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

Transcription

1 Medicaid 101: Basic Training for Medicaid MH/DD/SA Providers 1 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 2 1

2 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 3 Medicaid 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) 4 2

3 North Carolina 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 5 Provider Endorsement 6 3

4 Provider Endorsement Endorsement is a verification and quality assurance process using statewide criteria and procedures. 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. 7 Provider Endorsement Endorsement is an LME function Required for the provision of enhanced and residential services Each service requires a separate endorsement For more information or to initiate the endorsement process contact your local LME. 8 4

5 Provider Enrollment 9 Provider Enrollment Enrolling as a Medicaid Provider All providers must enroll directly with DMA Enrollment application packages are available on DMA s s website Enrollment takes about six to eight weeks Notified by mail when enrollment is complete 10 5

6 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 LME MD, LP, LPA, LPC, LMFT, LCSW, LCAS, CCS, CCNS, CNP 11 Provider Enrollment Report changes In Status to DMA An enrolled provider must use the Medicaid Provider Change Form Examples of some changes: Address change Phone number change Tax ID number change Report changes in status also to LME 12 6

7 The Role of the LME 13 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 agency. LMEs may receive Medicaid payment for acting as agents of DMA LMEs do not provide services unless they have a specific and time-limited waiver from the Secretary of Health and Human Services 14 7

8 Service Definitions 15 Medicaid Services Basic Benefit Basic Benefits Available to all Medicaid recipients Outpatient benefits Adults age 21 and over - (8 unmanaged visits per year per recipient) Children under age 21 - (26 unmanaged visits per year per recipient) Inpatient hospitalization 16 8

9 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 17 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 18 9

10 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 19 Medicaid Services Enhanced Benefit Services for Children (up to age 21) Diagnostic/Assessment (MH/DD/SA) Community Support Children/Adolescents (MH/SA) Mobile Crisis Management (MH/DD/SA) Intensive In-Home Services Multisystemic Therapy (MST) Child and Adolescent Day Treatment (MH/SA) Partial Hospital SAIOP 20 10

11 Medicaid Services Enhanced Benefit Developmental Disability Services Diagnostic/Assessment (MH/DD/SA) Mobile Crisis Management (MH/DD/SA) Targeted Case Management Community Alternative Program (CAP) 21 Access to Enhanced Medicaid Services 22 11

12 Note: Routine is now 10 working days

13 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 licensed QPs; ; one MD, DO, NP, PA or Licensed psychologist) 25 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

14 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; 27 Comprehensive Clinical Assessment Required elements (cont): 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

15 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 condition incorporate principles of education, wellness and recovery in partnership with the consumer work directly with the clinical home provider 29 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

16 Enhanced MH/SA Services 31 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 15% (minimum) of the total billable community support services provided per recipient must be provided by the Qualified Professional 25% (minimum) of the total aggregate billable Community Support services per month will be provided by the Qualified Professionals 60% face to face and 60% out of the facility 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 Newly Revised 32 16

17 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 s facility by a Team of practitioners (QP; LCAS, CCS or CSAC; Psychiatrist access; QP or AP with DD experience; Paraprofessionals with competency in crisis management) 33 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 0.5 QP; and other QP/AP/Paraprofessional/Certified Peer Support Specialist) Clinical Home Newly Revised 34 17

18 Enhanced MH/SA Services - Adults Assertive Community Treatment Team (ACTT) Service for SPMI, co-occurring 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/LCAS/CSAC, Certified Peer Support Specialist) Clinical Home 35 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 36 18

19 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 supervised 37 Enhanced MH/SA Services - Adults Professional Treatment Services in Facility- Based Crisis Program Alternative to hospitalization, MH/SA, intensified short-term, 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 38 19

20 Enhanced MH/SA Services - Substance Abuse Adults and Children Substance Abuse Intensive Outpatient Program (SAIOP) 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, LCAS, CSAC, QPs/APs for SA, and Paraprofessional staff Clinical Home 39 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/LCAS/CSAC, QP/AP for SA, and Paraprofessional staff and access to psychiatrist when needed Clinical Home 40 20

21 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 women) Short term service (thirty days per twelve month period) provided by CCS/LCAS/CSAC, QP/AP for SA, and paraprofessional staff 41 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/LCAS/CSAC, QP/AP in SA, and paraprofessional staff 42 21

22 Enhanced MH/SA Services Detoxification Services Adults and Children Ambulatory Detoxification Outpatient medically supervised evaluation, detoxification and referral services to achieve safe/ comfortable withdrawal and transition to ongoing treatment 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 LCAS or CCS 43 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 term period) provided by physicians, RN, appropriately licensed and credentialed staff, CCS/LCAS/CSAC, QP/AP in SA and paraprofessional staff 44 22

23 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/LCAS/CSAC, QP/AP for SA and paraprofessional staff 45 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

