Medicaid Focused Training for Audited Community Support by liaoqinmei


									       Medicaid 101:
Basic Training for Medicaid
   MH/DD/SA Providers
       December 2007

• Introductions
• Medicaid is a federal and state entitlement
    program that pays for medical assistance for
    certain individuals and families with low incomes
    and resources.
•   Federal - Centers for Medicare and Medicaid
    Services (CMS)
•   State – Division of Medical Assistance (DMA)

Department of Health and Human Services (DHHS)
• Division of Medical Assistance
  – Fees and rates
  – Policy
  – Maintain files (insurance, provider, eligibility)
• Division of MH/DD/SA
  – Provision of services through LME endorsed providers
  – State funded services


• Mission Statement
  – The Mission of the Department of Health and
    Human Services is to provide efficient services
    that enhance the quality of life of North
    Carolina individuals and families so that they
    have opportunities for healthier and safer
    lives resulting ultimately in the achievement
    of economic and personal independence.

          Goals of this Training
• To better understand Basic Medicaid policy and
  the role of the Qualified Professional in the
  delivery of services as they apply to:
  –   Provider Endorsement
  –   Provider Enrollment
  –   The Role of the LME
  –   Medicaid Services
  –   Proactive Interventions
  –   Authorizations and Utilization Review

Goals of this Training (cont.)
– Basic Medicaid Documentation Requirements
– Billing and Payment
– Quality Management/Self Monitoring
– Appeals
– Pitfalls to Avoid
– Fraud and Abuse in Medicaid

Provider Endorsement

Provider Endorsement
• Endorsement is a verification and quality
    assurance process using statewide criteria and
•   The endorsement process provides the LME with
    the objective criteria to determine the
    competency and quality of Medicaid providers.
•   Endorsement purpose is to assure that
    individuals receive Medicaid services and
    supports from providers that comply with state
    and federal laws and regulations.

Provider Endorsement
• Endorsement is an LME function
• Required for the provision of enhanced
  and residential services
• Each service requires a separate
• For more information or to initiate the
  endorsement process contact your local

Provider Enrollment

Provider Enrollment

Enrolling as a Medicaid Provider
• All providers must enroll directly with DMA
• Enrollment application packages are
  available on DMA’s website
• Enrollment takes about six to eight weeks
• Notified by mail when enrollment is

Provider Enrollment
• Licensed providers must be enrolled with
    Medicaid in order to be a North Carolina
    Medicaid provider.
•   Enrollment is open to all providers who meet the
    qualifications and receive endorsement from the
•   Providers should contact DMA Provider
    Enrollment at 919-855-4050 for further

Provider Enrollment

Reporting changes In Status
• An enrolled provider must use the
  Medicaid Provider Change Form
• Examples of some changes:
• Address change
• Phone number change
• Tax ID number change
Provider Enrollment
Provider Enrollment Agreement
• When an application for enrollment was submitted, the provider
    agreed to follow Medicaid rules. It is a 22 page application in order
    to get as much information as possible, to meet the requirements of
    CMS and State and to provide the applicant the expectations of
    participation with NC DMA.
• All questions on the applications must have been answered
• Signature-
“I certify that the above information is true and correct. I further
    understand that any false or misleading information may be cause
    for denial or termination of participation as a Medicaid Provider.”
- 1A: “Comply with federal , state laws, regulations, state
    reimbursement plan and policies governing the services…”

Provider Enrollment

• B 10: DMA may terminate this
- The provider is determined to have
  violated Medicaid rules or regulations
- The provider fails to provide medically
  appropriate health care services, etc.

Provider Enrollment

• C 1-14 further outlines the provider
  responsibilities to follow rules and
• Electronic Claims Submission Agreement
- Another signature attesting to
  understanding of the rules and
  requirements of Medicaid.

