1 QI Updates FY 2015-2016. 2 ◘ Bathrooms ◘ Breaks ◘ Silence Phones ◘ Taking Questions The small stuff

1QI Updates FY 2015-2016

QI UPDATES

THANK YOU FOR YOUR DEDICATION TO QUALITY,

CLIENT CARE, AND OUTCOMES

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QI Updates FY 2015-2016 2

◘ Bathrooms◘ Breaks

◘ Silence Phones◘ Taking Questions

The small stuff . . .


1. DHCS Statewide Information

2. Review MRR Results FY 14-15

3. Documentation Tips

4. MRR Process for FY15-16

5. Plans of Correction

6. Program Integrity (PI)

Today’s AGENDA


7. Serious Incident Reporting and SIROF

8. Notice of Actions

9. Diagnosis at Service (DAS)

10. ICD-10 Implementation

11. Other Updates & Looking Ahead

12. Performance Improvement Team

13. MIS Updates

Today’s AGENDA


Section 1915(b) Specialty Mental Health Services (SMHS) Waiver

◘ Services Waiver Renewal◘ Federal Requirements waived:

◘ Freedom of Choice◘ State-wideness◘ Comparability of Services


Section 1915(b) SMHS Waiver (cont.)

◘ 1915(b) SMHS Waiver Sections◘ Submitted by DHCS to CMS

◘ Section A: Program Description◘ Section B: Monitoring Plan◘ Section C: Monitoring Results (from last

waiver period)◘ Section D: Cost Effectiveness


Section 1915(b) SMHS Waiver (cont.)

◘ SMHS Waiver recently renewed, with Special Terms & Conditions

◘ MHP Dashboards◘ Quality◘ Access◘ Timeliness◘ Translation/interpretation capabilities◘ Must include subcontracted providers


Section 1915(b) SMHS Waiver (cont.)◘ Waiver STC’s cont.

◘ Tracking & measuring timeliness of care◘ Assessments◘ Provision of services◘ State to establish a baseline

◘ Provision of PIP reports to CMS◘ MHP POCs on State website◘ Annual grievance & appeal reports to

CMS◘ All information required to be posted on

State website


CMS Areas of Focus◘ CMS reviews of MHP Triennial

Reviews and EQRO reports raised concerns about findings and continued non-compliance

◘ CMS had directed DHCS to establish a process to enact fines, sanctions & penalties to ensure compliance

◘ CMS is focusing on coordination of care between MHP and Managed Care Plans


CMS Areas of Focus cont.

◘Areas Requiring Improvement◘ 24/7 telephone line with appropriate language

access◘ Tracking timeliness of access◘ TARs adjudicated in 14 days◘ Logging of Grievances and Appeals◘ Ensuring providers are Medi-Cal certified and

re-certified timely

◘ Disallowance rates


State Overall Disallowance Rates

◘ Continued increase in disallowance rates since FY 09-10

◘ FY 13-14 average % of OP claims disallowed= 46%

◘Average OP disallowance rate from ◘ FY 08-09 - FY 13-14= 31% ◘ FY 13-14 Day Treatment disallowance

rate= 99%


Triennial MHP Review Protocol

◘ Items out of compliance:◘ FY 13-14: range equals 3%-29%

◘ Findings include:◘ Chart issues◘ Compliant client plans


DHCS Enhanced Monitoring

◘ Considering a 3 Tier Review System ◘ Tier 1: MHP reviewed triennially◘ Tier 2: MHP reviewed biennially◘ Tier 3: MHP reviewed annually

◘ MHP could be in same or different tier for system reviews & chart reviews

◘ Fluid system as MHP could move from tier to tier after each review


MRR RESULTS FY14-15

RESULTS IN %

ASSESSMENT

CLIENT PLAN

PROGRESS NOTE

BILLING

UM/UR

DAY TREATMENT

PWB

TOTAL FY 14-15 92 83 95 90 82 98 96

TOTAL FY 13-14 93 90 96 95 90 99 95

A/OA FY14-15 90 78 93 88 74 NA NA

A/OA FY 13-14 92 88 94 93 85 NA NA

CYF FY14-15 93 87 97 92 91 98 96

CYF FY13-14 94 92 97 96 95 99 95


OVERALL COMPLIANCE SCORES QI Reviews Provider Self Review

OVERALL

SCORECYF A/OA

OVERALL

SCORECYF A/OA

ASSESSMENT

2Demographic form is updated if there was a change in client information after admission and at a minimum annually.

