DHHS LME Post Payment Review Training

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DHHS LME Post Payment Review Training

• May 4, 2007

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Training Agenda

• Review Implementation Memo27
• Define post payment review
• Discuss the tools and procedures for post payment
  reviews
• Questions/Answers

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Handouts in Packet

• Implementation Memo 27
• LME Summary
• Access to Data Instructions
• 1st Notification Letter
• 2nd Notification Letter
• Record Request Timeline
• Community Support Definition Key Elements
• Child and Adult
• Tool
• Reviewer Guidelines
• Decision Matrix
• Weekly Post Payment Report

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Things to ConsiderCommunicate, Communicate,
Communicate

• Educating Providers
• Posting documents on your web site
• Have provider meeting to discuss the process
• Have periodic meetings/updates as the process
  unfolds
• Identify a point person to field questions and
  comments
• Make sure that customer service understands the
  activity to field questions from families,
  consumers, providers, etc.
• Conduct In-service with CFAC

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Implementation Memo 27

• Handout in packet
• Will conduct post payment reviews of all current
  and new recipients of CS receiving excess of
  average of 12 hours per week
• Will result in
• Receiving appropriate clinical intervention and
  treatment
• Based upon this peer review, PCP and tx options
  require additional review for determination of
  appropriateness
• Provider requires training regarding the use of
  CS or treatment planning
• Referral to DMA
• Changes in tx options will be made through the
  treatment team and will follow routine
  authorization procedures through VO.

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Post Payment Review

• The Objective
• Is the recipient receiving the appropriate
  clinical intervention and treatment?
• This is a clinical review, not a record review
  and not an audit
• However, during your clinical review, you may
  find information that would lead to a need for a
  record review. Do not conduct the record review
  to determine clinical appropriateness
• Post Payment review is defined by the elements on
  the tool
• Will need clinical records
• Will need licensed clinical person to determine
  appropriateness
• As a result of review of the medical record and
  completion of the tool - clinical appropriateness
  is determined.
• There may be documentation issues that raise
  compliance issues that kicks it to another
  type of review.

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How to get the Data

• Data file identifies recipients receiving an
  average of 12 hours per week. Data is paid
  claims July 06 Feb, 07
• Data File
• Handout Directions to Access Community Support
  Data
• Excel Workbook for each LME is posted at ITS in
  the same directory where the Medicaid paid claims
  files are found
• Only persons with RACF security rights to this
  directory will be able to access the data (there
  is someone for each LME who can do this)
• The remote site directory will be
  DHR.MMR.PDCLAIMS.APXXX
• Where XXX is- there is a three digit
  number for each LME (e.g. 308 for Wake)
• The file name is CSHIGH
• This is a an Excel Workbook and is stored in
  BINARY, so it must be stored in BINAY as well.
• Note This is different from the instructions
  for the paid claims files, as they are stored in
  ASCII text files.
• Any questions please contact Adam Holtzman at
  919-715-7774 or adam.holtzman_at_ncmail.net

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Provider Letter

• Notify Provider
• Gather names of all consumers for provider
• Prepare notification letter to provider (handout)
• 1st written request to provider for medical
  records -allow 7 business days from date of
  letter
• 2nd written and final request for medical records
  OR missing documents allow 5 business days
• Certified or UPS manner to check if received or
  not. Refusal to sign demonstrates receipt of
  notification
• Receive documentation from Provider
• Review documentation for completion as requested

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Information Request

• Request most recent PCP and revisions to support
  claims being reviewed
• Assessment Information should support the PCP and
  revisions being reviewed
• Request progress notes that reflect dates to be
  reviewed
• Intent is to get enough progress notes to
  determine if services provided match PCP
  objectives which should reflect assessment
  information.
• If claims reflect inactive status go back in
  billing history through July, 06 to request
  progress notes to match claims.

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If the provider doesnt send the information

• LME notifies DMA that record has not been
  submitted as part of weekly status report
• DMA suspends payments until record or missing
  documentation is received.

