1 / 32

Post-Payment Review Tools for Provider Agencies

Post-Payment Review Tools for Provider Agencies. Presented by Alison Rieber Provider Network Evaluation Supervisor Alliance Behavioral Healthcare Representing the NC Council of Community Programs. Revised 3-4-14. Developed by the NC DHHS-LME/MCO-Provider Collaboration Workgroup

feo
Télécharger la présentation

Post-Payment Review Tools for Provider Agencies

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Post-Payment Review Toolsfor Provider Agencies Presented by Alison Rieber Provider Network Evaluation Supervisor Alliance Behavioral Healthcare Representing the NC Council of Community Programs Revised 3-4-14 Developed by the NC DHHS-LME/MCO-Provider Collaboration Workgroup February 2014

  2. Post-Payment Review Tools for Provider Agencies

  3. How to Navigate the Excel Workbook

  4. Organization of PPR Tools • The PPR Tool questions address these areas: • Authorizations/Consents/Eligibility/ Service Orders/Plans • Service Documentation • Qualifications/Training of Service Providers/Record Checks/Supervision

  5. The Post-Payment Review Tools Available for Provider Agencies Child & Adolescent Day Treatment Diagnostic Assessment Innovations Waiver Outpatient Opioid Treatment Psychiatric Residential Treatment Facility (PRTF) Residential Treatment Generic – used for all services other than those in bullets 1 – 6 above.

  6. Generic Agency PPR Tool Training will focus on the Generic Post-Payment Review Tool Most questions on the Generic Tool are found within most of the other 6 post-payment review tools

  7. Consents/Referrals/Authorizations/Eligibility/Service Orders/Service Plans Q 1: Is there a valid consent for treatment in the service record? 10A NCAC 27G.0205 • Review for a consent for treatment signed by the individual or LRP on or prior to the date of service being reviewed. • A separate consent for treatment form is not necessary if the individual/LRP has signed the PCP/service plan.

  8. Consents/Referrals/Authorizations/Eligibility/Service Orders/Service Plans Q 1 continued: • The individual/LRP signature on the treatment plan or PCP is sufficient to demonstrate consent.  • If written consent is not obtained, the provider must produce a written statement as to why consent could not be obtained.

  9. Consents/Referrals/Authorizations/Eligibility/Service Orders/Service Plans Q 2: Is there a valid/appropriate service plan current for the date of service? CCP 8A • The format required by service definition is used. • Plan is rewritten annually and/or updated/ revised: • If the needs of the person have changed • On or before assigned target dates • When a new service is added • When a provider changes

  10. Consents/Referrals/Authorizations/Eligibility/ Service Orders/Service Plans Q 2 continued: • If the plan is a PCP, the service must be identified in the Action Plan to be ordered via appropriate signature on the PCP. • If the service does not require a PCP, a separate service order form is acceptable.

  11. Consents/Referrals/Authorizations/Eligibility/ Service Orders/Service Plans Q 2 continued: Dated Signatures • Medicaid-funded services must be ordered by a licensed MD or DO, licensed psychologist, licensed nurse practitioner or licensed physician’s assistant unless otherwise noted in the Service Definition. • Each service order must be signed and dated by the authorizing professional. • Dates may not be entered by another person or typed in. • No stamped signatures unless there is a verified Americans with Disabilities Act [ADA] exception.

  12. Consents/Referrals/Authorizations/Eligibility/ Service Orders/Service Plans Q 3: Does the recipient meet entrance criteria per the service definition?CCP 8A • Review the Entrance Criteria listed in the service definition against the CCA. The CCA must support the required criteria. • The CCA must support the level of care assessment (CALOCUS, CASII, LOCUS, ASAM) for the treatment service recommended.

  13. Service Documentation Q 4: Is the documentation signed by the person who delivered the service? CCP 8A • Signature includes credentials, license, or degree for professionals; position name for paraprofessionals. Credentials/job titles may be typed, stamped or handwritten. • Do not rate “Not Met” if credentials are missing. If it is a systemic issue, require a Plan of Correction.

  14. Service Documentation Q 4 continued: • The note is written and signed by the person who provided the service [full signature, no initials]. “Written” means “composed.” If a signature is questionable, request the provider’s signature log to validate the signature. • Documentation is completed within 24 hours of the day the service is provided.

  15. Service Documentation Q 4 continued: • In order for a service to be billable, the note must be written or dictated within 7 working days (for the staff who provided the service). After the 24-hour time frame, the note shall be entered as a “late entry” and include a dated signature. If an electronic note is used and late entries are tracked/stamped in the system, this will meet documentation requirements. • If there is no note for the date being audited, then audit questions related the qualifications, training, supervision, record checks of the staff who provided the service are rated “N/A.”

  16. Service Documentation Q 4 continued: • If there is an unsigned note, review and rate other questions related to the note accordingly. Questions related to the staff person remain rated as “N/A." Do not assume based on handwriting that you can identify the service provider.

