Medical Necessity Concept in Practice Medical Necessity: Who

1
Medical Necessity

• Concept in Practice

2
Medical Necessity Who Cares?

• What payers?
• What about accreditors?
• Even for rehab option?
• What about recovery programs and services?
• Isnt this something only the doctor can
  determine?
• What about client choice?

3
Medical Necessity Who Cares?

• PAYERS
• Medicaid
• Medicare
• Champus/Tricare
• ODMH
• ODADAS
• Commercial insurers

4
OIGs Red Book

• 2002 Red Book once again cites
  MH
• the IG found that
• Medicare could save 685 million by reducing
  claims error rates for mental health services.
  (Error) Rates exceeded 34 suggesting numerous
  and widespread problems. The IG suggested CMS
  monitor cases of under-utilization,
  over-utilization, medical necessity and
  reasonableness.

5
OIG Audit of Medicare Part B Outpatient MH
Services

• May 2001 Release
• Review of core services, not partial hospital
• Review of 1998 services 1.2 billion spent on
  mental health by Medicare 60 is outpatient
• Over half of services audited were to
  beneficiaries who are eligible because of
  disability, not age

6
OIG Audit of Medicare Part B Outpatient MH
Services

• 34 of individual therapy services inappropriate
• 50 of group therapy services inappropriate
• 40 of psych testing services inappropriate
• 16 of pharmacological services inappropriate

7
OIG Audit of Medicare Part B Outpatient MH
Services

• 41 billed inaccurately wrong code, non-covered
  services, excessive billing
• 11 unqualified providers
• 65 poor documentation
• 23 medically unnecessary
• 22 receiving more services than necessary
• 8 not receiving enough services

8
GAO Testimony on Medicaid Fraud (Nov 1999)

• Three primary categories of fraud and abuse
• Improper billing practices upcoding, phantom TX,
  delivering more treatment than is necessary
• Misrepresenting qualifications false
  credentials, performing outside the bounds of
  ones license
• Improper business practices kickbacks for
  referrals to a provider or product, anti-trust,
  cost reports issues, enhancement of profits by
  limiting care

9
GAO and Medicaid

• This year for first time GAO adds Medicaid to
  list of programs at High Risk for fraud and abuse
• Cites schemes by states to leverage funds
• Waiver programs that increase costs
• Insufficient oversight to assure providers paid
  appropriately

10
GAO and Medicaid

• January 30, 2003 Report
• Argues for more and more aggressive state
  Medicaid anti-fraud initiatives
• States are not collecting all they could for
  fraud efforts from feds because they would have
  to match - .01 being spent on payment safeguards
• Efforts to identify improper payments limited and
  modest in scope

11
The OIGs Work Plan Other Medicaid Services

• Waiver Programs
• Cost neutrality and costs effectiveness of
  Medicaid waiver programs being questioned
• 2 years ago Home and Community Based Waiver
  programs for the Mentally Retarded were cited

12
Medical Necessity Who Cares?

• What about accreditors?
• Medical necessity is a payment concept
• Medical necessity and quality of care are linked
• Treatment should be the least restrictive,
  considering the safety of the client and their
  current status (signs, symptoms, functioning)

13
Medical Necessity Who Cares?

• Even for rehab option?
• Rehab option services are either paid for by
  Medicaid or by state funds that follow the
  Medicaid model
• Medical necessity is a foundation concept

14
Medical Necessity Who Cares?

• What about recovery programs and services?
• Many services that are critical to a
  recovery-based model of care are being paid for
  through the rehab option, e.g. skill building,
  psychosocial rehab, residential support, and
  others
• Some recovery-focused services such as peer
  support and most recreational services are not
  paid for under rehab option and payment is not
  based on medical necessity

15
Medical Necessity Who Cares?

• Isnt this something only a
• doctor can determine?
• No
• Diagnosing professionals
• Treatment planning signers
• Managers of care
• Once initial case made, continuing confirmation
  is found in progress notes and other
  documentation the entire treatment team
  participates

16
Medical Necessity Who Cares?

• What about client choice?
• They can choose to receive services that are not
  medically necessary
• Those services must be paid for by the client or
  by alternate available resources
• Billing for non-medically necessary services is a
  problem
• Paybacks
• Potential for investigations, fines, etc.

