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Post-Payment Review Tools for Licensed Independent Practitioners

Post-Payment Review Tools for Licensed Independent Practitioners

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Post-Payment Review Tools for Licensed Independent Practitioners

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  1. Post-Payment Review Toolsfor Licensed Independent Practitioners 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 Tool for LIPs

  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. Consents/Referrals/Authorizations/Eligibility/ Service Orders/Service Plans Q 1: Is there a referral from an approved source prior to the date of service, if applicable?CCP 8C 5.4.1, 5.4.2 and 7.3.6 • Children under 21 need an individual verbal or written referral from a CCNC/CA (Carolina Access) primary care provider, the LME-MCO or a Medicaid-enrolled psychiatrist. • Referrals may be accepted from schools or DSS, but must still be supported by one of the referral sources above.

  6. Consents/Referrals/Authorizations/Eligibility/ Service Orders/Service Plans Q 1 continued: • Documentation of the verbal or written referral includes the name and NPI # of the individual or agency making the referral • Services provided by a physician do not need a referral • Individuals 21 or over may be self-referred or referred by another source. If not self-referred, referral must be documented.

  7. Consents/Referrals/Authorizations/Eligibility/ Service Orders/Service Plans Q 2: Is there a valid utilization management authorization for the service billed, if applicable? • Prior approval needed after: • 16 unmanaged visits/calendar year for children under 21 • 8 unmanaged visits/calendar year for adults 21 or over • If unmanaged visits were exceeded review for LME-MCO authorization that covers date of service • E&M codes for medication management do not require prior authorization.

  8. Consents/Referrals/Authorizations/Eligibility/Service Orders/Service Plans Q 3: Is there a valid consent for treatment in the service record?10A NCAC 27G.0205; CCP 8C • 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.

  9. Consents/Referrals/Authorizations/Eligibility/Service Orders/Service Plans Q 3 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.

  10. Consents/Referrals/Authorizations/Eligibility/Service Orders/Service Plans Q 4: Is there a valid/appropriate service plan current for the date of service?CCP 8C • 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

  11. Consents/Referrals/Authorizations/Eligibility/ Service Orders/Service Plans Q 4 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.

  12. Consents/Referrals/Authorizations/Eligibility/ Service Orders/Service Plans Q 5: Is there a valid service order for the service billed, if applicable?CCP 8C • The need for a service order matches the need for an authorization. • If needed, service must be ordered on or before date of service. • If a PCP is not required, a separate service order form can be used. See Service Plan question for services ordered via PCPs.

  13. Consents/Referrals/Authorizations/Eligibility/ Service Orders/Service Plans Q 5 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.

  14. Consents/Referrals/Authorizations/Eligibility/ Service Orders/Service Plans Q 6: Is there an appropriate service plan that identifies the type of service billed? • The service plan must indicate the specific service in order to bill Medicaid. • Review the goals in a treatment plan or the Action Plan of a PCP for this information.

  15. Service Documentation Q7: Is the documentation signed by the person who delivered the service?CCP 8C – 7.3 • 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.

  16. Service Documentation Q7 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.

  17. Service Documentation Q7 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.

  18. Service Documentation Q7 continued: • 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.” • 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.

  19. Service Documentation Q 8: Does the service note relate to goals listed in the service plan?CCP 8C • Note reflects purpose of the intervention • Note states, summarizes and/or relates to a goal or references a goal # in the service plan. • Goal is not expired or overdue for review • If goal does not match the goal # indicated, review all goals to see if it relates to another goal

  20. Service Documentation Q 9: 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.

  21. Service Documentation Q 10: Does the documentation reflect the specific service billed?CCP 8C • Service documented must match procedure code billed. • Intervention must match procedure code billed. • No provider may bill H codes.

  22. Service Documentation Q 11: Is the service note individualized specific to the date of service?CCP 8C • 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

  23. Service Documentation Q 11 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.

  24. Service Documentation Q 12: Does the documentation reflect treatment for the duration of the service billed?CCP 8C • 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

  25. Service Documentation Q 12 continued: • The following are not billable: • Verifying eligibility and obtaining prior approval • Completing NCTOPPS • Internal agency supervision

  26. Qualifications/Training of Service Providers/Record Checks/Supervision Q 13: Is there documentation that the staff is qualified to provide the service billed? • Review personnel record for each person who provided a service • Verify staff has required licensure, experience and certification (as appropriate)

  27. Qualifications/Training of Service Providers/Record Checks/Supervision Q 13 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.

  28. Consents/Referrals/Authorizations/Eligibility/ Service Orders/Service Plans Q 14: Do the results of the Comprehensive Clinical Assessment (CCA) support the level of care for the treatment service recommended?CCP 8C • Review the Entrance Criteria listed in the service definition against the CCA. The CCA must support the required criteria.

  29. Consents/Referrals/Authorizations/Eligibility/ Service Orders/Service Plans Q 14 continued: • The CCA must support the level of care (LOCUS, CALOCUS, CASII, ASAM) for the treatment service recommended. • LOCUS – Level of Care Utilization System • CALOCUS – Child and Adolescent Utilization System (the precursor to the CASII • CASII – Child and Adolescent Service Intensity Instrument • ASAM – American Society of Addiction Medicine Patient Placement Criteria

  30. Consents/Referrals/Authorizations/Eligibility/ Service Orders/Service Plans Q 15: Is there documentation that coordination of care is occurring with both medical and non-medical providers involved with the individual receiving services?CCP 8C • May be found in service notes, summary reports, documentation of telephone calls, Tx planning notes • Coordination of Care expected as applicable for example with primary care, LME-MCO, other mh/dd/sa service providers

  31. 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.