Category Archives: ValueOptions

Medicaid Provider Tip: How to Read a Claim Audit Finding

Claim Audit Findings (CAF).  It even sounds scary. Not to mention, if you receive a CAF, it means that you have been audited by the State or an agent thereof (which, in it of itself, is a scary process). So seeing a CAF does not make you happy. But it helps if you understand what the CAF is and, more importantly, is NOT telling you.

Here is what a CAF looks like:

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This particular CAF was drafted more recently (the review was conducted March 2012, but this CAF was not drafted until much later).  I have seen earlier CAFs handwritten.

For the sake of this example, we are reviewing a CAF for 16 units billed for Community Support Team. Regardless of the type of health care service, the CAF will be on an identical form or very similar.

At the top of the CAF, you have all the information you need to pull the particular file to compare your file to the CAF.  The Medicaid recipient’s name, date of birth, and Medicaid number is listed.  Most importantly, the date of service (DOS) is listed.  No matter how many times you provided services to this recipient, the DOS on the CAF is the only DOS that matters.  However, word of caution, most of the time, you will receive 2-10 CAFs for one particular client for 2-10 DOS.  All the DOS matter in that case.

Moving to the middle section of the CAF, you can see on the left side, the CAF reads either “administrative” or “clinical.”  The middle of the middle (nice explanation, huh?) has a question.  Then the right side (of the middle section) has “Not Met/No,” or “Yes/Met,” etc.

I will go through each type of administrative or clinical topic.  The bottom of the CAF supposedly details more specifics about each topic.  Although I will show you how unhelpful the explanations are. In fact, the only helpful part of the bottom section is the fact that it shows you which year’s Clinical Policy the auditor used (as in which date. Since the policies have been revised so many times, the auditor frequently uses the incorrect policy.  It is important to have the policy in front of you that was in place for the particular DOS).

Ok, the topics on the CAF (the middle section of the CAF).  The topics are divided between administrative and clinical.  Administrative issues are (seemingly) objective; are the documents in the file? Clinical issues are more subjective, such as was there a demonstration of medical necessity and were the service notes adequately written (apparently these auditors believe that every provider should also be an ametuer novelist).

Let’s go through the administrative topics.

A1: Authorizations

“Is there an authorization in place covering this date of service?”  This is just a matter of did the Medicaid auditor review an authorization in the file at the time he or she reviewed the file.  Even if you had a valid authorization in place at the DOS, if  the auditor did not see the authorization in the file ate the time of the audit, you will receive a “Not Met” for A1.  

(“Not met” means you failed that particular facet of the audit and you will need to repay the amount received for the service.)

Another reason I have seen “Not Met” under A1 is for services that do not require authorizations.  The auditors apparently cannot figure out which services require authorizations and which do not.

A2: Service Orders:

“Is there a valid service order for the service billed?”  Again, the auditor looks in the file for a service order for the code billed.   The “Not Mets” I have seen for service orders range from the signature on the service order being illegible; therefore, the credentials of the signator could not be assessed to the service order ordering one CPT code, while the service was a different CPT code.  

A3: Person-Centered Plan (PCP)

“Is there a valid PCP in place for the date of service billed?”  Now, obviously, PCPs are used in Community  Support Team (CST), but not in all areas of health care, not even in all areas of behavioral health.  Nonetheless, I have seen CAFs require a PCP, even when a PCP is not required for particular service.  I’ve also seen CAFs that read “treatment plan/PCP,” but the CAF will not inform you for which (a treatment plan or PCP) the auditor has been told to look. Many “Not Mets” are because of the confusion on the part of the auditors as to what documentation is actually required for a service.

A4: Staffing Requirements:

“Does the team meet staffing requirements per the service definition?”  For A4, the auditors will actually look beyond the file (usually). As the onset of an audit you will be required to provide the auditor with all your staff’s credentials.  Beware: Many, many times I have a “Not Met” for A4 because the auditor could not read the signature; therefore, the auditor could not determine which staff member rendered services, much less whether the staff member met all required credentials.  But the auditor will not ask you whose signature is on the document; apparently, there is some rule somewhere in the world according to Medicaid auditors that signatures must be legible, because I sure as heck have not seen that rule.