17
Productivity and Medical Necessity
18
Medical Necessity Whats it mean?
19
Medical Necessity Whats It Mean?

• Starts with a qualified
• professional
• Assessment
• Clinical Formulation
• Diagnosis
• Determination of level of care
• Ordering treatment
• Scope of license issues

20
Medical Necessity Whats It Mean?

• Ohio Medicaid
• Services ordered are necessary for Dx or Tx of
  disease, illness, or injury and without which the
  patient can be expected to suffer prolonged,
  increased or new morbidity, impairment of
  function, dysfunction of a body organ or part, or
  significant pain and discomfort.1
• 1 Ohio Adminstrative Code, 51013-1-01

21
Medical Necessity Whats It Mean?

• Deconstructing Medical Necessity
• Services ordered are necessary for diagnosis
• Initial assessments are usually covered unless
  internal transfer
• Reassessments should be done only if there is a
  need to update information
• E.g. Medicare pays for an assessment every three
  years or after any changes to level of care
• Psych testing should be done for diagnostic
  purposes only and then only if additional
  information is needed that cannot be obtained
  from an interview
• Consultations and other diagnostic work e.g.
  labs, etc. may be covered in order to diagnose.
  Need clear link.
• 1

22
Medical Necessity Whats It Mean?

• Deconstructing Medical Necessity
• Services ordered are necessary for treatment of
  disease, illness, or injury
• Client must have a reimbursable diagnosis
• Mental health vs substance abuse
• DSM vs. ICD-9
• Axis III/Medical Conditions important
• Comorbidities may create additional complexity
• Mental retardation limits mental health services
  
• Alzheimers and other forms of dementia
• Deafness and other communication problems

23
Medical Necessity Whats It Mean?

• Deconstructing Medical Necessity
• without which the patient can be expected to
  suffer prolonged, increased or new morbidity,
  impairment of function, dysfunction of a body
  organ or part, or significant pain and
  discomfort.
• Treatment can be focused on preventing
  backsliding
• Treatment can be focused on impairment of
  function
• Treatment can be focused on prevention of new
  morbidities,

24
Medical Necessity Whats It Mean?

• Ohio Medicaid
• Medically necessary services are those that
• Are not experimental and are generally accepted
  as effective for the problem being addressed
• Delivered at an appropriate intensity
• Provided at the appropriate level of care setting
• When used for diagnosing capable of providing
  unique, essential and appropriate information

25
Medical Necessity Whats It Mean?

• Ohio Medicaid
• Medically necessary services are those that
• Are not experimental and are generally accepted
  as effective for the problem being addressed
• Watch inappropriate psychotherapy

26
Medical Necessity Whats It Mean?

• Ohio Medicaid
• Medically necessary services are those that
• Delivered at an appropriate intensity
• Be concerned with too little and too much
• Meds only clients
• Frequent no shows
• Non-compliance

27
Medical Necessity Whats It Mean?

• Ohio Medicaid
• Medically necessary services are those that
• Provided at the appropriate level of care setting
• Do you have written levels of care that are
  accessible, well distributed, and being
  appropriately used by staff?
• Be concerned with appropriate and timely
  transfers and discharges
• Be also concerned with non-compliance with
  appropriate levels of care good documentation
  to describe attempts to move clients

28
Medical Necessity Whats It Mean?

• Ohio Medicaid
• Medically necessary services are those that
• When used for diagnosing capable of providing
  unique, essential and appropriate information
• Additional diagnostic tests must be capable of
  providing information that is not available in
  other, less expensive ways.

