Opportunities for those who stress Compliance at the Start

Transcription

1 Opportunities for those who stress Compliance at the Start

2 Current Medicaid Audit Environment Risk Areas Service Content Medical Necessity Facility designation Documentation Copyright: Mary Thornton & Scott Migdole

3 Partial hospital programs - 80 to 100% denial rates 1980 s and 1990 s Rehabilitation option West Virginia series 70% and up denials - Abraxas: 1995 Georgia internal state audit led to rate changes and external ASO 1990 s Medicare outpatient almost 20% of medication management up to 50% of group therapy Rehabilitation option 2004 & 2005: Iowa adult services 100% error rates, kids lower 3

4 This is often the only information we get on the opinion of the federal government often their audits are content based What about internal state audits (from a provider s perspective): Focus on network maintenance in some cases financial viability Not necessarily rigor of an extrapolation Is it there audits Can be a confusing message compliance vs maximization of Medicaid dollars 4

5 The DRA Requires any provider who gets bills more or pays out more than $5mm must have a compliance program as of January 1, Condition of payment Going from suggestion to mandate Provider put on notice that they are on their own no degrees of separation between you and federal Medicaid Lots of money to investigators Splitting you vs your staff Similar to Medicare efforts 5

6 The OIG s Work Plan 2005, 2006: resurgence of BH issues continues today Inpatient Outpatient Rehabilitation services Outpatient Alcoholism More See handout 6

7 What is a false claim? Actual false claims False information that results in payment decisions that are inappropriate Conditions of payment Quality of care DRA requirements Looking for patterns: Numbers of claims Infrastructure and internal controls Fines and penalties, possibly exclusion

8 no proof of specific intent to defraud is required if a person: has actual knowledge of the information; acts in deliberate ignorance of the truth or falsity of the information; or acts in reckless disregard of the truth or falsity of the information; and Whistler-blower provisions

9 Everything that is therapeutic is not billable Remember Medicaid is like any other insurance it only pays for covered services Active treatment vs custodial care and oversight 9

10 To become a Medicaid provider you must meet certain criteria: Conditions of payment vs. service specific claims Certifications are implied in each claims 10

11 Medicaid and Medicare are both highly regulated and now highly enforced business environment. Medical model still reigns States push towards resiliency and recovery must be made within the confines of Medicaid/Medicare Baby steps PCPs but all in rescinded rules

12 Building an accountability structure Your actions now impact both current revenue and future audit risk Be clear about the culture of the organization don t fool yourselves clear up misunderstandings. Know your compliance officer 12

13 Remember your name is going on the bill All the rules that you follow actually protect you. The government does assess: Individual actions Corporate support of compliance Supervisor attention, supervision, and infrastructure development. 13

14 Understand the definitions of the services you provide and bill for Medicaid and Medicare are built on codes Billing may need to change codes to meet the payers software requirements but the medical record should be complete and accurate Do not bill for services you do not believe are covered services Accuracy is incredibly important consistent sloppiness can be viewed as deliberate flaunting of the requirements Timeliness is critical see handout Read the regulations always Use your supervisor or the compliance officer 14

15 The New Landscape in 2009

16 Shared cost federal, state, and county Two, possibly three opinions on quality and content of services Greater emphasis right now at federal level on cost savings Copyright: Mary Thornton & Scott Migdole

17 GAO: Fraud efforts are uneven Laws do not exist to prosecute as Feds would like Investment in investigating arms is inadequate given the risk Rules are different in each state making national coverage decisions and enforcement appear to be difficult Providers implementation of compliance efforts appear to be inadequate given audit findings Medicaiding services and other financing schemes particularly true in child welfare refinancing. 17

18 Hundreds of millions to enforcement and oversight Not just fraud any longer Big emphasis on improper payments Provider based audits as apposed to solely state based audits Extrapolation by provider, rather than by state.

19 State Responsibilities Federal Responsiblitiies Medicaid Fraud/Program Integrity Units within program Medicaid Fraud Control Units Miscellaneous 1. DMH/DMR Audit 2. County Audits 3. State Contoller RAC Auditors Perm Audits Medicaid Integrity Program OIG Audits 1. Often under funded. 2. No clear guidelines re: referrals differ by states. 3. Referrals out to MCFU s differ greatly by state 4. Provider focus 1. Funding greatly different by state. 2. Usually significant return on investment. 3. Provider focus. 4. Usually state attorney general. 1. Vary by state 2. Some takebacks -usually no extrapolation. 3. Look at state and provider. 1. Going nationwide by Tax Relief and Health Care Act 3. bounty hunters on contingency ROI 1. Medicaid error rates 2. Medical necessity, eligible for Caid, correct claim 3. Provider focused 4. Error rates >2.5% to Congress 1. Audit of providers state must require payback only appeal is by state 2. Audit and report card to state about program integrity ROI 1. OIG workplan 2. Lots more money for Caid In about 10 states these functions being centralized under a Medicaid Inspector General ROI State False Claims Acts Federal Oversight/ Error Rates, Required Paybacks, Report Cards DRA Whistleblower provisions Providers Mary Thornton & Associates, Inc. Compliance program DRA Book decisions Internal Education Watch for state activity Watch FCA and internal culture Pay back when you find errors Self-disclosure if necessary Be clear who is asking for what Watch for new patterns of denials Don t focus only on Medicaid mt ho rn to m ar yt ho rn to n. co m

