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Requirements Part 1:Consent Forms and

Treatment Plans

Melissa S. HooksDirector of Program Integrity

Overview of PresentationOverview of Presentation

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Background of Compliance Importance of Documentation Overview of Documentation Requirements: Two

Part Series

Part 1: Documentation Requirement Topics• Consent Forms• Treatment Plans

Background of Compliance

Why Compliance All the Time?Why Compliance All the Time?

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Required by Law Avoid High Risk to Individuals and Agencies

• False Claims Act Exclusion from participation in any federal programs Prison Corporate Integrity or Deferred Prosecution Agreement Criminal: $250,000 individuals/$500,000 companies Civil: $11,000/claim, plus 3x the amount of each claim

• HIPAA/HITECH Act—Civil and Criminal Penalties based on intent• Sanctions/loss of contracts• State False Claims Acts and Privacy/Security Laws • Impaired business reputation • Financial loss from provider billing errors and potential fraud

Compliance DefinitionsCompliance Definitions

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FRAUD• Any intentional deception or misrepresentation made by an

entity or person in a capitated MCO, Primary Care Case Management, or other managed care setting with the knowledge that the deception could result in an unauthorized benefit to the entity, him/herself or another responsible person in a managed care setting.


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ABUSE• Any practices in a capitated MCO, Primary Care Case

Management program, or other managed care setting that are inconsistent with sound fiscal, business, or medical practice and which result in unnecessary cost to the MA Program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards or contractual obligations (including the terms of the PA HC PSR, contracts, and requirements of state or federal regulations) for health care in the managed care setting.


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WASTE• Thoughtless or careless expenditure, consumption,

mismanagement, use or squandering of healthcare resources, including incurring costs because of inefficient or ineffective practices, systems or controls.

Compliance Requirements for FWACompliance Requirements for FWA

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Requirements of Compliance1. High level support and authority2. Written standards 3. Training and education4. Culture of open communication5. Monitoring and auditing6. Consistent enforcement and discipline of violations7. Appropriate response to detected problems8. Effective compliance program

Importance of Documentation

Importance of DocumentationImportance of Documentation

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“The absence of complete documentation in patient medical records can have a negative effect on statistical databases, financial planning, clinical preparedness, and gross revenue for the healthcare organization. It is for this reason that every healthcare organization should be focused on ensuring accuracy and completeness in clinical documentation, at any cost. Documentation improvement is not a new concept in healthcare, but rather an evolving trend.”

http://library.ahima.org/xpedio/groups/public/documents/ahima/bok3_005531.hcsp?dDocName=bok3_005531Ruthann Russo, JD, MPH, RHIT


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Documentation – Just as Important as the Service:• The ability of the physician and other healthcare professionals

to evaluate and plan the patient’s immediate treatment, and to monitor his/her healthcare over time

• Communication and continuity of care among the physicians and other healthcare professionals involved in the patient care

• Accurate and timely claims review and payment• Appropriate utilization review and quality of care evaluations• Collection of data that may be used for research and

education• Evidence that the services were provided


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Important Considerations for Documentation:• Timely• Respectful • Complete• Credible• Clear• Consistent• Integrity

http://www.vbh-pa.com/provider/info/value_archives/2014/VA-Aug-2014.pdf

Overview of Documentation Requirements

Two Part Series

Program Integrity Documentation RequirementsProgram Integrity Documentation Requirements

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Outline regulations for treatment and service documentation

Review the documentation requirements to receive payment from VBH-PA

Provide specific documentation requirements


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Part 1• Consent Forms

Regulations Minimum Documentation Requirements Potential Findings

• Treatment Plans Regulations Clinical Requirements Minimum Documentation Requirements Potential Findings


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Part 2• Progress Notes

Regulations Clinical Requirements Minimum Documentation Requirements Potential Findings

• Encounter Forms Regulations Minimum Documentation Requirements Potential Findings

Consent Forms

Consent FormsConsent Forms

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Main Purpose of Consent Forms1. Obtain consent to diagnosis or treat2. Obtain consent to release health information for

payment and continuity of care

PA Regulations for Consent FormsPA Regulations for Consent Forms

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Pennsylvania Code • Chapter 1101 General Provisions

http://www.pacode.com/secure/data/055/chapter1101/chap1101toc.html § 1101.75. Provider prohibited acts.

a) An enrolled provider may not, either directly or indirectly, do any of the following acts:

10) Except in emergency situations, dispense, render or provide a service or item without a practitioner’s written order and the consent of the recipient or submit a claim for a service or item which was dispensed or provided without the consent of the recipient.

