: Internal UM Processes, Credentialing and Authorization for Services:

Contact: [email protected]

202.684.7457

www.TheNationalCouncil.org

: Internal UM Processes,

Credentialing and Authorization for

Services:


202.684.7457


Compliance, Accountability &

MonitoringWebinar: Internal UM Processes, Credentialing and Authorization for Services: Center has implemented internal utilization management functions including

credentialing support for clinical staff; pre-certs, authorizations and re-authorizations; and referrals to

clinicians credentialed on the appropriate third party/ACO/Medical Home/Health Home panels

2


202.684.7457

UM/UR Why is this important?• Increased Accountability

• UM UR If we find that UM UR reviews

provide unsubstantiated claims

it will be deducted from your productivity If we have provided a bonus on these units then this will be deducted

from your next pay Horizontal and vertical accountability KPIs for clinical and non clinical team members

• We will follow our UM UR policy

Renewing Our Commitment


202.684.7457


• Just because we have passed a state audit is no guarantee that we are not open to problems.


202.684.7457

www.TheNationalCouncil.orgDocumentation

Get the CheckWithstand the audit

Keep the MoneySo, you can do it again.

Find the clientAssess the clientTreat the ClientDocument it all

Give the info to the next part of the process

SubmitThe

Claim for Payment to the Correct payer(s)


202.684.7457


UM/UR

• Is there a set of structures or methods that provide for authorization of care, using particular criteria. These are usually determined by the payer.


202.684.7457

Process for Authorizations and Re-Authorizations

• Gather insurance information over the phone or when an individual walks in by making a copy of their insurance card and when applicable running it through the state system to ensure it is active.

• Give information to Managed Care Staff assigned within your organization.

• Credentialing of staff is critical and key to payment so managed care staff need to be knowledgeable about providers and who is credentialed with what payer sources when seeking authorizations.

• Managed Care Staff will follow the process for each insurance company to seek an authorization. Tip: Establish a relationship with an individual from each payer source who authorizes services as “the go to individual” for questions and urgent situations.


202.684.7457

Process for Authorizations and Re-Authorizations• Set up a tracking system for authorizations. Ideally

the pre-authorization can be loaded in the EHR and monitored by Managed Care Staff. A notification is sent from the Managed Care Staff to the Clinician when they have 2 sessions left before needing a Re-Authorization.

• Managed Care Staff gives the clinician the necessary paperwork from that payer source to complete and sets a deadline to be returned.

• Managed Care submits and notifies the clinician when approval has occurred and loads those sessions into the EHR or additional information is needed or when it has been declined so the clinician can appeal.

• Patient is notified of current status of authorization or reauthorization.


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Working Rejections

• Receiving an authorization does not mean you automatically receive payment. Must have a designated individual or team to work

the rejections when payment is not received. Must have a process in place for working the

rejections. Rejections can be for a variety of reasons and it is

important this individual has an in-depth understanding of those codes and how to obtain the necessary information to re-submit the claim.

Must have a tracking process in place to ensure the payment is received after it is re-submitted from a denial.


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OVERVIEW

• AGENCY will employ an outside consultant to perform monthly reviews of all agency programs. Each program (including Adult Mental Health, Substance Abuse, C&A Mental Health, Psychiatry, PAS, SASS, DCFS, and others) will have at least 5% of its charts reviewed a minimum of 2 times each year.

• UR reports will be generated following each of these reviews and distributed to the manager of the affected programs. The managers will be responsible for instructing staff to amend what they can and will also search for trends of non-compliance that need further corrective action.

• Annually, the consultant will review each program and make recommendations on systemic improvement and assess each program’s strengths.


202.684.7457


NEW CLINICAL STAFF

• For the first six weeks of active clinical work, QA will review each chart weekly. She will then provide a personal review to the staff member regarding their paperwork timeliness and accuracy. At the end of this four week period, QA will either sign off that the clinician is competent or that the clinician requires another two weeks of review.

