Medicaid 101 Focused Training for Audited Community Support .ppt by shensengvf


									      Medicaid 101:
Focused Training for Audited
Community Support Providers

       April 4, 2007 - Raleigh
     April 11, 2007-Greensboro

Training Content
• Providers will increase understanding of:
  – Accountability with Medicaid
  – Medicaid Acceptable and Unacceptable
    documentation practices
     • Findings from CS Audits
  – Fraud and Abuse in Medicaid
  – Basic Medicaid Documentation requirements
  – Basic Medical Records requirements for billing
    Community Support
  – 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
   – 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.”
   – 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
  –   Rules
  –   Service Records Manual

Resources (cont.)

• Consider attending Basic Medicaid Billing
  – April 17, 18, 30th still have openings
  – Information can be located at
• ValueOptions
• EDS Web site
     • Provider Training
     Medicaid Acceptable and
     Unacceptable Practices
• 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

        Acceptable/Unacceptable (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
• 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.

          Acceptable/Unacceptable (cont.)
•   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

            Acceptable/Unacceptable (cont.)
• 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.

      Acceptable/Unacceptable (cont.)

• 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
    hours/units requested
  – 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.
• Documentation
  – 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
    crosswalk problems.
  – 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
    internal staff

           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
  for fraud.

     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

Record Documentation

• 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
    an outburst
  – 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
  CBS combined!

LME Role
• LMEs receive Medicaid payment for “acting” as
    agents of DMA.
•   Functions include:
    –   Endorsement
    –   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

Medicaid Contacts
• 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
      Innovations Team
• Resource and Regulatory Management
  – Phillip Hoffman, Chief (919 –715-7774)
  – Jim Jarrard, Accountability Team (919-881-2446)



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