Documentation Linkage Requirements and Utilization ...

Contact: [email protected]

202.684.7457

ww w. TheNat i ona l Counc i l . o rg

Presented by:

David Lloyd, Founder M.T.M. Services

P. O. Box 1027, Holly Springs, NC 27540

Phone: 919-434-3709 Fax: 919-773-8141

E-mail: [email protected] Web Site: mtmservices.org

October 29, 2013

Documentation Linkage

Requirements and Utilization

Management for Compliance

mailto:[email protected]


202.684.7457

Poll Questions That Focus on the Need for

Documentation Linkage and UM Support

1. How many different types and/or styles of

initial assessments, Service/Treatment Plans

and Progress Notes are being used in your

center? a. One

b. Two

c. Three

d. More than three

1 Presented By: David Lloyd, MTM Founder


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2. Does you center have a written Utilization

Management Plan to ensure a “third party”

type review of the clinical documentation? a. Yes

b. No



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3. Does your center tend to discuss over and

over again the same documentation

compliance concerns? a. Yes

b. No



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4. Do you feel that center would be at risk

under the Medicaid RAC audit program? a. Yes

b. No



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Medical Necessity Documentation Linkage

Models for Healthcare Services

• Audit outcomes by the Office of Inspector General have provided excellent guidance regarding what is needed to demonstrate initial and on-going Medical Necessity

• Move to “tracer” model of review provides increased emphasis on quantitative and qualitative soundness versus just quantitative

Presented By: David Lloyd, MTM Founder


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OIG Audit Notification Letter for MHCs in Illinois in December 2005

Presented By: David Lloyd, MTM Founder 6


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http://www.medicaid-rac.com/medicaid-rac-activity/









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New Mexico Audit Focus Areas

1. Claims Audit – 150 Randomly Selected

Claims Per Center

2. Longitudinal File Review –Risk Management

Capacity and Outcomes being Achieved

3. Enterprise Audit

4. Billing System Audit



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NM Audit Report Summary



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New Mexico Audit Findings Summary



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Five Documentation “Golden Thread” Linkage

Processes in Standardized Forms • Five major linkage processes are built into the standardized form

documentation system to support compliance with qualitative reviews.

1. Diagnostic Assessment – Identifies Treatment Recommendations/ Assessed Needs

2. Diagnostic Assessment Updates – Identifies New Treatment Recommendations/ Assessed Needs

3. Individualized Service Plan – Links goals to specifically numbered Treatment Recommendations/Assessed Needs

4. Individualized Service Plan Revisions - Links goals to specifically numbered Treatment Recommendations/Assessed Needs and/or changes in Objectives, Therapeutic Interventions, Frequency, Duration and/or Responsible Type of Provider.

5. Progress Notes – Links interventions being delivered to specific Goal(s)/Objective(s) and identified client response and outcomes/progress towards Goal(s)/Objective(s).



202.684.7457

Medical Necessity

Linkage Requirements for MH/DD/AoD Services 1. In the past, new information provided after the completion of the initial

Diagnostic Assessment, has been recorded in a Progress Note.

2. In this model, the Diagnostic Assessment became a historical document in the chart and not a current “Living Process” which collects ongoing assessed needs based on symptoms, behaviors or skills/abilities identified by the client/family.

3. Thus, the Progress Note has become the primary document in the chart, requiring staff to thoroughly read every Progress Note in the chart to learn what has been identified as assessed client needs.

4. The DA Update form provides a time- effective method to continuously update new Treatment Recommendations/ Assessed Needs identified after the initial Diagnostic Assessment is completed and link them to interventions provided.

5. By filing DA Updates in the charts in ascending date order, on top of the original Diagnostic Assessment, it will be easy for staff to quickly identify the ongoing assessed needs of the consumer.



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Medical Necessity

• Appropriately Qualified Practitioner • Clinically Appropriate Services and Interventions • At Appropriate Intensity and Duration

As Directed by an

• Individualized Service Plan

Designed to

• To Improve Functioning and Symptoms or Prevent their Worsening

Based on

• Assessed Needs and an Approved Diagnosis

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Source: Bill Schmelter, Ph.D. MTM Team Consultant



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Documentation Linkage “Auditor’s View”

Progress Notes

Clinical Summary & ID’s Assessed Treatment Needs and Service Recommendations

Service Plan Goals

Service Plan Objectives

Service Plan Interventions, Services, Intensity

Assessment Data

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Source: Bill Schmelter, Ph.D. MTM Team Consultant



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Primary Purpose of Diagnostic Assessment in

Medical Necessity Linkage Requirements

• DA provides an opportunity for clinician to list the

identified treatment recommendations/ assessed

needs of the consumer (based on assessment of

all three areas - symptoms, behaviors and

skills/abilities needs) as evidenced by information

gathered that supports each assessed need (i.e.,

Anger management as evidenced by anger at

spouse, parents, boss and co-workers).



