Medicaid 101: Focused Training for Audited Community Support Providers

1. Medicaid 101:Focused Training for Audited Community Support Providers April 4, 2007 - Raleigh April 11, 2007-Greensboro

2. Training Content • Providers will increase understanding of: • Accountability with Medicaid • Medicaid Acceptable and Unacceptable documentation practices • Findings from CS Audits • Fraud and Abuse in Medicaid • Basic Medicaid Documentation requirements • Basic Medical Records requirements for billing Community Support • The Role of the LME in monitoring documentation on behalf of Medicaid

3. Provider Enrollment Agreement • When the application was submitted, the provider agreed to follow Medicaid rules. It is a 22 page application in order to get as much information as possible, to meet the requirements of CMS and the State and to provide the applicant the expectations of participation with NC DMA. • All questions of the applications must have been answered honestly. • Signature • “I certify that the above information is true and correct. I further understand that any false or misleading information may be cause for denial or termination of participation as a Medicaid Provider.” • 1 A: “Comply with federal, state laws, regulations, state reimbursement plan and policies governing the services…”

4. Provider Enrollment (cont.) • B 10: DMA may terminate this agreement… • The provider fails to meet the conditions of participation.. • The provider is determined to have violated Medicaid rules or regulations • The provide fails to provide medically appropriate health care services, etc. • C 1-14 further outlines the provider responsibilities to follow rules and regulations • Electronic Claims Submission Agreement • Another signature attesting to understanding of the rules and requirements of Medicaid.

5. Resources • Review DMA Web Site (web site address is changing effective June 30, 2007) • Provider Information: http://www.ncdhhs.gov/dma/provider • 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 • http://www.ncdhhs.gov/mhddsas/index.htm • Joint DMA/DMH Implementation Memos • Rules • Service Records Manual

6. Resources (cont.) • Consider attending Basic Medicaid Billing Training. • April 17, 18, 30th still have openings • Information can be located at http://www.ncdhhs.gov/dma • ValueOptions http://www.valueoptions.com • EDS Web site • Provider Training

7. Medicaid Acceptable and Unacceptable Practices • For any Medicaid service, not just mh/dd/sa, there must be: • Treatment plan/PCP • Assessments and clinical recommendations justifying the course of treatment or service being rendered. • Appropriate prior authorization • Medical order or service order (now are annual) • Progress notes or other “documentation” that proves delivery of service

8. Acceptable/Unacceptable (cont.) • 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 • 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.

9. Acceptable/Unacceptable (cont.) • PCP/Treatment Plan • 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 • No consumer should have only a DD diagnosis for CS services (Dual diagnosis is ok) – except if authorization has been granted under auspices of EPSDT – the authorization letter will state such. • No “stamped” signatures

10. Acceptable/Unacceptable (cont.) • Service delivery will not be 100% Medicaid billable. • Prior Authorization does not guarantee payment for all units/hours authorized • 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 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. • Authorizations do not transfer from provider to provider. New authorizations are required.

11. Acceptable/Unacceptable (cont.) • Some activities are considered “nonbillable” but % of nonbillable time have been factored into rates. • White Out is not acceptable on any records.

12. Miscellaneous Audit Findings • In addition to the acceptable/unacceptable already listed, unacceptable or “red flag” provider practices also include: • recipients from an agency all have the same hours/units requested • Refusal to refer to other agencies or to other services • Self referring to “other” owned services/agencies instead of offering choice of providers • Making service receipt conditional of getting all services from provider

13. Fraud and Abuse • False Claims Act (FCA) – handout • Knowingly presents or causes to be presented to …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..

14. 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 3729. While the FCA imposes liability only when the claimant acts “knowingly,” it does not require that the person submitting the claim have actual knowledge that the claim is false.

15. 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 judgment.

16. Pitfalls to avoid • Service Delivery • Central is medical necessity. It is an individualized clinical decision and should not be confused with the needed amount of funding to support a service. Shifts the needs from the recipient of the service and compromises clinical decisions. • Closely monitor utilization patterns and incorporate in QA/peer review process. Establish clinical review process for “high need” recipients. • Documentation • Area of greatest number of errors and requires intensive QA to prevent paybacks.

17. Pitfalls to Avoid (cont.) • Claims Processing • Errors in claims processing can usually be corrected since these are commonly data entry errors or MIS crosswalk problems. • 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 • Quantitative or qualitative reviews indicate deficiencies that can’t be corrected • Requires close communication between external and internal staff

18. Fraud and Abuse (Cont.) • Investigation of Fraud and Abuse • May be planned or unannounced • Three agencies that typically review • 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 involvement and review • 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 agreement with CMS. DMA has the authority to revoke a provider’s participation, recoup payment and report any potential fraud to the Attorney General’s Office

19. Fraud and Abuse (cont.) • The State’s AG’s office and the US Attorney’s Office has 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). • 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.

20. Self Monitoring and Quality Assurance • Every provider agency should have a quality assurance program • Included in the QA process should be review of medical records along with many other components. This training is only addressing minimum documentation requirements and should not be considered “inclusive” of all requirements or a comprehensive QA program. • QA should also be based upon a risk management program • Voluntary payback or mandatory recoupment • Record checklist

21. Record Documentation • The Audit check sheet • Service Records Manual

22. What is Community Support • Get training on CS – this is not intended to be a training on the clinical aspects of the service. • CS is a rehabilitation services that focuses on supports necessary to assist the person in achieving and maintaining rehabilitative, sobriety, and recovery goals. • Skill building necessary to meet mh/sa treatment financial, social and other support needs • Coordination across all levels of care, with the family, providers, facilities, paid and non-paid. • Serves as first responder crisis response 24/7 • That is not call 911 or go to the ER

23. Community Support (cont.) • Community Support is not, for example, • Personal care • Monitoring the recipient in case the person may have an outburst • Working with the recipient on homework so he’ll pass math • Driving the person around in the car • CS goals and objectives should produce change for the better or maybe it is not the correct level of care or the proper interventions/strategies to achieve the person’s desired outcomes. • CS is NOT case management and the old CBS combined!

24. LME Role • LMEs receive Medicaid payment for “acting” as agents of DMA. • Functions include: • Endorsement • Record review • Ongoing monitoring – not just for the CS audits • 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.

25. Medicaid Contacts • Clinical Policy (919-855-4260) • Tara Larson, Assistant Director • Marcia Copeland • Provider Enrollment (919-855-4000) • Angela Floyd, Assistant Director • Kimberly Randolph • Program Integrity (919-647-8000) • Lynne Testa, Assistant Director • Pat Delbridge • Carleen Massey

26. Division of MH/DD/SA • Community Policy Management (919-715-1294) • Flo Stein, Chief • Christina Carter, Implementation Manager • Dick Oliver, LME Team Leader • Bonnie Morell, Best Practice and Community Innovations Team • Resource and Regulatory Management • Phillip Hoffman, Chief (919 –715-7774) • Jim Jarrard, Accountability Team (919-881-2446)

27. QUESTIONS