29
Criteria for Payment

• In addition to tests of medical
• necessity, Ohio Medicaid is looking for
  additional information before agreeing to pay
• Services must be voluntary and initiated by
  client
• Evidence of client choice of provider
• Eligible providers must render service
• Compliance with definition of service
• Service must be lowest cost service that
  effectively addresses clients problem

30
Additional Guidance for MH and SA

• DSM IV or ICD 9 CM diagnosis
• Client must be active participant
• Sufficient cognitive ability to benefit
• Services must be
• Provided according to an individualized service
  plan
• Least restrictive setting that is available and
  safe
• Developmentally appropriate for children

31
Additional Guidance for MH and SA

• DSM IV or ICD 9 CM diagnosis
• Dx alone is not enough
• Dx Signs/Symptoms
• Dx Functional Status
• Dx Signs/Symptoms and Functional Status
• Current signs/symptoms and functional status is
  critical to medical necessity
• Acuity/other clinical information in 5th digit of
  ICD 9
• Each service must be directed toward an
  appropriate diagnosis

32
Additional Guidance for MH and SA

• Client must be active participant
• Documentation must be clear about clients
  participation in treatment
• Besides being present- what else?
• Non-compliance
• Catatonia and other diagnoses that may prevent
  participation
• Watch billing for these
• Signing treatment plans, progress notes

33
Additional Guidance for MH and SA

• Sufficient cognitive ability to benefit
• Watch for
• Very young children
• Dementia all kinds fight if you think it is
  appropriate at early stages of disease
• Mental retardation except for mild and
  sometimes moderate
• Autism
• Other clients who cannot benefit e.g.
  intoxicated

34
Additional Guidance for MH and SA

• Services must be
• Provided according to an individualized service
  plan
• Every service must be ordered
• Least restrictive setting that is available and
  safe
• Please note available
• Rehabilitation option services must be
  considered.
• Developmentally appropriate for children

35
Rehabilitation Option

• Federal Definition
• Any medical or remedial services (provided in
  facility, home or other settings) recommended by
  a physician or other licensed practitioner of the
  healing arts, within the scope of their practice
  under state law, for the maximum reduction of
  physical or mental disability and restoration of
  the individual to the best possible functional
  level.

36
Rehabilitation Option

• IAPSRS Definition of
• Rehabilitation Model
• Focuses on the functioning of the individual in
  the normal, day to day environment, and looks at
  the strengths and skills people bring to the
  rehabilitation process and supports in the
  community.

37
Rehabilitation Option

• IAPSRS Definition
• of Rehabilitation Model continued
• Although an individual may still be symptomatic,
  the rehabilitation process helps a person learn
  ways to compensate for the effects of the mental
  illness thorough environmental supports and
  coping skills. The person with the mental illness
  becomes the the expert in managing the
  disability.

38
Why is Rehab Option so important to the payer?

• Research has
• demonstrated that rehabilitation leads to
• shorter hospitalizations
• improved social functioning
• greater satisfaction
• higher productivity and integration in community

39
Rehabilitation Option Services

• Specifically referenced as rehab option covered
  services in Ohio
• Basic/Daily Skills training
• Social Skills training
• Residential services
• Employment related services
• Social/Recreational services
• Family Education Services

40
Rehabilitation Option Services

• Social/Recreational Medical Necessity Criteria
  still very clear
• Services may not be for the exclusive purpose of
  social or recreational activity but must evidence
  a clear therapeutic objective specifically
  identified in the individuals service plan.

41
Rehab Option Model
Community Support Services Restoration of basic
or daily living skills Restoration of social or
personal skills Residential Support Illness
Management Others Pre-voc/ed
Medication and Somatic Treatment
Individual and Group Psychotherapy
Other Acute Services ACT, Partial Hospital, IOP
Peer, Recreational, Employment, Vocational
42
Documenting Medical Necessity

• Documentation Primary
• means or determining
• whether claims should be paid.
• Making the case for current and for on-going
  medical necessity
• Assessment
• Treatment plans
• Progress notes and,
• Related lab and other diagnostic work

43
Florida Outpatient Center

• Management did not act to promote integrity,
  efficiency and accountability
• Billed for ineligible clients ( did not meet GAF
  requirement)
• Destroyed audit trail by shredding service
  tickets.

