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how to ensure medicaid compliance with documentation
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How to Ensure Medicaid Compliance with Documentation
Melissa Skaggs and Robin Day
Know the documentation rules and requirements
Get really familiar with the documentation rules for the service(s) you organization is providing – read each rule THOURGHLY
All rules are available at doddportal.dodd.ohio.gov/rules/ineffect
If you are unsure of a requirement or an interpretation there is lots of sources available to help with understanding the rules – OPRA is your biggest go to place for this type of information
Don’t re-create the wheel; beg, borrow and steal(in a nice way lol) If another agency will share information take it all. 90% of all knowledge exists outside your agency so grab holds. Lots of folks are willing to share.
Provider ComplianceFRIEND or FOE?
FRIENDProvider Compliance is here to help and guide you not shut you down….unless you are doing things that are worthy of being shut down.
Compliance Review Tools are on the DODD website under the Provider Tab, then compliance along with their protocol.
ComplianceOffice of Provider Standards and Review (OPSR), OPSR conducts compliance reviews in licensed waiver funded settings, unlicensed waiver-funded settings, licensed Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFIIDs), and County Board settings. In order to ensure consistency, the review process and tools used are the same in all settings.Compliance Review – regularly scheduled reviews of a provider are conducted prior to the end of the provider’s term license, accreditation term or at least once every 5 years for non-licensed waiver settings. The review is conducted utilizing a single review tool.
Special Compliance Review – an unscheduled review, which occurs due to identified concerns such as complaints, Major Unusual Incidents, reports of fraud, or adverse outcomes identified by other entities such as the Ohio Department of Health or the Ohio Department of Job and Family Services.If you have questions or need additional information regarding compliance, the Office of Provider Standards and review can be reached by contacting 614-466-6670 or by email [email protected] .
Compliance Reviews of Community-Based Waiver Services
A variety of Home and Community-Based Services (HCBS) are provided in the homes and family homes of waiver recipients. Certified HCBS Waiver Providers deliver Homemaker Personal Care, Transportation, Adult Day Services and ancillary services such as Environmental Modifications, Social Work, Nutrition and Adaptive Equipment.
Compliance reviews for HCBS providers are conducted by the Ohio Department of Developmental Disabilities and by the County Boards of Developmental Disabilities. Ohio Administrative Code 5123:2-9-08 requires certified HCBS providers to be reviewed once during the period of certification to ensure compliance with continuing certification standards of the services provided.
In 2012, the department conducted 1,134 regular and special compliance reviews of both Agency and Independent Providers in non-licensed settings. In 2012, there were 414 newly certified providers subject to review within the year after first billing. Of that total, 379 were reviewed, of which 99% were conducted within the year. Thirty-seven providers were revoked or relinquished their certification.
MOST COMMON AREAS OF NON – COMPLIANCE STATEWIDE Independent Providers Top Citations • Annual MUI training • Annual training on the Rights of Individuals with DD • Service plan implemented as written • Current CPR certification • Current first aid certification Agency Providers Top Citations • Staff receive initial training prior to providing services with individuals • Staff have a Nurse Aide Registry check completed prior to direct contact with the individuals • Staff have an Abuser Registry check completed prior to direct contact with individuals • Service plan being implemented as written • Non-Medical Transportation, staff receive testing for controlled substances and was the staff person found to be drug free prior to providing transportation services
ICF/IID Providers Top Citations • IP being implemented as written • Medications, treatments, and dietary orders being followed • IP revised based on changes in the individual’s needs/wants • Any unreported incidents • Interior, exterior and grounds of the building maintained in good repair and in a clean and sanitary manner County Board Accreditation Review Top Citations • Personnel – Background and Abuser Registry checks • Behavior Support – Development and Committee Review • MUI/UI – Procedures and Logs • Individual and Family Service Planning and Assessment • Early Intervention – Service Planning and Documentation
Information obtained from the OPSR Annual Review Report for CY 2012
Documentation • Required Documents (as applicable)
ISP – Current and Previous Plans• Medications
• If Delegated Nursing have evidence of nurse supervision Behavior Support Plan Money Management Licensed Home Room and Board Req Waiver Administration Activities Documentation (for last 3 months) Personnel/Background Checks Staff Training/Certifications Drivers/Attendants/Transportation Physical Environment
Documentation Requirements Dates of service Documentation indicates where service took place
• NOTE – for Non Medical Transportation this is the vehicle license plate number
Name of the Individual receiving the services Individuals Medicaid Number on documentation Name of the Provider Provider Identifier (Billing Contract Number) Signature of person providing the service
• NOTE – can be initials if signature on file with provider Type of service being provided Units provided Group size (if applicable) Arrival and Departure times (if applicable) Description of service provided
QUALITY DOCUMENTATION IS YOUR BEST OFFENSE AND YOUR BEST
DEFENSE
• MEDICAID AUDITS• PROVIDERS• FAMILY • PHYSICIANS• ATTORNEYS
DOCUMENTATION IS IMPORTANT FOR MORE THAN JUST ONE
REASON
Putting It All Together• Keep records in a safe place• SCAN if possible
• Use the same filing system for all types of documentation
• Maintain up-to-date employee files• Uniform filing system• Checklist for certification renewals, abuser registry,
background checks, signature on file etc...• SCAN if possible
• Maintain your own review file and all information pertinent to the review
• Follow-up with staff – The Good, The Bad and The Ugly
Findings…now what Admit them and then fix them
Correct any billing issues and if it is systemic then you will need to fix current as well as past billing
Make sure you file your plan of correction within the guidelines and timeframes
Ask questions about ANYTHING you don’t understand
They may be wrong….challenge where and when appropriate