The Role of the LME

            The Role of the LME
• Functions include:
  –   Endorsement
  –   Record review
  –   Ongoing monitoring
  –   Client specific reviews and care coordination
  –   DMA expects that providers will accept LMEs in their
      offices/facilities just as if DMA contacted the provider
• LMEs may receive Medicaid payment for “acting”
  as agents of DMA

Service Definitions

 Medicaid Services – Basic Benefit

• Basic Benefits
  – Available to all Medicaid recipients
  – Outpatient benefits
    Adults – age 21 and over - (8 unmanaged
    Children – under age 21 - (26 unmanaged
  – Inpatient hospitalization

Outpatient Behavioral Health
• Assessment, treatment (individual medical
  evaluation and management, including
  medication management, individual and group
  therapy, behavioral health counseling), family
  therapy and psychological testing
  – 26 unmanaged visits for recipients under age 21
  – 8 unmanaged visits for recipients aged 21 and over
  – Services delivered by physicians, licensed clinicians,
    nurse practitioners, clinical nurse specialists, certified
    clinical supervisors, licensed clinical addictions

Inpatient Behavioral Health
  – Hospital setting 24 hours a day
  – Nursing and medical care provided under the
    supervision of a psychiatrist or a physician
  – Continuous treatment for recipients with acute
    psychiatric or substance abuse problems
• Inpatient Hospital Substance Abuse Treatment
  – Licensed 24 hour inpatient setting, licensed
    community hospital or licensed facility
• Inpatient Hospital Psychiatric Treatment
  – Licensed 24 hour inpatient setting or State operated

Medicaid Services – Enhanced Benefit

  – MH/SA Services for Adults
     • Community Support – Adults (MH/SA)
     • Mobile Crisis Management (MH/DD/SA)
     • Diagnostic/Assessment (MH/DD/SA)
     • Community Support Team (CST) (MH/SA)
     • Assertive Community Treatment Team (ACTT)
     • Psychosocial Rehabilitation
     • Partial Hospitalization
     • Professional Treatment Services in Facility-Based
       Crisis Program

Medicaid Services – Enhanced Benefit

  – Substance Abuse Specific Treatment Services
     • Substance Abuse Intensive Outpatient Program
     • Substance Abuse Comprehensive Outpatient
       Treatment Program
     • Substance Abuse Non-Medical Community
       Residential Treatment
     • Substance Abuse Medically Monitored Community
       Residential Treatment

Medicaid Services – Enhanced Benefit

  – Substance Abuse Specific Detox Services
     • Ambulatory Detoxification
     • Non-Hospital Medical Detoxification
     • Medically Supervised or ADATC
      Detoxification/Crisis Stabilization
    • Outpatient Opioid Treatment

Medicaid Services – Enhanced Benefit
  – Services for Children (up to age 21)
     • Diagnostic/Assessment (MH/DD/SA)
     • Community Support – Children/Adolescents
     • Mobile Crisis Management (MH/DD/SA)
     • Intensive In-Home Services
     • Multisystemic Therapy (MST)
     • Child and Adolescent Day Treatment (MH/SA)
     • Partial Hospital
     • SAIOP

Medicaid Services – Enhanced Benefit

  – Developmental Disability Services
     • Diagnostic/Assessment (MH/DD/SA)
     • Mobile Crisis Management (MH/DD/SA)
     • Targeted Case Management
     • Community Action Program (CAP)

Enhanced MH/SA Services

Enhanced MH/SA Services - Adults

• Community Support – Adult (MH/SA)
  – Services support independent community
    functioning/development of critical living and coping
    skills for recipients 21 and older
  – Direct and indirect periodic service provided in any
    location by QP, AP and Paraprofessional staff
  – Authorization up to 780 units for a 90-day period,
    based on the medical necessity – not intended to
    remain at this level of intensity long term
  – Clinical Home

Enhanced MH/SA Services – Adults
and Children
• Mobile Crisis Management (MH/DD/SA)
  – Crisis response, stabilization and prevention to divert
    individuals from inpatient psychiatric and
    detoxification services
  – Direct and periodic service provided 24/7/365 outside
    the agency’s facility by a Team of practitioners (QP;
    CCAS, CCS or CSAC; Psychiatrist access; QP or AP
    with DD experience; Paraprofessionals with
    competency in crisis management)

Enhanced MH/SA Services – Adults
and Children
• Diagnostic/Assessment (MH/DD/SA)
  – Evaluation of MH/DD/SA condition that results
    in issuance of D/A report with a
    recommendation for services
  – Direct periodic service provided in any
    location by a Team of clinicians (2 QPs; one
    MD, DO, NP, PA or Licensed psychologist)

