Welcome The Freedom to Succeed

Transcription

1 Welcome The Freedom to Succeed Liberty Healthcare PCS Provider Training May 2016

2 AGENDA 9:00-9:15 am Welcome and Introductions Denise Hobson, Director of Clinical Services Liberty Healthcare 9:15-9:45 am Review of PCS Policy Requirements 9:45-10:40 am Understanding the Beneficiary s Assessment Lyneka Judkins, Chief Operations Officer Liberty Healthcare Denise Hobson, Director of Clinical Services Liberty Healthcare 10:40-11:00 am Break 11:00 11:15 pm Proposed Policy 3L and Eligibility Updates Lyneka Judkins, Chief Operations Officer Liberty Healthcare 11:15 11:30 am Internal DMA Audit Lyneka Judkins, Chief Operations Officer 11:30 12:30 pm Q&A Session Liberty Healthcare 2

3 Review of PCS Policy Requirements (Interactive Presentation) The Freedom to Succeed

4 Test Your Knowledge 4

5 PCS ICD-10 Transition Forms When is an ICD-10 Transition Form required for a beneficiary? Before their annual review if scheduled after 10/1/2015 What are the two ways a provider may submit the transition form to Liberty? Fax or Upload into QiReport Where are the 3 places a PCS Provider can locate an ICD-10 Transition Form? DMA Website, LHC Website, Annual Notification Letter 5

6 PCS ICD-10 Transition Form Completed forms can be submitted to Liberty in one of two ways: Fax The PCS Provider or Practitioner can fax the form directly to Liberty at Upload The PCS Provider can upload the completed form to Supporting Docs through the provider portal. 6

7 PCS ICD-10 Transition Form To upload the Transition Form through the provider portal, select the Referrals tab on the top toolbar, then click Supporting Docs from the left index bar: 2. Select Supporting Docs to upload form. 1. Select the Referrals tab. 7

8 PCS ICD-10 Transition Form Where is the DMA 3137 PCS ICD-10 Transition Form located? 1. Liberty website: 2. N.C. Division of Medical Assistance (DMA) PCS webpage under Forms. 8

9 Completing the Service Plan How many days does the PCS Provider have to complete the required Service Plan? 7 Business Days How many days does the PCS Provider have to get the completed Service Plan signed and uploaded into QiReport? 14 Business Days When is a Service Plan required for a beneficiary? Every time a PCS Provider receives and accepts a referral in QiReport How should the PCS Provider proceed when the amount of approved hours does not match the hours reflected in the assessment? Complete a manual Service Plan, upload into QiReport, and Call Liberty 9

10 Discharges How many days does the PCS Provider have to complete a discharge when the beneficiary is no longer under their care? 7 Business Days How does a PCS Provider discharge a PCS beneficiary? Through QiReport If the beneficiary is not approved for PCS that is reimbursed by Medicaid, but remains under the care of the PCS Provider, do they have to discharge in QiReport? Yes. Does the PCS Provider need to discharge a beneficiary if they are hospitalized for a brief time? If the beneficiary has been approved for PCS and the PCS Provider will resume care once the beneficiary is discharged from the hospital, then a discharge is NOT required in QiReport 10

11 Discharges The PCS Provider is required to discharge a beneficiary from QiReport if they are no longer providing PCS that is reimbursed through Medicaid. 2. Select Discharge to discharge beneficiary. 1. Select the Referrals tab. 11

12 Provider Acceptance How many days does the PCS Provider have to respond to a referral for PCS? 2 Business Days What happens if the PCS Provider does not respond in 2 business days? The referral will be rejected and the next provider selection will be sent a referral Where can the PCS Provider locate their referrals and respond? In QiReport on the Referrals page Does the time the PCS Provider takes to accept a beneficiary effect their PA s? Yes. PA s are made effective based off of the provider acceptance date, with exception of initial assessments. 12

13 Provider Acceptance The PCS Provider should check their Referrals tab daily for any new PCS referrals. 2. Select beneficiary to accept/reject. 1. Select the Referrals tab. 13

14 Preadmission Screening and Resident Review (PASRR) Who requires a PASRR screen? Any Medicaid beneficiary seeking admission into an Adult Care Home after January 1, 2013; including those who are private pay and become Medicaid eligible after this date. Who does not require a PASRR screen? Any individual who was admitted into the Adult Care Home prior to 1/1/2013 regardless of payer, private pay individuals, and those who reside in the 5600 A or C settings What is the purpose of the PASRR screen? To evaluate for serious mental illness If a beneficiary is transferred from a nursing home to an Adult Care Home and has a PASRR with an A code, do they require another PASRR? Yes; the beneficiary must have a PASRR with an Adult Care Home code. 14

