Ensuring Quality Information

Transcription

1 CIRTS Reports Training Ensuring Quality Information West Central Florida Area Agency on Aging

2 FACILITATORS Katie Parkinson, Director of Programs, WCFAAA Martha Caron, Medicaid Waiver Specialist, WCFAAA Lauren Cury, Medicaid Waiver Specialist WCFAAA Sarah Ardelean, Program Manager, WCFAAA Debbie Hofer, Program Manager WCFAAA Disclaimer: The facilitators above are NOT data entry experts and do not claim to be! They will offer information from the programmatic perspective and can assist in locating data entry gurus to help with input questions. Please don t make them feel inadequate by asking questions like which line of code should the delimiter be on?. HUH?

3 Technical term # 1 GIGO CIRTS in CIRTS out

4 CIRTS GIGO creates : Missing information Typos Discrepancies Exceptions CIRTS in Work for you to analyze, explain, & correct

5 Focus on ENSURING QUALTIY INFORMATION Technical term #2 QIQO

6 QUALITY IN QUALITY OUT

7 OBJECTIVES: Attendees should be able to : Know which CIRTS Exception Reports to regularly run, and when to run them Analyze CIRTS Exception Reports to determine which client information is in error Correct CIRTS Database so error can be removed Provide feedback to AAA staff about action taken and verification that exception is resolved 7

8 APS ARTT Exceptions

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10 ARTT Referrals Not Acknowledged as Received or Rejected Contains referrals in the ARTT that have NOT been identified as received or rejected. Referrals in the ARTT for whom referral packets have been received should be acknowledged as received on the Aging Network tab. Includes referrals sent two or more days ago.

11 Referral Received or Rejected must be checked.

12 Incomplete ARTT Referrals Must complete: "Action Taken by Provider" field (#30) or "Staffing or Additional Comments" field (#31), "Service Provider's Signature" (#36), and for High risk referrals- the "Schedule Staffing Date" (#37) Must be entered into ARTT within 72 hours from time referral packet is received for "high-risk" referrals and within 10 business days for M and L risk referrals.

13 Must complete: #30 or #31, #36, and for High risk referrals- #37

14 ARTT Referrals In CIRTS or ARTT But Not the Other Contains APS referrals in CIRTS or ARTT that are not in the other system with referral dates within 90 days of each other. SSNs in CIRTS are first compared to the CIRTS SSNs in ARTT (on the Aging Network tab). If this field is not populated, DCF provided SSNs are used.

15 Compare SSN in CIRTS vs. ARTT

16 Before APS client s 701B is updated by Case Manager

17 After APS client s 701B is updated by Case Manager.

18 Performance Outcome Measures

19 Run Provider Level Report

20 Performance Outcome Measures 1. ADLs 2. IADLs 3. Environment 4. Nutrition 5. Imminent Risk referrals 6. APS referrals 7. MW time in CCE 8. Caregiver Likelihood 9. Caregiver Ability

21 ADLs and IADLs Compares a new client s ADL/IADL score, from the prior fiscal year, to the ADL/IADL score at reassessment, in the current fiscal year. The measurement evaluates the percent of clients with maintained or improved scores from initial assessment to reassessment.

22 Environment and Nutrition Compares the client s prior moderate or high environment/high nutrition score with the reassessed score. The report measures the percent of clients with improved scores in the second fiscal year.

23 Imminent Risk and APS referrals IRR: Measures the % of IRR clients served after the referral date. There are no restrictions on the timeframe for service delivery or the type of service being provided. APS: Measures the % of APS referred clients served within 72 hours. * Case Management services are not considered a service for this definition.

24 Average Time in CCE Program for MW Probable Clients Checks CCE clients who were active at some point during the reporting period, who have assessments reflecting Medicaid Waiver program eligibility and tracks their transition to MW funding. The measure reflects the length of time clients, who appear they would be eligible for the MW program, were enrolled in the CCE program for the current fiscal year.

25 Caregiver Likely Outcome Report Applies to the current fiscal year. The measure is the % of caregivers stating they are very likely to continue providing care to the client. *This report does not represent the case manager s estimate of whether the caregiver is capable of continuing care but reflects the caregiver s answer to the question.

26 Caregiver Ability Outcome Report Report compares the client s prior ability to provide care field with the value at reassessment. The report measures the % of clients whose ability to continue to provide care is maintained or improved in the second fiscal year.