A5: Staff Qualifications:

“Is there documentation that the staff is qualified to provide the service billed?”  This is a tad different from A4.  In A4, the governing criteria is the DMA Clinical Policy (whichever is applicable to the services you provide).  A5 is more specific.  If the staff member is providing substance abuse prevention, does the staff have the credentials showing that he or she is certified to provide substance abuse services.  The qualifications required depends on the service provided.

A6:Health Care Public Registry

“Did the provider agency complete a Health Care Public Registry check on any unlicensed staff providing the service billed prior to the date of service?”  Just as it reads, A6 requires the provider agency to complete a Health Care Public Registry for any unlicensed staff.  Here, the auditor will look for a piece of paper proving that the Registry check was conducted prior to the date of service.  But like most other topics, the auditor will not simply ask you whether you have completed a Registry check if the Registry check is not easily found, such as filed in the individual staff member’s file, not multiple copies filed with every single recipient who receives services from that staff member.  You will just receive a “Not Met.”

A7: Disclosure of Criminal Convictions

“Did the provider agency require disclosure of criminal convictions by staff person(s) who provided the service?”  A7 is so poorly drafted.  My high school English teacher would be appalled.  This is a classic example of a sentence in the English language not doing its job (which is to communicate).  Does the provider have to show the auditor that the provider has a written rule/policy that all staff members are required to disclose any criminal convictions? Or is the auditor actually looking for a criminal background check of all staff? A7 gives no guidance.  If you go down to A7 in the bottom section (that we will talk about later) you see that no further guidance is given.  So, you will just have to hold your breath in anticipation as to the answer until I get to the bottom section explanations.

C8: Entrance Criteria

“Does the Comprehensive Clinical Assessment support entrance criteria, per the service definition?”  C8 is the topic at which my blood begins to boil. Essentially, C8 is asking whether the Medicaid recipient meets entrance criteria for the service provided.  Mind you, providers (unless prior authorization is not required for the specific service) cannot bill for a service unless there is prior authorization from DMA (or, more specifically, the contracted company that was reviewing prior authorization for the state…it was ValueOptions for behavioral health).  So these auditors are reviewing services for recipients for which the provider already received prior authorization (meaning entrance criteria was met) from DMA or its acting agent and now, another contracted company, sometimes years later, is saying, “Hold on there. I know you already received prior authorization for this service, but in my subjective opinion, I disagree. I don’t think medical  necessity was met; entrance criteria was not met.” I don’t know how many due process or fundamental fairness rules C8 violates, but, so far, C8 is still part of the Medicaid audits.

C9: Individualized PCP

“Is the PCP individualized for the person?” Remember, above I wrote that sometimes, for different services, C9 will read treatment plan/PCP.  Regardless, if prior authorization is required for the service, the PCP was already reviewed before prior authorization was given.  See argument for C8.

C10: Crisis Plan

“Does the Crisis Plan include the required elements per the PCP Instruction Manual?” Again, C10 may change depending on the service.  But, regardless, if prior authorization is required for the service, the PCP, including the Crisis Plan, was already reviewed before prior authorization was given.  See argument for C8.

C11: Timeframe of Signature

“Is the documentation signed by the person who provided the service within the designated timeframe?”  This may be one of my favorites. Because you do not necessarily submit service notes for reimbursement daily, there are times that you submit multiple claims on one day.  Maybe you have an electronic service note system that you draft all service notes then sign them all as you submit them. (This is only one example of many of the nonsensical results of C11). The auditors will claim that you must sign all service notes on the DOS.  You will be told your service note is out of compliance if the dates of signature and service do not match. But my question is out of compliance with what? With the utopian laws of providing health care services? Certainly not out of compliance with the DMA clinical policy (that I have seen) or the Basic Medicaid Billing Guide.  Nothing that I have seen states that providers must sign the service notes on the date the service was provided.  The policies state the service notes must have the DOS and must be signed. Period.

