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For WebEx Participants:• Please put yourself on mute• You are free to type in your questions as we go along • Q & A session at the end

Gray Callout button is for you to type the questionsRed Microphone button is to put yourself on mute

Presenter

Presentation Notes

Ensure WebEx is working properly. Once we get a good number of participants– ask that all the WebEx attendees to kindly turn off their audio/ mute themselves. You are welcome to type your questions in chat box as we go along the presentation. We will try to address the questions at the end of the presentation.

For In-Person Participants:

• Restrooms/Passcode• Please silent your cell phones• There is no eating or drinking inside the conference room,

but you are free to eat outside in the hallway.

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Presentation Notes

Do you know the restrooms passcode for both M/F?

Quick Survey

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Presentation Notes

For everyone with us today, we passed out a quick survey. If you didn’t get it, please raise your hand and we will pass them out. If you are done with your survey, please raise your hand and a member of our team will come to collect it. Thanks! For everyone on WebEx- there is a same survey poll.

REVISED Mental Health Compliance Audit Tool

Garrett Chatfield, JD, CHC, Interim BHS Compliance OfficerCynthia Chinn, LCSW, Compliance Clinical Auditor

Lourdes Holt, RHIT - Compliance AuditorMatt Flores, RHIT - Compliance Auditor

Presenter

Presentation Notes

Here’s the rundown: Warm welcome. I want to thank everyone for taking time out of your busy day to attend this meeting. Garrett- self introduction MH Auditors/ Compliance Team introductions Audience introductions Hold the questions until the end (also include index cards) We will be making a note of all the questions and create a FAQ document that we will post on the website and emailed.

Overview of Presentation

1.Rationale for the revised tool2. Monitoring Plan3. New Audit Tool• Q & A Session

Presenter

Presentation Notes

My Presentation will be organized in 3 parts: First, we will talk about why we are having the new audit tool (many of you will probably want an answer for this one) Next, we will look at the new Monitoring Plan And last, we will be looking at the new audit tool (will be having the MH Auditors help me with this part) At the end of the presentation, we will have a Q & A session

Why are we having a new Mental Health audit tool?

1. Program Integrity:•Activities meant to ensure that federal and

state taxpayer dollars are spent appropriately on delivering quality necessary care

•To prevent Fraud, Waste and Abuse•Focus on definitive recoupments

Presenter

Presentation Notes

Why are we having a new Mental Health Audit Tool? There are three reasons. 1. To promote program integrity. And the definition of program integrity is performing activities that are meant to ensure that federal and state taxpayer dollars are spent appropriately on delivering quality necessary care. Also to prevent and detect FWA. Focus on definitive recoupments

Why are we having a new Mental Health Audit Tool?Cont.

2. Align to Minimum Medicaid Standards to insure plan integrity by providers.

3. To foster greater transparency and accountability in programs

(By establishing a monitoring plan)

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Presentation Notes

2. To align to Minimum Medicaid Standards to insure plan integrity by providers. 3. To foster greater transparency and accountability in programs. And we can achieve that by establishing a monitoring plan.

Monitoring Plan

0 - 4.99%

5 - 14.99%

15%+

Error Rate

Audit Annually

Programs will provide a CAP, do Internal review &

monitoring

Report to BHS Compliance every

month

Re-Audit in 6 months

Programs will provide a CAP, do Internal review &

monitoring

Report to BHS Compliance every

month

Re-Audit in 3 months

Presenter

Presentation Notes

What does the Monitoring Plan Look Like? There will be a 3 tier rating band based on your error rate…..

Programs greater than 5% error rate:1. Provide a Corrective Action Plan (CAP)

2. Do internal review and monitoring.

3. Report to BHS Compliance on a monthly basis.

4. Compliance Team will re-audit in 3/6 months.

Upon re-audit, if their error rate still over 5%:1. Revise Corrective Action Plan (CAP)2. Do internal review and monitoring. 3. Report to BHS Compliance on a monthly basis.4. Compliance Team will re-audit in 3/6 months.

Presenter

Presentation Notes

Go off the slide….and include: 1. Programs will be expected to repay us any disallowed claims they identify for the period that they are auditing. 2. We will hold off on implementing any sanctions this year, but this monitoring plan is what are working on for now.

When will the revised tool be effective?

The new Mental Health Compliance Audit Tool will be effective as of April 2020.

How is the new audit tool different from our old audit tool?

•We will be auditing less lines. We will be auditing up to 50 billing lines/claims as oppose to a larger load of charts.

Presenter

Presentation Notes

Garrett– do you want to mention that we will not have an audit schedule/calendar this time around, but will not notifying the programs one month in advance?

NOTE on New Audit Tool• What is NOT included in the new audit tool does not

necessarily mean the programs are not held accountable for them.

• The Documentation expectation remains the sameShortcut link to Doc Manual: tiny.cc/MHref

• We do reserve the right to do a targeted audit even if we will not disallow the initial audits

How is this new Audit Tool organized?