• 4.2 mm payback in cash and services

44
Florida Outpatient Center

• Tx plans incomplete, sometimes not there at all,
  or no signature or date of signature
• Geriatric Day Tx usually had no prior
  certification

• Physicians did not always sign treatment plans
• Physicians did not always participate in
  development of treatment plans or their review

45
Florida Outpatient Center

• Interns and other students billed w/out
  sufficient or evidence of supervision
• Dual billing of Medicaid and contracts

• No evidence of efforts to reduce level of care
  based on impact of Tx
• Tx Plans reflected maximum allowable under
  Medicaid not goals and needs of patients

46
Documenting the Medical Necessity of
Rehabilitation

• Service focus is on teaching not providing
  cueing, reminding, training, overcoming barriers
• Medical necessity based on functional criteria.
• Community Support is not case management

47
Documenting the Recovery Philosophy

• Consumer choice treatment planning
• Empowerment focus on strengths based skills
  development
• Non-coercion and self-determination engaging the
  consumer in their own recovery
• Protection of rights privacy, choice, complain,
  to choose their provider, and so forth
• Responsibility for managing ones own health
  treatment planning, provider choice, skills and
  resource development

48
Rehabilitation Services

• Skills development for restoration to maximum
  functional state
• Organized approach to development of new or
  redevelopment of old competencies
• Can use curriculum in community support too
• Implies that a baseline has been established
• Not clinically focused although clinical services
  may play an integral or supportive role in
  treatment
• Symptom reduction is not the focus symptom and
  disability management is

49
Rehabilitation Services - Examples

• Basic Skills
• Food planning and preparation
• Maintenance of living environment
• Community awareness and mobility skills
• Economic issues bill paying, budgeting, etc.
• Personal hygiene
• Medication self-administration

50
Rehabilitation Services - Examples

• Social Skills
• Those necessary for working, getting along with
  neighbors and landlords, social contacts and
  development of social network
• Problem solving, conflict resolution
• Management of stress
• Relationship building

51
Rehabilitation Services - Examples

• Disability management
• Identification and management of symptoms
• Effects of medication
• Vulnerability to stress
• Effects of drugs and alcohol
• Early recognition of warning signs of illness
• Development of skills for coping with deficits
  resulting from the mental illness

52
Disability Management What is there to do?

• What is going on with the consumer behaviorally?
• Inconsistent in compliance with meds
• Co-morbid medical condition that requires meds
  and medical management too
• Verbalization of fears/dislike of emotional or
  physical side effects
• Lack of knowledge of meds, side effects,
  usefulness
• Unwillingness to take meds at all
• Interactions with lifestyle activities causing
  negative side effects

53
Disability Management What is there to do?

• Goals a continuum of increased
• participation and self-management
• Consistent use of meds
• Stabilization of mental illness
• Including reduction in symptoms
• Increased understanding of their illness, meds,
  side effects, etc.
• Increased ability to report accurately about
  effects of meds on daily activities, peer
  relationships, mental illness

54
Disability Management What is there to do?

• Goals a continuum of increased
• participation and self-management
• Development of support network that can assist
  consumer in self-administration and management of
  meds and illness
• Decrease in side effects with correct dosing
  (backed up by blood levels) and lifestyle changes
• Ability to manage with medical team and with or
  without other support the medication, SS of
  mental and physical illnesses, and adverse
  effects
• Understanding of impact of physical illness on
  mental illness and vice versa

55
Disability Management What is there to do?

• Short term objectives
• Consumer can recognize meds, list them, verbalize
  when to take
• Consumer cooperates with medical staff in medical
  management of mental illness
• Shows up
• Answers questions accurately
• Interacts and anticipates or questions

56
Disability Management What is there to do?

• Short term objectives
• Consumer cooperates with diagnostic work
• Consumer recognizes signs and symptoms of mental
  illness
• After they happen
• Recognizes triggers or coming of SSs
• Same as above but for side effects

57
Disability Management What is there to do?

• Short term objectives
• Consumer understands where to go to get meds and
  can afford them
• Consumer develops supportive network to assist in
  management of mental illness including meds
• Consumer understands why taking meds
• Understands why taking each med
• Consumer and medical staff work in an integrated
  fashion with primary care physician

58
Disability Management What is there to do?

• Short term objectives
• Consumer complies with medication regimen
• Development of compliance aids
• Develop structure for taking meds
• Advocate/work towards less complicate dosing
  regimen
• Consumer understands lifestyle activities that
  increase risk, signs and symptoms, aggravate side
  effects
• Makes lifestyle changes recognizes cause/effect
• Consumer gets peer support re meds and lifestyle
  changes

