Focused Training for Audited
Community Support Providers
April 4, 2007 - Raleigh
April 11, 2007-Greensboro
• Providers will increase understanding of:
– Accountability with Medicaid
– Medicaid Acceptable and Unacceptable
• Findings from CS Audits
– Fraud and Abuse in Medicaid
– Basic Medicaid Documentation requirements
– Basic Medical Records requirements for billing
– The Role of the LME in monitoring documentation on
behalf of Medicaid
Provider Enrollment Agreement
• When the application 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 the State
and to provide the applicant the expectations of
participation with NC DMA.
– All questions of the applications must have been answered
• “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.”
– 1 A: “Comply with federal, state laws, regulations, state
reimbursement plan and policies governing the services…”
Provider Enrollment (cont.)
• B 10: DMA may terminate this agreement…
– The provider fails to meet the conditions of
– The provider is determined to have violated Medicaid
rules or regulations
– The provide fails to provide medically appropriate
health care services, etc.
• C 1-14 further outlines the provider responsibilities to
follow rules and regulations
• Electronic Claims Submission Agreement
– Another signature attesting to understanding of the rules and
requirements of Medicaid.
• Review DMA Web Site (web site address is
changing effective June 30, 2007)
– 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
– Service Records Manual
• Consider attending Basic Medicaid Billing
– April 17, 18, 30th still have openings
– Information can be located at
• EDS Web site
• Provider Training
Medicaid Acceptable and
• For any Medicaid service, not just mh/dd/sa,
there must be:
– Treatment plan/PCP
– Assessments and clinical recommendations justifying
the course of treatment or service being rendered.
– Appropriate prior authorization
– Medical order or service order (now are annual)
– Progress notes or other “documentation” that proves
delivery of service
• 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
• Progress Notes should not be preprinted or
• 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 documentation
• Progress Notes must provide enough detail and
explanation to justify the amount of billing.
• 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
• No consumer should have only a DD diagnosis
for CS services (Dual diagnosis is ok) – except if
authorization has been granted under auspices
of EPSDT – the authorization letter will state
• No “stamped” signatures
• Service delivery will not be 100% Medicaid
• 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 location.
– 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.
• Some activities are considered
“nonbillable” but % of nonbillable time
have been factored into rates.
• White Out is not acceptable on any
Miscellaneous Audit Findings
• In addition to the acceptable/unacceptable
already listed, unacceptable or “red flag”
provider practices also include:
– recipients from an agency all have the same
– Refusal to refer to other agencies or to other services
– Self referring to “other” owned services/agencies
instead of offering choice of providers
– Making service receipt conditional of getting all
services from provider
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..
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.
• 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 judgment.
Pitfalls to avoid
• Service Delivery
– Central is medical necessity. It is an individualized
clinical decision and should not be confused with the
needed amount of funding to support a service.
Shifts the needs from the recipient of the service and
compromises clinical decisions.
– Closely monitor utilization patterns and incorporate in
QA/peer review process. Establish clinical review
process for “high need” recipients.
– Area of greatest number of errors and requires
intensive QA to prevent paybacks.
Pitfalls to Avoid (cont.)
• Claims Processing
– Errors in claims processing can usually be corrected
since these are commonly data entry errors or MIS
– 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
• Quantitative or qualitative reviews indicate deficiencies that
can’t be corrected
– Requires close communication between external and
Fraud and Abuse (Cont.)
• Investigation of Fraud and Abuse
– May be planned or unannounced
– Three agencies that typically review
• 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
• 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 (cont.)
• The State’s AG’s office and the US Attorney’s Office has 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).
– Typically represents a hierarchy depending on the
nature and source of the complaint. Agencies
collaborate and communicate findings.
– 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
Self Monitoring and Quality
• Every provider agency should have a quality assurance
• Included in the QA process should be review of medical
records along with many other components. This training
is only addressing minimum documentation
requirements and should not be considered “inclusive” of
all requirements or a comprehensive QA program.
• QA should also be based upon a risk management
• Voluntary payback or mandatory recoupment
• Record checklist
• The Audit check sheet
• Service Records Manual
What is Community Support
• Get training on CS – this is not intended to be a
training on the clinical aspects of the service.
• CS is a rehabilitation services that focuses on
supports necessary to assist the person in
achieving and maintaining rehabilitative,
sobriety, and recovery goals.
– Skill building necessary to meet mh/sa treatment
financial, social and other support needs
– Coordination across all levels of care, with the family,
providers, facilities, paid and non-paid.
– Serves as first responder crisis response 24/7
• That is not call 911 or go to the ER
Community Support (cont.)
• Community Support is not, for example,
– Personal care
– Monitoring the recipient in case the person may have
– Working with the recipient on homework so he’ll pass
– Driving the person around in the car
• CS goals and objectives should produce change
for the better or maybe it is not the correct level
of care or the proper interventions/strategies to
achieve the person’s desired outcomes.
• CS is NOT case management and the old
• LMEs receive Medicaid payment for “acting” as
agents of DMA.
• Functions include:
– Record review
– Ongoing monitoring – not just for the CS audits
– Client specific reviews and care coordination
– DMA expects that providers will accept LMEs in their
offices/facilities just as if DMA contacted the provider
• Clinical Policy (919-855-4260)
– Tara Larson, Assistant Director
– Marcia Copeland
• Provider Enrollment (919-855-4000)
– Angela Floyd, Assistant Director
- Kimberly Randolph
- Program Integrity (919-647-8000)
- Lynne Testa, Assistant Director
- Pat Delbridge
- Carleen Massey
Division of MH/DD/SA
• Community Policy Management (919-715-1294)
– Flo Stein, Chief
– Christina Carter, Implementation Manager
– Dick Oliver, LME Team Leader
– Bonnie Morell, Best Practice and Community
• Resource and Regulatory Management
– Phillip Hoffman, Chief (919 –715-7774)
– Jim Jarrard, Accountability Team (919-881-2446)