15 Preadmission Screening and Resident Review (PASRR) The following are acceptable Adult Care Home Codes for PASRR: 15

16 Quality Improvement Program What form is required to be completed and submitted to DMA? DMA 3136 Internal Quality Improvement Program Attestation Form The DMA 3136 Form is required to be submitted by what date? December 31 st of each year 16

17 Quality Improvement Program What are the requirements for the PCS Provider regarding an Internal Quality Improvement Program? Develop, and update at least quarterly, an organizational Quality Improvement Plan or set of quality improvement policies and procedures that describe the PCS CQI program and activities; Implement an organizational CQI Program designed to identify and correct quality of care and quality of service problems; Conduct at least annually a written beneficiary PCS satisfaction survey for beneficiaries and their legally responsible person; Maintain complete records of all CQI activities and results; 17

18 Understanding the Beneficiary s Assessment

19 Where It All Starts.. PCS request is dropped in QIR queue for scheduling Scheduling schedules visit with the beneficiary and time and date are established Assessor receives the assignment and contacts beneficiary the day before to confirm appointment Assessor conducts the assessment based on the beneficiary s demonstrated ability to perform ADLs Assessor submits the assessment and a decision generates 19

20 What The Assessor Captures In An Assessment Available caregivers Daily medicine regimen Diagnosis information Paid supports/non Paid supports Demonstrations of a beneficiary s ability to perform their activities of daily living (ADLS) 20

21 What The Assessor Captures In An Assessment Special assistive tasks Exacerbating conditions that impact their ability to perform their ADLs Home safety evaluation Provider choice Need frequency 21

22 Activities of Daily Living (ADLs) Bathing Dressing Mobility Toileting Eating 22 22

23 Understanding Assessment Fields Demonstrated Ability Beneficiary attempts to demonstrate how they would perform an ADL task. Check If Required Assistance Level IADL Task Needs Frequency Need Fully Met PCS Need Frequency Weekend The beneficiary requires assistance to complete task. Level of assistance the beneficiary requires to complete the task. Identified if there is an assistance need for the indicated ADL. Number of days the beneficiary performs the task. Number of days the beneficiary has an alternate caregiver other than the PCS aide to assist with meeting the need. Auto-populated number of days of unmet need for PCS service. Task need is inclusive of weekend need. 23

24 24

25 Bathing: What Is Assessed? A beneficiary s ability to demonstrate/perform the following tasks: Bathe by means of shower, tub bath, bed bath,or sponge bath Hair care - shampooing and combing hair Nail care - cleaning/cutting nails Skin care - applying lotion/washing hands and feet Mouth care - brushing teeth, dentures etc. and reinserting Shaving - face, legs, axilla (armpit) areas 25

26 Bathing Section 26

27 Dressing: What Is Assessed? A beneficiary s ability to demonstrate/perform the following tasks: Don clothing/socks/shoes Remove clothing/socks/ shoes Manage clothing and shoe fasteners Manage TEDS (compression stockings) - removing and applying Manage splints/bracesremoving and applying Manage - removing and applying Manage prostheticsremoving and applying 27

28 Dressing Section 28 Factoid: TED is an acronym for thromboembolism-deterrent hose!

29 Mobility: What Is Assessed? A beneficiary s ability to demonstrate/perform the following tasks: Transfer to/from the bed Transfer to/from chair Ambulate room to room by limb or assistive device Negotiating stairs within the home only to areas of service provision Perform range of motion (ROM) Turn and reposition in bed 29

30 Mobility Section 30

31 Toileting: What Is Assessed? A beneficiary s ability to demonstrate/perform the following tasks: Remove /pull up/ fasten garment Perform hygiene after toileting/incontinence Transfer to and from the bedside commode or toilet 31

32 Toileting Section 32

33 Eating: What Is Assessed? The beneficiary ability to demonstrate/perform the following tasks: Cutting food Ability to feed self Use of utensils Ability to lift limb to mouth Ability to perform tube feedings Ability to clean meal service area Clean utensils/dishes/empty trash Perform meal prep: opening packages Perform meal prep: heat and assemble food 33

34 Eating Section 34

35 Special Assistive Tasks: What Is Assessed? A beneficiary s ability to demonstrate/perform the following tasks: Break up fecal impactions IV fluids O² therapy Ostomy Sterile dressing changes Suctioning Urinary catherization Wound irrigation Tube feeding and g tube management 35

36 Delegated Medical Monitoring Tasks A beneficiary s ability to demonstrate/perform the following tasks: BP monitoring Blood glucose monitoring Med self-administration reminders Other treatment monitoring IV fluids 36

37 Delegated Medical Monitoring Tasks 37

38 Special Assistive Tasks Section 38

39 Conditions Affecting Beneficiary ADL Performance/Assistance Time Exacerbating conditions or conditions affecting ADL performance allow the assessor to identify those that affect the beneficiary s ability to perform their ADLs. All body systems are covered in these conditions: Respiratory System Cardiovascular Gastrointestinal Neurological Behavioral Sensory Impairment, and Musculoskeletal system 39