59
Rehabilitation Services - Examples

• Residential Support Services
• Early identification of problems in living
  situations
• Ensuring success in living in a community setting
• Practicing skills in different settings to show
  how skills transfer
• Great deal of overlap tween this and basic skills
  development and social skills development

60
Rehabilitation Services - Examples

• Social and Recreational Activities
• Be careful but look to the goal of the service in
  these cases and not necessarily the service
  itself
• Should be carefully related to improving skills,
  reducing disabilities, restoration of functional
  level
• The government does consider the development of
  social skills and a social network to be
  important to the recovering individual
• You have more leeway with kids
• Must be clearly stated in treatment plan

61
Rehabilitation Services - Examples

• Employment Related Services
• Not vocational but pre-vocational
• Redevelopment of skills needed for successful
  employment
• Getting along with co-workers and supervisors
• Staying on task
• Working at the necessary pace
• Following instructions

62
Rehabilitation Services - Examples

• Education
• Not education but pre-education
• Skills necessary to locate and engage in a
  successful academic or other educational program
• Some of these same skills needed to be able to
  engage in your services as well

63
Rehabilitation Services - Examples

• Peer Services and Support
• No self help groups covered but could be in Tx
  plan
• Peers can sometimes provide services make sure
  of your rules
• Sometimes just provide some social support and
  encouragement

64
Documenting Medical Necessity

• Documentation is required under Ohio code
• all Medicaid providers are required to keep such
  records as are necessary to establish medical
  necessity and to fully disclose the basis for the
  type, extent, and level of the services provided

65
Documenting Medical Necessity

• Key Elements in
• Documentation
• Is there a diagnosis that meets payer criteria?
  Evidence that this is the correct diagnosis?
• Assessment of client functioning? Sufficient
  deficits or threats to justify level of care?
• Current ISP? Signed? Is array of services
  appropriate for the clinical picture?

66
Documenting Medical Necessity

• Key Elements in Documentation
• Services rendered in accordance with ISP and with
  payer definitions of services? Is the provider
  appropriately credentialed?

67
Documenting Medical Necessity

• Key Elements in
• Documentation
• Is there evidence of client participation?
• Cognitive ability if client has DX that would
  normally contraindicate treatment make sure there
  is an adequate explanation
• Willingness to participate may be exceptions
  for those individuals committed to the board

68
Documenting Medical Necessity

• Key Elements in Documentation
• Is there evidence that the client is benefiting
  from treatment?
• Medical necessity is closely linked to outcomes
• If client is not benefiting
• the services may not be medically necessary
• the level of care may be inappropriate
• Services dedicated to prevention of backsliding
  need continuous testing

69
Progress Notes

• Required for each billed service
• Must describe a service that is billable
• Must indicate necessity for service should speak
  to objective, not overall goals easier for
  auditor
• Clients circumstances
• Clients participation
• Clients response

70
Speaking to Objectives

• Goal Client wants to go to work - ObjClient
  will identify and join a job skills program.
• Discussed clients anxiety in interactions
  with strangers. Client identified and role-played
  strategies to reduce anxiety that she believes
  will work for her, including, deep breathing and
  maintaining her own space. Client was anxious
  during discussion and role-play but understands
  need to be able to work with strangers in any job
  or job development setting. She intends to
  practice new skills this week with two neighbors
  in her apartment building and report back.

71
The Service Must Be Billable

• Attempted to call consumer to reschedule
  appointment but no one home. Left message.
• Reviewed treatment plan and wrote up monthly
  documentation of what services have been
  provided.
• Consumer attended NA/AA conference with
  community support worker. Consumer picked out
  workshops and attended all. Very enthusiastic
  about conference.

72
Service Must be Coded Correctly

• Engaged client in a discussion of past trauma
  and coping strategies that have been used in
  past. Client assigned homework to record at least
  one positive statement daily about her life
  experiences.

73
Client Should Participate Voluntarily

• Consumer came in for check. We discussed her
  plans for weekend. She will see friends and
  attend church.
• Do not use rep payee status as hook for services

74
There must be an intervention

• Met with client today. He appeared well-groomed
  and in a good mood. He stated he went to choir
  practice and sang last Sunday at both services.
  States he felt exhausted. Client did state that
  he enjoyed himself but that he needed
  encouragement from family to participate.

