Provider Service Expectations Adult Mental Health/Substance Abuse Day Treatment SPC 704 Provider Subcontract Agreement Appendix N

Transcription

1 Provider Service Expectations Adult Mental Health/Substance Abuse Day Treatment SPC 704 Provider Subcontract Agreement Appendix N Purpose: Defines requirements and expectations for the provision of subcontracted, authorized and rendered services. Services shall be in compliance with the Provider Subcontract Agreement and the provisions of this service expectations document. 1.0 Service Definition Adult Mental Health/Substance Abuse Day Treatment- This service is a medically monitored, non-residential treatment service which consists of regularly scheduled sessions of various modalities such as; case management, individual & group therapy, occupational therapy, educational programming specific to medial aspects of the diagnosis and treatment, medication management, symptom management and conducted in a Wisconsin Statecertified day treatment program. 2.0 Standards of Service Medicaid Certification Provider agency and individual therapists must hold, as required by Day Treatment regulations, Wisconsin Medicaid Certification and appropriate licensure from the Department of Regulation and Licensing for the program and all applicable service disciplines. Provider and individual therapists must 2.1 have a Medicaid Provider Number that can be verified by WWC. This Medicaid Certification must remain current during the term of the contract. Provider must follow requirements as set forth in the Medicaid Provider Manual unless communicated otherwise by WWC. State Certification/Licensure Provider agency must be State of Wisconsin Medicaid certified and hold a Day Treatment license issued by the Division of Quality Assurance (DQA), Department of Health Service (DHS). 2.2 Mental Health Day Treatment providers must follow the program requirements set forth in DHS 61 (Community Mental Health and Developmental Disabilities) and AODA Day Treatment providers must follow program requirements set forth in DHS 75 (Community Substance Abuse Service Standards). Medicare Certified Day Treatment-Medical is a service eligible for reimbursement under Medicare when a Medicare recipient meets Medicare qualifications for the service. Medicare is a primary funding source over WWC funding. Therefore, it is preferred that providers of Day Treatment-Medical services are Medicare 2.3 certified. Provider must provide verification of Medicare certification or fully disclose to WWC prior to contracting if it is not Medicare certified. Provider must communicate to WWC any changes in Medicare certification status. Service must be provided in a manner which honors member s rights such as consideration for member 2.4 preferences (scheduling, choice of provider, direction of work), and consideration for common courtesies such as timeliness and reliability. 2.5 National Provider Identifier Day Treatment- Medical service providers must provide a NPI number to WWC. WWC subcontracted providers of long-term care services are prohibited from influencing members choice of long-term care program, provider, or Managed Care Organization (MCO) through communications that are misleading, threatening or coercive. WWC and/or the WI Department of Health Services may impose 2.6 sanctions against a provider that does so. Per Wisconsin Department of Health Services (DHS), any incidents of providers influencing member choice in a Family Care program must be reported to DHS immediately. 3.0 Service Descriptions Day Treatment- Medical service is a basic element of a mental health and/or AODA treatment program for 3.1 WWC members living in the community who are seriously impaired in basic areas of everyday functioning and

2 3.2* 3.3* 3.4* for whom less intensive, traditional, outpatient treatment is not adequate. Day Treatment provides treatment services for members who spend only part of the 24 hour day in services. Day treatment services are provided for a scheduled number of sessions per day and/or week and can be conducted during day or evening hours. The care must be determined to be medically necessary and approved by WWC as part of an approved plan of care. Day Treatment is a nonresidential program in a medically supervised setting that provides case management, medical care, psychotherapy, and follow-up services to alleviate problems related to mental illness or substance abuse, according to DHS (37), Wis. Admin. Code. Day treatment services are provided by an interdisciplinary team on a routine, continuous basis for a scheduled portion of a day and may include structural rehabilitative activities including training in basic living skills, interpersonal skills, and problem-solving skills. Assessment for Services Prior to involvement in the adult mental health day treatment program, the member is evaluated through the use of the functional assessment scale to determine the medical necessity for day treatment and the member's ability to benefit from it. Providers are required to submit the Mental Health Day Treatment Functional Assessment. Providers should also assess the member's willingness to participate in treatment at this time. Treatment Plan A treatment plan is developed with the member based on the initial evaluation and includes measurable, 3.5 individual goals/objectives, the specific treatment modalities (including identification of the specific group or groups to be used to achieve these goals), and the expected outcomes of treatment. The supervising psychiatrist approved, signed, and dated the treatment plan for the member and continues to review, sign, and date the treatment plan no less frequently than once every 60 days. 4.0 Units of Service and Reimbursement Guidelines SPC 704 Mental Health/AODA Day Treatment services (Procedure code H2012) are reimbursable at Medicaid 4.1 established rates. 4.2 All services must be prior authorized by WWC Care Management teams. 5.0 Staff Qualifications and Training Caregiver Background Checks- Providers will comply with all applicable standards and/or regulations related 5.1* to caregiver background checks as well as comply with the WWC Provider Policy on Caregiver Background Checks. Provider agencies and individual therapist must hold and upon request will provide to WWC a current copy of 5.2 the applicable State of Wisconsin certification/licensure to administer Day Treatment service and/or credentialing to provide therapy services to WWC members. Providers are required to meet the staffing requirements identified in DHS (4)(a)8., Wis. Admin. Code 5.3* (i.e., at least one qualified staff person is required to lead the service and be present in the room throughout the session). All employees providing services under this contract must have training regarding the Family Care Program 5.4 and expectations of WWC in the provision of services. WWC has posted training information on the WWC website; The agency must ensure that the therapists have received training on the following subjects pertaining to the clients served: A. Client rights and responsibilities B. Provider rights and responsibilities C. Record Keeping and Reporting 5.5 D. Confidentiality laws and regulations E. Effective therapy methodologies F. Documentation requirements G. Other information deemed necessary and appropriate H. Recognizing and appropriately responding to all conditions that might adversely affect the member s