69 67 72 83 89 76

4 BHA was updated as indicated or at a minimum of annually from previous BHA final approval date. 78 88 67 87 85 88

8

Cultural assessment information documents an understanding of client's culture and includes whether or not cultural issues impact the client’s mental health symptoms and/or perception and access to mental health services.

72 78 67 84 83 85

13When a client has discharged from an inpatient facility for suicidality or homicidally, an updated High Risk Assessment (HRA) is documented or updated.

79 83 75 87 96 77



OVERALL

SCORECYF A/OA

OVERALL

SCORECYF A/OA

ASSESSMENT & CLIENT PLAN

18

The Clinical Formulation documents impairments, substantiates program's diagnoses, and proposed plan of care/services to address the client's behavioral health needs.

86 85 87 93 93 93

20

A new Client Plan was written and final approved annually (program specific) and contains all required signatures or reason documented why not signed or final approved.

75 89 62 91 94 89

23 Objectives are specific, observable, and measurable. 79 92 67 90 94 85

24

Interventions include frequency, duration, and how interventions: (a) Will significantly diminish the impairment, or (b) If client is stabilized, will prevent significant deterioration, or (c) For children, will allow developmental progress.

62 60 64 78 82 75



OVERALL

SCORECYF A/OA

OVERALL

SCORECYF A/OA

CLIENT PLAN

25

If risk factors of harm to self or others have been identified in the BHA, there is evidence that the issues are addressed on the Client Plan, including interventions.

82 92 72 88 93 83

26

If a Substance Use Disorder has been identified in the BHA and diagnosed as an ongoing problem for client's mental health, there is evidence that the issues are addressed on the Client Plan, including interventions and/or referrals.

75 86 64 80 88 72

27

If a Physical Health Issue that affects the client's mental health has been identified in the BHA, there is evidence that the issues are addressed on the Client Plan, including interventions and/or referrals.

80 81 79 79 82 76



OVERALL

SCORECYF A/OA

OVERALL

SCORECYF A/OA

PROGRESS NOTES

32

For clients diagnosed with a co-occurring substance use disorder, progress notes document specific integrated treatment approaches.

84 79 90 86 88 83

34

Document client was seen by a mental health professional within 72 hours of discharge from an inpatient/crisis residential facility, if applicable.

88 100 76 79 94 64

36

Coordination and/or Referral of Physical and Behavioral Health Form is completed for each client (or documented reason why not completed). (Program may use own approved form).

80 91 70 86 93 79



OVERALL

SCORECYF A/OA

OVERALL

SCORECYF A/OA

BILLING, UM/UR, PWB

45Services are billable according to Title 9 (e.g., no-shows, lock-outs, non-billable activities, medical necessity, etc.).

75 87 63 94 95 93

46UM/UR is completed as required, which includes completion of applicable outcome measures.

82 91 73 89 90 87

59

Documentation supports that a CFT (Child Family Team) meeting has occurred a minimum of every 90 days and the client plan has been modified if applicable.

83 83 NA 80 80 NA


DOCUMENTATION TIPS

Documentation = what happened. If it’s not documented, it didn’t happen.

Medical necessity must be evident

Keep it , SIMPLE, SPECIFIC, STRUCTURED

Why is person getting services (impairment)?

What kind of service is delivered (intervention)?

What was the response of client (progress)?

What is the plan?


Travel Time Guidelines

Please see handout

Posted on OPTUM website

Do not need to include addresses

Make it clear and evident

DOCUMENTATION TIPS


• Presenting Problem• Demographics • Chief complaint• Precipitating factors• Referral source• Unique to your program• How impairment affects functioning• Integrate previous info into Psychiatric History• Establish medical necessity• What services are requested

DOCUMENTATION TIPS - ASSESSMENT


• Can be completed in multiple sessions

• Bill and document each assessment service

• Document ongoing medical necessity in presenting problem annually

• Update clinical formulation annually



CLINICAL FORMULATION:• This is YOUR formulation about client’s

functioning, medical necessity, need for services, and recommendations.

• Unique to your program, delete previous information

• Not a repetition of presenting problem



Considerations could include language of client/family,

primary language spoken at home, religious, spiritual

beliefs, family structures, customs, morals/legal systems,

life-style changes, socio-economic background, ethnicity,

race, immigration history/experience, age, subculture

(homelessness, gang affiliations, substance use, foster

care, military background), exposure to violence, abuse and

neglect, experience with racism, discrimination, and social

exclusion. Describe unique cultural and linguistic needs and

strengths that may impact treatment. Cultural formulation

includes an understanding of how client’s mental health is

impacted.