C12: Billed Units

“Does the documentation support the units billed?”  For this topic, the auditors are looking at the service note and trying to locate a “time in” and “time out.”  Or a duration period noted on the service note.  The issue with C12 that I have seen is that some CPT codes, not all, but some, have, in the very definition, the duration specified. For example, in Outpatient Behavioral Health services, 90834 (now) denotes 38-52 minutes of psychotherapy. Before January 2013, 90804 denoted 25-30 minutes of individualized therapy.  If the definition of the CPT code defines the duration, why is there an additional requirement to physically write the time in and out on the service note? Apparently, the auditors know of a reason.

C13: Goals on PCP

“Does the service note relate to the goals in the PCP?” Again, C13 may change depending on the service.  But, regardless, C 13 is asking whether the treatment plan or the medical objectives for the patient are germane to the activities on the service note.  This is such a subjective determination.  However, I’ve had auditors deem no germaneness when a goal for the recipient is improving relationships with non-family members, and the service note denotes that the therapeutic treatment was role-playing as if the therapist was a non-family member. Hmm. Germane?

C14: Assessment of Progress

“Does the service note reflect assessment of progress toward goals?”  C14 is similar to C13 as to its subjectiveness.  Here, I have had auditors determine “Not Met” for C14 when the service note stated that the recipient is improving, but scared of consequences of result. Hmmm. Assessed progress?

C15: Individualized Interventions

“Are the interventions in the service note individualized per person and reflective of the service definition?”  What? How are services for a specific individual not “individualized?” What the auditors are not telling you in C15 is that the auditors are looking for service notes that appear to “cut and pasted” from prior service notes with minimal changes.  Apparently the auditors believe that if you provide one hour of therapy to a Medicaid recipients that that specific goal was met and that at next therapy session you can move on to the next goal.  Apparently, you do not have to work on one goal more than once.

A16: Unit Conformity

“Do the units documented match the units paid?” This is an administrative topic, but basically, mirrors C12.

Ok, there are the topics and my 2 cents worth on them.

Going to the bottom section of the CAF, I believe I discussed most of the issues in the bottom while I was describing the middle section. 

But for example, in bottom section C7 (of which you have so calmly awaited the explanation), “no employee information” submitted means (in auditor language) the auditor did not see a criminal background check prior to DOS.  wouldn’t it be so much easier if the explanations found in the bottom section actually stated what document was actually needed?

Or, for example, in bottom section A5, the auditor may not necessarily be saying that no staff information was provided.  A5 may actually mean that either (1) the auditor could not read the staff’s signature; and, therefore, the auditor could not determine whether the qualifications had been submitted; or (2) the service note was not in the file at the time the auditor reviewed the file, so the auditor cannot determine which staff member conducted the service.  But it is up to you to decipher.

Or, for example, in bottom section C8, when the auditor writes that no documentation submitted to show entrance criteria was met, the auditor is actually saying that, at the time the auditor reviewed the file, the file did not contain either an assessment or initial intake or referral or something to show the diagnoses of the patient.  However, it is interesting to note that during the audit of the file, if a provider tries to supplement the file with documents for which he or she knows the auditor is looking, the auditor refuses, saying that he or she can only review the file.  But C8 can mean that, in the subjective opinion of the auditor, that the documentation provided does not meet entrance criteria, or it can mean that the auditor does not have a full understanding of the entrance criteria, or it can mean that a documents proving entrance criteria was accidentally misdated.  C8 can mean a plethora of different scenarios; none of which are explained in the “explanation” of C8.

So, there you go, Claim Audit Findings 101.  Surely, you have no questions; it’s so easy!!

Regardless, appeal, appeal, appeal.

Medicaid Story: WRAL 6:00 News Tonight

Today I was interviewed by WRAL.  The interview will be aired during the 6:00 news.  Please watch.

