Welcome [nc-pcs.com]

Liberty Healthcare PCS Provider Training May 2016

The Freedom to Succeed™

Welcome

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AGENDA

9:00-9:15 am Welcome and Introductions Denise Hobson, Director of Clinical Services

Liberty Healthcare

9:15-9:45 am Review of PCS Policy Requirements

Lyneka Judkins, Chief Operations Officer

Liberty Healthcare

9:45-10:40 am Understanding the Beneficiary’s Assessment

Denise Hobson, Director of Clinical Services

Liberty Healthcare

10:40 -11:00 am Break

11:00 – 11:15 pm Proposed Policy 3L and Eligibility Updates

Lyneka Judkins, Chief Operations Officer

Liberty Healthcare

11:15 – 11:30 am Internal DMA Audit Lyneka Judkins, Chief Operations Officer

Liberty Healthcare

11:30 – 12:30 pm Q&A Session

Review of PCS Policy Requirements (Interactive Presentation)


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Test Your Knowledge

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PCS ICD-10 Transition Forms

• When is an ICD-10 Transition Form required for a beneficiary?

• Before their annual review if scheduled after 10/1/2015

• What are the two ways a provider may submit the transition form to Liberty?

• Fax or Upload into QiReport

• Where are the 3 places a PCS Provider can locate an ICD-10 Transition Form?

• DMA Website, LHC Website, Annual Notification Letter

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PCS ICD-10 Transition Form

Completed forms can be submitted to Liberty in one of two ways:

Fax – The PCS Provider or Practitioner can fax the form directly to Liberty at 919-573-9694.

Upload – The PCS Provider can upload the completed form to ‘Supporting Docs’ through the provider portal.

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To upload the ‘Transition Form’ through the provider portal, select the ‘Referrals’ tab on the top toolbar, then click ‘Supporting Docs’ from the left index bar:

2. Select ‘Supporting Docs’ to upload form.

1. Select the ‘Referrals’ tab.

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Where is the DMA 3137 PCS ICD-10 Transition Form located?

1. Liberty website: http://nc-pcs.com/Medicaid-PCS-forms/

2. N.C. Division of Medical Assistance (DMA) PCS webpage under “Forms.”

http://www2.ncdhhs.gov/dma/pcs/pas.html

http://nc-pcs.com/Medicaid-PCS-forms/









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Completing the Service Plan

• How many days does the PCS Provider have to complete the required Service Plan? • 7 Business Days

• How many days does the PCS Provider have to get the completed Service Plan signed and uploaded into QiReport? • 14 Business Days

• When is a Service Plan required for a beneficiary? • Every time a PCS Provider receives and accepts a ‘referral’ in QiReport

• How should the PCS Provider proceed when the amount of approved hours does not match the hours reflected in the assessment? • Complete a manual Service Plan, upload into QiReport, and Call Liberty

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Discharges

• How many days does the PCS Provider have to complete a discharge when the beneficiary is no longer under their care?

• 7 Business Days

• How does a PCS Provider discharge a PCS beneficiary?

• Through QiReport

• If the beneficiary is not approved for PCS that is reimbursed by Medicaid, but remains under the care of the PCS Provider, do they have to discharge in QiReport?

• Yes.

• Does the PCS Provider need to discharge a beneficiary if they are hospitalized for a brief time?

• If the beneficiary has been approved for PCS and the PCS Provider will resume care once the beneficiary is discharged from the hospital, then a discharge is NOT required in QiReport

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Discharges

The PCS Provider is required to discharge a beneficiary from QiReport if they are no longer providing PCS that is reimbursed through Medicaid.

2. Select ‘Discharge’ to discharge beneficiary.


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Provider Acceptance

• How many days does the PCS Provider have to respond to a referral for PCS?

• 2 Business Days

• What happens if the PCS Provider does not respond in 2 business days?

• The referral will be rejected and the next provider selection will be sent a referral

• Where can the PCS Provider locate their referrals and respond?

• In QiReport on the ‘Referrals’ page

• Does the time the PCS Provider takes to accept a beneficiary effect their PA’s?

• Yes. PA’s are made effective based off of the provider acceptance date, with exception of initial assessments.

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Provider Acceptance

The PCS Provider should check their ‘Referrals’ tab daily for any new PCS referrals.

2. Select beneficiary to accept/reject.


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Preadmission Screening and Resident Review (PASRR)

• Who requires a PASRR screen?

• Any Medicaid beneficiary seeking admission into an Adult Care Home after January 1, 2013; including those who are private pay and become Medicaid eligible after this date.

• Who does not require a PASRR screen?

• Any individual who was admitted into the Adult Care Home prior to 1/1/2013 regardless of payer, private pay individuals, and those who reside in the 5600 A or C settings

• What is the purpose of the PASRR screen?