27 Why do we have Outcome Measures? Helps you know if programs are successful Used to justify expenditures of public funds to Legislature and Citizens Helps to identify effective providers Highlights best practices Helps to improve planning

28 So what can you do? Review client s file before doing re- assessments so you can make informed evaluation of client s current condition Phrase questions to ensure most accurate info Review CIRTS turnaround report to ensure accuracy

29 Outcome Measure Response Monthly explanations to WCFAAA for exceptions to goals not achieved Excel format Comments should provide information why client is not achieving goal

30 Sample Explanation for ADL goal not achieved Due to client s advancing dementia her ADL's have all increased to needing some help. Client has been placed on the CCE APCL list while receiving ADI services. In the mean time, client s son is meeting her increased needs.

31 CIRTS Reports

32 Assessment Due Report #1 Assessment Due Report

33 Enter your Provider ID Enter beginning of SFY ( i.e. 07/01/2010) Enter End date the last day of the most current month (i.e. 08/30/2010) Select Program (i.e. CCE/OAA, etc ) Select ACTV and APCL for complete listing of all clients due to assessment Include your agencies CIRTS approved address Submit Report

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37 Note 701B Assessment Missing -

38 Client with missing 701B noted on previous slide Since client is receiving home delivered meals, a 701B is now required

39 Example from previous slide of missing 701B note only 701C in CIRTS for client.

40 Correcting Assessment Due Report Exceptions Ask the following questions: Is the client still active? Yes determine assessment type needing to be completed and have assessment entered in CIRTS within 7 business days No terminate client enrollment(s) What type of assessment is overdue or missing? Sometimes client is made active with only a 701A Assessment completed, a 701B may be needed

41 #4 Clients Served Not Enrolled

42 Enter your Provider Id Choose location (should be all for completed listing) Enter start date the first day of the most current month (i.e. 08/30/2010) Enter End date the last day of the most current month (i.e. 08/30/2010) Submit Report

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46 Enrollment Example Cham Active enrollment in OA3B, on 5/01/10

47 Client received HMK on 4/25/10, enrollment started 5/1/10 Client s record needs to be reviewed to determine the appropriate action to be taken. (i.e. either HMK needs to be removed on 4/25/10 or Enrollment start date changed)

48 Correcting Clients Listed as Served without Enrollment Is the client an active client? If no terminate enrollment(s) lines in CIRTS, be sure to update client file if not already done Yes What service did client receive? Why is program enrollment part of client s CIRTS enrollment record? Update CIRTS enrollment record

49 #1. Active Clients not served in a Time Range. Looks at clients enrolled but not served in last 14 months

50 Utilize your agency s CIRTS Provider Id, choose the appropriate location and Program Code Submit Report

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52 Client active in CCE an LSP

53 Client has not received a CCE service since 5/07/09, but is still CCE Active. Client Question hasn t received should client any CCE still be services in enrolled over 14 in CCE? If yes, months why has any case management been billed since May 2009? If client was only LSP active in 2009, need to term CCE line when program enrollment actually ended (see client file for answers)

54 Correcting Active Clients with no Services in Time Frame Client is Active, but has not received services in 14 months (or shorter time frame as indicated) Enrollment issue evident Need to terminate client send 10-day termination notice if not yet done.

55 Age Verification Report Looks at clients who have received a service, but do not appear to be eligible due to age (i.e. under 60).

56 Age Verification Report *Utilize your agency s Provider Id, *Select program or use all Programs, *Enter beginning date July 1, 20## and *End date the last date of the previously completed month.

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58 Age Verification Reports Providers should regularly run this report to identify consumers who need a valid "Under 60" code entered. If any consumer appears who should never have been enrolled and/or served, please let Jeff Pacheco or Frank Wagoner know so these records can be removed from CIRTS thereby removing them from your report.

59 Correcting Age Verification Report Exceptions Determine if a PSA code been entered into CIRTS to justify services provided to a person under 60 years for EACH program the client has received services in? These codes can be entered into CIRTS for consumers via the "Additional Information" screen (i.e., screen 2) in CIRTS.

60 PSA Codes for ARRA Age Verification * ARR1 < 60 - FALSE AGE GIVEN * ARR1 < 60 - HANDIC/DISABL IN HOUSING FACILITY * ARR1 < 60 - HANDIC/DISABL TO MEAL SITE * ARR1 < 60 - SPOUSE ACCOMP TO MEAL SITE * ARR1 < 60 - VOLUNTEER AT MEAL SITE * ARR2 < 60 - FALSE AGE GIVEN * ARR2 < 60 - HANDIC/DISABL NON-INST HSE * ARR2 < 60 - SPOUSE AT RESIDENCE

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62 Report looks for clients in CIRTS that appear to be duplicate either by name, DOB or SSN

63 Currently we have Zero (0) exceptions!! Great Job However, if we did have exceptions, your agency would need to contact WCFAAA MIS Department to assist in moving the client records to the correct SSN.

