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Medical Necessity

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Medical Necessity

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  1. Medical Necessity Presented by Amy Simonds

  2. Objectives • Complete assessments, treatment plans, progress notes and discharges from a person-centered perspective. • Utilize medical necessity language in all documentation. • Utilize documentation as an advocacy tool in obtaining appropriate services for clients.

  3. Terms and Definitions • MaineCare • Medicaid • Medicare • 3rd party/payer • Insurance • ASO • MCO • Managed MaineCare • APS

  4. Managed MaineCare • As of 12/1/07, MaineCare has been managed by APS. • APS is an Administrative Services Organization providing prior authorization and utilization review. • Sweetser will continue to be paid by MaineCare and continue to adhere to MaineCare regulations. • Sweetser will remain subject to MaineCare audits. • APS audits the charts for medical necessity.

  5. Risks • Denials/partial denials • Pay backs • A practice in which the therapist is found to be out of compliance. Payments made to the therapist are returned, often with fines. • This occurs after an audit or review of documentation, if the documentation is found to be somehow out of compliance. • APS retrospective reviews • Federal audits • There is no “statute of limitations” for a MaineCare audit.

  6. Managed Care companies don’t ask your clients about your work. They read it.

  7. Understanding the System • Medical Necessity • Level of Care Criteria • Authorization • Utilization Review • Utilization Management

  8. Medical Necessity • “Simply stated, the documentation of medical necessity is the clear demonstration that there is a clinical need and that services provided are an appropriate response.” Treatment Planning for Person-Centered Care, Neal Adams, Diane M. Grieder, ElSevier Academic Press, 2005.

  9. Five Components of Medical Necessity • Indicated • Appropriate • Efficacious • Effective • Efficient (Adams and Grieder, 2005)

  10. Is the need for mental health treatment indicated in the following example? Presenting Needs and Challenges Reason for seeking service: X Housing • Health • Mental Health • Relational Difficulties • School Difficulties • Substance Abuse X Work • Other

  11. Is mental health treatment appropriate? • Sometimes referral sources see a need and make referrals but an assessment bears out other recommendations. • Examples: • Divorce/custody cases • Housing issues • Client doesn’t see a problem

  12. Is mental health treatment efficacious? • Efficacious: having the power to produce a desired effect.(Merriam-Webster, 2006-2007, www.Merriam-webster.com). • These are the generally accepted standards in the healthcare field. • If the diagnosis is depression, what are likely to be efficacious treatments? • Counseling • Medication

  13. Is mental health treatment effective? • What has the client’s response to treatment been in the past? • What are the client’s biases regarding mental health treatment? • These may be based on culture and/or experience.

  14. Efficient • Are the intensity, frequency and duration of services an efficient use of time and resources? • Consider, as well, how many different services are being utilized. • This leads us to consider “level of care”.

  15. Levels of Care • Levels of care are related to efficiency and clients’ rights. • General considerations are cost and restriction of the client. • Highest - locked units. • Lowest - outpatient.

  16. Levels of Care • The clinician must justify their recommendation regardless of the level of care recommended. • Why outpatient? Why not residential? Why not a lower level of care (i.e., parenting classes)? • Why do you need to justify this in all cases? • To advocate for your client • Risk management

  17. APS Levels of Care • APS publishes its level of care criteria on their website: www.qualitycareforme.com. • When making continued stay requests, it is important to review the levels of care to make sure you are adequately addressing the need for continued care.

  18. Authorization • When working with any ASO or MCO, clients are authorized to obtain certain services. • Authorizations are for specific services for specific time frames. For example one hour of outpatient treatment per week for 24 weeks. • Seeing a client outside of the authorization guidelines will result in non-payment.

  19. The nitty-gritty What does this mean to me on a daily basis when it comes to completing my paperwork?

  20. How to Read an Assessment • Different people read an assessment in different ways for different reasons. • Take a moment to consider what you are looking for when you read an assessment.

  21. Diagnosis • Read the diagnosis. When you read the assessment, consider whether or not you agree with or have enough evidence to support the diagnosis. • Read all five (5) Axis, especially the GAF. • Consider whether or not the writer included enough information on functioning to support the GAF.

  22. Clinical Formulations • Often referred to as a narrative summary or diagnostic summary. • NOT a simple re-statement of facts contained in the assessment. • It is written in the professional “voice” of the clinician and includes professional opinion. • Many 3rd party payers and other practitioners will not read beyond the clinical formulations.

  23. Standards • From Grieder and Adams (2005), the clinical formulation must contain: • A central theme about the individual • Findings from any assessment tools used • The consumer’s perception of their needs, strengths and abilities • Your perspective on the course of treatment • Recommended treatments and level of care • Anticipated duration of services • Goals of the treatment

  24. Other Elements may Include • Your insights into the underpinnings of the cause and/or perpetuation of the problem (family systems, personality traits, cognitive behavioral styles, etc.) • A hypothesis regarding a treatment plan • Speculation or understanding regarding success or failure of previous treatment efforts • Identification of barriers to reaching the goal • Anticipated outcomes of treatment

  25. Suggested Formats • The 6 P’s • Narrative outline

  26. The 6 P’s • Pertinent history • Presenting symptoms • Precipitating factors (why now?) • Predisposing factors • Perpetuating factors • Previous treatment and response

  27. Pertinent History • (Briefly summarize important historical details) • Mrs. Smith reports she began having trouble sleeping shortly after moving to Maine. She reports her job as a head nurse is very stressful and the stress has been increased with recent talk of a strike. She is referred by her PCP after requesting medication to address sleeplessness.

