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Medicaid Documentation Review October 23, 2012. WELCOME. Thank you for providing skilled professional treatment services to Medicaid beneficiaries. Today we want to provide an update about required charting standards and review some areas that have scored below standard in recent audits.

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Presentation Transcript
welcome

WELCOME

Thank you for providing skilled professional treatment services to Medicaid beneficiaries.

Today we want to provide an update about required charting standards and review some areas that have scored below standard in recent audits.

Presenters today are:

Rhonda Borders, LCSW, Quality Specialist

Maggie Tilley, Compliance Officer

era of health care reform

Era of Health Care Reform

Today’s providers work in an atmosphere of increasing regulation and review.

More and more audits of state Medicaid programs, hospitals and facilities, and individual providers, some with multi-million dollar paybacks, are occurring around the nation.

Documentation requirements for Medicaid are more detailed and extensive than for other insurance companies.

valueoptions colorado role

ValueOptions-Colorado Role

ValueOptions and its partner BHOs hold the Medicaid contract with the State of Colorado.

VO is responsible for quality review and for identifying and reducing issues of fraud, waste, and abuse.

We rely on State and Federal Medicaid rules for paying claims and auditing files.

ValueOptions is ramping up quality reviews, compliance audits, and claims verification to avoid significant negative consequences when a federal audit occurs in Colorado.

documentation and claims

Documentation and Claims

Documentation in the medical record is the only evidence of your work.

Documentation must be well done according to standards to support the claim that you make for payment.

Payments are made for a medically necessary covered service provided to an eligible individual by a qualified provider.

medicaid standards

Medicaid Standards

Revised standards went into effect for any new enrollment of a beneficiary after 1-1-12.

Previous training last year explained the standards.

That webinar is still available on your BHO website under Provider Information.

You will also find a set of suggested forms on those websites that may be helpful to you.

You are not required to use our forms.

recent audits

Recent Audits

About 70 records of independent providers have been reviewed since May, 2012.

Reviews done for all three BHOs.

Average scores in the 5 areas monitored remain below the 80% minimum.

Some providers received passing scores.

administrative area

Administrative Area

Medicaid Client Rights & Responsibilities Form.

The client/parent/gdn should sign this page at intake.

See the suggested forms. It includes information about Advance Directives and Well-Child Exams that a provider should also cover with a new client.

CCAR—Colorado Division of Behavioral Health requires a CCAR for each Medicaid client at admission, at annual update, and at discharge.

The CCAR can be submitted on line at the VO-CO website.

assessment area

Assessment Area

Many assessments need a little more detail:

Description of the problem

Mental Status exam

Psychiatric and substance abuse history of primary family members

Culture/Values/Beliefs:

Not only a statement of ethnicity, religion, or values, but also HOW they potentially will affect the therapeutic relationship or the nature of therapeutic interventions.

clinical formulation

Clinical Formulation

A short paragraph that explains your analysis of the assessment.

Justifies medical necessity by summarizing client symptoms & matching them to the DSM-IV criteria

States client’s willingness and ability to actively participate in treatment

Names initial goals and interventions until there is a formal treatment plan in place.

Includes anticipated Length of Stay.

treatment plans

Treatment Plans

Improvements can be made by including:

Discharge goal—How much change is necessary before it would be appropriate to discharge?

Measurable objectives to address goals

more than “increase” or “decrease”—how much change is enough?

depends on detail of symptom frequency and impact

reasonable and achievable in the # of authorized sessions

fit client’s developmental level and capacities

Therapist’s interventions—more than “individual” or “family”

Parent involvement in child’s treatment—what will they do?

Signatures AND a progress note that says you developed plan with client

progress notes elements

Progress Notes Elements

Each note must stand alone.

Elements must be present for each session.

Place of Service is most often missing (such as office, home, school, community)

Also…

Date of service

Start and end time

CPT code or service type

Persons present

Diagnosis being treated

Clinician signature AND date of signature

progress note content

Progress Note Content

Focus on the clinically important aspects of the session.

Notes should include:

which goal from the tx plan is being addressed in session

specific interventions used by therapist

the client response to session

client progress toward goals.

Avoid “daily report” progress note.

Do not include significant detail about what client said or did unless it is relevant .

coordination of care

Coordination of Care

Coordination among providers is important to prevent duplication of services.

Chart should show documentation of”

Routine letter to PCP: enrollment, dx and meds

Record of consultation with other providers or resources: teacher, pastor, caseworker, etc.

Referral to medical care (& f/U) if no physical in the last year

audit process clinical

Audit Process-Clinical

Approach is educational

First audit—educational letter and re-audit scheduled

Second audit—educational letter and request for Corrective Action Plan (CAP)

Third audit—referral to Quality of Care Committee

Potential removal from the network

audit process claims

Audit Process - Claims

Four claims per record are audited on 15 elements, including:

current treatment plan

txplan signatures

elements of the progress note

Auditor sends claim report to Compliance Officer who decides on further action, as needed.

Education or recoupment possible

Responds in a separate letter

contacts

Contacts

Rhonda Borders, LCSW, Quality Specialist

719-580-2010

rhonda.borders@valueoptions.com

Maggie Tilley, Compliance Officer

719-538-1435

maggie.tilley@valueoptions.com

Tom Dahlberg, LPC, Quality Specialist

719-538-4698

tom.dahlberg@valueoptions.com