• To evaluate for serious mental illness

• If a beneficiary is transferred from a nursing home to an Adult Care Home and has a PASRR with an A code, do they require another PASRR?

• Yes; the beneficiary must have a PASRR with an Adult Care Home code.

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Preadmission Screening and Resident Review (PASRR)

The following are acceptable Adult Care Home Codes for PASRR:

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Quality Improvement Program

• What form is required to be completed and submitted to DMA?

• DMA 3136 Internal Quality Improvement Program Attestation Form

• The DMA 3136 Form is required to be submitted by what date?

• December 31st of each year

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Quality Improvement Program

• What are the requirements for the PCS Provider regarding an Internal Quality Improvement Program?

• Develop, and update at least quarterly, an organizational Quality Improvement Plan or set of quality improvement policies and procedures that describe the PCS CQI program and activities;

• Implement an organizational CQI Program designed to identify and correct quality of care and quality of service problems;

• Conduct at least annually a written beneficiary PCS satisfaction survey for beneficiaries and their legally responsible person;

• Maintain complete records of all CQI activities and results;

Understanding the Beneficiary’s Assessment

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Where It All Starts…..

PCS request is dropped in QIR queue for

scheduling

Scheduling schedules visit

with the beneficiary and time and date

are established

Assessor receives the

assignment and contacts

beneficiary the day before to

confirm appointment

Assessor conducts the assessment

based on the beneficiary’s

demonstrated ability to

perform ADLs

Assessor submits the assessment

and a decision

generates

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What The Assessor Captures In An Assessment

Available caregivers

Daily medicine regimen

Diagnosis information

Paid supports/Non Paid supports

Demonstrations of a beneficiary’s ability to perform their activities of daily living (ADLS)

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What The Assessor Captures In An Assessment

Special assistive tasks

Exacerbating conditions that impact their ability to perform their ADLs

Home safety evaluation

Provider choice

Need frequency

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Activities of Daily Living (ADLs)

Bathing

Dressing

Mobility

Toileting

Eating

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Understanding Assessment Fields •Beneficiary attempts to demonstrate how they would perform an ADL task.

Demonstrated Ability

•The beneficiary requires assistance to complete task.

Check If Required

•Level of assistance the beneficiary requires to complete the task.

Assistance Level

•Identified if there is an assistance need for the indicated ADL.

IADL Task Needs

•Number of days the beneficiary performs the task.

Frequency

•Number of days the beneficiary has an alternate caregiver other than the PCS aide to assist with meeting the need.

Need Fully Met

•Auto-populated number of days of unmet need for PCS service.

PCS Need Frequency

• Task need is inclusive of weekend need. Weekend

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Bathing: What Is Assessed?

Bathe by means of shower, tub bath, bed bath ,or sponge bath

Hair care - shampooing and combing hair

Nail care - cleaning/cutting nails

A beneficiary‘s ability to demonstrate/perform the following tasks:

Skin care - applying lotion/washing hands and feet

Mouth care - brushing teeth, dentures etc. and reinserting

Shaving - face, legs, axilla (armpit) areas

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Bathing Section

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Dressing: What Is Assessed?

A beneficiary’s ability to demonstrate/perform the following tasks:

Don clothing/socks/shoes

Remove clothing/socks/ shoes

Manage clothing and shoe fasteners

Manage TEDS (compression

stockings) - removing and applying

Manage splints/braces- removing and applying

Manage - removing and applying

Manage prosthetics- removing and applying

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Dressing Section

Factoid: TED is an acronym for thromboembolism-deterrent hose!

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Mobility: What Is Assessed?

Transfer to/from the bed

Transfer to/from chair

Ambulate room to room – by limb or assistive device


Negotiating stairs within the home – only to areas of service provision

Perform range of motion (ROM)

Turn and reposition in bed

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Mobility Section

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Toileting: What Is Assessed?


Remove /pull up/ fasten garment

Perform hygiene after toileting/incontinence

Transfer to and from the bedside commode or toilet

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Toileting Section

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Eating: What Is Assessed?

Cutting food

Ability to feed self

Use of utensils

Ability to lift limb to mouth

Ability to perform tube feedings

The beneficiary ability to demonstrate/perform the following tasks:

Ability to clean meal service area

Clean utensils/dishes/empty trash

Perform meal prep: opening packages

Perform meal prep: heat and assemble food

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Eating Section

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Special Assistive Tasks: What Is Assessed?