24 Enhanced MH/SA Services - Children 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 staff 15% (minimum) of the total billable community support services provided per recipient must be provided by the Qualified Professional 25% (minimum) of the total aggregate billable Community Support services per month will be provided by the Qualified Professionals 60% face to face and 60% out of the facility Clinical Home 47 Enhanced MH/SA Services - Children Intensive In-Home Services Time limited family preservation intervention to stabilize living arrangement, promote reunification or prevent use of out-of of-home therapeutic resources for youth through age 20 Direct and indirect periodic service delivered primarily in the family s s home (any location) by a Team: licensed professional and minimum of 2 staff who are APs or provisionally licensed (CCS/LCAS/CSAC needed if focus is SA), team leader Clinical Home Newly Revised 48 24

25 Enhanced MH/SA Services - Children Multisystemic Therapy (MST) Behavioral therapy model for treating youth and their families, designed for 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 s level QP and 3 QPs Clinical Home Newly Revised 49 Enhanced MH/SA Services - Children 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/LCAS/CSAC if SA) 50 25

26 Residential Treatment Services Treatment in a structured, therapeutic, supervised environment for under age 21 Level I: low to moderately structured family setting Level II: moderate to highly structured family or program setting Level III: highly structured program setting Level IV: physically secure, locked program setting 51 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 interventions 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 52 26

27 Medicaid Services Developmental Disabilities Developmental Disability Services Targeted Case Management DD services habilitative versus rehabilitative Services covered under the CAP MR/DD Waiver 53 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) If refer to another clinical home the new service becomes the clinical home until the service ends STR is not a Medicaid billable service 54 27

28 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 following: Development and updating of the Person-Centered Plan and Crisis Plan Obtaining Authorizations (ITR/ORF2/CTCM) Completing the Consumer Admission Form (State Only) Completing the NC-TOPPS & NC-SNAP Serving as a First Responder (24/7) Must be able to respond by phone and face-to to-face Focus on prevention and proactive crisis intervention based on the crisis plan 55 Proactive Interventions Proactive Interventions is an aggressive and organized effort to fulfill each person s s fullest capacity. It requires an integrated, individually tailored program of services directed to achieving measurable, behaviorally-stated objectives. Integrated program of therapies Behavioral programming: positive reinforcement for appropriate behavior Psycho-educational programming: curriculum, games, experiential education, therapeutic recreation Generalization of skills: natural and designed 56 28

29 EARLY AND PERIODIC SCREENING, DIAGNOSTIC, AND TREATMENT (EPSDT) 57 EARLY AND PERIODIC SCREENING, DIAGNOSTIC, AND TREATMENT (EPSDT) 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 at: care/epsdt-mhddsa6 mhddsa6-07training-3.pdf 58 29

30 Authorizations and Utilization Review 59 Authorizations and Utilization Review 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 requirements. A referral is required for recipients under age 21 from the LME, Medicaid enrolled psychiatrist, or Carolina Access PCP

31 Authorizations and Utilization Review What services require authorization and when? Inpatient psychiatric hospitalization elective (on or before date of admission) and emergency admissions (within two working days of admission) Psychiatric residential treatment facility services on or before date of admission Out-of of-state services prior to admission Outpatient basic benefit services following unmanaged benefit Enhanced benefit MH/DD/SA services - following any unmanaged benefit 61 Authorizations and Utilization Review Value Options is the DMA contracted agency to provide authorization and utilization review. For more information: Call Value Options at Refer to the Value Options website at Piedmont Cardinal Health Plan If a recipient's eligibility is in Cabarrus, Rowan, Stanly, Union or Davidson counties, please call Piedmont Behavioral Health at : State Funded Services are authorized through the LME 62 31

32 Basic Medicaid Documentation Requirements 63 Basic Medicaid Documentation Elements 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 (as outlined in Medicaid Clinical Policy or the Records Management and Documentation Manual) that proves delivery of service 64 32

33 Basic Medicaid Documentation Requirements Enter information that is: Accurate Timely Objective Specific, Concise, Descriptive Consistent Substantive and pertinent Clear 65 Basic Medicaid Documentation Requirements All service notes must contain the following elements: Individual s 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 interventions/treatment/support 66 33

34 Basic Medicaid Documentation Requirements 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 s title (position) 67 Documentation Resources For more details about documentation refer to: Medicaid Clinical Policy and Service Definitions found at: Records Management and Documentation Manual found at: ons/manualsforms/aps/apsm_serv-record record-manual pdf 07.pdf Person-Centered Plan Instruction Manual found at: ss-care/pcp6 care/pcp manual.pdf 68 34

35 Billing and Payment 69 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 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 Guide dbillingguide0407.pdf and the EDS website

36 Billing and Payment New Change in Billing For Community Support, a modifier is necessary to identify units of service provided by the Qualified Professional For more information see the November 2007 Medicaid Bulletin 71 Quality Management/Assurance (QM/QA) 72 36