I am so thankful that WRAL saw a story in my client‘s injustice.  My client received a Medicaid termination letter recently, which means that she must discharge all Medicaid recipients and no longer provide Medicaid recipients with the mental health care they need.  She engaged in no fraud.  No, my client provided the mental health services to Medicaid recipients and billed for the services rendered.  The reason she was terminated from Medicaid was because a contracted company for the State decided that her documentation was inadequate (paperwork nit-picking).

Ok, I’m sure that a number of you is sitting there reading this thinking, “Well, her documentation was poor. She should have done a better job.”  No.  Let me explain.

The State has contracted with a couple of companies to audit Medicaid, Recovery Audit Contractors (RACs).  These companies are compensated on a contingent fee, meaning the more errors the companies find, the more money the companies receive.  A RAC audited my client’s documents.  My client provides mental health services (which receive prior authorization).  The RAC is auditing claims from 2009-2010.  So all the claims have been approved back in 2009-2010 by ValueOptions, the State’s contracted company to approve mental health services.  Now, in 2013, the RAC is claiming that the very documentation that was approved in 2009-2010, is now inadequate.

The problem? (And the problem I have seen over and over with many health care providers):

The contracted companies are not being overseen by the State. They have full reign. Unfortunately, many times, the RACs are applying the Medicaid policy requirements from 2013 to Medicaid claims from 2009-2010.  Meaning, the contracted companies are reviewing the current policies and applying them retroactively.

My favorite example of this (not necessarily applicable to my client in this instance) is Implementation Update #68. In Implementation Update #68, the State changed the practice of using an Introductory Person-Centered Plan (Intro PCP).  Before Implementation Update #68, an Intro PCP was written prior to any assessment.  Yet, I have had instances with clients in which the State (via its contracted companies) has stated that a health care provider owed the Medicaid reimbursement back to the State because the Intro PCP was dated prior to the assessment. Yes, NOW, the PCP will be dated after the assessment. But not back in 2009. Therefore, the contracted companies are using the criteria from current policies to audit Medicaid claims from the past.

Why is this important? Today, health care providers who accept Medicaid are getting audits, causing those health care providers to expend time, money and man-power on defending the claims. Who loses? The Medicaid recipients who need the services.  Already, a small percentage of health care providers accept Medicaid.  Medicaid recipients need health care providers willing to see them.

We are appealing my client’s termination of her Medicaid contract.  But the potential consequences (should our appeal not work) are dire. The Medicaid recipients receiving mental health services from my client will need to be discharged.  These people in need of mental health care, will have to find another psychologist, when over 60% of health care providers refuse to accept Medicaid.

Shouldn’t we, as a population, be grateful to health care providers who decide to accept Medicaid recipients? We are not paying high enough reimbursements already, most providers refuse Medicaid recipients. So when a health care provider does accept Medicaid, we should say, “Thank you.” Not scrutinize the documentation (when the services were provided) and say, “Hey, those documents are not compliant with 2013 standards. Yeah, I know the services were provided in 2009, but you should have had a crystal ball and known the policies would become more stringent. Your fault.”

How Medicaid Handles Mental Illness

Mental health in this country is not handled well. That is an understatement!!! Look at the atrocity in Connecticut last week. An young man, supposedly suffering from Asberger’s, a mild type of autism, shot his way into an elementary school and proceeded to slaughter young children and women. Our country does not handle mental health. However, mental health issues exist, are common, and are not treated appropriately. We cannot act like an ostrich and poke our heads in the sand.

The horrifying events of last week’s elementary school slaughter should make us realize that something must be done with how this country handles mental illness.  Folks, it’s not the guns that need control. Gun cannot act on their own. The people holding the guns need to be reasonable and sane. People who suffer mental illness in this country need real services. Real help.

How North Carolina handles mental illness is about to change drastically. The entire Medicaid mental health system is changing. This may be the biggest re-vamping of mental health we have undergone. If it doesn’t work, it will cost billions to change the system back. How will it change? See below.