Break up fecal impactions

IV fluids

O² therapy

Ostomy

Sterile dressing changes


Suctioning

Urinary catherization

Wound irrigation

Tube feeding and g tube management

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Delegated Medical Monitoring Tasks


BP monitoring

Blood glucose monitoring

Med self-administration reminders

Other treatment monitoring

IV fluids

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Delegated Medical Monitoring Tasks

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Special Assistive Tasks Section

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Conditions Affecting Beneficiary ADL Performance/Assistance Time

Exacerbating conditions or conditions affecting ADL performance allow the assessor to identify those that affect the beneficiary’s ability to perform their ADLs.

All body systems are covered in these conditions:

Respiratory System

Cardiovascular

Gastrointestinal

Neurological

Behavioral

Sensory Impairment, and

Musculoskeletal system

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Conditions Affecting ADL Performance Time

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Safety And Environmental Conditions

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Provider Choice /Return Frequency

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How Does The Beneficiary Qualify For Services?

The beneficiary must have:

At least 3 Limited Overall Self -Performance Capacity Ratings out of the 5 ADLs and have unmet needs.

At least 1 extensive or greater overall self performance capacity and one or more limited assist or greater overall self performance capacity and have unmet needs.

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How Many Hours Can A Beneficiary Receive?

80 Hours

• For a beneficiary who does not meet the criteria for Session Law 2013-306

60 Hours

• EPSDT on the initial assessment hour generation. All EPSDT assessments go to DMA for final hour calculation/evaluation

Up to 130 Hours

• For a beneficiary who meets the criteria for Session Law 2013-306

Proposed Policy 3L and Eligibility Updates

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Proposed Policy 3L & Eligibility Updates

• Policy 3L has been revised and will be open for public comment;

• The proposed policy will be located on the DHHS website here: http://dma.ncdhhs.gov/get-involved/proposed-medicaid-and-nc-health-choice-policies;

• Finalized changes will go into effect July 1, 2016; • Questions about proposed changes should be

submitted through the public comment page or via email at [email protected]

http://dma.ncdhhs.gov/get-involved/proposed-medicaid-and-nc-health-choice-policies

















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Section 4.2.2 Medicaid not covered specific criteria

Medicaid shall not cover PCS when:

13. Independent medical information does not validate the assessment, PCS hours may be reduced, denied, or terminated based on the additional information.

*13. added to existing Medicaid not covered specific criteria.

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Section 5.2.3 EPSDT Additional Requirements for PCS Medicaid may authorize services that exceed the PCS service limitations if determined to be medically necessary under EPSDT based on some or all of the following documents submitted by the provider before PCS is rendered:

a. Work and School verification, where applicable, for the beneficiary’s caregiver, legal guardian, or power of attorney…..

b. Verification from the Exceptional Children’s program per county if PCS is being requested in school setting; or

c. Health record documentation……or

d. Physician documentation of primary caregiver’s limitation that would prevent the caregiver from caring for the beneficiary, if applicable.

e. Any other independent records that address ADL abilities and need for PCS.

If additional information does not validate the assessment, PCS hours may be reduced, denied, or terminated based on additional records.

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Section 5.4.4 Requirements for PCS Expedited Assessment Process

To qualify for the expedited process the beneficiary shall:

a. be medically stable;

b. eligible for Medicaid or pending Medicaid eligibility;

c. have a Pre-Admission Screening and Resident Review (PASRR) if seeking admission to an Adult Care Home licensed under G.S. 131 D-2.4;

d. in process of being discharged from the hospital following a qualifying stay;

e. in process of being discharged from a skilled nursing facility;

f. be under adult protective services; or

g. be an individual served through the transition to community living initiative

*LME – MCO transition coordinators are responsible for requesting the expedited PCS process for individuals served through the transition to community living initiative.

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Pettigrew v. Brajer (Pashby v. Wos)

PCS will be amended to include additional program requirements agreed upon in this settlement; identified action items include:

Updates to Eligibility Criteria

Implementation of a Reconsideration Process

Reinstatement and Reassessment of Qualifying Individuals

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Updates to Eligibility Criteria: • The Settlement requires that DMA will assure the PCS eligibility

criteria is the same regardless of residential setting.

• In Adult Care Homes clean-up and basic meal preparation tasks are covered services paid for by State/County Special Assistance. Effective July 1, 2016, clean-up and basic meal preparation services that duplicate State/County Special Assistance (Section M, tasks 6-9 on the assessment) will be scored as needs met.

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Implementation of a Reconsideration Process:

Beneficiaries 21 and older who receive an initial approval for less than 80 hours per month may submit a Reconsideration Request to the IAE if they do not agree with the initial level of service determined. Section 5.6 Reconsideration Request for Initial Authorization for PCS

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Section 5.6 Reconsideration Request for Initial Authorization for PCS

When is reconsideration appropriate?

The request for increasing hours above the initial approval are not based on a Change of Status;

The beneficiary is able to provide supporting documentation that specifies, explains, and supports why

additional authorized hours of PCS is needed and which ADLs and tasks are not being met with the current hours.

