulting from the mental illness Mary Thornton & Associates, Inc

Disability Management: What is there to do?
What is going on with the consumer behaviorally? Inconsistent in compliance with meds Co-morbid medical condition that requires meds and medical management too Verbalization of fears/dislike of emotional or physical side effects Lack of knowledge of meds, side effects, usefulness Unwillingness to take meds at all Interactions with lifestyle activities causing negative side effects Mary Thornton & Associates, Inc

Goals: a continuum of increased participation and self-management Consistent use of meds Stabilization of mental illness Including reduction in symptoms Increased understanding of their illness, meds, side effects, etc. Increased ability to report accurately about effects of meds on daily activities, peer relationships, mental illness Mary Thornton & Associates, Inc

Goals: a continuum of increased participation and self-management Development of support network that can assist consumer in self-administration and management of meds and illness Decrease in side effects with correct dosing (backed up by blood levels) and lifestyle changes Ability to manage with medical team and with or without other support the medication, S&S of mental and physical illnesses, and adverse effects Understanding of impact of physical illness on mental illness and vice versa Mary Thornton & Associates, Inc

Short term objectives: Consumer can recognize meds, list them, verbalize when to take Consumer cooperates with medical staff in medical management of mental illness Shows up Answers questions accurately Interacts and anticipates or questions Mary Thornton & Associates, Inc

Short term objectives: Consumer cooperates with diagnostic work Consumer recognizes signs and symptoms of mental illness After they happen Recognizes triggers or coming of S&S’s Same as above but for side effects Mary Thornton & Associates, Inc

Short term objectives: Consumer understands where to go to get meds and can afford them Consumer develops supportive network to assist in management of mental illness including meds Consumer understands why taking meds Understands why taking each med Consumer and medical staff work in an integrated fashion with primary care physician Mary Thornton & Associates, Inc

Short term objectives: Consumer complies with medication regimen Development of compliance aids Develop structure for taking meds Advocate/work towards less complicate dosing regimen Consumer understands lifestyle activities that increase risk, signs and symptoms, aggravate side effects Makes lifestyle changes & recognizes cause/effect Consumer gets peer support re: meds and lifestyle changes Mary Thornton & Associates, Inc

Residential Support Services Early identification of problems in living situations Ensuring success in living in a community setting Practicing skills in different settings to show how skills transfer Great deal of overlap tween this and basic skills development and social skills development Mary Thornton & Associates, Inc

Social and Recreational Activities Be careful but look to the goal of the service in these cases and not necessarily the service itself Should be carefully related to improving skills, reducing disabilities, restoration of functional level The government does consider the development of social skills and a social network to be important to the recovering individual You have more leeway with kids Must be clearly stated in treatment plan Mary Thornton & Associates, Inc

Employment Related Services Not vocational but pre-vocational Redevelopment of skills needed for successful employment Getting along with co-workers and supervisors Staying on task Working at the necessary pace Following instructions Mary Thornton & Associates, Inc

Education Not education but pre-education Skills necessary to locate and engage in a successful academic or other educational program Some of these same skills needed to be able to engage in your services as well Mary Thornton & Associates, Inc

Peer Services and Support No self help groups covered – but could be in Tx plan Peers can sometimes provide services – make sure of your rules Sometimes just provide some social support and encouragement Mary Thornton & Associates, Inc

Documentation is required under Ohio code: “all Medicaid providers are required to keep such records as are necessary to establish medical necessity and to fully disclose the basis for the type, extent, and level of the services provided” Mary Thornton & Associates, Inc

Key Elements in Documentation Is there a diagnosis that meets payer criteria? Evidence that this is the correct diagnosis? Assessment of client functioning? Sufficient deficits or threats to justify level of care? Current ISP? Signed? Is array of services appropriate for the clinical picture? Mary Thornton & Associates, Inc

Key Elements in Documentation Services rendered in accordance with ISP and with payer definitions of services? Is the provider appropriately credentialed? Mary Thornton & Associates, Inc

Key Elements in Documentation Is there evidence of client participation? Cognitive ability: if client has DX that would normally contraindicate treatment make sure there is an adequate explanation Willingness to participate – may be exceptions for those individuals “committed to the board” Mary Thornton & Associates, Inc

Key Elements in Documentation Is there evidence that the client is benefiting from treatment? Medical necessity is closely linked to outcomes If client is not benefiting: the services may not be medically necessary the level of care may be inappropriate Services dedicated to prevention of backsliding need continuous testing Mary Thornton & Associates, Inc

Progress Notes Required for each billed service Must describe a service that is billable Must indicate necessity for service –should speak to objective, not overall goals – easier for auditor Client’s circumstances Client’s participation Client’s response Mary Thornton & Associates, Inc

Speaking to Objectives
Goal: Client wants to go to work - Obj:Client will identify and join a job skills program. “Discussed client’s anxiety in interactions with strangers. Client identified and role-played strategies to reduce anxiety that she believes will work for her, including, deep breathing and maintaining her own space. Client was anxious during discussion and role-play but understands need to be able to work with strangers in any job or job development setting. She intends to practice new skills this week with two neighbors in her apartment building and report back. ” Mary Thornton & Associates, Inc

