DMA’s Vague Clinical Policies: What’s Good for the Goose is NOT Good for the Gander

North Carolina Medicaid rules/regulations/policies require health care providers to maintain stringent documentation standards. An “I” is not dotted, then the provider must pay back a reimbursement.  So, obviously, what is good for the goose is good for the gander, right?  Nope.  The gander can be vague in documentation, just not the goose.

While casually reading some updated DMA Clinical Policies today, I realized how vague these policies are.  Understand, these Clinical Policies are doctrines in the Medicaid arena.  In the Medicaid arena, these policies are to providers as a recipe is to a perfectionist-chef.  If any ingredient is missing, the entire meal will fail. Or a child’s dot-to-dot worksheet; if any number is missed, the picture is incorrect.  In the Medicaid arena, if a provider fails any part of the policy, the provider fails; the picture is incorrect.  The service reimbursement must be returned…even if the service was rendered wonderfully and greatly serviced the Medicaid recipient.  Documentation is everything.

My question is: If documentation is everything, why are the policies that instruct the provider how to document so vague?

For example, in DMA Clinical Policy 4A, it states that, “Medicaid and NCHC shall not cover the following:…certain periodontal surgeries”

Really? “Certain periodontal surgeries?” What the heck? Certain? Hmmmmm…could you be a little more specific?

Another example: Clinical Policy 8A states, for Peer Support Services (PSS), that the eligibility criteria, in part, is, as follows:

“B. The individual has documented identified needs due to his or her mental health or substance abuse diagnosis in at least three of the following areas:

  •  Limited ability to self-manage symptoms and behaviors
  • Has recently experienced a crisis episode requiring intervention through Mobile Crisis Management, Facility-Based Crisis, hospitalization, or detoxification services
  • History of difficulty using traditional services (missing office appointments, difficulty maintaining medication schedules, etc.)
  • Limited ability to develop and utilize self-advocacy skills in order to increase independence
  • Limited ability to identify and utilize community services and supports without assistance
  • Limited ability to develop and maintain relationships, including natural supports
  • Limited ability to maintain in residence, physical health, community, school, job, or volunteer activity.”

Ok, let’s talk about the vagueness. “Limited ability?” Limited as compared to what?  Who determines “limited ability?”  Obviously, this is a subjective determination.  When I say it’s a windy Saturday, the wind may be 13-17 mph or 25-30 mph. Who is to say what is windy?

If I were to suffer from hypersomnia, would I qualify as having “limited ability?” If I had hypersomnia and I didn’t take my medicine, then I would fall asleep if I thought too hard.  If I didn’t take my medicine, I would have a limited ability to maintain a job, a limited ability to maintain relationships, and a limited ability to utilize self-advocacy skills. So would I qualify?

I believe identified needs of an individual, as written by DMA, would qualify under the definition of vagueness.

So, you, as a health care provider, believe that your client meets eligibility criteria for whatever Medicaid service. But eligibility is subjective. You may get prior approval from one entity but get a recoupment audit from another entity claiming no medical necessity.

The audits that are going on now subject the provider to stringent documentation rules. But why can DMA draft such vague policies that do not adhere to any stringent documentation rules?

What’s good for the goose is good for the gander, right?

Not in this case. The gander can be vague.  The goose must adhere to stringent documentation rules.

Posted on April 11, 2013, in Dentistry Services, Division of Medical Assistance, Health Care Providers and Services, Medicaid, Medicaid Audits, Medical Necessity, Mental Health, North Carolina, RAC and tagged , , , , , , . Bookmark the permalink. 3 Comments.

  1. Covered periodontal surgery services and the policy limits are clearly spelled out in DMA’s Clinical Coverage Policy No. 4A. Please read the coding sections that present what periodontal surgery services are covered. It seems that you quoted lagnuage from one section of the clinical coverage policy which is a general summary statement of what services are not covered and ignored the more detailed section which tells providers which periodontal surgery services are covered and gtheir limitations. This may be confusing to lawyers and other lay people, but not to dental profesiionals.

    • Corrected the typos–

      Covered periodontal surgery services and the policy limits are clearly spelled out in DMA’s Clinical Coverage Policy No. 4A. Please read the coding sections that present what periodontal surgery services are covered. It seems that you quoted language from one section of the clinical coverage policy which is a general summary statement of what services are not covered and ignored the more detailed section which tells providers which periodontal surgery services are covered and their limitations. This may be confusing to lawyers and other lay people, but not to dental professionals

    • GV,

      I am happy to hear the policies are so easily understood by you. I wager others would disagree. But, I would agree that of all the DMA clinical policies, the dental policies are probably the best worded.

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