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1 Medicaid Documentation Review October 23, 2012.

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Presentation on theme: "1 Medicaid Documentation Review October 23, 2012."— Presentation transcript:

1 1 Medicaid Documentation Review October 23, 2012

2 WELCOME Thank you for providing skilled professional treatment services to Medicaid beneficiaries. Today we want to provide an update about required charting standards and review some areas that have scored below standard in recent audits. Presenters today are: Rhonda Borders, LCSW, Quality Specialist Maggie Tilley, Compliance Officer 2

3 Era of Health Care Reform Today’s providers work in an atmosphere of increasing regulation and review. More and more audits of state Medicaid programs, hospitals and facilities, and individual providers, some with multi-million dollar paybacks, are occurring around the nation. Documentation requirements for Medicaid are more detailed and extensive than for other insurance companies. 3

4 ValueOptions-Colorado Role ValueOptions and its partner BHOs hold the Medicaid contract with the State of Colorado. VO is responsible for quality review and for identifying and reducing issues of fraud, waste, and abuse. We rely on State and Federal Medicaid rules for paying claims and auditing files. ValueOptions is ramping up quality reviews, compliance audits, and claims verification to avoid significant negative consequences when a federal audit occurs in Colorado. 4

5 Documentation and Claims Documentation in the medical record is the only evidence of your work. Documentation must be well done according to standards to support the claim that you make for payment. Payments are made for a medically necessary covered service provided to an eligible individual by a qualified provider. 5

6 Medicaid Standards Revised standards went into effect for any new enrollment of a beneficiary after Previous training last year explained the standards. That webinar is still available on your BHO website under Provider Information. You will also find a set of suggested forms on those websites that may be helpful to you. –You are not required to use our forms. 6

7 Recent Audits About 70 records of independent providers have been reviewed since May, Reviews done for all three BHOs. Average scores in the 5 areas monitored remain below the 80% minimum. Some providers received passing scores. 7

8 Administrative Area Medicaid Client Rights & Responsibilities Form. –The client/parent/gdn should sign this page at intake. –See the suggested forms. It includes information about Advance Directives and Well-Child Exams that a provider should also cover with a new client. CCAR—Colorado Division of Behavioral Health requires a CCAR for each Medicaid client at admission, at annual update, and at discharge. –The CCAR can be submitted on line at the VO-CO website. 8

9 Assessment Area Many assessments need a little more detail: –Description of the problem –Mental Status exam –Psychiatric and substance abuse history of primary family members Culture/Values/Beliefs: –Not only a statement of ethnicity, religion, or values, but also HOW they potentially will affect the therapeutic relationship or the nature of therapeutic interventions. 9

10 Clinical Formulation A short paragraph that explains your analysis of the assessment. Justifies medical necessity by summarizing client symptoms & matching them to the DSM-IV criteria States client’s willingness and ability to actively participate in treatment Names initial goals and interventions until there is a formal treatment plan in place. Includes anticipated Length of Stay. 10

11 Treatment Plans Improvements can be made by including: –Discharge goal—How much change is necessary before it would be appropriate to discharge? –Measurable objectives to address goals more than “increase” or “decrease”—how much change is enough? depends on detail of symptom frequency and impact reasonable and achievable in the # of authorized sessions fit client’s developmental level and capacities –Therapist’s interventions—more than “individual” or “family” –Parent involvement in child’s treatment—what will they do? –Signatures AND a progress note that says you developed plan with client 11

12 Progress Notes Elements Each note must stand alone. Elements must be present for each session. Place of Service is most often missing (such as office, home, school, community) Also… –Date of service –Start and end time –CPT code or service type –Persons present –Diagnosis being treated –Clinician signature AND date of signature 12

13 Progress Note Content Focus on the clinically important aspects of the session. Notes should include: which goal from the tx plan is being addressed in session specific interventions used by therapist the client response to session client progress toward goals. Avoid “daily report” progress note. Do not include significant detail about what client said or did unless it is relevant. 13

14 Coordination of Care Coordination among providers is important to prevent duplication of services. Chart should show documentation of” –Routine letter to PCP: enrollment, dx and meds –Record of consultation with other providers or resources: teacher, pastor, caseworker, etc. –Referral to medical care (& f/U) if no physical in the last year 14

15 Audit Process-Clinical Approach is educational First audit—educational letter and re-audit scheduled Second audit—educational letter and request for Corrective Action Plan (CAP) Third audit—referral to Quality of Care Committee Potential removal from the network 15

16 Audit Process - Claims Four claims per record are audited on 15 elements, including: –current treatment plan –tx plan signatures –elements of the progress note Auditor sends claim report to Compliance Officer who decides on further action, as needed. –Education or recoupment possible –Responds in a separate letter 16

17 Questions & Answers 17

18 Contacts Rhonda Borders, LCSW, Quality Specialist – Maggie Tilley, Compliance Officer – Tom Dahlberg, LPC, Quality Specialist –

19 THANK YOU 19


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