*Form and instructions will be made available on the DMA website.

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The Process:

1. After receiving an initial approval for an amount of hours less than 80 hours per month, a beneficiary must wait 30 days before submitting a request for reconsideration.

2. The beneficiary must submit a request to increase hours above the initial approval no earlier than 31 calendar days and no later than 60 calendar days from the date of the approval notification.

3. The Request for Reconsideration form and supporting documentation should provide information indicating why the beneficiary believes that the prior assessment did not accurately reflect the beneficiary’s functional capacity or why the prior determination is otherwise insufficient.

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The Process:

4. Upon receipt of a completed reconsideration request for additional hours, a reassessment may be scheduled or the previous assessment modified. A reconsideration request is not considered complete without supporting documentation as indicated in 5.6(d).

5. If the reconsideration determines a need for additional PCS hours, additional hours will be authorized according to Policy. This constitutes an approval and no adverse notice or appeal rights are provided. The provider will have to complete a new service plan.

6. If the reconsideration determines that the PCS hours authorized during the initial assessment are sufficient to meet the beneficiary’s needs, an adverse decision will be issued with appeal rights.

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Reinstatement and Reassessment of Qualifying Individuals:

Those denied or terminated under Clinical Coverage Policy 3L, prior to the amendment effective 7/1/16 whom:

• Were determined to have cognitive impairment or a mental health diagnosis with no third party present during the assessment; and

• Were denied or terminated due to receipt of hospice services.

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Qualifying Individuals for Reinstatement or Reassessment will be:

• Sent a letter with instructions on how to begin the process;

• If previously terminated from PCS, reinstated at the hours prior to termination (will be reassessed within 6 months under PCS policy effective 7/1/2016);

• If previously denied PCS, reassessed under PCS policy

effective 7/1/2016.

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Reinstatement and Reassessment of Qualifying Individuals, the PCS Provider must:

• Accept the referral from the beneficiary once the reinstatement is processed; and

• Provide Medicaid with a PCS ICD-10 Transition Form before the provider can bill Medicaid for your PCS services. However, this does not need impact effective start days for services.

*Providers may see the beneficiary displayed in their portal, but services should not begin until after formal acceptance and delivery of an approval letter.

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Provider Manual – New Version Coming July 2016!

Located on the Liberty Healthcare website at: http://nc-pcs.com/pcs-provider-manual/

Will include all new policy updates in addition to a few revisions.

http://nc-pcs.com/pcs-provider-manual/








PCS Internal Audit


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PCS Internal Audit

• In spring of 2015, PCS underwent an internal audit conducted

by Office of the Internal Auditor (OIA). This audit was concluded in July of 2015.

• Two areas of concern identified by OIA were Supervisory Visits and Aide Training requirements.

• As a result of the PCS program internal audit, DMA began conducting audits of PCS providers in January 2016.

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PCS Internal Audit

• The PCS internal audit is an independent audit conducted by DMA PCS nurse consultants and is not associated with DMA Program Integrity (pre or post-payment review).

• Although, this audit process is independent from Program Integrity; audit findings that are non-compliant with the PCS policy will be reported to DMA Program Integrity.

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Forwarded to DMA Staff Faxed to DMA

within 2 Calendar Days

by Provider

Faxed to DMA within 5

Calendar Days by Provider

PM Receives random sample of Beneficiaries for identified Month

DMA verifies Provider Fax Number and

Contact Information

DMA Requests by Fax specific documents from

Provider for RN Supervisory Visits and

PCS Aide Training

DMA Completes QI Parameter Review

Tool for each Beneficiary in

sample

DMA will follow up with the Provider

for any missing documentation

Results will be documented internally by

DMA

PM Review of Provider Compliance

Providers determined not in

Compliance submitted to PI

Providers may request the

results of their audit two weeks after submission

of documentation

PCS Internal Audit Process

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PCS Internal Audit

• DMA will conduct the PCS internal audit on a quarterly basis; randomly selecting between 50-75 beneficiaries each quarter for review of Supervisory visits and/or Aide Training Requirements.

• Providers will have five (5) calendar days from the date of contact to submit documentation via fax to DMA.

• Providers are contacted via telephone call with a follow-up fax sheet that requests required documentation.

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PCS Internal Audit

• Documentation on Supervisory visits will be audited based on PCS Clinical Coverage Policy Section 7.10 b. (1-9).

• Documentation on Aide Training Requirements will be audited based on PCS Clinical Coverage Policy Section 6.1.2 (a – g). Providers must submit corresponding aide task sheet for date requested by DMA staff.

* Aide Training documentation requested for residents who reside in an Adult

Care Home will be requested for first shift aides on the date requested.

Question and Answer Session

Liberty Healthcare PCS Provider Training May 2016


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