  28. Presenting Symptoms • (Describe major/significant symptoms that support diagnosis) • Mrs. Smith reports symptoms consistent with adjustment disorder with depressed mood. • She has made several recent and substantial changes including a move and a new job within the past six months. • Neurovegetative signs of depression are apparent including insomnia, weight gain, tearfulness, poor concentration, decreased interest in sexual activity and feeling listless (“dull”).

  29. Precipitating Factors • (Why seeking services now) • Mrs. Smith’s husband has asked her to obtain counseling as she’s been “crabby” with her family, co-workers and patients. She’s afraid of being “written up” at work for tardiness.

  30. Predisposing Factors • (Biological & psychosocial factors that predispose the client to challenges and/or require assistance) • Mrs. Smith notes sleeplessness is a common manifestation of stress for her, but it has never been “this bad”. She notes sleepless nights have occurred before when her mother was seriously ill.

  31. Perpetuating Factors • (Any issues perpetuating a client’s needs) • Mrs. Smith will not be able to control a possible strike that may be happening at work that appears to be exacerbating a reaction she’s been having to moving to a new state.

  32. Previous Treatment & Response • (Services received: their effectiveness and their ineffectiveness) • Mrs. Smith obtained mental health counseling about 11 years ago and reports it was helpful. She is here today to assist her doctor in determining if she is a good candidate for medication treatment for sleeplessness.

  33. Narrative Outline • Reason for seeking service • Individual’s understanding of the problem • Strengths and challenges of the individual • Barriers to community inclusion • Complicating factors such as co-morbidities • Goals

  34. Treatment Recommendations • Treatment recommendations are key. • A well written treatment plan is worthless if it is not driven by treatment recommendations. • It is not enough to recommend a service. You need to include what you think the service will or should work on specifically. • Case management to do what? • Outpatient therapy for what? • What are the goals or desired outcomes of the client?

  35. Example • It is recommended that Mrs. Smith discuss her history and current use of substances with her doctor before pursuing medication treatment for sleeplessness. It is also recommended she discuss with her doctor her use of caffeine relative to her inability to sleep. This therapist recommends a short course of outpatient therapy for Mrs. Smith to address her additional depressive symptoms and adjustment to life in a new state.

  36. Areas of Regulatory Concern • For licensing you must also make sure your plans include the following: • Target dates • Barriers to treatment • Unmet needs • Completed and signed by the due date • Indication of a copy being offered to the client • If the client is a child, the plan must be signed by the parent or legal guardian

  37. Exercise Right now, write down 1-3 goals you have for yourself. 37

  38. Treatment Plans (AKA: ISP) • From a medical necessity perspective, ISPs are the contract developed between the provider, the client and the payer. • It is an order for service. • You can only write down the service that you render, otherwise, you note the referrals you’ll make for other services. For example, only doctors can prescribe, so that shouldn’t be on the therapist’s ISP.

  39. We get paid for what’s on the plan • If you provide treatment for goals and objectives you did not identify on your treatment plan, we don’t get paid, or the payment will later be recouped, with fines. • The plan is a “living document” that can be added to at any time for any reason.

  40. Treatment Plan Elements • Discharge/Transition Criteria • Goals • Barriers • Objectives • Strengths • Interventions

  41. Discharge Criteria • This is where you discuss the age-old question: • How will you know when you don’t need my services anymore? • The discussion continues until you both come up with an understanding of what the client will be doing (not feeling and not being) when treatment is complete. • This is a negotiation, not dictation. • Now you are beginning to narrow the focus.

  42. Goals • Before you write a plan, take the time to talk with your client and open the way to the idea that there are alternatives. Get them talking about their hopes and dreams. • Consider several kinds of goals: • Life goals (“get my license back” or “get my kids back”) • Treatment goals (symptom related, “sleep most nights”) • Quality of life enhancement goals (“strengthen our marriage” or “improve communication”) • Do any of your goals say “symptom reduction”? Or “medication compliance”?

  43. Barriers • What are the barriers to meeting the goal or achieving the discharge criteria? • Use a fit circle or other brainstorming technique. • Remember, the most powerful part of brainstorming is prioritizing the list when it is complete. • Note three (3) priorities, or most significant barriers to address.

  44. Objectives • Objectives are relative to the goals. If there are several goals, there are several sets of objectives. • Tip: keep the goals broad and to a minimum. Too many very specific goals will get you stuck in the process. • With ACTION words, describe the specific changes in measurable and observable terms. • Tip: “learning” and “feeling” are not observable. Percentages are generally not observable.

  45. Strengths • Narrow down now from a broad list of strengths to the strengths which can be applied to achieving these objectives. • Consider: past accomplishments, aspirations, motivations, personal attitudes.

  46. Interventions • This is what we get paid for! • The specific activity, service or treatment you will be providing. • The intended purpose or impact relative to the objective(s). • The intensity, frequency and duration of treatment.

  47. Know your Covered Services Certain language is fine for certain services. Know what you get paid for so you know what to do and what to write. 47

  48. Progress Notes • Progress notes need to indicate: • What you did relative to your treatment plan and your service. • Using specific language relative to therapy is important: • “Challenged client’s negative thought patterns” • “Made a list of and evaluated pros and cons of separation” • “Explored the function of client’s current behavior” • The client’s response to what you did.

  49. Good Action Words (see additional handout) Cognitive domain: define, describe, identify, label, list, match, name, outline, reproduce, select, state. Psychomotor domain: assemble, build, change, clean, compose, design, fasten, identify, locate, manipulate, mend, sharpen, sketch, weigh. Affective domain: ask, give, hold, name, reply, answer, discuss, perform, present, report, write, complete, form, invite, justify, share, alter, compare, explain, synthesize, display, modify, question, verify.

  50. Progress Note Format • The most important elements include: • The client’s presentation • Your intervention • The client’s response