The sad truth is mental illness is a very under-treated health condition. The stigma that attaches to it is one reason.  But poverty is also a factor.

The N.C. Interagency Council for Coordinating Homeless Programs (ICCHP) conducts an annual survey of homeless people.  In 2008, the statistics were as follows:

  • 12,371 people identified as homeless, including
  • 3,643 people in families, 2,216 of whom were children.
  • 1,054 identified themselves as veterans of military service.
  • 1,961 identified themselves as having a serious mental illness.
  • 4,206 identified themselves as having a substance use disorder.
  • 1,108 identified themselves as being a victim of domestic violence.
  • 6.5 percent of people identified themselves as having been released from the criminal justice system.
  • 6 percent of people identified themselves as having been released from a mental health hospital or drug treatment program.

Half of the homeless identified themselves as suffering from a mental illness or suffering substance abuse! Half! How many homeless suffer a mental illness without a diagnosis?

These are people who should be receiving Medicaid. In order to receive mental health services covered by Medicaid, the mental health services must be determined to be medically necessary to treat the mental illness.

So what is “medical necessity?”

Medicaid covers procedures, products, and services when they are medically necessary. With all the Medicaid rules and regulations, somewhere, medical necessity must be defined. It is not. In North Carolina Clinical Policy 8A, medical necessity is described as: “All Medicaid services are based upon a finding of medical necessity, which is determined by generally accepted North Carolina community practice standards as verified by independent Medicaid consultants. There must be a current diagnosis reflecting the need for treatment.”  What?  Basically, an independent consultant, as of now, VO, must decide whether a health care service is medically necessary. Despite the amorphous definition, medical necessity has been somewhat uniform because all the prior authorizations went through VO. It did not matter in which county you lived. VO was state-wide.

Not for long. In upcoming changes to NC Medicaid, VO will no longer be the independent consultant for North Carolina’s mental health.  The State is creating Managed Care Organizations (“MCOs”).  Suffice it to say, if you are a health care provider in North Carolina, you have heard the term “MCO.” What is an MCO? I guess the correct question is what will be an MCO?

The best way to describe the new Medicaid system in North Carolina, I think, is to explain the process for getting prior approval now and explain how it will change in the upcoming 6-7 months.

To obtain prior authorization now for mental health services, the provider sends documents, usually a Person-Centered Plan (“PCP”) with a Service Order, among other papers, to ValueOptions.  Since 2006, VO has provided North Carolina with utilization management. Meaning health care professionals at VO would review the documents and determine whether the Medicaid recipient met “medical necessity” in order to receive the services requested.

When the MCOs take over, there will be no state-wide definition for medical necessity.  There will be no state contract with VO. Basically, the State will disperse all the Medicaid funds to the MCOs.  No one really knows how many MCOs there will be in North Carolina.  As of now, it appears there will be 12 or so. Alliance Behavioral Health will be one. Wake County could not get qualified on its own, so Wake County partnered up with Durham County.

The thought process was this: The State is too big to understand the needs of local regions. So let the localities decide what services are needed in Medicaid’s mental health. On paper, I think it sounds good. Trying to focus locally is a good thing. The problem I foresee is the lack of a uniform, well-defined criteria for medical necessity in mental health.

It is foreseeable that each different MCO will have different opinions as to what services are medically necessary or not. In Charlotte, Medicaid may cover hyperbolic oxygen treatment for autism. But Raleigh may not. In Raleigh, Medicaid may limit psychiatrist visits for people with violent tendencies, and, in Wilmington, the psych visits may be unlimited. A Medicaid recipient may be denied in Roxsboro for mental health services that would be covered if that Medicaid recipient lived in a different MCOs region.

Mental health is such an important topic. In the wake of the killings in Connecticut, we, as a country, need to learn to better provide services to those with mental illnesses. Medicaid recipients need solid mental health services. With the MCOs provide better mental health services? Maybe. But I think a good start would be to provide a state-wide definition for medical necessity.