Residential Providers Claims Billing & Audit Training October 11, 2013

1. Residential ProvidersClaimsBilling & Audit TrainingOctober 11, 2013 Debra A. Schuchert Director of Network Operations & Compliance Synergy Partners

2. Person Centered Plan (PCP) • The Person Centered Plan is completed annually. • If there are any changes to the Person Centered Plan an “amendment” is completed.. • The Person Centered Plan identifies the Objectives, Goals, Type/Level of Care - (procedure code) Amount -( Total # of Units), Scope/Duration (How much (in Units) and schedule, Start/Stop dates, Monitored by, & Frequency of Monitoring. • The Person Center Plan will identify the # of units and how often 1:1 Staffing is to be performed for a consumer. • When Synergy completes an audit the Person Centered Plan and Authorization # are reviewed to identify the codes, units, and frequency a procedure code is to billed by the provider.

3. Authorizations • The Authorization # identifies: • CPT/Revenue Code • Description • Modifier • Effective Dates • Rate • Units Authorized • Units Claimed • Units Paid • Units Available • The “APPROVED” authorization is used to submit your claim for adjudication.

4. Progress Notes • The Progress Notes are a vital part of review when preparing a claim for submission to Synergy for adjudication. • Progress Notes must identify the following: • Name of Consumer • Location • Correct dates of service being rendered • Accurate times –Shifts • Legible description of what has occurred during the shift • Signatures • Billers should not be billing using a calendar. You are to bill using the appropriate documentation that justifies the service being rendered. Home Managers must become responsible for the documentation being submitted by the staff. Implement a routine that ensures documents are completed after each shift and booked accordingly. • When the appropriate documentation is missing or not completed entirely the services become subject to a Debit/Credit Transaction which recoups the Medicaid dollars, and will now be reported to the Detroit-Wayne Mental Health Authority. • Each provider is subject to an audit. The audit can be scheduled or unscheduled, onsite or off site. If the provider is performing services according to their signed contract the Progress Notes should never be an issue. The Progress Notes must be available upon request. When the notes are not available, it raises suspicion to the services being submitted for Medicaid reimbursement.

5. Residential Occupancy Log (3806) • The Residential Occupancy Log (3806) is a State form that is to be completed accurately for each residential site and signed/dated. (Please remember this is a legal document and when the provider is signing it, it states that the information is accurate) • Synergy will no longer accept batches for adjudication without having the 3806 form prior to submission of the batch. • This Log is to be completed accurately and timely. The Leave of Absence or Hospital Admission of a consumer is to be identified on the log. According to the Medicaid False Claims Act, if a consumer is on a LOA or Hospital stay and the provider does not identify this information it can be suspect to fraud. • If Synergy identifies this LOA or Hospital stay and the provider has billed for these services the Medicaid dollars will be recouped through the Debit/Credit Transaction. If Synergy identifies a provider as submitting the logs incorrect on a consistent basis we will complete and Internal Investigation of the provider’s billing practices. The findings will be submitted to the Detroit-Wayne Mental Health Authority.

6. Residential Visitor Log • The Residential Visitor Log should identify the following: • Location/Site • Home Manager • Date • Arrival Time • Consumer Name • Reason for the Visit • Departure Time • Signature of Visitor • The Residential Visitor Log should document any visitor arriving & leaving the home. If the consumer is being taken home for the day or weekend it should show: • Time consumer left • Person leaving with the consumer from the home • Time consumer returned to the home • Person returning the consumer to the home This information should correlate with the 3806 log when a consumer is on a LOA. • The Residential Visitor Log is important for a number of reasons: • It is a safeguard for the home to have a record of people entering and leaving the site. • It identifies the presence or absence of our consumers • In the event of a fire or other mishap the provider has a log that identifies all persons in the home at the time of the incident.

7. One to One Staffing (1:1) • The Office of Inspector General (OIG) is focusing on the One to One staffing services being reimbursed by Medicaid. • When a consumer is seen in the Emergency Room and then admitted to the hospital, the 1:1 staffing services can only be billed during the emergency room visit. This should always be noted in the comment section of the claim. • The 1:1 staffing notes must be clearly written identifying what occurred during the hours this services is being performed. In addition, to shifts, signatures etc. • The audit of 1:1 Staffing will be ongoing. • During previous audits it has been identified that some staff are not arriving on time for their scheduled shifts, however still submitting the hours for reimbursement. The biller submitting these hours will be found to be in violation of the False Claims Act. Remember, providers you are ultimately responsible for your documentation and submission of claims. • There will be random audits conducted for all providers.