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NC DEPARTMENT OF HEALTH HUMAN SERVICES 2007
POST-PAYMENT REVIEW Flow Chart To Accompany
Post-Payment Review Tool, and Reviewer Guidelines
Step
Review PCP or T/HP
1
Enter N at a. Recipient Not Appropriate.
Refer to DMA
If No
Is PCP or T/HP Present?
2
If "Yes
Review Dx/Assessment Information
3
Q (a) Is MH/SA Diagnosis Present?
If "Yes
4
Enter Y at a.
If No
Q (a) Is Only DD Diagnosis Present?
5
If "Yes
Q (a) Is there is evidence of a second
diagnosis (MH/SA) somewhere in the record ?
If "Yes
6
Enter Y at a.
If No
Enter N at a. Recipient Not Appropriate.
Refer to DMA
Q (a) Is Recipient under age 21
If No
7
If "Yes
12
Enter N at a. Recipient Not Appropriate.
Refer to DMA
Q (a) Is EPSDT Referral/Approval Present?
If "Yes
If No
8
Enter Y at a.
Enter N at b. Training in PCP required.
Q (b) Do Dx/Assessments reflect DX Information?
If No
9
If "Yes
Enter N at b. Training in PCP required.
Q (b) Did Recommended referrals take place?
If No
10
If "Yes
Q (b) Were recommended consultations related
to accurate Dx/assessment information?
Enter N at b. Training in PCP required.
If No
If "Yes
Enter Y at b.
11
Review the recommendations made on the Summary of
Assessments and Observations page of the PCP, or
in treatment team notes for a T/HP
12
Enter N at c. Training in PCP required.
Q (c) Do recommendations reflect DX Information?
If No
If "Yes
13
Enter Y at c.
Review Symptoms/Observations listed on the
Summary of Assessments and Observations page of
the PCP or in assessment information for a T/HP.
14
13
Enter N at d. Training in PCP required.
Q (d) Are they actual symptoms/ Observations?
If No
15
If "Yes
Enter N at d. Training in PCP required.
Q (d) Do symptoms/observations relate To DX
Information?
If No
If "Yes
16
Enter Y at d.
17
Review Full Dx/Assessment Information from Q. a-d.
Recipient Not Appropriate. Refer to DMA.
If "Yes
Are b-d all rated N?
18
Review Personal and Family Interview sections of
the PCP.
19
Review Signature page of the PCP or T/HP and/or
revisions.
20
Is recipient under age 21?
If No
Is recipient own LRP?
21
If "Yes
If No
Review participation and agreement of the parent
or legally responsible party.
22
Review PCP for family participation, if families
identified as participants by individual.
23
14
Q (e) Did person/family or LRP participated in
the development of the plan?
Enter N at e. Training in PCP required.
If No
If "Yes
Enter Y at e.
24
Review Goal Statements in PCP or T/HP.
25
Q (f) In PCP, is there a symptom/
observation With each goal?
If "Yes
26
If No
Q (f) In T/HP, Is symptom/observation evident
with each goal?
Enter N at e. Training in PCP required.
If No
27
Q (f) Do symptoms and observations directly
relate to goals?
Enter N at e. Training in PCP required.
If "Yes
If No
Enter Y at f.
28
Review the Personal and Family interview sections
in the PCP for comparison to the goal statements
to determine if the Whats Important
information is reflected in the goals.
29
Q (g) In PCP, is the Whats Important
information reflected in the goals?
If "Yes
Enter Y at g.
30
If No
15
Q (g) If T/HP, do admissions assessments,
NC-TOPPS, etc., indicate what is important to
individual/family?
Enter N at h. Training in PCP required.
If "Yes
If No
Enter Y at g.
31
Review the goal statements and supporting
interventions in the PCP or T/HP against the
appropriate CS Service Definition
(Child/Adult/Team).
32
Q (h) Is service a paraprofessional service to
individual?
Proceed to
If No
33
42
If "Yes
Q (h) Is service a paraprofessional service to
person age 21 or older?
Proceed to
If No
34
38
If "Yes
Per Review Guidelines, assure skills identified,
beyond statement of activity, are clinical
interventions, provided in order to empower the
individual to learn the skills, and toward
teaching/assisting the individual to become
independent in the skill.
35
Enter N at h. Training in service definition
required.
Q (h) Are measurable interventions related to
skill building present?
36
If No
If "Yes
16
Q (h) Does goal reflect 1-on-1 intervention In
community per service definition and Review
Instructions?
Enter N at h. Training in service definition
required.
If No
If "Yes
37
Enter Y at h.
If No
Q (h) Is service a paraprofessional service to
person under age 21?
Proceed to
38
35
If "Yes
Proceed to
If No
Q (h) Is service provided in a school setting?
39
41
If "Yes
Per Review Guidelines, assure that interventions
identified are clinically justified and are
provided in order to assist the child in
developing skills to function successfully and
independently in the environment.
40
Q (h) Does goal reflect 1-on-1 intervention In
community per service definition and Review
Instructions?
Enter N at h. Training in service definition
required.
If "Yes
If No
41
Enter Y at h.
Proceed to
If No
Q (h) Is service a Q-Level Service?
42
33
If "Yes
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Per Review Guidelines, assure that the note
reflects Q-level activity such as coordination
and oversight of initial and ongoing assessment
activities, initial development and ongoing
revision of the PCP or T/HP, monitoring of the
implementation of the PCP or T/HP, and/or
additional case management functions of linking,
arranging for services and referrals.
43
Q (h) Does note reflect Appropriate QP
activity per service definition and Review
Instructions?
Enter N at h. Training in service definition
required.
If "Yes
If No
44
Enter Y at h.
Review Crisis Plan in PCP, or in T/HP.
45
Q (i) Do the symptoms listed make sense with
those indicated in assessments and treatment
goals?
Enter N at i. Training in service definition
required.
If No
46
If "Yes
Q (i) Do the strategies listed relate to the
overall level and intensity of CS treatment
provided?
Enter N at i. Training in service definition
required.
If "Yes
If No
Enter Y at i.
47
Review a sample of notes over the time period
indicated.
48
Are service notes not individualized (canned,
electronically copied)?
Recipient Not Appropriate. Refer to DMA
If Yes
49
18
Enter N at j. Training in service definition
required.
Q (j) Do the notes accurately relate to the
diagnostic information previously reviewed?
If "Yes
If No
Enter Y at j.
50
Q (k) Do the notes accurately reflect the
specific treatment goals in the PCP or T/HP?
Enter N at k. Training in service definition
required.
If No
If "Yes
Enter Y at k.
51
Enter N at l. Training in service definition
required.
Q (l) Do the intensity (frequency and duration)
of CS provided matches with services billed (paid
claims)?
If No
If "Yes
Enter Y at l.
52
Review the service notes in the PCP or T/HP
against the appropriate CS Service Definition
(Child/Adult/Team).
53
Q (m) Is service a direct service to individual?
Proceed to
If No
54
56
If "Yes
Q (m) Does note reflect 1-on-1 intervention In
community per service definition and Review
Instructions?
Enter N at m. Training in service definition
required.
If "Yes
Enter Y at m.
If No
55
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Q (m) Is service an indirect service to
individual?
Proceed to
If No
56
55
If "Yes
Q (m) Does note reflect Appropriate QP
activity per service definition and Review
Instructions?
Enter N at m. Training in service definition
required.
If "Yes
Enter Y at m.
If No
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Clinical Determinations (CD) based on Cumulative
Information in Considerations (a) (m)
CD1 Is the CS service clinically necessary?
If "Yes
If No
Enter N at CD1.
Enter Y at CD1.
58
If No
CD 1a Would this individual be better served
by access to more intensive services than CS?
Proceed to
If No
59
61
If "Yes
Identify suggested alternative services.
60
20
CD 2 Is the duration and frequency of the CS
clinically appropriate?
If "Yes
Enter Y at CD2.
61
If No
Identify recommended duration and frequency.
62
ADMINISTRATIVE (LME) RESPONSE ALTERNATIVES
A1 Do the PCP or T/HP and treatment choices
need additional review by LME staff to determine
appropriateness?
If No
If "Yes
Enter NA at A1.
Enter Y at A1.
63
A2 Is training in regard to the use of CS
services is needed?
If "Yes
Enter Y at A2.
If No
Enter NA at A2.
64
A3 Are the issues uncovered during this
review beyond the scope of further review or
training but warrant a Medicaid paid claims
audit?
If "Yes
Enter Y at A3.
If No
Enter NA at A3.
65
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A4 Are the issues uncovered During this review
beyond the scope of further review, training
and/or a Medicaid paid claims audit, and
referral to DMA for further review and
investigation is warranted?
If No
Enter NA at A3.
If "Yes
Enter Y at A3.
66
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Validating Clinical Decision

