Transcript Document

www.TheNationalCouncil.org
: Internal UM Processes,
Credentialing and
Authorization for Services:
July 14th, 2014
Contact: [email protected]
202.684.7457
www.TheNationalCouncil.org
Compliance, Accountability &
Monitoring
Webinar: Internal UM Processes, Credentialing and
Authorization for Services: Center has implemented
internal utilization management functions including
credentialing support for clinical staff; pre-certs,
authorizations and re-authorizations; and referrals to
clinicians credentialed on the appropriate third
party/ACO/Medical Home/Health Home panels
Contact: [email protected]
202.684.7457
1
UM/UR Why is this important?
• Increased Accountability
• UM UR
 If we find that UM UR reviews
provide unsubstantiated claims
it will be deducted from your productivity
 If we have provided a bonus on these units then this
will be deducted from your next pay
 Horizontal and vertical accountability
 KPIs for clinical and non clinical team members
• We will follow our UM UR policy
Contact: [email protected]
202.684.7457
Renewing Our
www.TheNationalCouncil.org
• Just because we have passed
a state audit is no guarantee
that we are not open to
problems.
Contact: [email protected]
202.684.7457
Documentation
Submit
The
Claim for
Payment to the
Correct payer(s)
www.TheNationalCouncil.org
Get the Check
Withstand the audit
Keep the Money
So, you can do it again.
Find the client
Assess the client
Treat the Client
Document it all
Give the info to the next part of the process
Contact: [email protected]
202.684.7457
UM/UR
www.TheNationalCouncil.org
• Is there a set of structures or
methods that provide for
authorization of care, using
particular criteria. These are
usually determined by the
payer.
Contact: [email protected]
202.684.7457
Process for Authorizations and Re-Authorizations
•
•
•
•
Gather insurance information over the phone or
when an individual walks in by making a copy of
their insurance card and when applicable running it
through the state system to ensure it is active.
Give information to Managed Care Staff assigned
within your organization.
Credentialing of staff is critical and key to payment
so managed care staff need to be knowledgeable
about providers and who is credentialed with what
payer sources when seeking authorizations.
Managed Care Staff will follow the process for each
insurance company to seek an authorization. Tip:
Establish a relationship with an individual from
each payer source who authorizes services as “the
go to individual” for questions and urgent
situations.
Contact: [email protected]
202.684.7457
Process for Authorizations and Re-Authorizations
•
•
•
•
Set up a tracking system for authorizations.
Ideally the pre-authorization can be loaded in the
EHR and monitored by Managed Care Staff. A
notification is sent from the Managed Care Staff to
the Clinician when they have 2 sessions left before
needing a Re-Authorization.
Managed Care Staff gives the clinician the
necessary paperwork from that payer source to
complete and sets a deadline to be returned.
Managed Care submits and notifies the clinician
when approval has occurred and loads those
sessions into the EHR or additional information is
needed or when it has been declined so the
clinician can appeal.
Patient is notified of current status of authorization
or reauthorization.
Contact: [email protected]
202.684.7457
Working Rejections
• Receiving an authorization does not
mean you automatically receive
payment.




Must have a designated individual or team to work
the rejections when payment is not received.
Must have a process in place for working the
rejections.
Rejections can be for a variety of reasons and it is
important this individual has an in-depth
understanding of those codes and how to obtain the
necessary information to re-submit the claim.
Must have a tracking process in place to ensure the
payment is received after it is re-submitted from a
denial.
Contact: [email protected]
202.684.7457
OVERVIEW
www.TheNationalCouncil.org
• AGENCY will employ an outside consultant
to perform
monthly reviews of all agency programs. Each program
(including Adult Mental Health, Substance Abuse, C&A
Mental Health, Psychiatry, PAS, SASS, DCFS, and others)
will have at least 5% of its charts reviewed a minimum
of 2 times each year.
• UR reports will be generated following each of these
reviews and distributed to the manager of the affected
programs. The managers will be responsible for
instructing staff to amend what they can and will also
search for trends of non-compliance that need further
corrective action.
• Annually, the consultant will review each program and
make recommendations on systemic improvement and
assess each program’s strengths.
Contact: [email protected]
202.684.7457
NEW CLINICAL STAFF
www.TheNationalCouncil.org
• For the first six weeks of active clinical work, QA will review each
chart weekly. She will then provide a personal review to the staff
member regarding their paperwork timeliness and accuracy. At
the end of this four week period, QA will either sign off that the
clinician is competent or that the clinician requires another two
weeks of review.
• Once the clinician has been signed off on, QA will review one week
of charts once per month for the next nine months. QA will
provide a written assessment of their performance to their
supervisor, which will be reviewed during supervision, signed off on
by both supervisor and employee, and placed in the employee’s
personnel file.