New Audit Tool

Fatal

Potentially Fatal

Non-Fatal

19 Questions

2 Questions

7 Questions

How is the new Audit Tool organized? Cont.

The Fatal Error section:(19 Questions)

Medical Necessity/ Assessment

Treatment Plan of Care (TPOC)

Claim/ Progress Note Review

Any one of the 19 questions that are answered NO would result in the billing line/claim disallowed.

FATAL ERRORSMedical Necessity/ Assessment

Audit Item Y/N/NA Auditor's Comments

1Is there an assessment that covers the service and signed by a LPHA?BHS Documentation Manual; Annual BHS AOA Performance Objectives

2 Is the primary diagnosis an included SMHS diagnosis?CCR Title 9, Chap 11, Sec 1830.205(b)(1)(A-R); 1830.210; Mental Health Plan Contract, Exhibit A, Attachment I)

3

Does beneficiary meet diagnostic criteria for an included DSM/ICD diagnosis for outpatient SMHS in accordance with the MHP contract?CCR Title 9, Chap 11, Sec 1830.205(b)(1)(A-R); 1830.210; Mental Health Plan Contract, Exhibit A, Attachment I)

4 Is the diagnosis determined by a LPHA?(CCR, Title 9, Section 1840.314 (d)

Presenter

Presentation Notes

Cynthia’s Slide 2- I know diagnosis is one of the 11 elements of a client assessment (#10) and that is the ONLY element that is counted as a fatal item Medical necessity must be documented in the assessment, client plan, progress notes and other chart documentation and must be determined by a person with diagnosis in his/her scope of practice. The Diagnostic criteria, a signed and finalized assessment and a diagnosis determined by a LPHA are all medical necessity criteria that must be met to be eligible for reimbursement.

Treatment Plan of Care


5 Does the TPOC include goals and objectives?(CCR, title 9, chapter 11, section 1830.205(b)(3)(B)(1-4)(c)

6 Does the TPOC include proposed interventions?(Mental Health Plan Contract, Exhibit A, Attachment I)

7Is the service date covered by the TPOC?BHS Documentation Manual; BHS-AOA Performance Objectives

8Is the TPOC signed with credential and dated by the clinician completing the plan? (Mental Health Plan Contract, Exhibit A, Attachment I)

9Is the TPOC co-signed by LPHA if completed/signed by staff other than LPHA?(CCR, Title 9, Chapter 11, Section 1840.314(e)(2); Mental Health Plan Contract, Exhibit A, Attachment I)

Presenter

Presentation Notes

Lourdes’ slide

Treatment Plan of Care


10

Is there documentation of beneficiary's participation and agreement with the TPOC as evidenced by the beneficiary's signature on the plan, or reference to beneficiary's participation in the body of the plan or in a progress note?(CCR, title 9, chapter 11, section 1810.440 (c)(2)(A)(B)

Presenter

Presentation Notes

Lourdes

Claim/Progress Note Review


11 Is the Service Date documented?BHS Documentation Manual; BHS Policies and Procedures 3.10-11

12

Is the signature of the person providing the service (or electronic equivalent) with the person's degree, license, or job title? (Mental Health Plan Contract, Exhibit A, Attachment I; BHS Documentation Manual; MH Staffing Qualifications for Service and billing privileges)

13 Is the service provided within the provider's Scope of Practice?

Presenter

Presentation Notes

11- PN must be entered in the client record within 24 hours but no later than 5 biz days (co-signature required.)I guess we can elaborate between late vs no service date. Would a PN be disallowed if there is a service date but it’s late? 12- is connected to #11 Matt’s slide-- #13 is not in our old audit tool, but this is one of the DHCS reasons for recoupment. Here are some examples: Only LPHAs can complete an assessment. MHRS & MHW, RNs cannot. MHRS cannot provide any individual or group psychotherapy. Feel free to modify/ edit. ;)

Claim/Progress Note Review


14

Is the progress note is co-signed by a LPHA or MHRS when required? (Mental Health Plan Contract, Exhibit A, Attachment I; BHS Documentation Manual; MH Staffing Qualifications for Service and billing privileges)

15 If the claim is a Medicare billing, is the service rendered with a Face-to-Face (FTF)?

Presenter

Presentation Notes

Matt’s Slide

Claim/Progress Note Review cont.


16 Is the service delivered contained in the beneficiary's TPOC? Mental Health Plan, Exhibit A, Attachment I; BHS Documentation Manual

17

Are group notes properly apportioned to all beneficiaries, including documentation of “total number” of participants and include an “individualized” note for each client participant?Mental Health Plan, Exhibit A, Attachment I; BHS Documentation Manual

Presenter

Presentation Notes

Matt

Claim/Progress Note Review cont.

Audit Item Fr old audit tool Y/N/NA Auditor's

Comments

18Does note match and support the appropriate service/billing code? Mental Health Plan, Exhibit A, Attachment I; BHS Documentation Manual

III-12

19Is the claim a billable service?CCR, Title 9, Chapter 11, Section 1810.355; Section 1840.312(a-d); Section 1840.312 (f); Section 1810.247 BHS Documentation Manual III-11

Presenter

Presentation Notes

Matt

What is a potentially fatal item?• There are mainly 2 questions in the potentially fatal section, and they

focus on the timeliness for the assessment and the treatment plan.

