Medicaid Audits

1
COMMUNITY SUPPORT
Medicaid Audits
March 2007
2
Audit Process

• Arrive no later than 830 AM.
• No pencils black or blue ink only.
• LME staff will be paired with State staff at the
  audit site.
• Please do not make zeros with slash marks
  through them.
• Ask questions.

3
2007 COMMUNITY SUPPORT Audit Tool
NEW
Check that the LRP has signed the plan.
4
Service Orders

• Services must be ORDERED prior to or on the first
  day service is provided.
• As of first use of the PCP on or after 6/1/06,
  Medicaid services are ordered by signature on the
  plan, by either a
• Licensed physician
• Licensed psychologist
• Licensed family nurse practitioner
• Licensed physicians assistant

5
Service Orders

• Old service orders expire with first use of PCP
  or when it should have been first used.
• Only need new SO signature at the annual review
  or if adding a service before the annual review.
• Old CBS order OK until first use of PCP.

6
VALID SERVICE ORDER/CURRENT PLAN SignaturesPAGE
11 OF PCP
7
2007 COMMUNITY SUPPORT Audit Tool
NEW
Check that the LRP has signed the plan.
8
Service Plans

• Service Plans are updated/revised based on the
  persons needs, target dates, provider changes.
• PCP format must be used for all folks new to the
  system and for existing service recipients at the
  next required review on or after 6/1/06.

9
Service Plans

• A PCP Revision page is not adequate for first use
  of PCP. The entire plan needs to be rewritten
  using the PCP format.
• Anytime a PCP is reviewed and documented on the
  PCP, whether or not there are any changes,
  required signatures must be obtained.
• ValueOptions does not approve PCPs.

10
Service Plans

• Contd
• For Medicaid audit purposes, a valid plan has
  the REQUIRED SIGNATURES on or before services
  begin and
• COVERS THE DATE OF SERVICE being reviewed.
• Must IDENTIFY THE SERVICE billed.
• Must have MEASUREABLE GOALS and appropriate
  INTERVENTIONS.

11
30 Day Window

• 30 day window only for people brand new to the
  MH/DD/SAS system not just new to the provider
• The 30 day window is closed as soon as the PCP is
  developed and signed
• To find FROM/TO dates if called out look for
  Admission/Intake form and make a copy. Explain
  in Comment section.

12
VALID SERVICE ORDER/CURRENT PLAN SignaturesPAGE
11 OF PCP
13
CURRENT SERVICE PLAN Signatures
PAGE 11 OF PCP
14
2007 COMMUNITY SUPPORT Audit Tool
NEW
Check that the LRP has signed the plan.
15
PLAN IDENTIFIES THE SERVICE SUMMARY OF
ASSESSMENTS / OBSERVATIONS PAGE 6 OF PCP
16
PLAN IDENTIFIES THE SERVICE Action Plan PAGE 7
OF PCP
Long Range Outcome (Ensure that this is an
outcome desired by the individual, and not a
goal belonging to others.)
Where am I now in relation to this outcome?
SYMPTOM/OBSERVATION      
17
2007 COMMUNITY SUPPORT Audit Tool
NEW
Check that the LRP has signed the plan.
18
Signatures on Documentation

• Each service note must be signed by the person
  who provided the service.
• The signature shall include
• For Professionals credentials/degree/license
• For Paraprofessionals position name
• Do not call out if credentials missing
• No initials or stamps are acceptable
• If there is NO NOTE, Qs 4-10 are rated 6.

19
COMMUNITY SUPPORT AUDIT TOOL, contd
Be sure to reference auditor instructions!
NEW!
20
It's as Simple as PIE!
MAKE SURE DOCUMENTATION INCLUDES

• PURPOSE of the treatment/service. This means be
  sure to reflect the outcome that was addressed.
• INTERVENTION provided. This means be sure to
  indicate what YOU/SUPPORT STAFF did.
• EFFECT for the person/Progress toward goal. This
  means be sure to indicate what the person did or
  didnt do what the result was for him/her.

21
It's as Simple as PIE!

• All 3 elements must be present.
• We are not evaluating quality for this question.
• If the intervention does not relate to the goal
  documented, it is out.

22
COMMUNITY SUPPORT AUDIT TOOL, contd
Be sure to reference auditor instructions!
NEW!
23
Service Notes

• EVERY SERVICE BILLED must have a service note.
• Each service note must RELATE TO A GOAL in the
  plan. Compare the purpose of the service note to
  the Action Plan. Watch for target
  dates/termination of goals/expiration of goals.
• If goal doesnt match exactly, determine if it
  relates by its intent to one of the goals.
• Service notes can not be completed on a grid or
  check sheet, including for QP activities. Must be
  full narrative notes.
• Cannot bill for transportation.

24
Service Notes

• Units billed must MATCH DURATION of service.
• Compare the units billed (on top of audit tool)
  with documentation of duration in the service
  note.
• If more units were billed than were documented,
  call Q9 out.
• If fewer units were billed than were documented,
  do not call Q9 out.
• Units billed must REFLECT TREATMENT for that
  duration of time.

25
COMMUNITY SUPPORT AUDIT TOOL, contd
Be sure to reference auditor instructions!
NEW
26
Service Definition Requirements

• Rate this question 9 for QP (CM-type) activity.
  Note must reflect direct service.
• Measurable interventions related to skill
  building.
• What skills were worked on while proceeding
  through activities?
• What was taught to assist person to become more
  independent?

27
Service Definition Requirements

• Rate this question 9 for QP (CM-type) activity.
  Note must reflect direct service.
• Measurable interventions related to skill
  building.
• What skills were worked on while proceeding
  through activities?
• What was taught to assist person to become more
  independent?