Contact: [email protected]
202.684.7457
EXISTING STAFF
www.TheNationalCouncil.org
• All staff will have 20% of their charts audited the
month before their annual review. QA will provide a
written evaluation to assist the manager with the
review process. If their compliance is above 95%,
they will be placed in the “A” category. If less than
95% compliance is noted on this annual review, the
clinician will be put into the “B” category. If less than
85% compliance is noted, the clinician will be placed
in the “C” category.
Contact: [email protected]
202.684.7457
Category A:
www.TheNationalCouncil.org
• Clinicians in this category
will receive semi-annual spot
audits in addition to their
annual review audit.
Contact: [email protected]
202.684.7457
Category B:
www.TheNationalCouncil.org
• Clinicians in this category will be required
to adjust any
incorrect documentation in the audited charts. They
will also be subjected to once-per-month spot audits
that will be documented and reviewed in supervision.
They will have to make any necessary adjustments to
the documentation and will need to have their
supervisor sign-off on their spot-audit sheet verifying
that this is done. This will continue monthly until
compliance meets 95% or until 6 months have passed.
If 95% compliance is not reached within 6 months, the
clinician will be put into category C.
Contact: [email protected]
202.684.7457
Category C:
www.TheNationalCouncil.org
• Clinicians in this category will be required to submit all
documentation daily to Compliance Review Staff. She will
evaluate it for completeness and accuracy and will provide
the supervisor with a daily report. She will be available to
provide additional training to the clinician if required to
ensure compliance. This will continue for 30 days, at which
time compliance should reach 95%. The clinician will then
be placed in Category B, although they will have expanded
evaluation of treatment plan compliance for the first three
months. If compliance does not reach 95% within 30 days,
further disciplinary action will need to be taken at the
discretion of the supervisor.
Contact: [email protected]
202.684.7457
UM/UR’s Role in CORPORATE
COMPLIANCE AND ACCOUNTABILITY
Contact: [email protected]
202.684.7457
CORPORATE COMPLIANCE
 Manage risk of unexpected losses or
expenses caused by regulatory action
◦ Prevent large payback sums, costly attorney’s
fees, negative public relations, employee
resources committed to response
◦ Civil/criminal liabilities
 Implement proactive Corporate Compliance
initiatives to meet increased scrutiny from
state and federal funders
 Meet our ethical obligations of quality care
Contact: [email protected]
202.684.7457
CORPORATE COMPLIANCE
• Compliance Program Review:
Identify, retrieve and prevent
inappropriate Medicaid/Medicare
billing ahead of audit
Conduct risk assessment, noting
payback risk (including extrapolation: if
5% error rate, extrapolate 5% across all
services billed, e.g. 30 claims becomes
200,000 claims or $4K becomes $6M)
Build a culture of transparency and
integrity
Contact: [email protected]
202.684.7457
CORPORATE COMPLIANCE
• Compliance risk assessment
 Train employees
 Review documents (UR: billing and coding, medical
necessity documentation)
 Identify risk areas (CI, CM, Family and Group Rx,
Fidelity to EBP, etc.)
• Infrastructure review
Review program components (selfdisclosure, corporate compliance log,
removing billings that are
unsubstantiated)
Contact: [email protected]
202.684.7457
Examples of Two Identified Risk Areas and QA
measures taken monthly at a CBHC
• All information is shared monthly
with the providers
• Prescribers
 Billing code patterns
 Quality Assurance Review/ Peer Reviews
• Community Support Specialist/
Case Managers



Chart review
Talking to the consumer
Field supervision
Contact: [email protected]
202.684.7457
February 2013 Service Code by Physician
Contact: [email protected]
202.684.7457
Clinical/Medical Necessity Peer Review
•
•
•
•
All Board Certified Psychiatrists must meet requirements
of MOC which include PIP (Performance in Practice)
through chart reviews and second party external reviews.
Each agency should have a clinical review/quality
assurance system.
Review of Medication Indicators includes Risk
Assessment, Co-existing medical, Substance Use/OTC
meds, Pregnancy, Established Treatment, Past and
Current Medications, Appropriate Dosages, Instruction for
taking medication, Rational for use discussed with client,
Drug to Drug interactions were discussed, Informed
consent, AIMS, Labs/tests, Additional Referrals.
Monitoring targeted indicators such as No Poly Pharmacy
(no more than 5 medications used for more than 60
days), Atypical Antipsychotic Mono-therapy, Patient failed
to fill medication within 15 days.