• Medical Director or Clinical Director must review
  and sign off on at least 5 of total post payment
  reviews. Reasons for this review
• Inter-rater reliability
• To mirror post payment reviews when completed by
  DMA and their vendors
• Maintain complete records of this process
• Is subject for disclosure during appeals

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After The Clinical Decision Is Made Next Steps

• Recipient
• Follow guidelines for clinical decision, referral
  for record audit, referral to DMA
• Notify the provider of recommendation
• Submit to DMA by COB on Monday, the status report
  of prior week activities (handout)
• Must be submitted electronically using the Excel
  spreadsheet
• Forward client specific tools to section in LME
  that is responsible for plans of corrections,
  endorsement and/or medical record reviews

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• Systemic
• Summarize client specific findings in order to
  create a provider report.
• Percent is determined by dividing the number of
  Nos by the total number of tools X (times) the
  13 considerations (a-m),
• If a finding of less than 10 - the licensed
  clinician may make recommendations for
  improvement in writing to the provider
• A Provider Plan of Correction is needed if
• 10 to 20 - POC
• Above 20 - POC and full record audit
• Plan of Correction should be completed in
  accordance to the LME POC policy
• Link provider POC to endorsement requirements
• Utilize systemic information to revise LMEs
  local business plan within strategic objectives

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Medical Record Review

• If a medical record review is needed
• Must follow state medical record protocol
• Must use Medicaid Record Audit Tool and Auditors
  Instructions
• Please consult DMH Program Accountability to
  assure statewide consistency

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When to refer to DMA?

• Referral to DMA Program Integrity may occur at
  any point during the process. Referrals
  concerning an individual provider should be made
  only upon completion of all reviews for that
  single provider.
• Automatic referrals should occur if
• Single incidents that are so problematic or
  appear to be fraudlent
• No PCP
• No diagnosis or only DD for adults
• Service notes are not individualized

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Follow Up

• DHHS will convene a follow up meeting to evaluate
  the process and review status
• LMEs may request consultation from DMA/DMH at any
  point
• Questions about the post payment project
• Tara Larson and Christina Carter
• Questions