64 CIRTS Clean-Up Report # 18. CIRTS Data Clean-Up Report

65 Report looks for enrollment discrepancies, by running this report in Delimited Data, you have the ability to drop the information into an Excel document for easy sorting, tracking, sharing with staff and providing feedback.

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67 Client s CCE line termed, but OAA lines still active

68 Correcting CIRTS Clean-up Reports Update CIRTS with termination lines for all programs if client has passed away. Notify other Providers who may not be aware that the client has terminated program so they will know to terminate their provider enrollment lines.

69 Vital Statistic Reports Three (3): Vital Statistic Reports

70 Understanding Vital Stat Exception Reports On a quarterly basis, providers are required to run and reconcile the above referenced DOD exception reports and submit verification that all appropriate corrections were taken to bring CIRTS up to date.

71 Requirements Per the MIS Section of your Master Agreement states you are responsible for correcting: Deceased clients are listed on the wait lists. Deceased clients have active program enrollments. Deceased clients have services reported after the date of death. Deceased clients have assessments performed after the date of death. Date of death is not indicated in CIRTS.

72 Reconciliation actions include: Verify the client is deceased. Enter the client s date of death (DOD) on the CIRTS demographics screen. Terminate open enrollments in CIRTS for clients who have died. This includes APCL, APPL and ACTV enrollments. Enter the enrollment end date as the date of death and the termination code T_CD (client died).

73 This report indicates clients reported as having died by DOH Vital Statistics, that are still showing as enrolled in a DOEA funded program. Tip: By running in delimited data, information can be placed in Excel document

74 The client on this exception report has the same last name, different first name, same SSN and DOB. They appear to be the same person. Waitlist enrollment records need to be closed once verification is made.

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76 The clients on this report all have the same first and last name and matching DOB(s) These clients appear to match Vital Stat reports and indicate an assessment was completed after DOD

77 Correcting Vital Stat Report due to Assessments Reported after DOD The data should be left in CIRTS if the WCFAAA paid for the service. Provide WCFAAA with confirmation that the client is no longer receiving services and the reason why your agency did not document DOD previously. For services other than CM or CA, reported beyond 60 days of the DOD, WCFAAA must obtain additional information from the your agency containing documentation of the reasons given, but NOT adjust CIRTS service records at this time.

78 Services More Than 2 Months after DOD

79 These errors do not have PSA Codes entered to explain exceptions

80 These Services have had PSA Codes entered to explain why the exception is occurring.

81 Correcting Services Provided After DOD The data should be left in CIRTS if the WCFAAA paid for the service. Provide WCFAAA with confirmation that the client is no longer receiving services and the reason why your agency did not document DOD previously. For services other than CM or CA, reported beyond 60 days of the DOD, WCFAAA must obtain additional information from the your agency containing documentation of the reasons given, but NOT adjust CIRTS service records at this time.

82 Services after DOD cont For case management (CM) or case aide (CA), effective immediately, providers are to ensure that a PSA code is entered in CIRTS. The PSA code means Case Closure-Billing after date of death was appropriate and allowable in order to close the client record. Details on this process are included in the NOI # Updating CIRTS Enrollment Due to Death.

83 Medicaid Waiver Reports MW Reports are generated by MWS and cannot be run by the provider network

84 Level of Care (LOC) This report, run quarterly by the MWS, lists all clients who have an active program enrollment status according to CIRTS as of the date the report is run. "Last LOC Date" is the date of the last LOC determination. The LOC is out of date on the first day following the one-year anniversary of the previous LOC date. Provider is given two weeks to respond to the exception. The report can otherwise be used to track LOC due dates.

85 Level of Care (LOC)

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89 Possible issues: Client unavailable CIRTS issue LOC already received Packet was sent to CARES 3008 issue

90 Ensuring LOC s Are Timely Updated Follow up with CARES Ensure 701B is completed within 90 days of LOC request 3008 Fill in the proper effective date before sending to Doctor Submit 3008 as early as possible Ensure client is available Ensure that CIRTS is timely updated once the LOC is obtained.