Enhanced MH/SA Services - Adults

• Community Support Team (CST) (MH/SA)
  – Intensive service for recipients to assist with rehabilitative and
    recovery goals. May exhibit high use of psychiatric hospital or
    crisis, risk factors, medication refractory, co-diagnosis of SA,
    legal, homeless, suicidal, inappropriate public behavior, self
    harm, cognitive/behavioral/ medical conditions, lower level of
    care inappropriate
  – Direct and indirect periodic service provided in any location by a
    Team of practitioners (3 person team including 1.5 QP; and
    other QP/AP/Paraprofessional/Certified Peer Support Specialist)
  – Clinical Home

Enhanced MH/SA Services - Adults

• Assertive Community Treatment Team (ACTT)
  – Service for SPMI, co-occurring disorders, dual and triple
    diagnosed to promote symptom stability, appropriate use of
    medication, restore personal community living and social skills,
    promote and maintain physical health, access entitlements,
    housing, work and social opportunities, promote highest possible
    level of functioning in the community
  – Direct and indirect periodic service provided in any location by
    an Interdisciplinary Team trained in ACTT (QPs, psychiatrist,
    RNs, AP, CCS/CCAS/CSAC, Certified Peer Support Specialist)
  – Clinical Home

Enhanced MH/SA Services - Adults

• Psychosocial Rehabilitation
  – Skill and resource development for adults with
    psychiatric disabilities (SPMI) to increase functioning
    and ability to live as independently as possible with
    minimal professional intervention. Supports
    functional, social, educational and vocational goals
  – Day/night facility service provided five hours or
    more/day, five days/week, day or night by QP, AP
    and Paraprofessional staff

Enhanced MH/SA Services – Adults
and Children
• Partial Hospitalization
   – Short term service to prevent hospitalization or to
     step down from inpatient facility: therapy,
     recreational therapy, community living skills, coping
     skills, medical services
   – Physician involvement in diagnosis, treatment
     planning, and admission/discharge
   – Day/night facility service provided four hours/day, five
     days/wk, (may or may not be hospital based) by a
     Team: social workers, psychologists, therapists, case
     managers, or other MH/SA paraprofessional staff, MD

Enhanced MH/SA Services - Adults

• Professional Treatment Services in Facility-
 Based Crisis Program
  – Alternative to hospitalization, MH/SA,
    intensified short-term, medically supervised
    24 hour residential facility with 16 beds or less
    to alleviate acute or crisis situations
  – Assess, monitor, stabilize acute symptoms
  – Under direction of a physician

Enhanced MH/SA Services -
Substance Abuse – Adults and
• Substance Abuse Intensive Outpatient Program
  – Structured individual and group addiction activities to
    assist recipients to begin recovery and learn skills for
    recovery maintenance
  – Licensed facility service provided three hours/day,
    three days/week by CCS, CCAS, CSAC, QPs/APs for
    SA, and Paraprofessional staff
  – Clinical Home

Enhanced MH/SA Services -
Substance Abuse - Adults
• Substance Abuse Comprehensive Outpatient
 Treatment Program (SACOT)
  – Time limited, multi-faceted approach treatment to
    achieve and sustain recovery
  – Day and evening periodic licensed facility service
    provided a minimum of four hours/day, five
    days/week by CCS/CCAS/CSAC, QP/AP for SA, and
    Paraprofessional staff and access to psychiatrist when
  – Clinical Home

Enhanced MH/SA Services -
Substance Abuse Adults
• Substance Abuse Non-Medical Community
 Residential Treatment
  – 24 hour residential recovery program for adults who
    provide/have potential to provide primary care for
    their minor children without 24 hour medical/nursing
    monitoring (may provide services to individuals with
    their children in residence and/or to pregnant
  – Short term service (thirty days per twelve month
    period) provided by CCS/CCAS/CSAC, QP/AP for SA,
    and paraprofessional staff

Enhanced MH/SA Services -
Substance Abuse - Adults
• Substance Abuse Medically Monitored
 Community Residential Treatment
  – Non Hospital 24 hour rehabilitation facility
    with 24 hour medical/nursing monitoring
  – Short term service (thirty days per twelve
    month period) provided by physicians, RN,
    CCS/CCAS/CSAC, QP/AP in SA, and
    paraprofessional staff