20 Issues: Contractors must learn on their own Most audits will be desk audits Requests will come on the contractors letterhead may end up with a CMS cover letter but not yet WATCH for these requests In some cases identifying consumer only by Medicaid # Will sample be vigilant about sampling if No limits on numbers of records that can be requested they will not pay for copies Illinois has a very short window for appeals Make sure you have a process in place!!! They will not be posting audits can we get information from providers even redacted?

21 Behavioral Healtth Services Copyright: Mary Thornton & Scott Migdole

22 Service failures vs. documentation failures vs Quality Documentation: only tangible proof of our interventions Historically: documentation standards low; purpose was to speak to treatment team; some liability issues Now: competing pressures and new risks: Payer demands high value on its timeliness and accuracy Consumer and Privacy demands HIPAA encourages access by person you are treating so it must be understandable pressures from PCP to use more of client s own words vs medical model; lots of documentation completed by paraprofessionals. EMR s: cloning ; copy and paste 22

23 Service content Big problem in the recent audits Services not directed to the exclusive benefit of the client Non-covered services Integrated services: unbundling difficult Milieu questions Non-specific services 23

24 Will result in functional improvement that is significant to the client s ability to perform daily living tasks that are age appropriate Should be able to be achieved in a reasonable amount of time Changes in components of function that do not have an impact on the client s ability to perform age appropriate tasks are not covered *Michigan Regs 24

25 Therapy must be a skilled intervention Medicaid must be payer of last resort Must be medically necessary *Michigan Regs 25

26 Courts: Who s decision trumps? Can a judge order a client into a Medicaid reimbursed service? Do issues like willingness to participate, ability to participate, medical necessity still matter? Impact both in mental health and in substance abuse TRIS audit and juvenile justice issues 26

27 Who is responsible for what? Medicaid appears to be reaching its limits note in new regulations great concern with duplicate services that are intrinsic to other funded services New Rule Rehab: intrinsic element Case Management Definition 27

28 Medicaid does not consider the family to be a unit/individual for treatment purposes. Services must be directed exclusively to the individual who has the diagnosis and who s Medicaid number is on the claim Indirect benefit to the individual is not enough Parent issues particular focus 28

29 consultation with other family members can be a necessary part of planning and providing care to patients in need of psychiatric services. Consultation can, however, devolve to a point where it becomes a means of treating others rather than, or in addition to, the primary recipient. Medicaid would not reimburse for services provided to ineligible family members for treatment of their problems not related to the treatment of the Medicaid patient. In addition, Medicaid would not reimburse for family psychoeducation classes unless tailored specifically toward the Medicaid beneficiary. Definition CM and Rehab confirm this as well 29

30 Primary purpose of the therapy must be the treatment of the client s condition Family treatment is the process of family participation in the treatment process of the client. Not for treating family or family members other than identified client Not for history taking or coordination of care Expect to see intervention in the family in order to change or modify the structure, dynamics and interactions that act on the client s emotions and behavior. 30

31 Therapy: Is it actually therapy and do you know? Is there a therapeutic strategy? Is the there evidence that the therapeutic strategy is appropriate and being implemented? Is there evidence that the cognitive abilities of the therapist are being used? Is the consumer responding to the therapeutic interventions? How? 31

32 Iowa Adult Audit: In addition, section 4385(B) of the State Medicaid Manual states that although a social service, in the course of addressing an individual s basic life needs (adequate food, housing, or income), may indirectly affect the individual s health as well, it is not covered under Medicaid because it is not directly and primarily concerned with the individual s health. 32

33 Helping client with homework: social service Linkage to tutor: case management/ community support Teaching client/family to advocate for special teacher attention: case management/community support Teaching client/family how to organize and manage responsibilities re: schoolwork: skill building (rehabilitative)/community support 33

34 Going with client to basketball game: friend, Big Sister/Brother Linkage client to YMCA: case management/ community support Teaching client/family to apply for a scholarship to Y Camp: case management/community support Teaching client how to use bus to get to YMCA on own: skill building (rehabilitative)/community support 34

35 Purely recreational and socialization not covered by Medicaid Therapeutic recreational possibly but mental health goal must be clear Why is this the best or only vehicle for skill development? What is clinical outcome? Opportunities to socialize not covered Meals and other social settings must be examined for medical necessity Documentation is sophisticated and subtle This is reiterated in the new regs as well Monitoring of a client activity not covered in FFS 35

36 Parenting skills Normal developmental goals or benchmarks 36

37 Black box warnings NY OMIG - any kid under 14 on antipsychotics Medication cocktails Parent abuse and understanding of meds % of kids in program on meds Does not mean you cannot do it but it requires extra documentation.