91 Medicaid Waiver CIRTS Clean-Up Report 1. Incomplete TAEL List for ADA,ALE,CDC 2. List of individuals with a TAEL program enrollment status but without a subsequent APPL/ACTV nor terminated from APPL/ACTV enrollment record according to CIRTS. 2. Deceased with Open Enrollment List List of individuals with both an ACTV and a T_CD (i.e. TRCD, TACD, TPCD) program enrollment status according to CIRTS 3. Active Without Paid Claims List for ADA,ALE,CDC List of individuals with an ACTV program enrollment status (for at least 6 months) in CIRTS but without any paid claims for the past 6 months

92 Medicaid Waiver CIRTS Clean-Up Report

93 Possible reasons: Incorrect CIRTS entry See next slide for analysis This report lists individuals with potentially incorrect or outdated CIRTS enrollment information. Possible reasons: HCE stipend must be paid Client not terminated in CIRTS Possible reasons: Program change: lost eligibility, transferred to NH Incorrect Social Security # Facility did not have NOCA Problem with Medicaid Number

94 What is wrong with this picture? What are we trying to determine? What did the CIRTS Clean-Up Report for Incomplete TAEL List tell us?

95 Correcting CIRTS Data Clean-up Reports Errors frequently occur because one enrollment line is terminated, but the others remain active. Close lines which remain open but which should be closed. Be vigilant when there are multiple programs. Correct any incorrect or outdated client information If your agency is not the responsible for closing all lines, notify appropriate agency or request WCFAAA Program Manager assistance.

96 ADA MW Paid Claim Exception Report

97 Medicaid Waiver Paid Claim Exception Reports Detail and Summary Report

98 Summary Report ADA MW Error Exceptions: Currently there is over $15K in paid claims that appear to be an exception in PSA 6!!!

99 Client enrollment shows ALW start date = 9/1/09 End = 8/12/10 Client enrollment shows ADA start date = 10/1/05 end = 8/31/09 Client has a total of $54 in exceptions for Procedure code 5130 U2 = Homemaker

100 Client has a total of $54 in exceptions for Procedure code 5130 U2 = Homemaker Hmk provided on 9/1/09 and billed to ADA MW client ALE at time

101 Client has $2,019 in error exceptions

102 Client appears to be a CDC consumer per Mainsl billing on January 1st Food with Care is not allowed to bill ADA Medicaid Waiver once the client becomes an active CDC client. F w/care needs to void claims billed to MW and seek recoupment elsewhere. Lead Agency may be responsible for F w/ Care billing if they did not provide a notice to terminate services to provider.

103 CDC Enrollment did not begin until 2/1/10 Questions??: Was client a CDC consumer in January? Mainsl billed January 1 st do they need to void that billing? or does the CIRTS enrollment need to be corrected?

104 ALE MW Error Exception Report ALE Paid Claim Error Exception Reports

105 Client Example has $5,924 in paid claims that appear to be in error

106 Topline billed Medicaid for ALE services July, August, September, October, November and December st MWS have to determine who Topline is before the report is disseminated to providers. We were able to determine this is a HMK/COMP agency in Gainesville. Topline used their MW # to bill for ALE services. MWS now need to contact Gainesville MWS to request assistance correcting error exception.

107 Client active in ALE MW program from 8/22/06 to 10/19/2008, no other enrollment lines following TRMO (terminated client moved)

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109 Client Active in ALE Medicaid Waiver since 2/04/10

110 Provider billed ALE MW on January 1/31/10 for ALE services.

111 MW Error Exceptions Report Wrap-up Errors frequently occur because: - the enrollment begin/end dates are inaccurate. - the consumer was not enrolled on the service date the claim was billed for. - the consumer s SSN is invalid. - the consumer s SSN has been switched with their Medicaid id or pin number. - the consumer is not a valid PSA6 consumer. - the provider agency is not a valid PSA6 agency.

112 Correcting MW Error Exceptions Reports Verify the consumer and the provider agency is a valid PSA6 consumer or provider. Verify the enrollment span begin/end dates and correct the CIRTS entry. Verify the consumer s correct SSN and work with Frank Wagoner, Director of MIS to correct.

113 Lead Agency Response To facilitate the Reconciliation Process: The following codes should be used in the report to indicate what action was taken: 1. CIRTS Data Error - CIRTS was corrected - use "CC" 2. Invalid claim - Claim was voided - use "CV" 3. Invalid ALF claim - Claim should be voided - use "ACV *for ALF s but lead agency must still notify them of the exception Indicate the claim Transaction Control Numbers to reference voided claims, and Fax a copy of the voided claim to the MWS as documentation.

114 KEEP IN MIND Even if, your Lead Agency is not the responsible provider, you still must notify the appropriate individual service provider of what action to take. - WHY??? Because you hold the consumer s case file and care plan, which governs when, which and how services are to be provided. Request WCFAAA Medicaid Waiver Specialist assistance only if that provider resists correcting the claim or claims as requested.

115 Resources CIRTS User Guidelines APS Operational Manual Performance Outcome Measure Overview reports and of course WCFAAA Staff

116 QUALITY QUESTIONS?