Provider Point of Contact (POC) Designation: 1. How will we identify the designated contact person to whom we will send a request letter? The contact person will be the individual who is currently listed in the DMAS provider file. If a provider would like to change this individual they may do so. (Roanoke 25) Provider Survey: 2. Is the survey to be completed with current data or data from SFY 08? The intent of the survey is to collect current provider information. Information provided will trigger a utilization review (Fairfax 7) Provider/ Case/Claim Selection: 3. How will cases be selected within the 10%? Cases will be selected based on data analysis and data mining criteria such as patient growth, intensity of services per patient, patient discharge trends, episode of care attributes and potential billing errors. (Roanoke number 1) 4. Is the list of recipient and documentation to be reviewed forwarded in the letter notifying the provider of the On-Site review? The lists of recipients to be reviewed will be given to the providers at the entrance conference when HMS arrives to conduct a scheduled On-Site review. (Fairfax 8) 5. Even though KePro has issued a PA for medical necessity will HMS review the case again for medical necessity? The review by HMS of a case that has already been authorized by KePro will focus on whether there is documentation of an authorization number and whether the documentation provided to KePro is corroborated within the medical record. KePro PA approvals may be for an extended period of time. It is the provider s responsibility to continue to provide service only when they are medically necessary. (Roanoke 2 ) 6. Will more than one service type be reviewed at the same time? This may occur. (Roanoke 16) 7. Will HMS ever review more than a 10% sample, and will extrapolation be utilized if a larger issue is identified. Situations may occur where initial findings suggest the need for an expanded review scope. In these situations, HMS will work with DMAS to determine the appropriate expansion scope and next steps. The use of extrapolation is used by DMAS. (Virginia Beach)
8. Can you explain how the providers are paired with the data mining process? Among their peers, they are compared with regard to patient growth, intensity of services per patient, patient discharge trends, episode of care attributes and potential billing error indicators. (Webinar 8-26-09) 9. If someone has Medicaid as secondary insurance are they eligible for review? These reviews will not be excluded. 10. Are psychological testing/assessment eligible for review? Under psychiatric services, this diagnostic code may be selected for review. DOS Range of Claims to be Reviewed: 11. Clarification was made regarding the SFY 08 review period- Claims will be reviewed with patient DOS from 7/1/07-6/30/08. (Roanoke 20) 12. If you have a case that is covered by both DMAS criteria and criteria that does not meet DMAS criteria, but has been paid for by CSA funding, will you look at both files? DMAS and HMS will only review the claims paid by VA Medicaid. The FAPT and localities can agree to fund IIH. We have no authority to review how CSA or FAPT funds care. (Webinar 8-26-09) 13. If a program began on Nov. 2008, will it be audited? Initial reviews are focused on fiscal year 2008, which covers dates of service from July 1, 2007 through June 30, 2008, so programs beginning in November 2008 would most likely not be part of this initial review scope, unless referred or recommended by DMAS (Virginia Beach) Frequency of Reviews/Overlap of Other Reviews: 14. Will reviews be duplicated, that were conducted for SFY 08 by Clifton Gunderson and/or DMAS? Providers will only be reviewed once per year, per service and those already reviewed by Clifton Gunderson and/or DMAS will not be selected to be reviewed by HMS for this upcoming audit year. (Fairfax 1) 15. Will HMS review providers beyond the SYF 08 time frame? HMS has contracted with DMAS for three years so the assumption is yes. (Fairfax 5) 16. Will DMAS continue to perform reviews or will they stop now that HMS will be conducting review? DMAS will continue to review providers as they have in the past. DMAS needs additional manpower to perform needed reviews thus has contracted with HMS. (Roanoke 5) 17. If a provider has already been audited this year will they be audited again? A provider will be audited only once a year unless a need for additional review has been determined based on a complaint or quality of care issue. (Roanoke 6)
18. Will reviews include HMO clients? Service being reviewed that is carved out of Medicaid HMOs may include HMO clients.. (Roanoke 10) 19. Will HMS be identifying underpayments as well as overpayments? Underpayments will not be listed on findings reports; reviewers will identify situations to providers so that they can correct billing errors. (Roanoke 13) 20. Regarding the interaction of services, if it is unknown that another provider is providing IIH, specifically CM, is there any insight regarding who would be retracted - the IIH or the CM agency? CM is inherent in IIH so CM should not be billed separately and although the providers should coordinate with each other, the retraction will be from the CM agency (Webinar 8-27-09) 21. Will these audits be similar to the RAC audits? No The RAC program audits Medicare claims for (primarily) inpatient hospital stays. (Roanoke 23) 22. Who will be conducting the Psychosocial Rehabilitation and Case Management reviews? DMAS will continue to conduct these reviews. (Richmond 2) 23. Will HMS and DMAS be reviewing services together? HMS is augmenting DMAS efforts. (Richmond 4) 24. Will reviews by Clifton Gunderson and DMAS be duplicated? No (Richmond 5) 25. We