DHHS LME Post Payment Review Training

1. DHHS LME Post Payment Review Training May 4, 2007

2. Training Agenda • Review Implementation Memo#27 • Define post payment review • Discuss the tools and procedures for post payment reviews • Questions/Answers

3. Handouts in Packet • Implementation Memo #27 • LME Summary • Access to Data Instructions • 1st Notification Letter • 2nd Notification Letter • Record Request Timeline • Community Support Definition Key Elements • Child and Adult • Tool • Reviewer Guidelines • Decision Matrix • Weekly Post Payment Report

4. Things to ConsiderCommunicate, Communicate, Communicate • Educating Providers • Posting documents on your web site • Have provider meeting to discuss the process • Have periodic meetings/updates as the process unfolds • Identify a point person to field questions and comments • Make sure that customer service understands the activity to field questions from families, consumers, providers, etc. • Conduct In-service with CFAC

5. Implementation Memo #27 • Handout in packet • Will conduct post payment reviews of all current and new recipients of CS receiving excess of average of 12 hours per week • Will result in • Receiving appropriate clinical intervention and treatment • Based upon this peer review, PCP and tx options require additional review for determination of appropriateness • Provider requires training regarding the use of CS or treatment planning • Referral to DMA • Changes in tx options will be made through the treatment team and will follow routine authorization procedures through VO.

6. Post Payment Review • The Objective • Is the recipient receiving the appropriate clinical intervention and treatment? • This is a clinical review, not a record review and not an audit • However, during your clinical review, you may find information that would lead to a need for a record review. Do not conduct the record review to determine clinical appropriateness • Post Payment review is defined by the elements on the tool • Will need clinical records • Will need licensed clinical person to determine appropriateness • As a result of review of the medical record and completion of the tool - clinical appropriateness is determined. • There may be documentation issues that raise compliance issues – that “kicks it” to another type of review.

7. How to get the Data • Data file identifies recipients receiving an average of 12 hours per week. Data is paid claims July 06 – Feb, 07 • Data File • Handout: Directions to Access Community Support Data • Excel Workbook for each LME is posted at ITS in the same directory where the Medicaid paid claims files are found • Only persons with RACF security rights to this directory will be able to access the data (there is someone for each LME who can do this) • The remote site directory will be: DHR.MMR.PDCLAIMS.APXXX • *Where ‘XXX’ is- there is a three digit number for each LME (e.g. 308 for Wake) • The file name is CSHIGH • This is a an Excel Workbook and is stored in BINARY, so it must be stored in BINAY as well. • **Note: This is different from the instructions for the paid claims files, as they are stored in ASCII text files. • Any questions please contact Adam Holtzman at: 919-715-7774 or adam.holtzman@ncmail.net

8. Provider Letter • Notify Provider • Gather names of all consumers for provider • Prepare notification letter to provider (handout) • 1st written request to provider for medical records -allow 7 business days from date of letter • 2nd written and final request for medical records OR missing documents – allow 5 business days • Certified or UPS – manner to check if received or not. Refusal to sign demonstrates receipt of notification • Receive documentation from Provider • Review documentation for completion as requested

9. Information Request • Request most recent PCP and revisions to support claims being reviewed • Assessment Information should support the PCP and revisions being reviewed • Request progress notes that reflect dates to be reviewed • Intent is to get enough progress notes to determine if services provided match PCP objectives which should reflect assessment information. • If claims reflect inactive status – go back in billing history through July, 06 to request progress notes to match claims.

10. If the provider doesn’t send the information • LME notifies DMA that record has not been submitted as part of weekly status report • DMA suspends payments until record or missing documentation is received.

11. NC DEPARTMENT OF HEALTH & HUMAN SERVICES 2007 POST-PAYMENT REVIEW Flow Chart To Accompany Post-Payment Review Tool, and Reviewer Guidelines Step 1 Review PCP or T/HP Enter “N” at “a.” Recipient Not Appropriate. Refer to DMA If “No” 2 Is PCP or T/HP Present? If "Yes” 3 Review Dx/Assessment Information Q (a): Is MH/SA Diagnosis Present? If "Yes” 4 Enter “Y” at “a.” If “No” Q (a): Is Only DD Diagnosis Present? 5 If "Yes” Q (a): Is there is evidence of a second diagnosis (MH/SA) somewhere in the record ? If "Yes” 6 Enter “Y” at “a.” If “No” Enter “N” at “a.” Recipient Not Appropriate. Refer to DMA Q (a): Is Recipient under age 21 If “No” 7 If "Yes”