Enhanced MH/SA Services –
Detoxification Services – Adults and
• Ambulatory Detoxification
  – Outpatient medically supervised evaluation,
    detoxification and referral services to achieve safe/
    comfortable withdrawal and transition to ongoing
  – Ten day maximum licensed facility service provided
    by physicians, RN, and appropriately licensed and
    credentialed staff and counselors, QP/AP for SA under
    supervision of CCAS or CCS

Enhanced MH/SA Services –
Detoxification Services - Adults
• Non-Hospital Medical Detoxification
  – Medical and nursing professionals in 24 hour
    medically supervised evaluation and withdrawal
    management in a facility affiliated with a hospital or
    in a freestanding facility of 16 beds or less
  – Short term licensed facility service (not more than
    thirty days in a short-term period) provided by
    physicians, RN, appropriately licensed and
    credentialed staff, CCS/CCAS/CSAC, QP/AP in SA and
    paraprofessional staff

Enhanced MH/SA Services –
Detoxification Services - Adults
• Medically Supervised or ADATC Detoxification/
  Crisis Stabilization
  – 24 hour medically supervised evaluation and
    withdrawal management in a permanent facility with
    inpatient beds (fewer than 16)
  – Short term service (not more than 30 days in a twelve
    month period) provided by physicians, psychiatrists,
    RN, appropriately licensed and credentialed staff,
    CCS/CCAS/CSAC, QP/AP for SA and paraprofessional

Enhanced MH/SA Services -
Substance Abuse - Adults
• Outpatient Opioid Treatment
  – Methadone treatment, rehabilitation and
    medical services for patients with opiate
    addiction disorders
  – Periodic service provided in a licensed Opioid
    Treatment Program by RN, LPN, pharmacist,
    or physician under 10A NCAC 27G .3600.

Enhanced MH/SA Services -
• Community Support –
 Children/Adolescents (MH/SA)
  – Psychoeducational/supportive services for
    children age 3-20 and their caregivers to
    assist with rehabilitative and recovery goals
  – Direct and indirect periodic service provided in
    any location by QP, AP and paraprofessional
  – Clinical Home

Enhanced MH/SA Services -
• Intensive In-Home Services
  – Time limited family preservation intervention to
    stabilize living arrangement, promote reunification or
    prevent use of out-of-home therapeutic resources for
    youth through age 20
  – Direct and indirect periodic service delivered primarily
    in the family’s home (any location) by a Team:
    licensed professional and minimum of 2 staff who are
    APs or provisionally licensed (CCS/CCAS/CSAC needed
    if focus is SA), team leader
  – Clinical Home

Enhanced MH/SA Services -
• Multisystemic Therapy (MST)
  – Behavioral therapy model for treating youth and their
    families, designed for 7-17 year olds who have
    antisocial, aggressive/violent, delinquent behaviors,
    are at risk for (or returning home from) out of home
    placement, or have SED or substance abuse
  – Direct and indirect periodic service provided primarily
    in the home (any location) by a Team of
    practitioners: 1 master’s level QP and 3 QPs
  – Clinical Home

Enhanced MH/SA Services -
• Child and Adolescent Day Treatment
  – Structured treatment service program for children 20
    or younger: MH/SA interventions in the context of a
    treatment milieu to enhance capacity to function in
    inclusive setting or to be maintained in community
    based services; reintegrate into school or transition
    into employment
  – Facility based day/night service provided minimum
    three hours/day, minimum two days/week by QPs,
    APs and Paraprofessionals (CCS/CCAS/CSAC if SA)

Residential Treatment Services
• Treatment in a structured, therapeutic,
 supervised environment for under age 21
  – Level I: low to moderately structured family
  – Level II: moderate to highly structured family
    or program setting
  – Level III: highly structured program setting
  – Level IV: physically secure, locked program

Psychiatric Residential Treatment
Facilities (PRTF) - for children under the
                    age of 21

 – Non Acute inpatient facility care for recipients
   under 21 years of age
 – 24 hour supervision and specialized
 – Program operates under the direction of a
   board-eligible or certified child psychiatrist or
   general psychiatrist with experience in the
   treatment of children
 – May be hospital based
Medicaid Services – Developmental
  – Developmental Disability Services
     • Targeted Case Management
  – DD services habilitative versus rehabilitative
  – Services covered under the CAP MR/DD

