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
Contact: [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
Contact: [email protected]
202.684.7457
Poll Questions That Focus on the Need for
Documentation Linkage and UM Support
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
2 Presented By: David Lloyd, MTM Founder
Contact: [email protected]
202.684.7457
Poll Questions That Focus on the Need for
Documentation Linkage and UM Support
3. Does your center tend to discuss over and
over again the same documentation
compliance concerns? a. Yes
b. No
3 Presented By: David Lloyd, MTM Founder
Contact: [email protected]
202.684.7457
Poll Questions That Focus on the Need for
Documentation Linkage and UM Support
4. Do you feel that center would be at risk
under the Medicaid RAC audit program? a. Yes
b. No
4 Presented By: David Lloyd, MTM Founder
Contact: [email protected]
202.684.7457
5
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
Contact: [email protected]
202.684.7457
OIG Audit Notification Letter for MHCs in Illinois in December 2005
Presented By: David Lloyd, MTM Founder 6
Contact: [email protected]
202.684.7457
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
8 Presented By: David Lloyd, MTM Founder
Contact: [email protected]
202.684.7457
NM Audit Report Summary
Presented By: David Lloyd, MTM Founder 9
Contact: [email protected]
202.684.7457
New Mexico Audit Findings Summary
Presented By: David Lloyd, MTM Founder 10
Contact: [email protected]
202.684.7457
New Mexico Audit Findings Summary
Presented By: David Lloyd, MTM Founder 11
Contact: [email protected]
202.684.7457
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).
Presented By: David Lloyd, MTM Founder 12
Contact: [email protected]
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.
Presented By: David Lloyd, MTM Founder 13
Contact: [email protected]
202.684.7457
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
14
Source: Bill Schmelter, Ph.D. MTM Team Consultant
Presented By: David Lloyd, MTM Founder
Contact: [email protected]
202.684.7457
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
15
Source: Bill Schmelter, Ph.D. MTM Team Consultant
Presented By: David Lloyd, MTM Founder
Contact: [email protected]
202.684.7457
16
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).
Presented By: David Lloyd, MTM Founder
Contact: [email protected]
202.684.7457
17
Diagnostic Assessment –
Treatment Recommendations/Assessed Needs
Presented By: David Lloyd, MTM Founder
Contact: [email protected]
202.684.7457
18
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.
Presented By: David Lloyd, MTM Founder
Contact: [email protected]
202.684.7457
19
Sample Service Plan Model
with Goal Linkage to Assessed Needs
Presented By: David Lloyd, MTM Founder
Contact: [email protected]
202.684.7457
20
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.
Presented By: David Lloyd, MTM Founder
Contact: [email protected]
202.684.7457
21
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
Presented By: David Lloyd, MTM Founder
Contact: [email protected]
202.684.7457
24
Update Indicators Sections of the DA Update Form
Presented By: David Lloyd, MTM Founder
Contact: [email protected]
202.684.7457 25 Presented By: David Lloyd, MTM Founder
Contact: [email protected]
202.684.7457 26
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.
Presented By: David Lloyd, MTM Founder
Contact: [email protected]
202.684.7457
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
Presented By: David Lloyd, MTM Founder 27
Contact: [email protected]
202.684.7457
Local UM Reviews to Support “Third Party Like” Approach
28
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
Individual/ Family/ Group
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
Individual/ Family/ Group
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
Presented By: David Lloyd, MTM Founder
Contact: [email protected]
202.684.7457
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
Presented By: David Lloyd, MTM Founder 29
Contact: [email protected]
202.684.7457
30
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.)
Presented By: David Lloyd, MTM Founder
Contact: [email protected]
202.684.7457
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?
Presented By: David Lloyd, MTM Founder 31
Contact: [email protected]
202.684.7457
UM Plan Clinical Tools Needed
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.
Presented By: David Lloyd, MTM Founder 32
Contact: [email protected]
202.684.7457
UM Plan Clinical Tools Needed
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
Presented By: David Lloyd, MTM Founder 33
Contact: [email protected]
202.684.7457
UM Plan Clinical Tools Needed
Utilization Management Procedures (Cont’d):
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?
Presented By: David Lloyd, MTM Founder 34
Contact: [email protected]
202.684.7457
UM Plan Clinical Tools Needed
Utilization Management Procedures (Cont’d):
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
Presented By: David Lloyd, MTM Founder 35
Contact: [email protected]
202.684.7457
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.
Presented By: David Lloyd, MTM Founder 36
Contact: [email protected]
202.684.7457
UM Plan Clinical Tools Needed
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.
Presented By: David Lloyd, MTM Founder 37
Contact: [email protected]
202.684.7457
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.
38 Presented By: David Lloyd, MTM Founder
Contact: [email protected]
202.684.7457
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.
Presented By: David Lloyd, MTM Founder 39
Contact: [email protected]
202.684.7457
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.
Presented By: David Lloyd, MTM Founder 40
Contact: [email protected]
202.684.7457 41
Contact: [email protected]
202.684.7457 Presented By: David Lloyd, MTM Founder 43
Questions and Feedback
• Questions?
• Feedback?
• Next Steps?