PA Regulations for Consent FormsPA Regulations for Consent Forms

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Pennsylvania Code• Chapter 5100 Mental Health Procedures

http://www.pacode.com/secure/data/055/chapter5100/chap5100toc.html

• Chapter 5200 Psychiatric Outpatient Clinics http://www.pacode.com/secure/data/055/chapter5200/chap5200toc.html § 5200.41. Records.

a) Under section 602 of the Mental Health and Mental Retardation Act of 1966 (50 P. S. § 4602), and in accordance with recognized and acceptable principles of patient record keeping, the facility shall maintain a record for each person admitted to a psychiatric clinic. The record shall include the following:

4) Appropriately signed consent forms.

VBH-PA Requirements for Consent FormsVBH-PA Requirements for Consent Forms

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VBH-PA Provider Manual • Treatment Records

http://www.vbh-pa.com/provider/info/prvmanual/4_PartPrvResp/tx_record_standards.htm

Participating providers are expected to maintain clinical record keeping systems that meet the following basic requirements:

• 8) Each record includes the patient’s address, employer or school, home and work telephone numbers, emergency contacts, marital/legal status, appropriate consent forms and guardianship information, if relevant;

• 26) Informed consent for medication and the patient’s understanding of the treatment plan are documented;

VBH-PA Fraud and Abuse Webpage• Coming Soon!

Minimum Documentation for Consent FormsMinimum Documentation for Consent Forms

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Informed consent prior to treatment, with the following elements:

• The diagnosis• The nature and purpose of a proposed treatment or service• The benefits and risks of the proposed treatment or service• Alternatives including benefits and risks• The risks and benefits of not receiving treatments or services

AMA 1998

*Consent should be referenced in the treatment plan.

Minimum Documentation for Consent FormsMinimum Documentation for Consent Forms

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Consent Form should include the following:• Name and signature of the patient, or if appropriate, legal

representative • Name of the provider • Type of services or treatment• Name of all providers• Benefits and any potential risks • Alternative procedures and treatments and their risks • Date and time consent is obtained • Statement that procedure was explained to patient or guardian • Signature of person witnessing the consent • Name and signature of person who explained the procedure to the

patient or guardian Federal Code (Title 42 C.F.R. § 482.51 (b) (2)) Interpretive Guideline A-0392

Consent to Treatment FindingsConsent to Treatment Findings

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VBH-PA Program Integrity Potential Findings• No consent to treatment in member record• Consent to treatment was not signed• Consent to treatment was signed after the treatment plan• Consent to treatment was signed after services were provided

Treatment Plans

Treatment (Service) PlansTreatment (Service) Plans

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“The treatment plan is the road map that a patient will follow on his or her journey through treatment.”

“Treatment planning begins as soon as the initial assessments are completed. The patient might have immediate needs that must be addressed. Treatment planning is a never-ending stream of therapeutic plans and interventions. It is alwaysmoving and changing.”

www.sagepub.com/upm-data/18970_Chapter_5.pdf

Treatment (Service) PlansTreatment (Service) Plans

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Main Purpose of Treatment (Service) Plans1. Definition of Treatment

Goals and Objectives Utilization

2. Description of Informed Consent As recorded on the Consent Form

3. Mechanism to Track Individual Plans, Treatments, and Outcomes throughout Treatment

PA Regulations for Treatment PlansPA Regulations for Treatment Plans

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Pennsylvania Code • Chapter 1101 General Provisions

http://www.pacode.com/secure/data/055/chapter1101/chap1101toc.html 1101.51. Ongoing responsibilities of providers.

(1) General standards for medical records. A provider, with the exception of pharmacies, laboratories, ambulance services and suppliers of medical goods and equipment shall keep patient records that meet all of the following standards:

(v) Treatments as well as the treatment plan shall be entered in the record. Drugs prescribed as part of the treatment, including the quantities and dosages shall be entered in the record. If a prescription is telephoned to a pharmacist, the prescriber’s record shall have a notation to this effect.


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http://www.pacode.com/secure/data/055/chapter5100/chap5100toc.html § 5100.15. Contents of treatment plan.(a) A comprehensive individualized plan of treatment shall:

1. Be formulated to the extent feasible, with the consultation of the patient. When appropriate to the patient’s age, or with the patient’s consent, his family, personal guardian, or appropriate other persons should be consulted about the plan.