 Clinical Home
• Nine services that can be accessed directly by Screening
  Triage and Referral (STR)
   –   Intensive In-Home (IIH)
   –   Multisystemic Therapy (MST)
   –   Assertive Community Treatment Team (ACTT)
   –   Community Support Team (CST)
   –   Substance Abuse Intensive Outpatient Program (SAIOP)
   –   Substance Abuse Comprehensive Outpatient Treatment (SACOT)
   –   Targeted Case Management (TCM)
   –   Community Support Child/Adolescent (CS-Child/Adolescent)
   –   Community Support Adult (CS-Adult)

Clinical Home
• Clinical Home
  – The clinical home is considered the service
    best able to provide continuity of care for a
    recipient in the system. The Qualified
    Professional at the Clinical Home provides the
     • Development and updating of the Person-Centered
       Plan and Crisis Plan
     • Obtaining Authorizations (ITR/ORF2/CTCM)
     • Completing the Consumer Admission Form (State
     • Completing the NC-TOPPS & NC-SNAP
     • Serving as a First Responder (24/7)
Proactive Interventions
• “Proactive Interventions” is an aggressive and organized
  effort to fulfill each person’s fullest capacity. It requires
  an integrated, individually tailored program of services
  directed to achieving measurable, behaviorally-stated
• Integrated program of therapies
   – Behavioral programming: positive reinforcement for appropriate
   – Psycho-educational programming: curriculum, games,
     experiential education, therapeutic recreation
   – Generalization of skills: natural and designed

Access to Enhanced Medicaid

Comprehensive Clinical Assessment
• Alternative to the Diagnostic Assessment as a
    means to gather the clinical and diagnostic
    information necessary to develop the PCP.
•   Purpose is to give the Qualified Professional
    completing the PCP the assessment information
    necessary to complete the PCP.

Comprehensive Clinical Assessment
• Required elements:
   – chronological general health and behavioral health history;
   – biological, psychological, familial, social, developmental and
     environmental dimensions and identified strengths and
     weaknesses in each area;
   – description of the presenting problems, precipitating events,
     symptoms, and current medications;
   – strengths/problem summary;
   – evidence of recipient or family participation;
   – analysis and interpretation of the assessment information with
     an appropriate case formulation;
   – diagnoses on all five (5) axes of DSM-IV; and
   – recommendations for additional assessments, services, support,
     or treatment based on the Comprehensive Clinical Assessment.
Comprehensive Clinical Assessment
• Services for Children
    – Involve the Child and Family Team as appropriate
    – assess the strengths of the child/youth and their family
    – utilize information such as reports from psychological testing
      and/or Individualized Education Plans

•   Mental Health
    –   identify the clinical services appropriate to treat the diagnosed
    – incorporate principles of education, wellness and recovery in
      partnership with the consumer
    – work directly with the clinical home provider

Comprehensive Clinical Assessment
• Developmental Disabilities Services
  – persons with a developmental disability have multiple disabilities
    necessitating a comprehensive approach often requiring a
    variety of clinical assessments (e.g., intellectual assessment,
    psychiatric assessment, physical evaluation,
    educational/vocational assessment, PT/OT evaluation).
  – identify the person’s current functioning status and needed
    supports for the PCP
• Substance Abuse Services
  – The information gathered in the comprehensive clinical assessment
    should be utilized to determine the appropriate level of care using the
    ASAM Patient Placement -2 as a clinical guide. The ASAM level of care
    recommendation should be included in the disposition of the
    comprehensive clinical assessment.


• Provides for medical and dental screenings and medically
    necessary health care to correct or ameliorate a defect,
    physical or mental illness, or a condition identified
    through a screening.
•   Services have to be medically necessary.
•   Any proper request for services for a recipient under 21
    years of age is considered a request for EPSDT services.
•   Does NOT eliminate the need for prior approval if prior
    approval is required.
•   For more information review the training material found

Authorizations and Utilization

     Authorizations and Utilization
• Prior Authorization is required for all services.
   – Exceptions (one time pass though)
      • 8 hours of Targeted Case Management
      • 4 hours of Community Support – Adult to complete the
        Introductory PCP
      • 8 hours of Community Support – Child to complete the
        Introductory PCP
      • Unmanaged basic benefit visits
• Refer to the specific service definition for
  utilization management and authorization