38 Milieu: non-covered except in PRTF, considered to be custodial care (watch this in day programs as well) Contracts have separate payments for room and board and treatment Medicaid will challenge the relative costs of Medicaid vs. room and Board 38

39 West Virginia Audit: Between 8:00 AM and 11:00 AM, client was transported to dentist s office for fillings. The client showed positive behavior by following rules, regulations, staff directions, and cooperating with the dentist and his staff. The staff gave the client positive verbal and written feedback and the client thanked the staff for the positive feedback. Units of Service: 6 Dollar Value: $

40 West Virginia Audit: services did not appear to be therapeutic activities that focus on basic living skills or services designed to improve or preserve a recipient s level of functioning as required by the state plan. Rather, the services represented observations and monitoring of client activities, not medical or remedial services. 40

41 Risk Areas

42 Managed Care PMPM payment for: Penetration Access Service array Medical necessity Utilization management to produce outcomes Reasonable costs

43 Asst US Attorney, Jim Sheehan Factors the government looks at in determining denial or unavailability of services is fraud: 1. Representations made to beneficiaries by the plan, physicians, sales reps, contractors, plan documents, and customer service reps. 2. Internal records, specifically UM and tracking by practice, demographic group, subscriber and outcome. 3. Accounting and actuarial systems that show where the plan makes its money. 4. Threats, inducements, bonuses, and recognition. 5. Measurement of quality outcomes.

44 Asst US Attorney, Jim Sheehan 6. Institution and practice comparative records, which may reveal that statistically similar patients are treated differently 7. Frictions and conflicts (such as malpractice litigation) with subscribers, providers, regulators, accrediting agencies, and competitors.

45 Managing the Risk

46 Is it there is usually the first order as we discussed in the Revenue Cycle section Minimum elements national standards: Is there a complete and accurate note Is there a current and appropriately signed treatment plan New developing standards: Is it a clone? Copy and paste? Is there a current assessment that provides evidence of eligibility at federal level seem to be looking for an assessment that is not longer than one year old. HIPAA standards: security and privacy both Medication management: vitals, BMI, labs, etc.

47 What is there is second: The provider must know what they intend to do at each visit s/be on treatment plan both intervention and expected outcomes of interventions Treatment, Rehab or Case Management Treatment: reduction of symptoms, lowering of distress Rehab: ability to achieve or manage a sought after role through increases in functionality and supports Case Management: linkage to supports and services

48 The Golden Thread: Assessment: diagnosis, treatment, rehab, and case management needs not necessarily detailed at the first meeting or in the first treatment plan Treatment Plan: road map specific, measurable, outcome oriented, and changing in response to provider interventions and client s level of commitment and work towards their own recovery. Progress notes: documentation of both service and intent of service from the treatment plan; meet definition of service and medically necessary.

49 The Golden Thread: Forms help but not necessarily all that much in the end it is all about content

50 1. It treats a mental health condition/illness or functional deficits that are the result of the mental illness CM addresses functionality 2. It has been ordered or prescribed credentials critical 3. The service should be generally accepted as effective for the mental illness being treated. 4. The individual must be willing to participate in treatment 5. The individual must be able to benefit from the service being provided 6. There must be active treatment Copyright: Mary Thornton & Scott Migdole

51 The client has a Mental health/substance Abuse condition/illness that has produced a current problem in functional status including current signs and symptoms that interfere with functionality that can be helped by delivering the services ordered in the treatment plan. 51

52 Help can be focused on the: reduction or better management of signs and symptoms, betterment of a functional status, prevention of a worsening or maintenance of functional status, development of age appropriate functioning in a child where mental illness has prevented age appropriate functioning, or the prevention of new morbidities where they are threatened by the individual s mental illness. Copyright: Mary Thornton & Scott Migdole

53 MD other credential: diagnosis and treatment plan All others on team: on-going medical necessity through following plan and documenting services See handout: Medicare Doc

54 Legibility Modifications or additions must follow agency rules very specifically Timeliness Accuracy: dates, times, signatures Must relate to a service ordered on treatment plan Must relate to a focus or issue listed for that service on the treatment plan Must describe what you did with the client 54

55 There is adequate content for time billed (can t have one sentence for a 3 hour service) The client is responding to the treatment: are they participating and are they benefiting? Is an appropriate treatment strategy being implemented? Copyright: Mary Thornton & Scott Migdole

56 CEOs: read your medical records not all just some do you really understand what services are being provided and the level of sufficiency of the documentation? You must do this in order to understand the level of resources that must be directed towards compliance. CEOs and QA and Compliance: if you were not a clinician would the treatment plan be detailed enough so that you could figure out what to do at each meeting and what you were supposed to accomplish? Compliance and QA: work together no silos at all Develop your Is it there plan make sure it is tight.

57 If your record reviews are bad: start training and stop auditing until you have people trained. This is a process not an event. Think about how training and on-going tools will support your efforts Develop an audit plan do not outrun your resources this is another process. Work with your finance department on paybacks and start doing and tracking it. Develop a formal compliance program Hope you are overlooked in first round

58 Mary Thornton