8. Claim Submission /Adjudication • The Residential Occupancy Report must be submitted to Synergy prior to submitting your batch for adjudication. • Claims should be billed according to the Residential Occupancy Report & Progress Notes to ensure the service was rendered. • Providers are responsible for moving their batches through all 3 steps. Numerous providers forget to move their batch to final step causing a delay in your payment. It is not Synergy’s responsibility to call and continue to inform you to move your batch. We have been making those calls as a courtesy to our providers, but our future demands will be limiting are available time. • If you click on the edits and adjudicate your batch on your side before moving it to Synergy you can view the obvious errors, and it will save you time and effort on your part. In addition, Synergy will not have to return the batch back for correction.

9. Provider Performance Audits • The Claim Adjudicator will also conduct “random” internal audits on providers when issues arise or on selected procedure codes. There are specific reports that are completed for these audits. It is now Synergy’s responsibility to inform Detroit-Wayne Mental Health Authority of the findings. • The Internal Corporate Compliance Investigation Report • Corporate Compliance Response to a Governmental Inquiry or Investigation • When an audit is conducted the authorization is reviewed and a random list of consumers and dates is generated, depending on the number of consumers and services at the provider location. The staff will begin the audit by requesting documentation that supports the rendered services. If the documentation does not support the services or is not available we will submit the Debit/Credit Transaction to our Finance department for recoupment of the dollars on the providers next batch that is submitted for adjudication.

10. “REASONS” A Claim Is Returned To Provider • Residential Occupancy Report (3806 Log) was not received prior to submitting the batch. • Incorrect Residential Occupancy Report (3806 Log). • Submitting billing when consumer is on a Leave of Absence or in the Hospital. • Not submitting a correct Timely Waiver Form or Administrative Waiver Form. • Comment section on the claim is left blank when the claims is a late submission. • Maximum Units Exceeded. • Duplicate Billing (Biller entering claim twice for the same date of service). • Comment section on the claim is left blank when submitting duplicate billing. • CPT Code – No Fee Schedule Found • Billing CPT Code / Missing modifier • Return batch/batches for adjudication without reading the billing error. • Under billing procedure codes. • Batches being sent past 4:00 on FRIDAYS cannot be adjudicated. • Batches being submitted near the close of business will not be adjudicated until the next day, due to the necessary review of the claim.

11. Claim Requirements • On the Residential Occupancy Report – 3806 Log • Column # 8-Total Per Diem x Total Days Amount must match the amount of the claim. For each consumer. • 3806 Log must be sent to Synergy prior to moving batch for adjudication. Synergy will not adjudicate until 3806 Log is received. The batch will be returned with the explanation “Missing 3806 Log”. • 3806 Log from the previous month must be received by the 10th of the following month. • Example: September 2013 must be received by October 10, 2013. • Must begin to review adjudication report on your billing side. This would eliminate Synergy returning your batch for errors. • When a claim is late you must enter an explanation in the comment section of the claim, or the batch will be returned delaying your reimbursement. • You must begin to use the “NEW” Timely Waiver Form & Administrative Review Form. The sections of the forms have been enhanced to require the “Date of Request for Authorization # & “Date of Supervisor Approval of Authorization”. You will no longer receive a phone call from the Synergy Claim Adjudicator requesting the new form. The batch will be returned with the explanation “Missing correct Waiver or Review Form”. (These forms were sent via e-mail to all providers and is on the Synergy Website). I have attached the forms for your convenience. • Providers you must complete the billing process. When you leave your batch in Step #2 or Step #3 you are delaying your reimbursement. Synergy will no longer call each provider and ask them to move their batch through the billing process. As a provider this is your responsibility.

12. Annual Audit Requirements • Residential Home audits will begin in January-2014. • Synergy will notify the provider by e-mail of the following : • Random selection of consumers • Four (4) or more consumers in each home will require five (5) dates per month for each consumer chosen. • Three (3) or less consumers in each home will require ten (10) dates per month for each consumer chosen. • Three (3) month audit period. • The attendance log, visitor log, progress notes etc. will be requested. You are to fax to Synergy at (313)-748-7405 or you can scan them and send it through the e-mail process. There should not be any delay in this process. The documentation is required promptly. You are not to go back and recreate a record, as all billing is to be done according to the documentation and not a calendar. • A summary identifying the findings will be sent to each provider. If the findings identify a 10% error rate , the provider will be placed under a Plan of Correction , and possible 100% review of claims. • All errors will be deducted through the Debit/Credit Transaction process.