The Service Must Be Billable
“Attempted to call consumer to reschedule appointment but no one home. Left message.” “Reviewed treatment plan and wrote up monthly documentation of what services have been provided.” “Consumer attended NA/AA conference with community support worker. Consumer picked out workshops and attended all. Very enthusiastic about conference.” Mary Thornton & Associates, Inc

Service Must be Coded Correctly
“ Engaged client in a discussion of past trauma and coping strategies that have been used in past. Client assigned homework to record at least one positive statement daily about her life experiences.” Mary Thornton & Associates, Inc

Client Should Participate Voluntarily
“Consumer came in for check. We discussed her plans for weekend. She will see friends and attend church.” Do not use rep payee status as hook for services Mary Thornton & Associates, Inc

There must be an intervention
Met with client today. He appeared well-groomed and in a good mood. He stated he went to choir practice and sang last Sunday at both services. States he felt exhausted. Client did state that he enjoyed himself but that he needed encouragement from family to participate. Mary Thornton & Associates, Inc

The Stable Client “Met briefly with consumer. He reports that he is psychiatrically stable and taking his medications as prescribed. He agreed to a follow-up appointment. He reported no difficulties at this time.” Mary Thornton & Associates, Inc

Community Support Goal: Stable Psychiatric Functioning; Objectives: Consumer will determine housing choice. Consumer will develop a plan for obtaining permanent housing. “Consumer in crisis bed and is homeless with no entitlements. Educated consumer about options for housing if SSI is denied. Explored consumer’s preferences. Consumer stated she would prefer SRO but is open to other options. Agreed we will follow-up by end of week.” Mary Thornton & Associates, Inc

Community Support Goal: Client will return to work; Objective: client will research local supports and benefits for vocational counseling and training. “Client reports that he called benefits counseling service and located his information about VA benefits as well. Client did not make an appointment because he was anxious about process. We role-played some possible scenarios and client agreed that he will call again this week and set up appointment.” Mary Thornton & Associates, Inc

Community Support Goal: Client wants to stay out of hospital; Obj: Travel Training “ Intervention: Reviewed steps with client on how to catch bus from her apartment to the store, I.e., arriving to the bus stop 10 minutes ahead of time; showing her bus ID to the driver, sitting where she feels comfortable, having her bus schedule available, familiarizing her with names of streets and keeping an eye out for the stops ahead of hers for her apartment and for the store. “ Mary Thornton & Associates, Inc

Community Support Goal: Client wants to stay out of hospital; Obj: Travel Training R: “Client had her bus schedule available to find out the time for the bus, greeted the bus driver appropriately, showed her ID, sat where she felt comfortable and asked the driver for names of streets for familiarization. Client still very anxious but happy about her progress.” Mary Thornton & Associates, Inc

Community Support Goal: Client wants to stay out of hospital; Obj: Travel Training P: “Will accompany client one additional time next week and then plan for a solo visit to the store. The next visit will also include skills development in grocery shopping as per her ISP.” Mary Thornton & Associates, Inc

Progress vs. encounter notes
Documenting Progress Progress vs. encounter notes Mary Thornton & Associates, Inc

Case Study 1 Mary Mary Thornton & Associates, Inc

Community Support Curriculum Specific instructions for teaching – topics, step approach to gaining and integrating subject matter – breaking larger goals into smaller, more manageable steps Teaching tools – handouts, transparencies, etc. Suggestions for discussion, activities, role plays, homework, sub-group work – opportunities for consumer to demonstrate expertise Mary Thornton & Associates, Inc

Community Support Curriculum Plans for how to generalize skills to community and other environments Additional resources for consumers, family, and staff Plan for skills retention - individualized Mary Thornton & Associates, Inc

Community Support Curriculum SAMSHA – handouts Others: see handout Mary Thornton & Associates, Inc

Relevant Coordinating Centers of Excellence
OMAP: Promotion of the utilization of medication algorithms to guide psychiatric medication decision-making in Schizophrenia, Bipolar Disorder, Major Depression Clusters: no website yet Promoting client clustering to organize services Illness Management and Recovery: no web-site yet Promoting the adoption of illness management and recovery principals to improve outcomes Supported Employment: coming soon Mary Thornton & Associates, Inc

Case Study 2 Paul Mary Thornton & Associates, Inc

OMAP: Promotion of the utilization of medication algorithms to guide psychiatric medication decision-making in Schizophrenia, Bipolar Disorder, Major Depression Clusters: Promoting client clustering to organize services SAMI: Promoting integrated model of MH/SA care Supported employment: coming soon Mary Thornton & Associates, Inc

Case Study 3 Frank Mary Thornton & Associates, Inc

Clusters: Promoting client clustering to organize services Illness Management and Recovery: Promoting the adoption of illness management and recovery principals to improve outcomes Learning Excellence: Promotion of school-based mental health services ACT: coming soon Mary Thornton & Associates, Inc

Coordinating Centers of Excellence
Coming soon: ACT MI/MR Supported Employment Mary Thornton & Associates, Inc

Thank You Mary Thornton & Associates, Inc

Mary Thornton & Associates, Inc

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