12. Enter “N” at “a.” Recipient Not Appropriate. Refer to DMA Q (a): Is EPSDT Referral/Approval Present? If "Yes” If “No” 8 Enter “Y” at “a.” Enter “N” at “b”. Training in PCP required. Q (b): Do Dx/Assessments reflect DX Information? If “No” 9 If "Yes” Enter “N” at “b.” Training in PCP required. Q (b): Did Recommended referrals take place? 10 If “No” If "Yes” Q (b): Were recommended consultations related to accurate Dx/assessment information? Enter “N” at “b.” Training in PCP required. If "Yes” If “No” 11 Enter “Y” at “b.” Review the recommendations made on the Summary of Assessments and Observations page of the PCP, or in treatment team notes for a T/HP 12 Enter “N” at “c.” Training in PCP required. Q (c): Do recommendations reflect DX Information? If “No” If "Yes” 13 Enter “Y” at “c.” Review Symptoms/Observations listed on the Summary of Assessments and Observations page of the PCP or in assessment information for a T/HP. 14

13. Enter “N” at “d.” Training in PCP required. Q (d): Are they actual symptoms/ Observations? If “No” 15 If "Yes” Enter “N” at “d.” Training in PCP required. Q (d): Do symptoms/observations relate To DX Information? If "Yes” If “No” 16 Enter “Y” at “d.” 17 Review Full Dx/Assessment Information from Q. a-d. Recipient Not Appropriate. Refer to DMA. If "Yes” Are b-d all rated “N”? 18 Review Personal and Family Interview sections of the PCP. 19 Review Signature page of the PCP or T/HP and/or revisions. 20 Is recipient under age 21? If “No” Is recipient own LRP? 21 If "Yes” If “No” Review participation and agreement of the parent or legally responsible party. 22 Review PCP for family participation, if families identified as participants by individual. 23

14. Q (e): Did person/family or LRP participated in the development of the plan? Enter “N” at “e.” Training in PCP required. If "Yes” If “No” Enter “Y” at “e.” 24 Review Goal Statements in PCP or T/HP. 25 Q (f): In PCP, is there a symptom/ observation With each goal? If "Yes” 26 If “No” Q (f): In T/HP, Is symptom/observation evident with each goal? Enter “N” at “e.” Training in PCP required. If “No” 27 Enter “N” at “e.” Training in PCP required. Q (f): Do symptoms and observations directly relate to goals? If "Yes” If “No” Enter “Y” at “f.” 28 Review the Personal and Family interview sections in the PCP for comparison to the goal statements to determine if the “What’s Important” information is reflected in the goals. 29 Q (g): In PCP, is the “What’s Important” information reflected in the goals? If "Yes” 30 Enter “Y” at “g.” If “No”

15. Q (g): If T/HP, do admissions assessments, NC-TOPPS, etc., indicate what is important to individual/family? Enter “N” at “h.” Training in PCP required. If "Yes” If “No” 31 Enter “Y” at “g.” Review the goal statements and supporting interventions in the PCP or T/HP against the appropriate CS Service Definition (Child/Adult/Team). 32 Proceed to Q (h): Is service a paraprofessional service to individual? If “No” 33 42 If "Yes” Q (h): Is service a paraprofessional service to person age 21 or older? Proceed to If “No” 34 38 If "Yes” Per Review Guidelines, assure skills identified, beyond statement of activity, are clinical interventions, provided in order to empower the individual to learn the skills, and toward teaching/assisting the individual to become independent in the skill. 35 Enter “N” at “h.” Training in service definition required. Q (h): Are measurable interventions related to skill building present? 36 If “No” If "Yes”

16. Q (h): Does goal reflect 1-on-1 intervention In community per service definition and Review Instructions? Enter “N” at “h.” Training in service definition required. If "Yes” If “No” 37 Enter “Y” at “h.” If “No” Q (h): Is service a paraprofessional service to person under age 21? Proceed to 38 35 If "Yes” Proceed to If “No” Q (h): Is service provided in a school setting? 39 41 If "Yes” Per Review Guidelines, assure that interventions identified are clinically justified and are provided in order to assist the child in developing skills to function successfully and independently in the environment. 40 Q (h): Does goal reflect 1-on-1 intervention In community per service definition and Review Instructions? Enter “N” at “h.” Training in service definition required. If "Yes” If “No” 41 Enter “Y” at “h.” Proceed to If “No” Q (h): Is service a Q-Level Service? 42 33 If "Yes”

17. Per Review Guidelines, assure that the note reflects Q-level activity such as coordination and oversight of initial and ongoing assessment activities, initial development and ongoing revision of the PCP or T/HP, monitoring of the implementation of the PCP or T/HP, and/or additional case management functions of linking, arranging for services and referrals. 43 Q (h): Does note reflect Appropriate QP activity per service definition and Review Instructions? Enter “N” at “h.” Training in service definition required. If "Yes” If “No” 44 Enter “Y” at “h.” 45 Review Crisis Plan in PCP, or in T/HP. Q (i): Do the symptoms listed make sense with those indicated in assessments and treatment goals? Enter “N” at “i.” Training in service definition required. If “No” 46 If "Yes” Q (i): Do the strategies listed relate to the overall level and intensity of CS treatment provided? Enter “N” at “i.” Training in service definition required. If "Yes” If “No” Enter “Y” at “i.” 47 48 Review a sample of notes over the time period indicated. Are service notes not individualized (canned, electronically copied)? Recipient Not Appropriate. Refer to DMA 49 If “Yes”