40 Conditions Affecting ADL Performance Time 40

41 Safety And Environmental Conditions 41

42 Provider Choice /Return Frequency 42

43 How Does The Beneficiary Qualify For Services? The beneficiary must have: At least 3 Limited Overall Self -Performance Capacity Ratings out of the 5 ADLs and have unmet needs. At least 1 extensive or greater overall self performance capacity and one or more limited assist or greater overall self performance capacity and have unmet needs. 43

44 How Many Hours Can A Beneficiary Receive? 80 Hours For a beneficiary who does not meet the criteria for Session Law Hours EPSDT on the initial assessment hour generation. All EPSDT assessments go to DMA for final hour calculation/evaluation Up to 130 Hours For a beneficiary who meets the criteria for Session Law

45 BREAK

46 Proposed Policy 3L and Eligibility Updates

47 Proposed Policy 3L & Eligibility Updates Policy 3L has been revised and will be open for public comment; The proposed policy will be located on the DHHS website here: Finalized changes will go into effect July 1, 2016; Questions about proposed changes should be submitted through the public comment page or via at 47

48 Proposed Policy 3L & Eligibility Updates Section Medicaid not covered specific criteria Medicaid shall not cover PCS when: 13. Independent medical information does not validate the assessment, PCS hours may be reduced, denied, or terminated based on the additional information. *13. added to existing Medicaid not covered specific criteria. 48

49 Proposed Policy 3L & Eligibility Updates Section EPSDT Additional Requirements for PCS Medicaid may authorize services that exceed the PCS service limitations if determined to be medically necessary under EPSDT based on some or all of the following documents submitted by the provider before PCS is rendered: a. Work and School verification, where applicable, for the beneficiary s caregiver, legal guardian, or power of attorney.. b. Verification from the Exceptional Children s program per county if PCS is being requested in school setting; or c. Health record documentation or d. Physician documentation of primary caregiver s limitation that would prevent the caregiver from caring for the beneficiary, if applicable. e. Any other independent records that address ADL abilities and need for PCS. If additional information does not validate the assessment, PCS hours may be reduced, denied, or terminated based on additional records. 49

50 Proposed Policy 3L & Eligibility Updates Section Requirements for PCS Expedited Assessment Process To qualify for the expedited process the beneficiary shall: a. be medically stable; b. eligible for Medicaid or pending Medicaid eligibility; c. have a Pre-Admission Screening and Resident Review (PASRR) if seeking admission to an Adult Care Home licensed under G.S. 131 D-2.4; d. in process of being discharged from the hospital following a qualifying stay; e. in process of being discharged from a skilled nursing facility; f. be under adult protective services; or g. be an individual served through the transition to community living initiative *LME MCO transition coordinators are responsible for requesting the expedited PCS process for individuals served through the transition to community living initiative. 50

51 Proposed Policy 3L & Eligibility Updates Pettigrew v. Brajer (Pashby v. Wos) PCS will be amended to include additional program requirements agreed upon in this settlement; identified action items include: Updates to Eligibility Criteria Implementation of a Reconsideration Process Reinstatement and Reassessment of Qualifying Individuals 51

52 Proposed Policy 3L & Eligibility Updates Pettigrew v. Brajer (Pashby v. Wos) Updates to Eligibility Criteria: The Settlement requires that DMA will assure the PCS eligibility criteria is the same regardless of residential setting. In Adult Care Homes clean-up and basic meal preparation tasks are covered services paid for by State/County Special Assistance. Effective July 1, 2016, clean-up and basic meal preparation services that duplicate State/County Special Assistance (Section M, tasks 6-9 on the assessment) will be scored as needs met. 52

53 Proposed Policy 3L & Eligibility Updates Pettigrew v. Brajer (Pashby v. Wos) Implementation of a Reconsideration Process: Beneficiaries 21 and older who receive an initial approval for less than 80 hours per month may submit a Reconsideration Request to the IAE if they do not agree with the initial level of service determined. Section 5.6 Reconsideration Request for Initial Authorization for PCS 53

54 Proposed Policy 3L & Eligibility Updates Section 5.6 Reconsideration Request for Initial Authorization for PCS When is reconsideration appropriate? The request for increasing hours above the initial approval are not based on a Change of Status; The beneficiary is able to provide supporting documentation that specifies, explains, and supports why additional authorized hours of PCS is needed and which ADLs and tasks are not being met with the current hours. *Form and instructions will be made available on the DMA website. 54