• If the treatment plan has not been finalized within the time period yet (late TPOC), but NO services are provided within that time period, then this would be considered a non-fatal disallowance. (Non-Fatal)

• If there were services provided prior to having a finalized assessment or treatment plan, then these services would be disallowed. In this case, the billing line would be disallowed. (Fatal)

Presenter

Presentation Notes

Cynthia- here is an example I wrote, but feel free to edit and modify as needed.

POTENTIALLY FATAL ERRORS

Audit Item Y/N/NA Auditor'sComments

PF-1

Initial AssessmentFor Outpatient - Is the initial assessment completed within 60 days of opening?For Residential Treatment - Is the initial assessment completed within 3 full days of admission?BHS Documentation Manual; BHS-AOA Performance Objectives

For Reassessments, is the annual assessment update completed timely?BHS Documentation Manual; Annual BHS AOA Performance Objectives

Presenter

Presentation Notes

Cynthia

POTENTIALLY FATAL ERRORS


PF-2

Initial TPOCFor Outpatient- Is the initial TPOC completed within 60 days of episode opening or prior to any planned services?For Residential Treatment- Is the initial TPOC completed within 3 full days of admission?BHS Documentation Manual; BHS-AOA Performance Objectives

For Updated TPOC- Is the TPOC updated annually or when there are significant changes in the client's condition?BHS Documentation Manual; BHS-AOA Performance Objectives

NON-FATAL ERRORS


NF-1 Does the assessment include the 11 required elements?Mental Health Plan Contract, Exhibit A, Attachment I; Documentation Manual

• Non-Fatal does NOT mean it is not required. • E.g. 11 elements of assessment are still required

• Non-Fatal items means No $$ recoupment • Reserve the right for targeted audits

Presenter

Presentation Notes

Garrett’s slide I know this part can be confusing. Some people have asked me, why is this question in the non-fatal section? And completing the 11 requirement elements on an assessment is probably one of the most time consuming parts. But I want to emphasize that this is still a requirement. We want to still stick to the documentation standards. Lets say only have 6 out of the 11 elements, this will not result in a recoupment. But let’s say if the note was clearly poorly written or none of the 11 elements are there, we will make a note of this in the comments section, and flag this as a potential special project to revisit the program.

NON-FATAL ERRORS


NF-2

Are goals/objectives specific, quantifiable and/or observable, and related to the beneficiary’s mental health needs and functional impairments as a result of the mental health diagnosis? (Identify/ provide method of measurement from current baseline to goal.)(CCR, title 9, chapter 11, section 1830.205(b)(3)(B)(1-4)(c)

NF-3 Is the progress notes finalized within 5 business days?BHS Documentation Manual; BHS Policies and Procedures 3.10-11

NF-4Does the Progress Note content describe a service that is linked to a goal/objective in the TPOC? Mental Health Plan, Exhibit A, Attachment I; BHS Documentation Manual

Presenter

Presentation Notes

These are more subjective questions that falls more in the quality part of SOC, but we feel this is an important arena that we will review, but not disallow for.

NON-FATAL


NF-5

Does the note independently describe how the provided services reduced impairment, restored functioning, or prevented significant deterioration in an important area of life functioning outlined in the TPOC?Mental Health Plan, Exhibit A, Attachment I; BHS Documentation Manual

NF-6 Was the face-to-face (FTF) time in range/ reasonable for the service provided?

NF-7Was the documentation time in range/ reasonable for the service provided? If no, enter total time for documentation for type of service below:

So how can I prepare for the Compliance Audit?

• Share the tool with everyone in your team• Use this audit tool as a guide/checklist as you are documenting• Make it a program-wide goal to strive for under 5% error rate

• You can’t improve on what you can’t measure• Track your audit progress over time• Do take time to give acknowledgement for a superb

documentation job!• Implement an ongoing internal auditing/review• Take time to periodically review the documentation manual

Implement Internal

Monitoring as part of the process!

Internal Monitor

Strong Team

Service Delivery

Presenter

Presentation Notes

Instead of waiting for the fire to happen and then respond, we can take certain preventive measures we can to minimize the damage/potential harm. You have the choice to be proactive. And the best proactive measures programs can take now is to start the internal monitoring process even BEFORE we start auditing your program. With this revised audit tool, you will find that most of the fatal and potentially fatal questions should not take long to go through, they are simple yes/no questions. You are mainly looking to see if something is there, or not there.

THANK YOU!QUESTIONS?COMMENTS.

Presenter

Presentation Notes

Share the survey results….both WebEx & the in person (if available) Closing After the Q & A Session (Optional) Once again, I would like to thank all of you for taking time out of your busy day to attend information session. And in closing, I say this with my utmost sincerity that I hope to see all of you succeed and to do well on your next Compliance Audit. Thank you.

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Documents