2. Be based upon diagnostic evaluation which includes examination of the medical, psychological, social, cultural, behavioral, familial, educational, vocational, and developmental aspects of the patient’s situation.

3. Set forth treatment objectives and prescribe an integrated program of therapies, activities, experiences, and appropriate education designed to meet these objectives.

4. Result from the collaborative recommendation of the patient’s interdisciplinary treatment team. 5. Be maintained and updated with progress notes, and be retained in the patient’s medical record

on a form developed by the facility and approved by the Deputy Secretary of Mental Health, as part of the licensing approval process.


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§ 5100.15. Contents of treatment plan(b) The treatment plan shall indicate what less restrictive alternatives were considered and why they were not utilized. If the plan provides for restraints, the basis for the necessity for such restraints must be stated in the plan under Chapter 13 (relating to use of restraints in treating patients/residents). (c) Individual treatment plans shall be written in terms easily explainable to the lay person and a copy of the current treatment plan shall be available for review by the person in treatment. (d) When the most appropriate form of treatment for the individual is not available or is too expensive to be feasible, that fact shall be noted on the treatment plan form.

VBH-PA Requirements for Treatment PlansVBH-PA Requirements for Treatment Plans

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http://www.vbh-pa.com/provider/info/prvmanual/4_PartPrvResp/tx_record_standards.htm

3. Accurately document at least the following on each case for which services are being provided:

a. Member information (demographic);b. Clinical information;c. Clinical assessments;d. Treatment plans;e. Services provided;f. Contacts with member’s family, guardians or significant others;g. Treatment outcomes; andh. PCPC/ASAM for substance abusers;


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5. All members’ treatment records must contain a bio-psychosocial assessment; treatment plan, follow-up assessments, focus of treatment and disposition/discharge plan. Medical and psychological treatment documentation and progress notes must be current and treatment plans shall be updated as necessary for the level of care.

6. It is necessary that the provider initiating treatment document an initial treatment plan that describes the active target interventions with specific, measurable goals, and stated in behavioral terms, at the level of care proposed;


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24. Treatment plans are consistent with diagnoses and have objective, measurable goals and estimated time lines for achieving goals or resolving problems;

25. The focus of treatment interventions is consistent with the treatment plan goals and objectives;

26. Informed consent for medication and the patient’s understanding of the treatment plan are documented;

27. Progress notes describe the patient’s strengths and limitations in achieving treatment plan goals and objectives;


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VBH-PA Fraud and Abuse Webpage• Minimum Documentation Standards for Payment:

http://www.vbh-pa.com/fraud/pdfs/Minimum-Provider-Documentation-Standards-for-Payment.pdf

A. Treatment Plan: Minimum Requirements for Payment for all Provider Types:

1. Must be completed according to service requirements2. Treatment plan date3. Diagnoses and/or symptoms addressed4. Clinician’s signature, credentials, and signature date5. Member or guardian’s signature and signature date6. Evidence member or guardian participated with treatment plan development7. Goals and objectives based on evaluation and mental health strengths and needs


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VBH-PA Fraud and Abuse Webpage• Minimum Documentation Standards for Payment:

8. Treatment objectives and prescribe as an integrated program of therapies, activities, experiences, and appropriate education designed to meet these objectives9. Treatment goals are measurable10. Treatment goals have established timeframes11. Treatment plan address notes less restrictive alternatives that were considered12. Treatment plan is easy to read and understand13. Treatment plan documents necessity for services14. Treatment plan documents the utilization of services


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Clinical Tips for Treatment Plans• Include diagnosis with symptoms and behaviors as identified

on the evaluation or assessment• Identify strengths and needs• Mental health treatment plans should have goals for referrals

to substance abuse providers, since drug and alcohol services are provided separately under PA Medical Assistance

• Define utilization of services, such as frequency• Continuously monitor and update the treatment plan

Treatment Plans FindingsTreatment Plans Findings

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VBH-PA Fraud and Abuse Webpage• Common Audit Exceptions and Findings

http://www.vbh-pa.com/fraud/pdfs/Program-Integrity-Exceptions-and-Findings.pdf

Clinical Documentation Exceptions and Findings:• No valid treatment plan for date of service• Incomplete treatment plan for date of service

Missing member/parent signatures Does not include frequency of services, such length of service and session

per week or month Does not include diagnosis and/or symptoms and behaviors Does not describe consent to treatment and/or member/parent

involvement Treatment goals and objectives are not measurable Treatment goals and objectives do have timeframes Treatment plan does not reference information from evaluation

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