• Once the clinician has been signed off on, QA will review one week of charts once per month for the next nine months. QA will provide a written assessment of their performance to their supervisor, which will be reviewed during supervision, signed off on by both supervisor and employee, and placed in the employee’s personnel file.


202.684.7457

www.TheNationalCouncil.orgEXISTING STAFF

• All staff will have 20% of their charts audited the month before their annual review. QA will provide a written evaluation to assist the manager with the review process. If their compliance is above 95%, they will be placed in the “A” category. If less than 95% compliance is noted on this annual review, the clinician will be put into the “B” category. If less than 85% compliance is noted, the clinician will be placed in the “C” category.


202.684.7457


Category A:

• Clinicians in this category will receive semi-annual spot audits in addition to their annual review audit.


202.684.7457


Category B:

• Clinicians in this category will be required to adjust any incorrect documentation in the audited charts. They will also be subjected to once-per-month spot audits that will be documented and reviewed in supervision. They will have to make any necessary adjustments to the documentation and will need to have their supervisor sign-off on their spot-audit sheet verifying that this is done. This will continue monthly until compliance meets 95% or until 6 months have passed. If 95% compliance is not reached within 6 months, the clinician will be put into category C.


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Category C:

• Clinicians in this category will be required to submit all documentation daily to Compliance Review Staff. She will evaluate it for completeness and accuracy and will provide the supervisor with a daily report. She will be available to provide additional training to the clinician if required to ensure compliance. This will continue for 30 days, at which time compliance should reach 95%. The clinician will then be placed in Category B, although they will have expanded evaluation of treatment plan compliance for the first three months. If compliance does not reach 95% within 30 days, further disciplinary action will need to be taken at the discretion of the supervisor.


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UM/UR’s Role in CORPORATE COMPLIANCE AND ACCOUNTABILITY


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Manage risk of unexpected losses or expenses caused by regulatory action◦Prevent large payback sums, costly attorney’s

fees, negative public relations, employee resources committed to response

◦Civil/criminal liabilitiesImplement proactive Corporate Compliance

initiatives to meet increased scrutiny from state and federal funders

Meet our ethical obligations of quality care

CORPORATE COMPLIANCE


202.684.7457

• Compliance Program Review: Identify, retrieve and prevent inappropriate Medicaid/Medicare billing ahead of auditConduct risk assessment, noting payback risk

(including extrapolation: if 5% error rate, extrapolate 5% across all services billed, e.g. 30 claims becomes 200,000 claims or $4K becomes $6M)

Build a culture of transparency and integrity



202.684.7457

• Compliance risk assessment Train employees Review documents (UR: billing and coding, medical necessity

documentation) Identify risk areas (CI, CM, Family and Group Rx, Fidelity to

EBP, etc.)

• Infrastructure reviewReview program components (self-disclosure,

corporate compliance log, removing billings that are unsubstantiated)



202.684.7457

Examples of Two Identified Risk Areas and QA measures taken monthly at a CBHC

• All information is shared monthly with the providers

• Prescribers Billing code patterns Quality Assurance Review/ Peer Reviews

• Community Support Specialist/ Case Managers Chart review Talking to the consumer Field supervision


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February 2013 Service Code by Physician


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Clinical/Medical Necessity Peer Review• All Board Certified Psychiatrists must meet requirements

of MOC which include PIP (Performance in Practice) through chart reviews and second party external reviews.

• Each agency should have a clinical review/quality assurance system.

• Review of Medication Indicators includes Risk Assessment, Co-existing medical, Substance Use/OTC meds, Pregnancy, Established Treatment, Past and Current Medications, Appropriate Dosages, Instruction for taking medication, Rational for use discussed with client, Drug to Drug interactions were discussed, Informed consent, AIMS, Labs/tests, Additional Referrals.

• Monitoring targeted indicators such as No Poly Pharmacy (no more than 5 medications used for more than 60 days), Atypical Antipsychotic Mono-therapy, Patient failed to fill medication within 15 days.