DOCUMENTATION TIPS - CULTURE


• When staff REVIEW the annual Client Plan, clinical narrative must be updated. Update the reason for extending treatment, ongoing medical necessity and changes to the client plan.

• Enter Unit/Subunit and Date in TIER NARRATIVE SECTIONS

• Example: 9900/9901 7/18/14

• REVIEW = Annual Re-write and at CYF UM Cycle

• REVISE = Updates within the year

DOCUMENTATION TIPS – CLIENT PLAN


• Completed with all Tiers included (Goals, Strengths, Applied Strengths, Area of Need, Objectives, Interventions)

• All narratives completed (include unit/subunit & date)

• Objectives must be observable and measurable

• Interventions must include frequencies and duration

• Area of Need – Needs to be linked to the presenting problem and document the impairment.

DOCUMENTATION TIPS – CLIENT PLAN


• Avoid• The play by play note - “client said this, I said

that”• psycho-babble or jargon• Wordy, rambling, run-ons• Cloned documentation• Vague, generic language

DOCUMENTATION TIPS – PROGRESS NOTES


ISSUES

• One or two sentences to describe the group and client’s participation

• Lack documentation of skills taught/reviewed

• Lack client response to intervention

• Two staff billing for group not justified

DOCUMENTATION TIPS - GROUP


• Documentation that is worded exactly alike or very similar to previous entries.

• Every visit with patient is unique. So the client’s problem, presentation, symptoms, intervention, response should be unique for each visit.

• This problem has been observed too frequently this past year in progress notes.

The Compliance Bulletin # 30, October 17, 2011

CLONED DOCUMENTATION


MRR PROCESS FY15-16• GOAL

• Collaborative approach• Increase knowledge of documentation

standards• Review of all direct service staff• MRR Feedback Survey

• FOCUS – MEDICAL NECESSITY• Assessment• Client Plan• Progress notes• Billing


• QI Specialist will contact PM with client names

• Programs will conduct their own MRR

• Complete review within two weeks (10 business days)

• Attestation by Legal Entity Executive staff

• QI Specialist conduct MRR and exit interview

• Final MRR sent within 30 days

• Plan of Correction due within 14 days

• Follow up and ongoing monitoring

MRR PROCESS FY15-16


• AFTER THE REVIEW• Exit Interview• Ask Questions – there should be no surprises• Complete Anonymous Survey to QM

• ISSUE RESOLUTION – Compliance Items• QI Specialist

• QI Supervisor• QI Program Manager

• APPEAL – Must include request letter and evidence• Only Recoupments are subject to appeal

• Level One – QI Program Manager• Level Two – QI Chief

MRR PROCESS FY15-16


• Required if overall compliance < 90% or disallowance rate greater than 5%

• QM has discretion to ask for a POC for specific issues

• 14 days to respond

• Respond specifically to deficiencies

• Submit evidence (sign in sheet, training, monitoring plan)

PLANS OF CORRECTION


• Submit billing documentation to verify completed corrections (See Billing Summary)

• Conditional POC approval until all billing corrections are completed to final adjudication

• How do you ensure Plan of Correction is working

• Follow up to QM on POC activities

PLANS OF CORRECTION


PLANS OF CORRECTION - BILLING RECOMMENDATIONS

• Before you make any corrections have your admin support check the BILLING STATUS of each service. – This will save you time & energy!

• Understand the difference between using service codes 999 vs. 998

• Group Progress Notes Correction

• Collaborate: Program-OH Help Desk-MHBU


CLIENT SERVICES MAINTENANCE WINDOW


PLANS OF CORRECTION - BILLING RECOMMENDATIONS

• Original State – Service can be edited!

• Pending – Service has been batched for processing. Import SC 998 & wait before you can make the correction.

• Paid/Denied – Service has been processed by the State. You can now submit the void request to MHBU & make the Cerner correction.


SERVICE CODE 999 VS.

SERVICE CODE 998

• Service Code 998 is used to avoid duplication of services. This is a temporary place holder while the service is pending payment.

• Service Code 999 is used to label a voided progress note.


GROUP PROGRESS NOTES

• Used for services that include multiple clients.

• Both the progress note and service is link to all clients.

• Therefore, when you are making a progress note or billing correction, you MUST void the entire progress note and billing for ALL clients.


BILLING & COLLABORATION

• Create a correction process workflow

• Educate Clinicians and Admin Support to identify and know what they can and cannot correct.

• Use Optum Help Desk to void your progress notes.

