Category Archives: DMA Clinical Policy 3A
This blog pertains to all Medicaid providers regardless the state and regardless the Medicaid service provided.
Heard of the “Way Back Machine?” Perhaps, you should have!!!
You are a Medicaid provider, and you get a Tentative Notice of Overpayment (TNO) based on a Medicaid post-payment review by Public Consulting Group (PCG) or HMS in the extrapolated amount of $800,000 based on a sample size of 100 dates of service (DOS) and multiplied out to some extrapolation universe. You look at the extrapolation data and determine tha you were not even paid $800,000 during the time frame PCG determined was the universe. Or you say…What???…My documents complied with policy!
What do you do?
Sound like a horrible SAT question? Or sound like reality?
Hopefully you answered the former, but if you answered the latter, read on…
You’ve read my blogs before and understand the importance of appealing PCG or HMS’ extrapolated audit. But you do not have the financial means to hire an attorney. Or you honestly believe that if the Department of Health and Human Services (DHHS) reviewed your documents that its employees would also agree that PCG or HMS was wrong. Or you, personally, want to self-audit to determine the veracity of the audit. Or for whatever reason, you want to know whether PCG or HMS was correct for your own well-being.
How do you self-audit….the audit?
This may be one of the best “tips” I have given… (sorry for tooting my own horn, but, seriously, this blog can be helpful! I had a client that pointed out he/she had no idea about this “tip.”)
PCG and HMS conduct post-payment reviews. This means that PCG and HMS are looking at 1-2-3-year-old medical records.
Think about how quickly Medicaid changes. Now think about the number of times in which the DMA Clinical Policy applicable to your practice has been revised in the last few years.
When I say DMA Clinical Policy, I mean, if you provide Outpatient Behavioral Therapy, Policy 8C is applicable. If you provide dental services to Medicaid recipients, then Policy 4A is applicable. If you provide durable medical equipment (DME) to Medicaid providers, then Policy 5A is applicable. For a full list of the NC Medicaid policies, please click here.
The DMA Clinical Policies change significantly throughout the years. For example, DMA Clinical Policy 8A, revised January 1, 2009, allowed Community Support for adults and children. Yet Policy 8A, revised August 1, 2013, does not even allow Community Support (obviously Community Support was disallowed prior to August 2, 2013, but I am making a point). Also, now we have 16 unmanaged outpatient behavioral therapy visits for children, whereas a couple of years ago we had 26 unmanaged visits.
The point is that when PCG or HMS audits your particular service, the auditors are not always experts in your particular service, nor experts in your particular service’s Clinical Coverage Policy. See my blog on Dental Audits Gone Awry. In this blog I show the required (or lack thereof) education/experience to become a PCG auditor.
Therefore, it is imperative that you have access to the applicable Clinical Coverage Policy applicable for the DOS audited.
But, if you google 2009 clinical policy for NC Medicaid dental services, you can’t find it.
So how are you supposed to get access to these old policies that are being used (or mistakenly NOT being used) in Medicaid audits for the older DOS?
It is called: The Way Back Machine.
I know, cheesy! But I did not name it.
The “Way Back Machine” website looks like this:
The beauty of the “Way Back Machine” is that you can go to any current website. Copy the internet address. Paste that internet address into the “Way Back Machine” where you see “Way Back Machine” and a white box appears in which to type the website address. Type in the address, and hit the button “Take Me Back.” VOILA…time travel!!!!
Small Tip: I have found that if I use the internet address for the specific policy for which I am researching, I am less successful than if I use the general DMA Policy address found here. Once you get to the appropriate year on DMA’s general policy website, you can click on the specific policy in which you are interested.
Using the “Way Back Machine,” you can go to the DMA Clinical Policy (for whatever Medicaid service) applicable years ago.
You should never need to go more than 3 years back, as Recovery Audit Contractors (RACs) without permission by DHHS, cannot audit DOS more than three years ago.
But, you need to review the Clinical Policy for [fill-in-the-blank] Medicaid service 2 years ago? No problem! Use the “Way Back Machine” and travel back in time.
Wouldn’t it be great if we could travel back in time “for real?” Prior to RACS…prior to PCG…prior to HMS….? We need a “Way Back Machine” for Medicaid providers (and me) “for real!”