37 Quality Management/Assurance What is Quality Management, Assurance, Improvement, etc.? 73 Quality Management/Assurance What is the goal of Quality Management, Assurance, Improvement, etc.? 74 37

38 Quality Management/Assurance What is the role of the Qualified Professional in Quality Management, Assurance, Improvement, etc.? 75 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 76 38

39 Quality Management/Assurance Are you doing things right? Record keeping Complete Accurate requires intensive QM to prevent paybacks. 77 Quality Management/Assurance Are you doing things right? Billing Complete Accurate Timely 78 39

40 Quality Management/Assurance Are you doing things right? Practice Management Efficient Cost effective Staff Licensing Certification Privileging 79 Quality Management/Assurance Are you doing things right? Service Delivery Accessible Culturally competent Efficient 80 40

41 Quality Management/Assurance Are you doing the right thing? Most appropriate service At the right time With the right person 81 Quality Management/Assurance Are you doing the right thing? Medical Necessity: A clinical decision as to if a service will benefit the individual. The responsibility of the Qualified Professional Supervision Staff should be under the supervision of a licensed professional according to clinical need and requirements Service Definitions Certification and/or Licensure Policy on supervision required 82 41

42 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- referring balance between clinical, regulatory, and QA functions 83 Quality Management/Assurance Are you looking at yourself? Utilization: monitor utilization patterns establish clinical review process for high need recipients. Risk Management 84 42

43 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 Health Service Regulation Incident in depth report form located at: crdeathrep.pdf 85 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? NCTOPPS Endorsement Quality of provider organization and of the services major part of LME endorsement 86 43

44 Quality Management/Assurance RULES 87 Quality Management/Assurance RULES FOR MENTAL HEALTH, DEVELOPMENTAL DISABILITIES, AND SUBSTANCE ABUSE FACILITIES AND 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 88 44

45 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. 89 Pitfalls to Avoid 90 45

46 Billing Pitfalls to Avoid 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 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. 91 Treatment Plans Pitfalls to Avoid 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 92 46

47 Documentation Pitfalls to Avoid 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 No stamped signatures White Out is not acceptable on any records. 93 Documentation (cont) Pitfalls to Avoid Making service receipt conditional of getting all services from provider 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

48 Claims Pitfalls to Avoid Errors delay your claim Usually are common 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 95 Authorizations Pitfalls to Avoid Authorizations do not transfer from provider to provider. New authorizations are required. Recipients from an agency all have the same hours/units requested Other Business Plan should account for not being able to bill 100% of everything done Some non-billable activities are factored into the rate 96 48

49 Appeals 97 Appeals 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 98 49

50 Appeals Two hearing options: informal hearing by the DHHS Hearing Office formal or evidentiary hearing by the Office of Administrative Hearings (OAH) in Raleigh 99 Fraud and Abuse

51 Fraud and Abuse False Claims Act (FCA)- handout -Knowingly presents or causes to be presented to a 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) t2.pdf 101 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 While the FCA imposes liability only when the claimant acts knowingly, knowingly, it does not require that the person submitting the claim have actual knowledge that the claim is false

52 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. 103 Fraud and Abuse (cont.) Degrees of DMA intervention -Warning letter - Withhold of payment Suspension of enrollment -Termination -DMA has the authority and obligation to: - recoup payment - revoke a provider s s participation -report any potential fraud to the Attorney General s s Office

53 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 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 s agreement with CMS. DMA has the authority to revoke a provider s s participation, recoup payment and report any potential fraud to the Attorney General s s Office 105 Fraud and Abuse 3. The State s s AG s 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 findings. The finding of fraud does not require an intent of wrongdoing, however, it is more than a simple mistake. The lack of knowledge is not a defense for fraud

54 Resources 107 Resources 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

55 Resources Medicaid State Plan at: DMA Clinical Coverage Policy 8-A, 8 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 tm 109 Resources ValueOptions Provider Relations: EDS Website at: EDS Provider Services: or Provider Training at: asic-medicaid medicaid-chris-ferrell.pdf

56 Medicaid Contacts Clinical Policy ( ) Behavioral Health Care Section ( ) Marie Britt RN, BC, MS Acting Chief Bert Bennett, Ph.D Bert.Bennett@ncmail.net Recipient Services - ( ) Program Integrity ( ) Provider Services ( ) 111 Division of MH/DD/SA Community Policy Management ( ) 1294) Christina Carter, Implementation Manager Dick Oliver, LME Team Leader Bonnie Morell, Best Practice and Community Innovations Team Resource and Regulatory Mgmt. ( ) Jim Jarrard, Accountability Team Leader Advocacy and Customer Service ( ) Chris Phillips, Chief

57 Division of MH/DD/SA Advocacy and Customer Service Customer Service and Community Rights Stuart Berde,, Team Leader State Facilities Advocates Wendi McDaniel, Team Leader Consumer Empowerment Ann Remington, Team Leader TTY/Voice TTY/Voice/Spanish) EVALUATION & QUESTIONS