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Diagnostic Assessment –

Treatment Recommendations/Assessed Needs



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Individualized Service Plan and Medical Necessity Linkage

Requirements

• Treatment Recommendations/Assessed Needs prioritized numerically (i.e., 1, 2, 3, etc.) in the initial Diagnostic Assessment (DA Update, Crisis Intervention and Initial Psychiatric Evaluation) are linked to and become the core basis for each Goal in the Individualized Service Plan.

• The linkage occurs by entering the Treatment Recommendation number, form date and checking the specific form type adjacent to the specifically numbered Goal.



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Sample Service Plan Model

with Goal Linkage to Assessed Needs



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Link to Medical Necessity Based

Reimbursement Summary

• Progress Notes provide an opportunity for specific linkages between the therapeutic interventions provided in the service visit/session to the ISP and/or ISP Revision by requiring that the specific Goal(s) and Objective(s) being addressed in the service be

clearly identified within the note.



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Structured Progress Notes and Medical

Necessity Linkage Requirements

• As the client continues in treatment, he/she

reveals/identifies additional personal information that

enhances the original assessed information in the DA

• Progress Notes provide a critical linkage in the section

entitled “New Issue(s) Presented Today”. This section

accommodates the documenting of this new information

and is illustrated below



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Update Indicators Sections of the DA Update Form



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Diagnostic Assessment Update Process

Linked to Treatment Plan Revision

• If existing Goals, Objectives, Interventions, Services, frequency and provider types will NOT meet the client’s newly identified Treatment Recommendations/Assessed Needs, then link the newly assessed needs from the DA Update to an ISP Revision by checking the indicator in the “Change In ISP Required” field in the For Annual or Interim Updates section of the DA Update.



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UR/UM Plan Monitoring

HIPAA Compliance CMS Corporate

Compliance

QI Director

Integrated Quality Improvement/ UM Organizational Structure

Clinical and Support/Admin staff assigned based on size of organization and active caseload



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Local UM Reviews to Support “Third Party Like” Approach

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Access & Quality

Improvement Department

Access to Care: Screening/Triage

Emergency Services

Eligibility (Includes Part C)

Provider Profiling

Customer Service

Education

Referral

Follow-up

Utilization Management: Internal Utilization Review/

Corporate Compliance

External Authorization/ Re-

Authorizations

Appeals

Contract Compliance

Qualitative and Quantitative

Auditing

Quality Improvement: Quality Management Council

Office of Consumer Services

Consumer Satisfaction Surveys

Clinical Outcomes

Health Information System Community Relations:

Grant Writing

Public Information and Marketing

Prev. Community Education

Contract Negotiations: Satisfaction

Clinical Provider Supports - Insurance Provider

Enrollment - Licensure Preparation

Support

- Performance Based Contracting

Support Staff

Child/Family Department

Assessment: Intake

Crisis Stabilization Outpatient Therapy:

IOP

Individual/ Family/ Group

- VOCA - Detention-based Services

- Sexual Offender - Restoration

Early Intervention:

Project Daniel

Transition School School/Community Based Services:

Day Treatment

In-School Outpatient Indiv/ Groups

SA Prevention Programs

Behavior Support Services Home-Based Services:

In-home Training/Supports


Behavior Support Services Family Supports:

Parent Support Services

Early Intervention Service Coordination:

Case Management

Residential Services: Therapeutic Foster Care

Respite

Independent Living Psychiatric/Medical Services:

Psychiatry/Medical Doctor

Nursing Support Staff

Adult/Family Department

Assessment: Intake

Crisis Stabilization

Outpatient Therapy: IOP


Pegasus

Family Support - MESA

- SA Family Support Service Coordination:

Case Management

Community Support: Day Program (LRC)

Supported Living

Psychosocial Rehab

Wrap-Around Services

PACT

Census Reduction

Residential: Group Homes/ ICF

Respite

Residential Treatment: Residential

Detox

Halfway House Psychiatric/Medical Services:

Psychiatry/ Medical Doctor

Nursing

Support Staff

Finance & Support Services Department

Finance: Accounts Payable

Purchasing

General Ledger

Reimbursement: Billing

Collecting and Posting

Payments

Reporting

Information Technology: Tech Support

CMHC Operating System

Hardware and Software for

Network E-mail Communications Internet Access

Information and Management

Reports

Installation and Maintenance of

PCs Computer Training

Human Resources: Center Focused Staff Training

Payroll

Recruitment

Personnel Policies and Files

Receptionists

Performance Contracting with State

Building/Maintenance:

Vehicle Fleet Management and

Maintenance Building and Grounds

Support Staff: Agency Program Support

Operational Policy & Procedure

Training



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Utilization Review Vs. Utilization Management

• Utilization Review is primarily focused on

retrospective review of what has or has not happened

in services

• Utilization Management is focused on retrospective,

concurrent and prospective management of service

delivery capacity from intake to discharge and every

thing in between



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Focus Areas for Utilization Management Plan

Front End (i.e., Screening/Triage, Eligibility, Emergency Services, Referrals, etc.)

