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Tips for Providers: Organizing & Preparing. Presented by Caroline Fisher Director of Quality Management Monarch Representing Benchmarks. Revised 3-15-14. Developed by the NC-DHHS LME/MCO-Provider Collaboration Workgroup February 2014. Some Monitoring Process Points.
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Tips for Providers:Organizing & Preparing Presented by Caroline Fisher Director of Quality Management Monarch Representing Benchmarks Revised 3-15-14 Developed by the NC-DHHS LME/MCO-Provider Collaboration Workgroup February 2014
Notification of Routine Monitoring Provider agencies will be notified in writing 21 – 28 calendar days prior to the date of review. Provider agencies will be notified of specific service records needed for review no less than 5 business days prior to the date of review.
Timeframe for Review Samples The sample for service events for both Routine and PPR tools is drawn from paid claims. Paid claims and service dates will represent service events from 6 months prior to the review date, through the following 90 days.
Timeframe for Samples Continued If there are not enough service events during the 90 day time frame, the sample may go back as far as one year. EXAMPLE: If the on-site review is March 1, the sample drawn will be paid claims and service dates from Sept. 1 – Nov. 30.
During Monitoring Agencies should have staff available to help navigate records/documentation if needed. It is not required to be present during the review, but having staff available can enhance the process. If documentation for a specific item is not immediately available, it will be accepted at any time during the on-site review.
Exit Interview An Exit Interview will occur following the on-site review to provide the agency with some immediate feedback: General impressions on preparedness and results of the review General information on any major findings, trends, etc. Expectations, if any, for technical assistance needed, plan of correction and follow-up Verify contact(s) for receipt of report: Name, Mailing Address, Email Address.
Reports and Plans of Correction Comprehensive findings will be reported by the LME-MCO within 15 calendar days. Ensure POC is specific, detailed and addresses each of the systemic areas noted in the findings. Fully implement the POC – seek technical assistance as warranted.
Know the requirements Fully understand the regulations that apply to your services. Train employees on requirements. Assign staff to keep abreast of changes to LME-MCO web sites. Review all communication bulletins, Medicaid updates, and informational updates carefully. Ask your LME-MCO for help if regulations or updates are unclear.
Have QA Systems Use the tools themselves and conduct mock audits in your own agency. Incorporate key items in other systems. (i.e. use peer review to routinely review for rights notification requirements). Use the tools to train your employees. Crosswalk your policies, procedures, systems, and forms to the rules routinely.
QA Systems Continued Set up multiple levels of checks for items easily overlooked. (i.e. signatures – check at time of documentation, supervisory review, peer review, and at filing). Reinforce individual staff knowledge of the service they are providing, and the expectations for the service. Test your own 1st responder system.
QA Systems Continued Do observations of service delivery to verify that day-to-day processes match what is outlined in policy and procedure. Make talking about your agency’s commitment to compliance by routinely talking about requirements. Be ready for audit at all times.
Incidents Match level I incidents against rule classifications at the time of the incident. Conduct random checks of level I classification. File documentation (including level II and III incidents) that follow up was conducted as outlined in the incident report and investigation information.
Review • Set a positive tone. Greet reviewers and make introductions. • Have information ready and organized. • Flag information to be reviewed in records so reviewers can go straight to it. • Make staff available to answer questions . • Do not allow staff to hover. Let the reviewers work.
Review Continued At the time of the review/audit ensure all filing/scanning is up-to-date. When you disagree with findings, present rule based documentation to back up your point.
General Use scheduling software to track dates. Ask questions if you are unsure of anything. Network and talk with other agencies about how they handle systems that you may be struggling with.
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.