28
COMMUNITY SUPPORT AUDIT TOOL, contd
Be sure to reference auditor instructions!
NEW
29
Individualized Notes/Plans

• Do not call Q8 out if the Service Plan is not
  valid evaluate for individualized notes.
• Service Plans should not be so GENERIC that they
  could be used for anyone.
• Service Plans per provider should VARY FROM
  PERSON TO PERSON.
• Service Notes must be INDIVIDUALIZED PER PERSON
  PER SERVICE EVENT
• In clear cases of cookie cutter plans or notes,
  Q8 will be called out

30
COMMUNITY SUPPORT AUDIT TOOL, contd
Be sure to reference auditor instructions!
NEW
31
Service Authorizations

• Services must be AUTHORIZED either by the LME or
  ValueOptions.
• LME authorization for children is good through
  7/14/06.
• LME authorization for adults is good through
  8/14/06.
• After these dates, only VO may authorize.
• Service dates reviewed during audit must be
  covered by a valid authorization if not within
  first 30 day window.

32
Service Authorizations

• If the provider does not have their
  authorization, check the VO spreadsheet.
• If no authorization, ask for evidence of having
  submitted a request.
• Fax Receipt
• QP note stating when request submitted
• Initial/date by staff on fax sheet
• If 11a 1, 11b MUST be rated 1. No 9s in Q11,
  unless in first 30 days.

33
REQUIRING PLANS
OF CORRECTION
34
PLANS OF CORRECTION

• May be required for Questions 1-11.
• Are used to address issues found out of
  compliance that represent systemic issues.
• Contain standardized language relating
  specifically to the question asked.
• Recommendations not requiring corrective action,
  may be made for lower level issues or best
  practice intent.

35
PLANS OF CORRECTION

• Original Pink Sheet from first audit will be in
  packets. Do not start new ones.
• Add new date to top of Pink Sheet
• Initial and date any additions to the Pink Sheet
• No deletions of earlier entries

36
COMMUNITY SUPPORT SERVICES Medicaid Audit 2006 /
2007 REPORT SUMMARY
INFORMATIONLME __________________ Last Date
of this Audit _____________ COMMUNITY SUPPORT
Provider ____________________________________Tea
m Leader ________________ Auditor Completing
Form____________

• Team Leader Check List
• All blanks filled in Record s, Ratings,
  Signatures, etc.
• All items out of compliance have a comment
  (that makes sense) on the bottom.
• All items out of compliance have appropriate
  copies attached.

Complete this form for each CS provider

• No Plan of Correction required
• No Recommendations made
• Plan of Correction is required as follows (for
  Medicaid audits)

37
COMMUNITY SUPPORT SERVICES Medicaid Audit 2006 /
2007REPORT SUMMARY INFORMATION, contd

• A. Ensure there is a valid service order for
  the service billed.
• B. Other Ensure that

2. A. Ensure the service plan is current with
the date of service.
B.
Other Ensure that
38
COMMUNITY SUPPORT SERVICES Medicaid Audit 2006 /
2007REPORT SUMMARY INFORMATION, contd
3. A. Ensure the service plan identifies the
type of service billed. B. Other Ensure
that
4. A. Ensure that all documentation is signed by
the person who provided the service. B.
Ensure that there is a service note entry for
every service event billed. C. Ensure that
signatures on documentation include the degree,
credentials, license (for professional staff), or
the position name for paraprofessional staff.
D. Other Ensure that
39
COMMUNITY SUPPORT SERVICES Medicaid Audit 2006 /
2007REPORT SUMMARY INFORMATION, contd
5. A. Ensure that all service notes reflect
the purpose of contact. B. Ensure that all
service notes reflect staff intervention.
C. Ensure that all service notes reflect the
assessment of progress toward goals. D.
Other Ensure that
6. A. Ensure that all service notes relate to
goals listed in the service plan. B. Other
Ensure that
40
COMMUNITY SUPPORT SERVICES Medicaid Audit 2006 /
2007REPORT SUMMARY INFORMATION, contd
7. A. Ensure that the Community Support Adult
service notes reflect 11 interventions with the
community to develop interpersonal community
coping skills including adaptation to home,
school work environments B. Ensure
that the Community Support Child service notes
reflect 11 interventions with the community to
develop interpersonal community relational
skills including adaptation to home, school and
other natural environments. C. Other
Ensure that


41
COMMUNITY SUPPORT SERVICES Medicaid Audit 2006
/ 2007REPORT SUMMARY INFORMATION, contd
8. A. Ensure that all service note/service
plans are individualized per person. B.
Other Ensure that
9. A. Ensure that service notes indicate the
duration of the service and that it matches the
units billed. B. Other Ensure that
42
Community Support Medicaid Audit 2006 /
2007REPORT SUMMARY INFORMATION, contd
10. A. Ensure that service notes reflect
treatment for the duration of service that was
billed. B. Other Ensure that

• A. Ensure that a service authorization is in
  place
• covering all dates of service.
• B. Other Ensure that

43
Community Support Medicaid Audit 2006 /
2007REPORT SUMMARY INFORMATION, contd

• Recommendations, not requiring Corrective
  Action
• 1.
• 2.

Summary comments for this survey
General Comment for the survey Yes
No This provider received their initial letter
announcing their Medicaid audit on
______________.  The letter outlined the complete
audit process and indicated all materials that
were needed on-site for the audit.  This letter
also included copies of the audit tools, audit
instructions and plan of correction information. 
On ______________, this provider received the
list of records to be audited on their scheduled
audit date of ___________.  At the beginning of
the audit, the items needed for the audit were
reviewed and the provider was informed of the
deadline time that day to have all items
available. This provider was unable to provide
the following information.________________________
___ _____________________(The provider is waiting
for this agency__________________________________
__________________ to provide this
documentation____________________________________
______________________