provide four of the services and two of them have been reviewed this year. Does this mean that the other two may be reviewed? Yes (Richmond 6) 26. Will the CSBs be targeted since they serve the most severely mentally ill populations? No, the CSBs will not be specifically targeted. All providers have the same chance for selection for review based on consistently applied data mining criteria. (Webinar 8-26-09) 27. Will DMAS continue to review for other services, such as Case Management? Yes (Webinar 8-26-09) 28. Is a recipient eligible for review if on a Medicaid Managed Care Plan? This depends on the service provided. If the service is a carve out and not covered by the managed care plan, then the recipient may be selected for review. (Webinar 8-27-09) Desk vs. on-site Review: 29. How is it determined whether an On-Site or a Desk Review will be conducted? HMS has contracted to review at least 50% of providers On-Site and the decision regarding which type of review will be conducted will be based on geographical information, organization size, as well as data mining results. (Fairfax 2) 30. Is it possible HMS would perform both an onsite and a desk audit of the same provider at the same time? That would be unlikely. Reviews will either be onsite or desk based. (Virginia Beach)
31. Can a provider have both on-site and desk reviews at the same time or within the one year time frame? More than likely it would be one review type or the other. Based on complaints or quality of care issues, providers may be reviewed more than once per year. (Webinar 8-26-09) Retrieval/Submission of Medical Records: 32. How will records be retrieved from a school site? Will the provider be asked to go to the school to get the records or does HMS plan on going to the school themselves? This process will need to be worked out but most likely the provider would need to retrieve the records from the school so that they can be reviewed by HMS. (Roanoke 3 ) 33. Will the provider be able to request an extension in order to produce medical records? For a desk review, a provider may request a one time extension. For an onsite visit the review staff will attempt to accommodate reasonable requests, but the records will need to be provided during the onsite audit. (Roanoke 12) 34. Will the provider be reimbursed for copies made of medical records? No. (Roanoke 15) 35. What will happen if the provider has to go offsite to another building to provide the medical records? HMS will work with you but records must be provided during the on sight review. (Roanoke 24) 36. Does the provider have to be on site during the audit? Someone from the organization does need to be on-site to gather documentation and answer questions. (Richmond 7) 37. Is the contact person generally the reimbursement person? The contact person is the person identified through the First Health enrollment. This contact person may be changed by the provider through First Health. (Richmond 8) 38. Should a copy of the approved PA be kept in the documentation? This is encouraged as it will be helpful for review purposes as HMS will verify services that required PA in SFY 08. 39. What about the charts that are located off site? For example, for TDT, when the charts are located at the schools? We will work with the provider but the expectation is that the charts will be made available when on-site. (Webinar 8-26-09) Electronic Medical Record Review: 40. Do HMS reviewers have experience reviewing electronic medical records? Will they review electronically while onsite or will paper copies have to be made? HMS reviewers are experienced with electronic medical records and can perform the review in this format if the provider so chooses. (Roanoke 4 )
Documentation Related (Progress Notes, ISP, Assessment etc) Progress Notes: 41. How should the progress notes be documented to reflect actual time spent with the recipient and treatment progress? It is recommended that start and stop times should be included, as well as treatment progress on goals and objectives and session content. DMAS trains regularly on services and providers may reference training information from the DMAS Learning Network for further clarification. They may also send clinical questions to the following cmhrs@dmas.virginia.gov (Fairfax 4) 42. If during a desk review something is missing, do the providers have an opportunity to submit the missing information? The provider will have the opportunity to submit additional documentation once he/she receives the Preliminary Findings Letter. (Richmond 1) 43. Do start and stop times need to be included? This information is helpful with regard to the review of documentation but is not mandatory for CMHRS services. For outpatient psychiatric and substance abuse services, the actual length of the session must be documented. (Richmond 9) ISP: 44. Please provide clarification regarding how often an ISP needs to be reviewed, approved and signed? How does this differ from the assessment? The 5 services under HMS review have different requirements with regard to assessments, ISPs and/or POCs. The providers should refer to the DMAS Provider Manuals to ensure that they are meeting the requirements. If they still need clarification they can email DMAS at cmhrs@dmas.virginia.gov. (Roanoke 8) 45. Does an ISP have to be signed by a QMHP or a LMHP for TDT services? The ISP may be completed by a QMHP; a cosignature by the LMHP is not required. (Roanoke 21) Assessment: 46. Will the same documentation be required for onsite and desk audits? Yes. For desk audits, HMS will provide the specific documentation required in the review notification letter. (Virginia Beach)