       Authorizations and Utilization
• Value Options is the DMA contracted agency to
    provide authorization and utilization review. For
    more information:
     – Call Value Options at 888-510-1150
     – Refer to the Value Options website at
•   Piedmont Piedmont Cardinal Health Plan
     – If a recipient's eligibility is in Cabarrus, Rowan,
       Stanley, Union or Davidson counties, please call
       Piedmont Behavioral Health at :
•   State Funded Services are authorized through the
    LME                                                  66
Basic Medicaid Documentation

   Basic Medicaid Documentation
• For any Medicaid service, not just
 MH/DD/SA, there must be:
 – Assessments and clinical
   recommendations justifying the course
   of treatment, or service being rendered
 – Treatment Plan/PCP
 – Service Order
 – Progress notes or other documentation
   that proves delivery of service

   Basic Medicaid Documentation
• Enter information that is:
  – Accurate
  – Timely
  – Objective
  – Specific, Concise, Descriptive
  – Consistent
  – Substantive and pertinent
  – Clear

   Basic Medicaid Documentation
All service notes must contain the following
• Individual’s name, record number and Medicaid
   ID number must be on every service note page
• Full date of service (month, day, year)
• Name of the service that was provided
• Purpose of contact (tied to PCP goals)
• Description of the

    Basic Medicaid Documentation
Service Note elements (cont.)
• Total amount of time spent performing the service
  (required for all periodic services and many others)
• Effectiveness of the interventions
• Proper signature of person who provided the service
   – For professionals signature must include credentials,
      degree, or licensure
   – For paraprofessionals, signature must include the
      person’s title (position)

    Documentation Resources

• For more details about documentation refer to:
  – Medicaid Clinical Policy and Service Definitions
    found at:
  – Service Records Manual found at:
  – Person-Centered Plan Instruction Manual found at:

Billing and Payment

             Billing and Payment
Billing to and Payment From
• Electronic Data Systems (EDS) is the fiscal agent
  contracted by DMA to:
   – Process claims for enrolled Medicaid providers according to
     DMA’s policies and guidelines
   – Establish and maintain a presence with the Medicaid provider
     community through:
      • Provider seminars
      • On-site visits to providers for assistance with billing issues
      • For detailed instructions on billing refer to the Basic Medicaid Billing
        7.pdf and the EDS website

Quality Management/Assurance

Quality Management/Assurance

        What is Quality …
     Management, Assurance,
       Improvement, etc. ?

Quality Management/Assurance

    What is the goal of Quality …
      Management, Assurance,
        Improvement, etc. ?

Quality Management/Assurance

     What is the role of the Qualified
  Professional in Quality … Management,
     Assurance, Improvement, etc. ?

Quality Management/Assurance
• Are you doing things right?
  – Efficiency
  – Productive
• Are you doing the right thing?
  – Effectiveness
  – Best/Evidenced Based Practices
• Are you looking at yourself?
  – Self-Monitoring

Quality Management/Assurance

Are you doing things right?
• Record keeping
  – Complete
  – Accurate
  – requires intensive QM to prevent paybacks.

Quality Management/Assurance

Are you doing things right?
• Billing
  – Complete
  – Accurate
  – Timely

Quality Management/Assurance
Are you doing things right?
• Practice Management
  – Efficient
  – Cost effective
• Staff
  – Licensing
  – Certification
  – Privileging

Quality Management/Assurance

Are you doing things right?
• Service Delivery
  – Accessible
  – Culturally competent
  – Efficient

Quality Management/Assurance

Are you doing the right thing?
• Most appropriate service
• At the right time
• With the right person

Quality Management/Assurance
Are you doing the right thing?
• Medical Necessity:
  – A clinical decision as to if a service will benefit the
  – The responsibility of the Qualified Professional
• Supervision
  – Staff should be under the supervision of a licensed
    professional according to clinical need and
     • Service Definitions
     • Certification and/or Licensure
  – Policy on supervision required

Quality Management/Assurance

Are you doing the right thing?
• referring to other agencies or to other
  services when indicated
• offering choice of providers vs. self-
• balance between clinical, regulatory, and
  QA functions