• Don’t forget to submit the void/replace request to MHBU.


Provider Name Legal Entity Name COR

0 0 0

Unit # 0 State Provider # 0 QM Reviewer(s)

SubUnit(s) # 0 Contract # 0 0

Total Disallowed Services

divided by

Total Reviewed Services

Disallowance Rate Review Date Review Period

01/00/00 01/00/00 to 01/00/00

Reason Codes: (1) Documentation does not establish an included diagnosis. (2) Documentation does not establish impairment criteria. (3) Documentation does not establish proposed intervention to address the impairment. (4) Documentation does not establish expectation intervention will diminish impairment, prevent significant deterioration or allow child to progress developmentally. (5) Initial Client Plan not completed within time period. (6) Client Plan not updated within time period. (7) No documentation of client participation/agreement with Client Plan. (8) No Progress Note for service claimed. (9) Time claimed greater than time documented on Progress Note. (10) Service provided where ineligible for FFP or in a setting subject to lockouts. (11) TBS service provided in Juvenile Hall. (12) Service provided was solely academic, vocational, recreational, or socialization. (13) Claim for group activity not properly apportioned. (14) Progress Note does not contain a signature. (15) Service provided was solely transportation. (16) Service provided was solely clerical. (17) Service provided was solely payee related. (18) No show billed when no service provided. (19a) Data Entry Error - The wrong date of service. (19b) Data Entry Error - Wrong service Indicator. (19c) Data Entry Error - Wrong procedure code. (19d) Data Entry Error - Wrong therapist. (19e) - Data Entry Error - Wrong time entered. (19f) Data Entry Error - Wrong client. (19g) wrong unit/sub unit. (19h) Data Entry Error - Wrong location code. (19i) Data Entry Error - Client is absent. (19j) Data Entry Error - Duplicate entry. (20) Documentation done 14 days after date of service. (21) FFS - Retro Medicare/OHC. (22) FFS - Claim paid in error.

The services listed below have a required action (edit, void, replace, delete). Program is responsible for taking the appropriate action to edit/void/replace/delete service(s). Billing corrections shall be completed within 14 days of receipt of final MRR and a copy of the Billing Summary Form verifying actions taken shall be submitted to the QM Reviewer. The Plan of Correction is not considered approved until all items below have been adjudicated to their final action. Program shall submit proof of final adjudication to the QM Reviewer. By submitting this form, you are attesting that all corrective actions have been taken and that all billing corrections will be tracked and evidence returned to QM when final corrective action is taken (998s). Only disallowed/recouped services are subject to an APPEAL. Compliance items not subject to disallowance shall be discussed first with the QM Reviewer and then with their UR/QI Supervisor.

Chart #: Client # Service CodeDate of Service

Server ID Total TimeReason Code

Corrective Action Type (For Program Use)Place an "X" in the column below to indicate the corrective action for each service(s) and the date action was completed. Final Action Date: The date

in which the SC 998 was deleted and the correct service was imported into the progress note. Program is required to submit a "final" Billing Summary Form to the QM Specialist when all 998 services have had final adjudication.

Edit Service

Delete Service

Void PN (999)

Claimed Service (998)

Void Service (MHBU) CommentsInitial Action

DateFinal Action Date (998)


• Fraud: an intentional act of deception, misrepresentation, or concealment in order to gain something of value

• Waste: over-utilization of services (not caused by negligent actions) or the misuse of resources

• Abuse: excessive or improper use of services or actions that is inconsistent with acceptable business or medical practices

• Fraud, Waste, and Abuse may be in every phase of every program and will include acts of both commission and omission

PROGRAM INTEGRITY


1. Billing for services not performed

2. Billing for duplicate times for one service

3. Misrepresenting procedures codes

4. Rounding time claimed

QM has seen all of the above this past fiscal year.

Examples of Fraud, Waste, Abuse


PROGRAM INTEGRITY

Program Integrity evidence has been reviewed and is in compliance? (P&P review, evidence of paid service verification)

Yes No

• QM will review PI practices during the onsite review portion of your MRR

• P & P Review• Review evidence of verification of

paid services• Review Program’s finding• Review of Corrective Actions if taken


SERIOUS INCIDENTS & SIROF• Include Name, Client ID, incident date, and

details of incident, use most current form dated 01/01/2015, type, signed by Program Manager

• RCA required for completed suicide, alleged client homicide, privacy incident, or QM request

• Serious Incident Report of Findings (SIROF)• A thorough review of incident, analysis of

what happened and why, mitigating factors, programmatic issues, systemic issues, etc.

