MENTAL HEALTH COMMUNITY HEALTH CENTER FRAUD

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MENTAL HEALTH COMMUNITY HEALTH CENTER FRAUD

• Elizabeth Bradley
• New Mexico Human Services Dept.
• Office of the Inspector General

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COMMUNITY MENTAL HEALTH CENTERS

• WHAT IS THE DEFICIT REDUCTION ACT?
• The act strengthens Medicaids status as payer of
  last resort relative to private health insurance.
• It is the most sweeping legislation to impact
  Medicaid in over 30 years
• It aims to cut 11B from Medicare and Medicaid
  programs over the next 5 years (Note total
  Medicare and Medicaid billing is 515B for 2006)
• Focus is on deterring and preventing fraud, waste
  and abuse.

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COMMUNITY MENTAL HEALTH CENTERS

• Medicaid Rehabilitation Option Services
• Specific Medicaid funded behavioral health
  services include, but are not limited to
• Psychosocial Rehabilitation
• Residential Treatment
• Assertive Community Treatment

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COMMUNITY MENTAL HEALTH CENTERS

• 4. Treatment Foster Care
• 5. Targeted Case Management
• 6. Functional Family Therapy
• 7. Multi-systemic Therapy

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COMMUNITY MENTAL HEALTH CENTERS

• COMMON DOCUMENTATION MISTAKES

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COMMUNITY MENTAL HEALTH CENTERS

• Example 1
• Progress note with insufficient info to support
  service
• John refused to participate in any groups this
  week. Clearly needs to continue treatment.
• Whats missing?

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COMMUNITY MENTAL HEALTH CENTERS

• John continues to believe that he owns the
  residential center and that the groups are
  activities provided for his guests. Continue to
  work with John on social skills building and
  reality testing individually and in small groups.

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COMMUNITY MENTAL HEALTH CENTERS

• Example 2
• Progress note that does not match service
  definition/service code
• Accompanied John to the doctor and sat in with
  him so staff would know what was said.
• Whats missing?

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COMMUNITY MENTAL HEALTH CENTERS

• Accompanied John to the doctor and sat in with
  him. Following visit, asked John to recall what
  the doctor said. John was unable to remember.
  Reminded John of the three main points that the
  doctor had made

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COMMUNITY MENTAL HEALTH CENTERS

• Example 3
• Progress note that does not clearly link the
  consumers condition with the intervention.
• Continuously corrected Gabriels bad language.
• Whats missing?

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COMMUNITY MENTAL HEALTH CENTERS

• When Gabriels anxiety increases, his verbal
  aggression and use of profanity increase as well.
  Coached Gabriel on self-monitoring of his
  language as a cue to begin anxiety reduction
  techniques we have been practicing.

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COMMUNITY MENTAL HEALTH CENTERS

• Example 4
• Progress note that does not identify the
  intervention and is not related to the treatment
  plan.
• Jane attended cooking class.
• Whats missing?

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COMMUNITY MENTAL HEALTH CENTERS

• Jane holds a job as a cook at In-N-Out Burger.
• Jane does not have independent living skills on
  her treatment plan.
• She does have anger management and social
  interaction skills on her treatment plan.
• Make sure that you document what Jane practiced
  in this group, such as not interrupting, waiting
  her turn, and being supportive to others.

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COMMUNITY MENTAL HEALTH CENTERS

• Progress note that does not demonstrate progress
  toward identified goals.
• Charlie continues to make progress.
• Whats missing?

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COMMUNITY MENTAL HEALTH CENTERS

• An explanation of how recipient has achieved or
  is taking action toward a specific goal and to
  what extent consumer has made progress
  (quantifiable measurement).
• Improved note Charlie is now able to take his
  medication independently with minimal prompting
  about 50 of the time.

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COMMUNITY MENTAL HEALTH CENTERS

• Questions?