75
The Stable Client

• Met briefly with consumer. He reports that he
  is psychiatrically stable and taking his
  medications as prescribed. He agreed to a
  follow-up appointment. He reported no
  difficulties at this time.

76
Community Support

• Goal Stable Psychiatric Functioning Objectives
  Consumer will determine housing choice. Consumer
  will develop a plan for obtaining permanent
  housing.
• Consumer in crisis bed and is homeless with
  no entitlements. Educated consumer about options
  for housing if SSI is denied. Explored consumers
  preferences. Consumer stated she would prefer SRO
  but is open to other options. Agreed we will
  follow-up by end of week.

77
Community Support

• Goal Client will return to work Objective
  client will research local supports and benefits
  for vocational counseling and training.
• Client reports that he called benefits
  counseling service and located his information
  about VA benefits as well. Client did not make an
  appointment because he was anxious about process.
  We role-played some possible scenarios and client
  agreed that he will call again this week and set
  up appointment.

78
Community Support

• Goal Client wants to stay out of hospital Obj
  Travel Training
• Intervention Reviewed steps with client on
  how to catch bus from her apartment to the store,
  I.e., arriving to the bus stop 10 minutes ahead
  of time showing her bus ID to the driver,
  sitting where she feels comfortable, having her
  bus schedule available, familiarizing her with
  names of streets and keeping an eye out for the
  stops ahead of hers for her apartment and for the
  store.

79
Community Support

• Goal Client wants to stay out of hospital Obj
  Travel Training
• R Client had her bus schedule available to
  find out the time for the bus, greeted the bus
  driver appropriately, showed her ID, sat where
  she felt comfortable and asked the driver for
  names of streets for familiarization. Client
  still very anxious but happy about her progress.

80
Community Support

• Goal Client wants to stay out of hospital Obj
  Travel Training
• P Will accompany client one additional time
  next week and then plan for a solo visit to the
  store. The next visit will also include skills
  development in grocery shopping as per her ISP.

81
Documenting Progress

• Progress vs. encounter notes

82
Case Study 1

• Mary

83
Community Support

• Curriculum
• Specific instructions for teaching topics, step
  approach to gaining and integrating subject
  matter breaking larger goals into smaller, more
  manageable steps
• Teaching tools handouts, transparencies, etc.
• Suggestions for discussion, activities, role
  plays, homework, sub-group work opportunities
  for consumer to demonstrate expertise

84
Community Support

• Curriculum
• Plans for how to generalize skills to community
  and other environments
• Additional resources for consumers, family, and
  staff
• Plan for skills retention - individualized

85
Community Support

• Curriculum
• SAMSHA handouts
• Others see handout

86
Relevant Coordinating Centers of Excellence

• OMAP www.bestpractice.com
• Promotion of the utilization of medication
  algorithms to guide psychiatric medication
  decision-making in Schizophrenia, Bipolar
  Disorder, Major Depression
• Clusters no website yet
• Promoting client clustering to organize services
• Illness Management and Recovery no web-site yet
• Promoting the adoption of illness management and
  recovery principals to improve outcomes
• Supported Employment coming soon

87
Case Study 2

• Paul

88
Relevant Coordinating Centers of Excellence

• OMAP www.bestpractice.com
• Promotion of the utilization of medication
  algorithms to guide psychiatric medication
  decision-making in Schizophrenia, Bipolar
  Disorder, Major Depression
• Clusters
• Promoting client clustering to organize services
• SAMI www.ohiosamiccoe.cwru.edu
• Promoting integrated model of MH/SA care
• Supported employment coming soon

89
Case Study 3

• Frank

90
Relevant Coordinating Centers of Excellence

• Clusters
• Promoting client clustering to organize services
• Illness Management and Recovery
• Promoting the adoption of illness management and
  recovery principals to improve outcomes
• Learning Excellence www.cle.osu.edu
• Promotion of school-based mental health services
• ACT coming soon

91
Coordinating Centers of Excellence

• Coming soon
• ACT
• MI/MR
• Supported Employment

92
Thank You