18. Enter “N” at “j.” Training in service definition required. Q (j): Do the notes accurately relate to the diagnostic information previously reviewed? If "Yes” If “No” Enter “Y” at “j.” 50 Q (k): Do the notes accurately reflect the specific treatment goals in the PCP or T/HP? Enter “N” at “k.” Training in service definition required. If “No” If "Yes” Enter “Y” at “k.” 51 Enter “N” at “l.” Training in service definition required. Q (l): Do the intensity (frequency and duration) of CS provided matches with services billed (paid claims)? If “No” If "Yes” Enter “Y” at “l.” 52 Review the service notes in the PCP or T/HP against the appropriate CS Service Definition (Child/Adult/Team). 53 Proceed to Q (m): Is service a direct service to individual? If “No” 54 56 If "Yes” Q (m): Does note reflect 1-on-1 intervention In community per service definition and Review Instructions? Enter “N” at “m.” Training in service definition required. Enter “Y” at “m.” If "Yes” If “No” 55

19. Proceed to Q (m): Is service an indirect service to individual? If “No” 56 55 If "Yes” Q (m): Does note reflect Appropriate QP activity per service definition and Review Instructions? Enter “N” at “m.” Training in service definition required. Enter “Y” at “m.” If "Yes” If “No” 57 Clinical Determinations (CD) based on Cumulative Information in Considerations (a) – (m) CD1: Is the CS service clinically necessary? If "Yes” If “No” Enter “N” at “CD1.” Enter “Y” at “CD1.” 58 If “No” CD 1a: Would this individual be better served by access to more intensive services than CS? Proceed to If “No” 59 61 If "Yes” Identify suggested alternative services. 60

20. CD 2: Is the duration and frequency of the CS clinically appropriate? If "Yes” Enter “Y” at “CD2.” 61 If “No” Identify recommended duration and frequency. 62 ADMINISTRATIVE (LME) RESPONSE ALTERNATIVES A1: Do the PCP or T/HP and treatment choices need additional review by LME staff to determine appropriateness? If “No” If "Yes” Enter “NA” at “A1.” Enter “Y” at “A1.” 63 A2: Is training in regard to the use of CS services is needed? Enter “Y” at “A2.” If "Yes” If “No” Enter “NA” at “A2.” 64 A3: Are the issues uncovered during this review beyond the scope of further review or training but warrant a Medicaid paid claims audit? Enter “Y” at “A3.” If "Yes” If “No” Enter “NA” at “A3.” 65

21. A4: Are the issues uncovered During this review beyond the scope of further review, training and/or a Medicaid paid claims audit, and referral to DMA for further review and investigation is warranted? If “No” Enter “NA” at “A3.” Enter “Y” at “A3.” If "Yes” 66

22. Validating Clinical Decision • Medical Director or Clinical Director must review and sign off on at least 5% of total post payment reviews. Reasons for this review: • Inter-rater reliability • To mirror post payment reviews when completed by DMA and their vendors • Maintain complete records of this process • Is subject for disclosure during appeals

23. After The Clinical Decision Is Made: Next Steps • Recipient • Follow guidelines for clinical decision, referral for record audit, referral to DMA • Notify the provider of recommendation • Submit to DMAby COB on Monday, the status report of prior week activities (handout) • Must be submitted electronically using the Excel spreadsheet • Forward client specific tools to section in LME that is responsible for plans of corrections, endorsement and/or medical record reviews

24. Systemic • Summarize client specific findings in order to create a provider report. • Percent is determined by dividing the number of No’s by the total number of tools X (times) the 13 considerations (a-m), = % • If a finding of less than 10% - the licensed clinician may make recommendations for improvement in writing to the provider • A Provider Plan of Correction is needed if: • 10% to 20% - POC • Above 20% - POC and full record audit • Plan of Correction should be completed in accordance to the LME POC policy • Link provider POC to endorsement requirements • Utilize systemic information to revise LME’s local business plan within strategic objectives

25. Medical Record Review • If a medical record review is needed • Must follow state medical record protocol • Must use Medicaid Record Audit Tool and Auditor’s Instructions • Please consult DMH Program Accountability to assure statewide consistency

26. When to refer to DMA? • Referral to DMA Program Integrity may occur at any point during the process. Referrals concerning an individual provider should be made only upon completion of all reviews for that single provider. • Automatic referrals should occur if: • Single incidents that are so problematic or appear to be fraudlent • No PCP • No diagnosis or only DD for adults • Service notes are not individualized

27. Follow Up • DHHS will convene a follow up meeting to evaluate the process and review status • LMEs may request consultation from DMA/DMH at any point • Questions about the post payment project • Tara Larson and Christina Carter • Questions