Quality Management/Assurance

Are you looking at yourself?
• Utilization:
  – monitor utilization patterns
  – establish clinical review process for “high
    need” recipients.
• Risk Management

Quality Management/Assurance
Are you looking at yourself?
• Incident monitoring
  – Critical Incident Reports
     • Licensed facilities are required to report critical incidents to
        the LME and DMH/DD/SAS
      • Deaths must also be reported to the Division of Facility
      • Incident in depth report form located at: http://facility-

Quality Management/Assurance
Are you looking at yourself?
• Quality improvement committee
  – Quality improvement plan
  – Quality improvement studies
• Outcomes
  – What is the effect of your treatment?
• Endorsement
  – Quality of provider organization and of the services
    major part of LME endorsement

Quality Management/Assurance

       Pitfalls to Avoid

 Quality Management/Assurance
Pitfalls to Avoid
• Prior Authorization does not guarantee payment for all
  units/hours authorized
   – Billing may not occur if documentation is not complete or timely
   – Billing may not occur if the person is not present for the delivery
     regardless of making a trip to the person’s home or other
   – Billing may not occur if the recipient and provider are not
     actively engaged in the implementation of the strategies and/or
     curricula used to address the goals of the plan.
   – Authorizations do not transfer from provider to provider. New
     authorizations are required.
• PCP/Treatment Plan
   – PCP/Plan should not be signed prior to the plan meeting date
   – PCP/Plans are valid when the consumer/legally responsible
     person and the person who developed the plan sign and date it
 Quality Management/Assurance
Pitfalls to Avoid (cont)
• No Canned Documentation
   – Progress Notes that look the same for other recipients or day
     after day the same words
   – PCPs/Treatment Plans that look the same for other recipients
Progress Notes should not be preprinted or predated
• The progress note should match the goals on the plan
  and the plan should match the needs of the recipient.
  There should be clear continuity between the
• Progress Notes must provide enough detail and
  explanation to justify the amount of billing.
 Quality Management/Assurance
Pitfalls to Avoid (cont)
• Claims Processing
  – Errors in claims processing delay your claim
     • can usually be corrected since these are commonly data
       entry errors
  – Primary fraudulent issue is the lack of payback of
    funds when errors in documentation or service
    delivery have been found.
      • Recipient no longer Medicaid eligible
      • Location of service negates billing for Medicaid
  – Requires close communication between everyone
    involved in the care and billing
 Quality Management/Assurance
Pitfalls to Avoid (cont)
• No “stamped” signatures
• White Out is not acceptable on any
• Making service receipt conditional of
  getting all services from provider

Quality Management/Assurance

Pitfalls to Avoid (cont)
• Recipients from an agency all have the
  same hours/units requested
• Business Plan should account for not
  being able to bill 100% of everything done
  – Some non-billable activities are factored into
    the rate

Quality Management/Assurance


Quality Management/Assurance
  SERVICES 10A NCAC 27G.0201 states:
• The governing body shall develop and implement written
  policies for the following:
   –   review of medical records
   –   risk management
   –   quality assurance and quality improvement committee
   –   written quality assurance and quality improvement plan;
   –   methods for monitoring and evaluating the quality and
       appropriateness of client care, including delineation of client
       outcomes and utilization of services

Quality Management/Assurance
 Governing Body Policies (Cont.)

 – professional or clinical supervision
 – strategies for improving client care;
 – review of staff qualifications and a
   determination made to grant
   treatment/habilitation privileges;
 – review of all fatalities in residential programs.


• Every Medicaid recipient has appeal rights that
  can apply to situations in which a recipient is:
  – denied a requested service; or
  – informed that a current service will be reduced,
    suspended, or terminated.
• If services are being denied, reduced,
  suspended or terminated, the recipient will
  receive an letter detailing their appeal rights


• Two hearing options:
  – informal hearing by the DHHS Hearing
  – formal or evidentiary hearing by the Office
    of Administrative Hearings (OAH) in

Fraud and Abuse

Fraud and Abuse
• False Claims Act (FCA)- handout
-Knowingly presents or causes to be presented to…a false
  or fraudulent claim for payment or approval;
-Knowingly makes, uses or causes to be made or used a
  false record or statement to get a false claim…
-Conspires to defraud the Government by getting a false or
  fraudulent claim paid or approved…
-Knowingly makes, uses or causes to be made or used a
  false record or statement to…an obligation to pay or
  transmit money..
• False Claims Act (FCA) –
Fraud and Abuse (cont.)