• Summary of Findings and Action Items from RCA should be included in the SIROF.


SERIOUS INCIDENTS FY14-15YTD 7/1/14 to 5/31/15 (MH ONLY)

Incident in Media

Death by Suicide

Death Under Questionable Circumstances

Suicide Attempt

Tarasoff (report made by program)

Tarasoff (Report received by Program)

Serious Physical Injury

Apparent Overdose Alcohol - Drugs

Privacy Incident

ADULT TOTAL

13 18 10 35 34 5 11 11 24

CYF TOTAL 6 1 0 13 4 0 3 3 13

MHSOC TOTAL

19 19 10 48 38 5 14 14 37


NOTICE OF ACTIONS – NOA-A

• Think “A” for Assessment

• On basis of assessment consisting of a face-to-face clinical interview, the MHP determines the beneficiary lacks medical necessity or is otherwise not entitled to receive MH services.

• If client is insured under a Medi-Cal Managed Health Plan and referred back to the Health Plan following the assessment, an NOA-A is required to be given to client.


NOTICE OF ACTIONS – NOA-E

• BHS has established an access to services standard of 60 days.

• When this standard is not met, programs must issue to the client an NOA-E (lack of timely service).


DIAGNOSIS AT SERVICE (DAS)

• New functionality in the electronic health record

• Provides the ability to designate an active diagnosis from an existing diagnosis assessment to a specific service and render that information to a claim

• Entered when completing a progress note

• Required information prior to final approval

• Effective on October 1, 2015

• All services provided on or after Oct. 1, will require a selected diagnosis

• Includes individual and group services

• Print on progress note


• Programs will be provided a Resource Packet



• The Client Service Diagnoses window displays. Click on the diagnosis that was treated during this service, and move it to the top by clicking “Up” as many times as necessary



ICD-1O IMPLEMENTATION

• Webinar Overview • Presented by Dr. Krelstein, MD• August 13, 2015• 1:00 – 2:00 pm• Registration thru BHETA

• Go LIVE on October 1, 2015



• ICD-10/DAS CCBH Webinar • Presented by QM• September 2015• How it all works in the EHR• Registration link coming soon

• Go LIVE on October 1, 2015


IMPACT ON OPERATIONS:

• On Oct. 1, 2015 and thereafter, all services must include the updated diagnosis (ICD-10) code

• Think about operational challenges• Revised Diagnosis Assessment form• Transitioning from ICD-9 to ICD-10 diagnosis• Coordination with other programs• Resources – ICD 10 Blue Book, DSM IV & V,

Colorful Code Grid




• Make sure all Diagnosis Assessments are final approved by 9/30/15

• Run Reports• All active clients as of 10/1/15 will need to have a

new/updated diagnosis assessment completed prior to providing and claiming for services

• How do you get there?• Admin. Staff can enter diagnosis assessments• Clinicians could complete paper forms to give to

admin staff to enter• Organize updates via scheduled appointments –

prioritize• Other ideas?


OTHER UPDATES

• Prepping new hires – webinars before CCBH training

• Request webinar link via QIMatters email• Demographic update standard

• At admission• Annually• Bad addresses• CSI reporting to State

• Duplicate Client Charts


• Client Plan workgroup implementation

• WRAP guidelines workgroup

• Brief Individual Client (CYF UM) Contact Workgroup

• Increased technical assistance to programs

LOOKING AHEAD – NEW OPPORTUNITIES


• CYF OP BRIEF TX MODEL UM GUIDELINES

• TRAVEL TIME GUIDELINES

• NOA A-E Table

• DHCS Documentation Training June 2014

• MRR Tool FY 2015-2016

• FY14-15 MRR PROCESS LIVE TRAINING SLIDES

OPTUM WEBSITE – REFERENCES


PERFORMANCE

IMPROVEMENT

TEAM


MIS Updates


ASP Migration – Remote Host

Performance Improvements

User Access

Connection

Tip Sheets


Cerner Community Behavioral Health

Name change

Rebranding


Data Export

Policy

Training

Tip Sheets


ARF – Account Request Form

Areas of Concentration:

Menu SelectionCorrect CredentialsCorrect Taxonomy

Business Email AddressSignature

Missing Data


MIS Support Desk

619-584-5090

Optum Support Desk

800-834-3792

Documents

1 QI Updates FY 2015-2016. 2 ◘ Bathrooms ◘ Breaks ◘ Silence Phones ◘ Taking Questions The small stuff