55 Proposed Policy 3L & Eligibility Updates Section 5.6 Reconsideration Request for Initial Authorization for PCS The Process: 1. After receiving an initial approval for an amount of hours less than 80 hours per month, a beneficiary must wait 30 days before submitting a request for reconsideration. 2. The beneficiary must submit a request to increase hours above the initial approval no earlier than 31 calendar days and no later than 60 calendar days from the date of the approval notification. 3. The Request for Reconsideration form and supporting documentation should provide information indicating why the beneficiary believes that the prior assessment did not accurately reflect the beneficiary s functional capacity or why the prior determination is otherwise insufficient. 55

56 Proposed Policy 3L & Eligibility Updates Section 5.6 Reconsideration Request for Initial Authorization for PCS The Process: 4. Upon receipt of a completed reconsideration request for additional hours, a reassessment may be scheduled or the previous assessment modified. A reconsideration request is not considered complete without supporting documentation as indicated in 5.6(d). 5. If the reconsideration determines a need for additional PCS hours, additional hours will be authorized according to Policy. This constitutes an approval and no adverse notice or appeal rights are provided. The provider will have to complete a new service plan. 6. If the reconsideration determines that the PCS hours authorized during the initial assessment are sufficient to meet the beneficiary s needs, an adverse decision will be issued with appeal rights. 56

57 Proposed Policy 3L & Eligibility Updates Pettigrew v. Brajer (Pashby v. Wos) Reinstatement and Reassessment of Qualifying Individuals: Those denied or terminated under Clinical Coverage Policy 3L, prior to the amendment effective 7/1/16 whom: Were determined to have cognitive impairment or a mental health diagnosis with no third party present during the assessment; and Were denied or terminated due to receipt of hospice services. 57

58 Proposed Policy 3L & Eligibility Updates Pettigrew v. Brajer (Pashby v. Wos) Qualifying Individuals for Reinstatement or Reassessment will be: Sent a letter with instructions on how to begin the process; If previously terminated from PCS, reinstated at the hours prior to termination (will be reassessed within 6 months under PCS policy effective 7/1/2016); If previously denied PCS, reassessed under PCS policy effective 7/1/

59 Proposed Policy 3L & Eligibility Updates Pettigrew v. Brajer (Pashby v. Wos) Reinstatement and Reassessment of Qualifying Individuals, the PCS Provider must: Accept the referral from the beneficiary once the reinstatement is processed; and Provide Medicaid with a PCS ICD-10 Transition Form before the provider can bill Medicaid for your PCS services. However, this does not need impact effective start days for services. *Providers may see the beneficiary displayed in their portal, but services should not begin until after formal acceptance and delivery of an approval letter. 59

60 Provider Manual New Version Coming July 2016! Located on the Liberty Healthcare website at: Will include all new policy updates in addition to a few revisions. 60

61 PCS Internal Audit The Freedom to Succeed

62 PCS Internal Audit In spring of 2015, PCS underwent an internal audit conducted by Office of the Internal Auditor (OIA). This audit was concluded in July of Two areas of concern identified by OIA were Supervisory Visits and Aide Training requirements. As a result of the PCS program internal audit, DMA began conducting audits of PCS providers in January

63 PCS Internal Audit The PCS internal audit is an independent audit conducted by DMA PCS nurse consultants and is not associated with DMA Program Integrity (pre or post-payment review). Although, this audit process is independent from Program Integrity; audit findings that are non-compliant with the PCS policy will be reported to DMA Program Integrity. 63

64 PCS Internal Audit Process PM Receives random sample of Beneficiaries for identified Month DMA verifies Provider Fax Number and Contact Information Forwarded to DMA Staff Faxed to DMA within 5 Calendar Days by Provider DMA Requests by Fax specific documents from Provider for RN Supervisory Visits and PCS Aide Training DMA Completes QI Parameter Review Tool for each Beneficiary in sample Results will be documented internally by DMA PM Review of Provider Compliance DMA will follow up with the Provider for any missing documentation Faxed to DMA within 2 Calendar Days by Provider Providers determined not in Compliance submitted to PI Providers may request the results of their audit two weeks after submission of documentation 64

65 PCS Internal Audit DMA will conduct the PCS internal audit on a quarterly basis; randomly selecting between beneficiaries each quarter for review of Supervisory visits and/or Aide Training Requirements. Providers will have five (5) calendar days from the date of contact to submit documentation via fax to DMA. Providers are contacted via telephone call with a follow-up fax sheet that requests required documentation. 65

66 PCS Internal Audit Documentation on Supervisory visits will be audited based on PCS Clinical Coverage Policy Section 7.10 b. (1-9). Documentation on Aide Training Requirements will be audited based on PCS Clinical Coverage Policy Section (a g). Providers must submit corresponding aide task sheet for date requested by DMA staff. * Aide Training documentation requested for residents who reside in an Adult Care Home will be requested for first shift aides on the date requested. 66

67 Question and Answer Session

68 The Freedom to Succeed Liberty Healthcare PCS Provider Training May 2016