Retrospective (i.e., Qualitative/ Quantitative Review of Charts and Outcomes/Satisfaction Measures, etc.)

Concurrent (i.e., Urgent/Routine Transfer/Discharge Criteria/Planning, Services for high risk consumers, qualitative review of clinical documentation and treatment planning, etc.)

Prospective (i.e., Qualitative/ Quantitative focus for future care for each client based on retrospective/concurrent review.)



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UM Plan Clinical Tools Needed

• Entry Into Care

1. What are the Access to Care standards for consumers per level of acuity (Emergent, Urgent and Routine)?

2. Who will assign the initial Level of Care for the consumer entering services?

3. What clinical tool(s) will they use to make the assignment?

4. Who will authorize initial services?



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Utilization Management Procedures:

The center needs to have a written utilization

management plan and ongoing activities to assess:

1. The clinical appropriateness of Medicaid

funded services

2. Intensity/level of services, and

3. Continued services for the client.

4. Such services may be subject to utilization

management parameters established by the

public payer.



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Utilization Management Procedures (Cont’d):

5. Describe in the written Plan the methods and procedures

for performing and recording individual case reviews by

persons not involved in providing services to the clients

whose records are reviewed (i.e., 10% sampling of charts

and if there is more than a 5% adverse finding, double

the sampling size and the results are a final finding)

6. Need to define the authority and functions of the

individual case review designated unit, which may be: A representative committee, chaired by a QMHP, and

including QMHPs, MHPs, and RSAs; or

A QMHP



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7. How will the centre ensure that appropriate utilization management

reviews are provided by UM Program?

8. Will the reviews be retrospective or concurrent and how will result affect

each six-month treatment plan review/revision?

9. Need procedures in Plan describing the method for selecting cases for

quarterly case review and the procedures for reviewing a 10% or greater

sampling of the clients served under annually (Refer to state standards)

10. Need procedures in Plan to ensure that the review includes and

summarizes the client’s progress over the previous 90 days and if there

is a lack of progress what changes will be made to the

interventions/methods, service modality, frequency and provider type. If

there has been progress achieved, does the frequency and type of

service need to be titrated?



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11.Need Policies and Procedures for documenting

and reporting individual case review findings,

determinations and recommendations to the

supervising QMHP and, if applicable, the billing

department

12.Need provisions in the Plan for ensuring

confidentiality of individual case reviews,

determinations, results and/or recommendations

in accordance with the HIPAA



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UM Plan Clinical Tools Needed Monitoring Client Care

1. What treatment milestones that will be used to

monitor consumers’ care and progress (i.e.,

Treatment Plan Reviews or Annual Updates)?

2. Who will monitor consumer services delivered

and progress attained?

3. What procedures will be used for utilization

review of individual client’s use of available

funds, medication expenditures or other

community based resources.



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UM Information Sources and Documentation

Requirements

1. What data elements/fields or information will be used to

monitor/measure outlier management process?

2. What forms/written process will be used to document

utilization reviews and inform staff and clinical managers of

findings?

3. How will information regarding findings be conveyed to

appropriate staff?

4. Need procedures in Plan for following up on case review

findings.



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Sample UM Plan Notice of Adverse Findings

1. If an adverse finding has been identified by the UM

Committee, written notification of the findings will be

sent within two business days to the clinician and

supervisor/program director requiring that a

corrective action plan be submitted within two

business days of receipt of the notice.

2. Following receipt of the correction action plan,

continued monitoring will be provided by the UM

Committee to ensure that the non compliance

behavior has changed. If not, then staff involved will

be sanctioned.



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UM Plan Summary

• Authority and Responsibility

• It will be the responsibility of Utilization Management to assist

administrators to manage service utilization. Utilization

Management will provide oversight of service utilization for all

MH/SU programs and clinicians. Utilization Management will

assist MH/SU staff to manage client care from the point of entry

into services to discharge. All reviews of service allocation to

individual clients will be subject to the same care standards and

medical necessity criteria. All MH/SU staff will be expected to

follow the same utilization management and utilization review

procedures. Utilization Management staff will be empowered to

make decisions about individual client service plans and authorize

or deny services.



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UM Plan Summary Authority and Responsibility Lead to Sanctions to Close

Accountability Loop:

• SANCTIONS: Staff are expected to maintain clinical records in

accordance with all applicable laws, rules, regulations, and policies.

When clinical records are found to be in non-compliance, Management

will work with staff to develop corrective plans of action to address

deficiencies. Management will monitor the progress toward

completing corrective plans of action and will continue to review files to

make sure that the problem has been corrected within the time frames

agreed upon in the corrective plan. Staff who fail to follow-through

with the corrective plan of action will be subject to disciplinary action,

up to, and including, termination. Failure to follow through with

recommendations made at any review level will result in disciplinary

action, up to, and including, termination.



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202.684.7457

Presented By: David Lloyd, President

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