  17. Service Documentation Q 5: Does the documentation reflect treatment for the duration of the service billed? CCP 8A • Intervention relates to the stated purpose of goal • Intervention/Tx documented justifies amount of time billed – reasonably took place in the amount of time documented • There is actual treatment reflected in the intervention related to goals, symptoms, diagnoses

  18. Service Documentation Q 5 continued: • The following are not billable: • Verifying eligibility and obtaining prior approval • Completing NCTOPPS • Internal agency supervision

  19. Service Documentation Q 6: Is the service note individualized specific to the date of service? CCP 8A Review notes around the date of service. Notes should vary from day to day and person to person No xeroxed notes with dates or signatures changed No handwritten notes copied throughout with different service dates

  20. Service Documentation Q6 continued: Look very closely if you see any of the following: Exact wording across 2 or more notes for one person or across records Conflicting pronouns (he/she, him/her) The name or identifying information of another individual is found within the service note.

  21. Service Documentation Q 7: Do the units billed correspond to the duration documented on the service note? Provider Participation and Electronic Claims System agreements Duration of periodic services must be documented Billing and duration must be an exact match, however, if fewer units are billed than documented do not rate “Not Met”

  22. Qualifications/Training of Service Providers/Record Checks/Supervision Q 8: Is there documentation that the staff is qualified to provide the service billed? Review personnel record for each person who provided a service Verify both required education and experience are evident Use Qualification Checklist (there is one for each PPR Tool) which lists education and training required for the service

  23. Qualifications/Training of Service Providers/Record Checks/Supervision Q 8 continued: If service provider is unknown (note not signed or illegible or unverifiable my signature log), rate all staff related questions as “N/A.” Do not assume based on handwriting in a note that you can identify the provider of an unsigned note. If staff name is typed but not signed, review for qualifications but rate “Not Met” for the question about the note being signed.

  24. Qualifications/Training of Service Providers/Record Checks/Supervision Q 9: Is the staff supervision plan implemented as written? 10A NCAC 27G .0104, .0203 Supervision plan must be in place for Associate Professional and Paraprofessional staff. If staff is a QP or licensed, rate this item “N/A.” Evidence of implementation is based on requirements of the plan. For example, most plans include the frequency/duration of required supervision. Determine if documentation of supervision matches with the supervision plan requirements. An agency policy on supervision, even if it includes frequency/duration of supervision is not acceptable as an individual supervision plan

  25. Qualifications/Training of Service Providers/Record Checks/Supervision Q 10: Was there a Health Care Registry check completed for the staff prior to this event’s date of service [unlicensed employees only]? GS 131E-256, 10A NCAC 27G .0202 There may be no substantiated findings of abuse or neglect. Ensure the registry check belongs to the staff being reviewed (check name, SSN if available, etc.)

  26. Qualifications/Training of Service Providers/Record Checks/Supervision Q 11: Did the provider agency require disclosure of any criminal conviction by the staff person(s) who provided this service? [for unlicensed services and staff hired to provide licensed services prior to 3/24/05] 10A NCAC 27G .0202 Disclosure statements most often found on employment application or in a separate statement completed during application process. If no disclosure statement, a request for a criminal record check prior to the date of service is acceptable

  27. Qualifications/Training of Service Providers/Record Checks/Supervision Q 11 continued: If disclosures are not in place and is a systemic issue, assign a POC even if background checks are evident. The criminal record disclosure must have occurred prior to the date of service.

  28. Qualifications/Training of Service Providers/Record Checks/Supervision Q 12: Was the appropriate criminal record check completed prior to this date of service? GS 122-80 Not required for licensed staff Determine date of hire General Statute Requires the Following: If applicant had been a resident of NC for less than 5 years, must have consent for a State and National background check before conditional employment If applicant had been a resident for 5 years or more, must have consented to a State check before conditional employment.

  29. Qualifications/Training of Service Providers/Record Checks/Supervision Q 12 continued: The provider, within 5 days of conditional employment must submit request to the DOJ to conduct the criminal background check. A NC county or company with access to the Division of Criminal Information data bank may conduct the check. You do not need to see the actual background check results, auditors need only see the request. For purposes of the PPR, the request must occur prior to the date of service. Do not rate “Not Met” if the request did not occur prior to conditional employment. Rate “Not Met” only if it did not occur prior to the date of service or not at all.

  30. Service Documentation Q 13 (Optional): Does the documentation indicate that the requirements of the service definition/rule were met? CCP 8A Review CCP 8A for service definition Each service definition includes allowable activities, team composition (if applicable) and other critical elements

  31. Service Documentation Q 14 (Optional): Does the service documentation include an assessment of progress toward goals? CCP 8C • Service note needs to indicate progress made toward the goal/effectiveness (how it turned out for the person; how did he/she respond to the intervention) • If the information is not in the traditional section of the note, read the entire narrative note to determine if it was addressed.

  32. Questions If you have any questions about how the use the automated workbook and review tools, please send your questions to the Provider Monitoring mailbox: provider.monitoring@dhhs.nc.gov Please include in the Subject line the nature of your question.

More Related