3 health and safety including how to respond to emergencies and Critical Incidents. 6.0 Supervision and Staff Adequacy The agency shall maintain adequate staffing to meet the needs of members referred by WWC and accepted 6.1 by the provider for service. Providers must have an acceptable back up procedure, including notification of member, when a therapist is 6.2 unavailable for a scheduled visit/session. 6.3 The program must have a method of verifying that the therapy service is provided as referred and scheduled. Provider agency will ensure: Staff are supervised and assessed to assure they are working effectively and collaboratively with members by conducting adequate on-site supervision and review. Performance issues with staff are addressed promptly, WWC teams are kept informed about 6.4 significant issues that affect the WWC member. Supervisory staff are involved in assessment, goal planning and tracking, and supervision for WWC members. Provider staff are working collaboratively and communicating effectively with WWC staff 7.0 Service Referral and Authorization The WWC team will provide a written service referral form to the provider agency that specifies the expected 7.1 outcomes, amount, frequency and duration of services. The provider agency will notify the WWC team within 2 business days of receiving a referral regarding the ability to accept the member for services. If the referral is accepted, notification should also include the 7.2 anticipated start date or any delays in staffing by the requested start date. The provider agency must continue to report status of an open referral on a weekly basis to the WWC team until the referral is filled. The WWC team will issue a new written referral form when the tasks assigned, amount, frequency or duration 7.3 of the service changes. 7.4 The provider agency will retain copies of the WWC referral forms in the agency file as proof of authorization. Authorizations for Member Services Current and active authorizations are obtained by accessing the WWC Provider Portal. Providers must sign up with WWC to access the portal. 7.5 The provider agency is responsible for ensuring only currently employed and authorized staff have access to the WWC provider portal and using the member authorization information available on the portal to bill for services accurately. Questions on active authorizations should be directed to the WWC team. 8.0 Communication, Documentation and Reporting WWC communicates with providers regularly in the following formats: Vendor forums Mass notifications via , fax, or mail Notices for expiring credentialing 8.1 Notices are sent to providers via when the provider has available to ensure timeliness of communication. Provider agencies are required to ensure WWC Provider Network, WWC Teams, guardians and other identified members of the interdisciplinary team for a member have accurate and current provider contact information to include address, phone numbers, fax numbers, and addresses. The provider agency shall report to the WWC team whenever: 1. There is a change in service provider There is a change in the member s needs or abilities 3. The member is not available for scheduled services Member Treatment Plans Providers of Day Treatment services shall follow the WWC Provider Reporting Policy. The Day Treatment 8.3 agency shall complete a treatment plan that details the member s goals and progress toward each of the outcomes (goals) outlined. The WWC team may use these provider reports to evaluate the need for continuation or modification of services.

