Download - Medical Necessity
Mary Thornton & Associates, Inc1
Medical Necessity
Concept in Practice
Mary Thornton & Associates, Inc2
Medical Necessity: Who Cares?
• What payers?• What about accreditors?• Even for rehab option?
• What about recovery programs and services?
• Isn’t this something only the doctor can determine?
• What about client choice?
Mary Thornton & Associates, Inc3
Medical Necessity: Who Cares?
• PAYERS– Medicaid – Medicare– Champus/Tricare– ODMH– ODADAS– Commercial insurers
Mary Thornton & Associates, Inc4
OIG’s 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.”
Mary Thornton & Associates, Inc5
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
Mary Thornton & Associates, Inc6
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
Mary Thornton & Associates, Inc7
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
Mary Thornton & Associates, Inc8
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 one’s license
– Improper business practices: kickbacks for referrals to a provider or product, anti-trust, cost reports issues, enhancement of profits by limiting care
Mary Thornton & Associates, Inc9
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
Mary Thornton & Associates, Inc10
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
Mary Thornton & Associates, Inc11
The OIG’s 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
Mary Thornton & Associates, Inc12
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)
Mary Thornton & Associates, Inc13
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
Mary Thornton & Associates, Inc14
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
Mary Thornton & Associates, Inc15
Medical Necessity: Who Cares?• Isn’t 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
Mary Thornton & Associates, Inc16
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.
Mary Thornton & Associates, Inc17
Productivity and Medical Necessity
Capacity
Revenue Risk
RevenueRisk
Productivity
UM Training
Productivity Productivity
UM andTraining
Marketing
RevenueRisk
Mary Thornton & Associates, Inc18
Medical Necessity: What’s it mean?
Payer Acute Rehab
Medicare Primarily Limited
Medicaid X X
ODMH X X
ODADAS X X
Commercial Primarily Limited
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Medical Necessity: What’s It Mean?
• Starts with a qualified professional
– Assessment– Clinical Formulation– Diagnosis– Determination of level of care– Ordering treatment
• Scope of license issues
Mary Thornton & Associates, Inc20
Medical Necessity: What’s 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, 5101:3-1-01
Mary Thornton & Associates, Inc21
Medical Necessity: What’s 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
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Medical Necessity: What’s 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
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Medical Necessity: What’s 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,
Mary Thornton & Associates, Inc24
Medical Necessity: What’s 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”
Mary Thornton & Associates, Inc25
Medical Necessity: What’s 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
Mary Thornton & Associates, Inc26
Medical Necessity: What’s 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
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Medical Necessity: What’s 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
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Medical Necessity: What’s 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.
Mary Thornton & Associates, Inc29
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 client’s problem
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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
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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
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Additional Guidance for MH and SA
• Client must be active participant– Documentation must be clear about
client’s 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
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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
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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
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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.”
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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. “
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Rehabilitation OptionIAPSRS 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.”
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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
Mary Thornton & Associates, Inc39
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
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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 individual’s service plan….”
Mary Thornton & Associates, Inc41
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 TreatmentIndividual and Group Psychotherapy
Other Acute Services: ACT, Partial Hospital, IOP
Peer, Recreational, Employment, Vocational
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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
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Florida Outpatient
Center
$4.2 mm payback in cash and services
• 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.
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Florida Outpatient
Center
• Physicians did not always sign treatment plans
• Physicians did not always participate in development of treatment plans or their review
• Tx plans incomplete, sometimes not there at all, or no signature or date of signature
• Geriatric Day Tx usually had no prior certification
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Florida Outpatient
Center
• 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
• Interns and other students billed w/out sufficient or evidence of supervision
• Dual billing of Medicaid and contracts
Mary Thornton & Associates, Inc46
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
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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 one’s own health: treatment planning, provider choice, skills and resource development
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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
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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
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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
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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
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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
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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
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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, S&S of mental and physical illnesses, and adverse effects
• Understanding of impact of physical illness on mental illness and vice versa
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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
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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 S&S’s
– Same as above but for side effects
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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
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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
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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
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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
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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
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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
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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
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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”
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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?
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Documenting Medical Necessity
• Key Elements in Documentation– Services rendered in
accordance with ISP and with payer definitions of services? Is the provider appropriately credentialed?
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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”
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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
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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– Client’s circumstances– Client’s participation– Client’s response
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Speaking to Objectives
• Goal: Client wants to go to work - Obj:Client will identify and join a job skills program. “Discussed client’s 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. ”
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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.”
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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.”
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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
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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.
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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.”
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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 consumer’s preferences. Consumer stated she would prefer SRO but is open to other options. Agreed we will follow-up by end of week.”
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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.”
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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. “
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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.”
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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.”
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Documenting Progress
Progress vs. encounter notes
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Case Study 1
Mary
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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
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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
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Community Support
• Curriculum– SAMSHA – handouts– Others: see handout
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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
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Case Study 2
Paul
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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
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Case Study 3
Frank
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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
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Coordinating Centers of Excellence
• Coming soon:– ACT– MI/MR– Supported Employment
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Thank You