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Community Support Services QA Activities• Supervisor reviews 2 charts a month for each

supervisee. ENSURES DOCUMENTATION REQUIREMENTS

• Supervisor makes two calls a month to consumers for each supervisee. QUALITY AND VERIFICATION OF SERVICE MATCHES PROGRESS NOTE

• Supervisor does one ride along a month per supervisee. ENSURES MEDICALLY NECESSARY INTERVENTION AND COACHING OPPORTUNITY

• If the Community Support Specialist falls deficient in any area additional corrective action is taken in that area. Each addresses unique issues.


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Example of QA Phone Calls for Community Support Services

• Hello Mr. Jones I wanted to follow up to see how your visit was today with Mike

• Did you meet with Mike today?• What treatment plan goals did you work on

today?• How long was your appointment today with

Mike?• Was Mike on time for your appointment?• Any other concerns or questions you have for

me?• This is cross-referenced with the Progress

Note to ensure accuracy.


202.684.7457

• Compliance is Everyone’s ResponsibilityReview the Corporate Compliance/False

Claims Act Policy●Fraud is “knowingly” submitting

false/fraudulent claims●Actual knowledge, act in deliberate

ignorance, act in reckless regardReport any concerns about billing, required

when there is knowledge of improper billing



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Document and Claim Services Accurately◦Meet credentialing requirements◦Signatures must be original, dated and

accompanied by credentials (or meet e-signature standards)

◦Document actual time, date, duration ◦Reflect service provided as required

◦ Include required documentation elements◦Do not up code, i.e. bill for greater service

◦Include medical necessity, “golden thread”



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Follow protocol for corrections and amendments to documentation

Do not:●Bundle services; ●Backdate documentation; ●Overlap service time/duration; ●Bill the same service by multiple staff (CI

exception)

Remember timekeeping, mileage, managing client funds



202.684.7457

• Medical Necessity LPHA determines:

● Diagnosis of MI or SED (Healthy Kids Screen can initiate services as MHA is completed)

● Impairment in functioning in 1 or more areas

Individual needs MH services to:● Alleviate emotional disturbance/stabilize● Reverse/change maladaptive patterns● Restore/rehabilitate to maximum life functioning

• Golden Thread Assessment > Treatment Plan> Service Documentation>Updates



202.684.7457

MHA ● Description of time spent with client or collateral gathering information● Include client preference/compliance ● Review “ability to participate” (e.g. TBI, DD, Dementia, etc.)

ITP ● Description of time spent with client or collateral developing, reviewing or

modifying ITP● Review Stages of Change/Treatment/Recovery ● Incorporate client goals



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Therapy/Counseling● Include description of the activity (action taken on behalf

of clients to facilitate receipt of service) and interventions provided (deliberate interaction between staff and clients or a client’s collateral for the purpose of alleviating the client’s symptoms of MI and improving the client’s level of functioning)

● Include client’s response● Include progress toward goal(s) as a result of

intervention



202.684.7457

Case Management● Review medical necessity; case management mental health as required…● State action taken on behalf of client, e.g. assessed, advocated, linked, etc. ● Do not bill for transportation only● Review parenting services as they relate to client’s diagnosis

Community Support● Document skill building activities● Develop curriculum training for skill building



202.684.7457

• Client Centered (Joint Commission) Culturally competent

● Culture● Language (e.g. Spanish speaking interpreter, written materials in translation)● Health literacy● Disability● Learning needs

Documentation of services Effective communication

● EC, ethics, informed consent, law & regulatory compliance, assessment/education, values and beliefs

Complaints/grievances



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Culture of Transparency - Self/Agency Monitoring and Reporting ◦Report when an error is made/found◦Seek direction if corrections are needed ◦Discuss opportunities for training and

performance improvement



202.684.7457

Presented byMichael Flora, MBA, M.A.Ed, LCPC

MTM Services

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