47. We (MHS and TDT provider) are having trouble getting the LMHP to sign the assessment for reasons unrelated to the Assessment itself (for instance, the LMHP has a question on the ISP and is returning the entire package unsigned). Would this constitute an issue in the review? Providers need to be sure that the documentation requirements are being fulfilled as described and in accordance with timeframes outlined in the provider manual, and they need to work with the reviewing LMHP to ensure that the assessment is appropriately approved. (Virginia Beach) Discharge Reporting Requirements: 48. For IIH Services, what are the Discharge report requirements? The discharge plan should be incorporated in the fully developed ISP and is based on individual recipient treatment and step down plans. Please note the Intensive In Home Discharge criteria located in the Community Mental Health Rehab Services Manual, Chapter IV page 7. Also, you will need to notify KePro via a case update if you discharge the recipient before the PA time period ends. (Fairfax #3) Observance of Issues Requiring Technical Issues: 49. How will technical assistance issues be handled? Depending on the scope and severity, a Corrective Action Plan may be recommended and technical assistance issues will also be viewed as a training opportunity. (Fairfax 6) 50. How will situations regarding technical assistance be handled? Will these monies be recouped? It will depend on the type and severity of errors, some issues will be handled by providing education and money may not be recouped. (Roanoke #18) Appeals Process: 51. Will the appeals process be the same as we are accustomed to? Yes, the appeals process remains the same. (Roanoke #7) 52. What is the Fiscal Accounts Receivable Unit s phone # @ DMAS? 804-786-5433 (Webinar 8-27-09)
Staff Credentialing/Licensure: 53. Please provide clarification regarding non licensed personnel providing out patient psychiatric and substance abuse? Services and supervision by a LMHP, such as an LPC? For out patient psychiatric and substance abuse services, a LMHP needs to be onsite during the session and the progress notes must include a dated signature of both the supervisee and supervisor on the same day as the billed session. Supervision of non-licensed staff is also required. Please see the Psychiatric Service or Mental Health Clinic manuals for specifics. (Roanoke #9) 54. Will we pull personnel files to make a determination regarding staff credentials? Yes. (Roanoke #17) 55. Regarding outpatient psychiatric and substance abuse services- will we be reviewing the physicians who prescribe the services and provide med management, or the clinicians who are providing the treatment, or both? Both may be reviewed. (Roanoke #11) Medical Necessity Determination: 56. What criteria will be used for a medical necessity determination? HMS will use information contained within the DMAS Provider Manuals to make this determination. (Roanoke #14) 57. If a person is approved for IIH Services, what are some examples of what would not meet medical necessity? Please note the CMHRS DMAS Provider Manual for specific criteria guidelines. (Richmond 3) 58. Back in SFY 08 the provider manuals and regulations may have been different. Will the Reviewers use the manuals from SFY 08? The manual covering the period under review will be used. (Webinar 8-26-09) 59. With regard to the changes made to the DMAS manuals over the past years, will the HMS audits be performed according to the information provided in the manuals for that time frame? Can audit tools be given to the providers? Can the providers have access to the DMAS SFY 08 manuals? The manual covering the period under review will be used. Providers may request the manuals from DMAS if they do not have them. HMS does not plan to provide the audit tools to the provider. Prior Authorization: 60. Many providers are having billing issues due to the new PA process. Will these claims be audited? No all reviews will be based on paid claims. (Roanoke #19)
Patient Release for Information: 61. Will a provider be required to have their clients sign a release for information in order for HMS to conduct their reviews? No- DMAS has contracted with HMS and the provider has a signed provider agreement allowing DMAS or it designee to review medical records. HMS will also bring onsite with them an introductory letter from DMAS. Also the recipient in signing for acceptance of Medicaid coverage also agrees to medical record review by DMAS. (Roanoke #22). Physician Review: 62. Is Dr. Toney in active practice and board certified? Will we use other psychiatrists besides Dr. Toney? Yes, Dr. Toney is in active practice and is board certified. If additional psychiatric review is required, HMS will recruit qualified individuals (Roanoke #26). Provision of HMS Audit Form (Template): 63. Can HMS provide providers with a copy of the audit form? (DMAS provides theirs.) No, HMS is not planning on sharing the audit form which was developed in close consultation with DMAS. HMS is performing reviews using the criteria established and approved by DMAS. HMS will be consistent with answering questions, addressing issues and following criteria already set forth by DMAS. (Virginia Beach) 64. Can we provide a copy of the Outpatient Services audit form? No, HMS is not planning on sharing audit form/tools. Our reviews utilize the same criteria established by DMAS for outpatient psychiatric services and will be consistent with information already published to providers in the manuals. (Virginia Beach) Audit Observations: 65. What are some of the types of findings that we are seeing in these audits? Reviews have not yet begun, however the examples provided in the Power Point handouts are the types of issues that we may expect to find. (Virginia Beach)