4 Submission Timeframes: The initial treatment plan shall be submitted to WWC within 30 days from start of service. Each subsequent plan update shall be submitted to WWC thereafter. 8.4 Submission Instructions: Providers are required to electronically submit progress reports via to or by faxing to Member Incidents Provider agencies shall report all member incidents to the WWC team. Providers must promptly communicate with the WWC team regarding any incidents, situations or conditions that have endangered or, if not addressed, may endanger the health and safety of the member. Acceptable means of communicating member incidents to the WWC team would be via phone, fax or within 24 hours. Additional documentation of incidents may be requested by the WWC team or WWC Quality Assurance. Providers and WWC will comply with the WWC Incident Reporting Policy which is available on the WWC website at: > Providers > Provider Policy & Procedure. The provider agency shall give at least 30 days advance notice to the WWC team when it s unable to provide authorized services to individual members. The provider agency shall be responsible to provide authorized 8.5 services during this time period. The WWC team or designated staff person will notify the provider agency when services are to be discontinued. The WWC team will make every effort to notify the provider at least 30 days in advance. The provider agency must maintain the following documentation; and make available for review by WWC upon request. Provider meets the required standards for applicable staff qualification, training and programming Verification of criminal, caregiver and licensing background checks as required Policy and procedure related to supervision methods by the provider agency including frequency, 8.6 intensity and any changes in supervision Policy and procedure for responding to complaints, inappropriate practices, or matters qualifying as member-related incidents Policy and procedure regarding work rules, work ethics and reporting variances to the program supervisor Employee time sheets/visit records which support billing to the WWC. 9.0 Quality Assurance Purpose 9.1 WWC quality assurance activities are a systematic, departmental approach to ensuring and recognizing a specified standard or level of care expected of subcontracted providers. These methodologies are established to review and inspect subcontracted provider performance and compliance. WWC will measure a spectrum of outcomes against set standards to elicit the best picture of provider quality. WWC provider quality assurance practices: 1. establish the definition of quality services; 2. assess and document performance against these standards; and 3. detail corrective measures to be taken if problems are detected It is the responsibility of providers and provider agencies to maintain the regulatory and contractual standards as outlined in this section. WWC will monitor compliance with these standards to ensure the services purchased are of the highest quality. Resulting action may include recognition of performance at or above acceptable standards, working with the provider to repair and correct performance if it is below an acceptable standard, or action up to termination of services and/or contract should there be failure to achieve acceptable standards and compliance with contract expectations.

5 Quality Performance Indicators Legal/Regulatory Compliance- evidenced by regulatory review with no deficiencies, type of deficiency and/or effective and timely response to Statement of Deficiency Education/Training of staff- Effective training of staff members in all aspects of their job, including handling emergency situations. Established procedures for appraising staff performance and for effectively modifying poor performance where it exists. Performance record of contracted activitieso tracking of number, frequency, and outcomes of assigned WWC Quality Teams related to provider performance o tracking of successful service provision (member achieving goals/outcomes, increased member independence and community participation, etc.) Contract Compliance- formal or informal review and identification of compliance with WWC contract terms, provider service expectation terms, applicable policies/procedures for WWC contracted providers Availability and Responsiveness- related to referrals or updates to services, reporting and communication activities with WWC WWC Sources and Activities for Measuring Provider Performance Member satisfaction surveys Internal or external complaints and compliments Onsite review/audits Statement of Deficiency (SOD)- state regulated entities Quality Teams- as assigned based on significant incidents, trend in quality concerns or memberrelated incidents, or issued Statement of Deficiency. Tracking of performance and compliance in relation to the subcontract agreement and appendices Statistical reviews of time between referral and service commencement Expectations of Providers and WWC for Quality Assurance Activities Collaboration: working in a goal oriented, professional, and team based approach with WWC representatives to identify core issues to quality concerns, strategies to improve, and implementing those strategies Responsiveness: actions taken upon request and in a timely manner to resolve and improve identified issues. This may include submitted documents to WWC, responding to calls, s, or other inquiries, keeping WWC designated staff informed of progress, barriers, and milestones achieved during quality improvement activities Systems perspective to improvement: approaching a quality concern, trend, or significant incident with the purpose of creating overall improvements that will not only resolve the issue at hand, but improve service and operations as a whole Member-centered solutions to issues: relentlessly striving to implement solutions with the focus on keeping services member-centered and achieving the goals and outcomes identified for persons served WWC is committed to interfacing with providers to collaboratively and proactively discuss issues identified with processes and assist with implementing improvements and reviewing the impact of the changes as a partner in the mission to serve members. PSE #: Date Issued January 1, 2012 DT Approval Date: Document Owner K Lubinski State Approval Date: N/A Contract Reference Subcontract Appendix N Next Review Date: 8/1/2016

6 Revision History: Revision # Date Description of Changes/Reason Requested By 1 12/16/9 Initial Draft Trussoni 2 12/22/09 Updates Trussoni 3 12/1/10 Revision to Section 7.0 N Schmidt, C Anderson 4 10/6/11 N. Schmidt reviewed, no changes except corrected dates at top of document and made minimal typo correction. N Schmidt 5 9/18/12 Reviewed for inclusion with 2013 contract, minimal changes, tracked changes N Schmidt 6 10/20/13 Reviewed for inclusion with 2014 subcontract agreement, no changes K Lubinski 7 10/24/14 Added procedure code to 4.1; Revised 8.5 for new reporting process K Lubinski Re-formatted to standard layout, standardized language 8 10/27/15 used, updated to reflect new provider policies and contract S. Strittmater language When Staff Instructed