New revisions to Medicaid policy limit the number of home health aide services for Medicaid recipients, regardless of medical need.
North Carolina Department of Health and Human Services (DHHS), Division of Medical Assistance (DMA) revised the Clinical Policy 3A. The revised policy took effect July 1, 2013.
Prior to this revised policy, home health aide services were limited to the amount, frequency, and duration of services as ordered by the physician and documented in the Plan of Care (POC). As in, if you needed services four times a week, if your physician ordered the services and the need for such services were documented on the POC, you could receive home health aide services four times a week.
What are home health aide services?
“Home Health (not aide) Services, generally, include medically necessary skilled nursing services, specialized therapies (physical therapy, speech-language pathology, and occupational therapy), home health aide services, and medical supplies provided to beneficiaries who live in primary private residences. Skilled nursing, specialized therapies, and medical supplies can also be provided if the beneficiary resides in an adult care home (such as a rest home or family care home).”
Home health aide services are a subpart of Home Health Services.
“Home health aide services are hands-on paraprofessional services provided by a Nurse Aide I or II (NA I or NA II) under the supervision of the RN. The services are provided in accordance with the established POC to support or assist the skilled service (skilled nursing and specialized therapies).
Home health aide services help maintain a beneficiary’s health and facilitate treatment of the beneficiary’s illness or injury. Typical tasks include:
a. Assisting with activities such as bathing, caring for hair and teeth, eating, exercising, transferring, and eliminating.
b. Assisting a beneficiary in taking self-administered medications that do not require the skills of a licensed nurse to be provided safely and effectively.
c. Assisting with home maintenance that is incidental to a beneficiary’s medical care needs, such as doing light cleaning, preparing meals, taking out trash, and shopping for groceries.
d. Performing simple delegated tasks such as taking a beneficiary’s temperature, pulse, respiration, and blood pressure; weighing the beneficiary; changing dressings that do not require the skills of a licensed nurse; and reporting changes in the beneficiary’s condition and needs to an appropriate health care professional.”
See DMA Clinical Policy 3A, p. 1-3 (emphasis added).
The revised Policy 3A has 5 additional pages (it went from 29 pages to 34 pages, in total), but many more restrictions, many of which are without regard to medical necessity.
Such as, “Home health aide services must be limited to 100 total visits per year per beneficiary.” Click here for the full text of the revised Policy 3A. Of course, always remember the exception for children: EPSDT.
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) is a federal Medicaid requirement that requires the state Medicaid agency to cover services, products, or procedures for Medicaid beneficiary under 21 years of age if the service is medically necessary health care to correct or ameliorate a defect, physical or mental illness, or a condition [health problem] identified through a screening examination (includes any evaluation by a physician or other licensed clinician).
For more information on EPSDT, see my blog: “EPSDT’s Impact on Medicaid Audits.”
Now, going back to our Medicaid recipient in medical need of 4 home health aide services/week (208 visits/year), he or she is now limited to 100/year (almost 2 visits/week) (This math is using 52 week/year, not 52.1775).
There are other services possible, depending on the medical necessity. But as for home health aide services, you only get 100.
Remember, this limit not only affects Medicaid recipients (obviously the limit impacts the recipients most greatly), but, also, providers will have less work for their home health aides. As one of my readers pointed out to me, the aides are only making around $8/hour.
DMA Clinical Policy 3A, revised July 1, 2013, has other restrictions. See below for some other restrictions.
Skilled Nursing Visits
Pre-filling insulin syringes/Medi-Planner visits (RC 581) must be limited to a maximum of one visit every two (2) weeks with one (1) additional PRN visit allowed each month. There is a limit of 75 skilled nursing visits (inclusive of, and in any combination with, RC 550, RC 551, RC 559, RC 580, RC 581, and RC 589) per beneficiary per state fiscal year.
Miscellaneous Code T1999
Use of the T1999 code for billing miscellaneous supplies is limited as follows:
- A maximum of $250 per beneficiary per state fiscal year may be billed without prior approval required.
- Any amount over $250 per beneficiary per state fiscal year, whether for a single item or a cumulative total, requires prior approval.
- A maximum of $1,500 per beneficiary per state fiscal year may be billed.
Are these new restrictions only because of a tight Medicaid budget? My question is when does medical necessity for Medicaid recipients become a factor in policy limits?