1. Assuring your TCM program is in compliance
TCM Documentation Training
November 1, 2012
Assuring your TCM program is in compliance
Presented by Patricia Calloway and Pat Ericsson
TCM Conference April 2017

2. Topic for discussion Case Manager qualifications Agency qualifications
Program policies
Audit file
Best practices

3. Agency Qualifications
Must have system of coordination between programs
Demonstrate experience in providing case management
Employ staff with CM qualifications
Have or establish referral systems for linkages

4. Agency Qualifications – Cont’d
5 year minimum of providing CM to target group
Admin capacity to ensure quality of services
Financial management capacity to comply with OMB A-87
Capacity to document and maintain case records to meet regulation standards
Ability to evaluate quality and effectiveness

5. Case Manager Qualifications
RN or PHN with active license
Bachelor’s degree with agency approved CM training
Documentation of initial and annual time survey training
Duty statements
NPI
Documentation of case management training for Non – RN/PHNs

6. Program Policies Part of the Annual Participation Prerequisite:
Performance Monitoring Plan/Non- duplication/Care Coordination
Freedom of Choice
Fee Mechanism
Managed Care MOU

7. Program Policies - continued
Annual Participation Prerequisite
subcontractors
Provider Participation Agreement
Signature Authority
MEDS Access
Sub program codes
Third Party Liability

8. Program Policies - continued
TCM Payment System
Time Surveys
Confidentiality
Duty Statements
Payment by invoice
Quality Assurance
Chart audit and peer review

9. Audit File Billable vs Non-billable Encounter Logs
Organizational Charts
Duty Statements/Job Description
Case Management Qualifications
Billable vs Non-billable
Encounter Logs

10. Best Practices Best Practices Required Documentation Red Flags
Duty Statements
Client satisfaction
Grievance procedure
Required Documentation
Red Flags
Resources

11. Alameda County Public Health Nursing : Patient Experience
“Staff is very friendly and the nurse answered all my questions”
“She was great, very helpful. She is the right resource, and was helped right away!”
“Excellent! I like her, she was right! I’d recommend xxxx. She is very helpful and I love her to death!”
“She is excellent! Best nurse around! So understanding!”
“Professional, super nice, really sweet”
“Every staff RN PHN service was sufficient”
“I am going to move out of state, and the nurses gave me really good references!”
“This helps lots of people”
“Helpful to me, took her time and explained everything. She was very good”
“Definitely recommend, I really enjoy working with xxx”
“She really helped me. Very nice”
“She was very helpful and she was really nice”
“Very nice, very helpful . I am very happy”
“I had 2 strokes. I needed a new pharmacy and delayed meds because medical needs to do that in the clinic”
“Everything was good, very satisfied”
“Always helpful to provide more information. Xxx was very nice”
“Was very helpful, they helped me a lot”
“Yes, very helpful. I got to know a lot of things”
“It’s great service. Provided good information and literature”
“They are my best friends”
“Good worker, helped me a lot. Kept me from stressing out”
“Timing of visits can be off; otherwise happy with services”
“She was on top of everything”
“xxx. She is nice, helpful – Tell her I said ‘hello’”
“She really helps me. I want her to come back”
“xxx goes above and beyond. I can’t say enough good things about her”
“It’s been great!”

12. Freedom of Choice Must have a Freedom of Choice policy
Best Practice: Note on assessment form that Freedom of Choice was explained

13. Freedom of Choice Client must be told: Services are voluntary
May go to a different TCM provider
May request a different CM
May terminate TCM services at any time

14. Fee Determination and Waiver
It must be documented that the client was reviewed for a fee for TCM services
Each LGA or TCM provider must have an income-based scale to determine if client must pay a fee
There are no state or federal parameters

15. Fee Determination and Waiver
If it is determined that the client must pay a fee, the fee may be waived by the Case Manager
Client has a communicable disease
CM determines client will not continue in the Program and could be detrimental to the client

16. Billable vs. Non-Billable
TCM Documentation Training
November 1, 2012
Billable vs. Non-Billable
A billable encounter is:
Face-to-face visit with Medi-Cal client
In TCM target group
During which case manager renders one or more TCM service components.
All TCM criteria must be met to be billable

17. Performance Monitoring Plan
LGA must submit their Performance Monitoring Plan with their Annual Participation Prerequisite.
Details how LGA will ensure case management service will not be duplicated
Details your Quality Assurance Plan

18. Quality Assurance
No formal requirements exist – each LGA should determine its own QA protocols
LGAs develop a written policy for reviewing TCM cases

19. TCM Documentation Training
November 1, 2012
Quality Assurance
Best Practices
Include criteria, sample methodology, and frequency of reviews
May involve coordinator’s review, supervisor review and/or peer review
Include periodic checks to assure that client case documentation, encounter logs, and billings are consistent in details

20. Common Documentation Errors
Not clearly identifying the TCM service that was provided
Not identifying one of the four TCM
service components
Billing for a TCM encounter when a TCM service has not been documented

21. Common Documentation Errors
Not addressing who, what, when, where and why
Not clearly distinguishing individual care plans, assessments and progress notes within family charts
Not clearly identifying how a client meets the Target Population criteria

22. Red Flags for Auditors Not using TCM words in case file documentation
Making frequent client visits without documenting client outcomes or new needs
Documenting multiple home visits where no new information was received or new referrals made

23. Red Flags for Auditors
Needs identified on the Assessment are not the same needs identified in the Care Plan
Using local agency acronyms without a key to full names or meanings
Illegible writing
Documenting for a family versus an individual

24. Resources State Website LGA Website TCM FAQs MAA/TCM Regional Meetings
TCM Guidelines Workgroup
Annual Conference

25. TCM Documentation Training
November 1, 2012
Resources-FAQs
View the complete FAQ document:
ortiumworkgroups/home/tcm- workgroup/tcm-faqs

26. TCM FAQs

27. TCM FAQs

28. Questions