Contact: [email protected]
202.684.7457
Community Support Services QA Activities
•
•
•
•
Supervisor reviews 2 charts a month for each
supervisee. ENSURES DOCUMENTATION
REQUIREMENTS
Supervisor makes two calls a month to consumers
for each supervisee. QUALITY AND VERIFICATION
OF SERVICE MATCHES PROGRESS NOTE
Supervisor does one ride along a month per
supervisee. ENSURES MEDICALLY NECESSARY
INTERVENTION AND COACHING OPPORTUNITY
If the Community Support Specialist falls deficient
in any area additional corrective action is taken in
that area. Each addresses unique issues.
Contact: [email protected]
202.684.7457
Example of QA Phone Calls for Community Support
Services
• Hello Mr. Jones I wanted to follow up to see
•
•
•
•
•
•
how your visit was today with Mike
Did you meet with Mike today?
What treatment plan goals did you work on
today?
How long was your appointment today with
Mike?
Was Mike on time for your appointment?
Any other concerns or questions you have for
me?
This is cross-referenced with the Progress
Note to ensure accuracy.
Contact: [email protected]
202.684.7457
CORPORATE COMPLIANCE
• Compliance is Everyone’s Responsibility
Review the Corporate Compliance/False
Claims Act Policy
●Fraud is “knowingly” submitting
false/fraudulent claims
●Actual knowledge, act in deliberate
ignorance, act in reckless regard
Report any concerns about billing, required
when there is knowledge of improper billing
Contact: [email protected]
202.684.7457
CORPORATE COMPLIANCE
 Document and Claim Services Accurately
◦ Meet credentialing requirements
◦ Signatures must be original, dated and
◦
◦
accompanied by credentials (or meet e-signature
standards)
Document actual time, date, duration
Reflect service provided as required
◦ Include required documentation elements
◦ Do not up code, i.e. bill for greater service
◦ Include medical necessity, “golden thread”
Contact: [email protected]
202.684.7457
CORPORATE COMPLIANCE
Follow protocol for corrections and
amendments to documentation
Do not:
●Bundle services;
●Backdate documentation;
●Overlap service time/duration;
●Bill the same service by multiple
staff (CI exception)
Remember timekeeping, mileage,
managing client funds
Contact: [email protected]
202.684.7457
CORPORATE COMPLIANCE
• Medical Necessity
 LPHA determines:
● Diagnosis of MI or SED (Healthy Kids Screen can initiate services as MHA is
completed)
● Impairment in functioning in 1 or more areas
 Individual needs MH services to:
● Alleviate emotional disturbance/stabilize
● Reverse/change maladaptive patterns
● Restore/rehabilitate to maximum life functioning
• Golden Thread
 Assessment > Treatment Plan> Service Documentation>Updates
Contact: [email protected]
202.684.7457
CORPORATE COMPLIANCE
 MHA
● Description of time spent with client or collateral gathering information
● Include client preference/compliance
● Review “ability to participate” (e.g. TBI, DD, Dementia, etc.)
 ITP
● Description of time spent with client or collateral developing, reviewing or
modifying ITP
● Review Stages of Change/Treatment/Recovery
● Incorporate client goals
Contact: [email protected]
202.684.7457
CORPORATE COMPLIANCE
 Therapy/Counseling
● Include description of the activity (action taken on behalf
of clients to facilitate receipt of service) and interventions
provided (deliberate interaction between staff and clients
or a client’s collateral for the purpose of alleviating the
client’s symptoms of MI and improving the client’s level
of functioning)
● Include client’s response
● Include progress toward goal(s) as a result of
intervention
Contact: [email protected]
202.684.7457
CORPORATE COMPLIANCE
 Case Management
●
●
●
●
Review medical necessity; case management mental health as required…
State action taken on behalf of client, e.g. assessed, advocated, linked, etc.
Do not bill for transportation only
Review parenting services as they relate to client’s diagnosis
 Community Support
● Document skill building activities
● Develop curriculum training for skill building
Contact: [email protected]
202.684.7457
CORPORATE COMPLIANCE
• Client Centered (Joint Commission)
 Culturally competent
●
●
●
●
●
Culture
Language (e.g. Spanish speaking interpreter, written materials in translation)
Health literacy
Disability
Learning needs
 Documentation of services
 Effective communication
● EC, ethics, informed consent, law & regulatory compliance,
assessment/education, values and beliefs
 Complaints/grievances
Contact: [email protected]
202.684.7457
CORPORATE COMPLIANCE
 Culture of Transparency - Self/Agency
Monitoring and Reporting
◦ Report when an error is made/found
◦ Seek direction if corrections are needed
◦ Discuss opportunities for training and
performance improvement
Contact: [email protected]
202.684.7457
What Questions do you have…
Questions?
Feedback?
Next Steps?
Contact: [email protected]
202.684.7457
Presented by
Michael Flora, MBA, M.A.Ed, LCPC
MTM Services