• Knowing (and knowingly) mean that a
 person, with respect to information (1)
 has actual knowledge of the information,
 (2) acts in deliberate ignorance of the
 truth or falsity of the information; or (3)
 acts in reckless disregard of the truth or
 falsity of the information, and no proof of
 specific intent to defraud is required.

Fraud and Abuse (cont.)

• 31 USC 3729. While the FCA imposes
 liability only when the claimant acts
 “knowingly,” it does not require that the
 person submitting the claim have actual
 knowledge that the claim is false.

Abuse and Fraud (cont.)

• It is incumbent upon all providers to
  become familiar with potential areas of
  fraud and abuse.
• Fraud may be often interpreted to mean
  intentional deception in this regard, it can
  also entail unintentional patterns of errors.
  Work must be completed with utmost
  accuracy and soundness of judgement.
Fraud and Abuse (cont.)
• Degrees of DMA intervention
-Warning letter
-Suspension of enrollment
-Withhold of payment
• DMA has the authority and obligation to:
-revoke a provider’s participation
-recoup payment and
-report any potential fraud to the Attorney General’s Office

              Fraud and Abuse
• Investigation of Fraud and Abuse
  –   May be planned or unannounced
  –   Three agencies that typically review
      1. DMH/DD/SA may monitor compliance with regulations and
          determine financial payback for deficiencies. Results are
          forwarded to DMA.
          –   This may begin with the LME’s involvement and review
      2. DMA is the official Medicaid agency in NC, on behalf of
          CMS. DMA may initiate its own investigation or CMS may
          initiate an investigation. The investigation determines
          compliance with all regulations in implementing the State’s
          agreement with CMS. DMA has the authority to revoke a
          provider’s participation, recoup payment and report any
          potential fraud to the Attorney General’s Office

          Fraud and Abuse
    3. The State’s AG’s office and the US Attorney’s Office have
        the authority to investigate and prosecute potential
        Medicaid fraud as contained in the Federal False Claim Act,
        Federal Civil Monetary Penalty Law and Medical Assistance
        Provider False Claims Act (State criminal and civil law).
–   These three typically represents a hierarchy
    depending on the nature and source of the
    complaint. Agencies collaborate and communicate
–   The finding of fraud does not require an intent of
    wrongdoing, however, it is more than a simple
–   The lack of knowledge is not a defense for fraud.


• Review DMA Web Site
  – Provider Information:
     • Monthly Medicaid Bulletins, Clinical policy, billing guide,
       check schedules, Fee Schedules, Administrative rules, etc.
     • Service Definitions, Implementation Memos
• Division of MH/DD/SA Web site
  – Joint DMA/DMH Implementation Memos
  – Rules
  – Service Records Manual

• Medicaid State Plan at:
•   DMA Clinical Coverage Policy 8-A, “Enhanced
    Mental Health and Substance Abuse Services”,
    can be found at the following link:
•   Basic Medicaid Billing Training (all providers
    should attend) Information can be located at
• Provider Relations: 888-510-1150
EDS Website at:
• EDS Provider Services: 1-800-688-6696
  or 919-851-8888
  – Provider Training at:

           Medicaid Contacts
• Clinical Policy (919-855-4260)
• Behavioral Health Care Section (919-855-
     • Marcia Copeland, Chief
     • Marie Britt RN, BC, MS - 910-674-4226
     • Bert Bennett, Ph.D. - 336-724-4539
• Recipient Services - (919-855-4000)
• Program Integrity – (919-647-8000)
• Provider Services – (919-855-4050)
Division of MH/DD/SA
• Community Policy Management (919-715-1294)
    – Christina Carter, Implementation Manager
    – Dick Oliver, LME Team Leader
    – Bonnie Morell, Best Practice and Community
      Innovations Team
• Resource and Regulatory Mgmt. (919-881-2446)
     – Jim Jarrard, Accountability Team Leader
•   Advocacy and Customer Service (919-715-3197)
     – Chris Phillips, Chief



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