Search for Compliance - Beacon Health Options€¦ · Search for Compliance Additional Topics for Residential Treatment Facilities Melissa S. Hooks Director of Program Integrity

Search for ComplianceAdditional Topics for

Residential Treatment Facilities

Melissa S. HooksDirector of Program Integrity

Overview of Compliance TopicsOverview of Compliance Topics

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Background of Compliance RTF Regulations and Contractual Requirements Framework of RTF Service Delivery Documentation Requirements Compliance Audits Provider Self-Audits

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

RTFBackground

RegulationsRegulations

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Federal• Centers for Medicare and Medicaid (CMS) www.cms.gov

Mental Health Services for Medicaid Programs• http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-

Topics/Benefits/Mental-Health-Services-.html Medicaid Documentation Requirements

• 42 CFR www.gpo.gov Program Integrity Requirements for Medicaid


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State• Pennsylvania Code Chapter 55

www.pacode.com

3800. Child Residential and Day Treatment Facilities 1101.51. Ongoing responsibilities of providers


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State• PA Bulletins

http://www.dpw.state.pa.us/publications/bulletinsearch/index.htm

OMHSAS Best Practice Guidelines for Family Involvement with Youth who are in Residential Treatment Facilities (RTF’s)

Process to Handle Residential Treatment Facility (RTF) Reports of Death, Serious Injury or Attempted Suicide (Serious Occurrences) 053-01-01 OMAP The Use of Restraint and Seclusion in Psychiatric Residential Treatment Facilities (RTF)

Payment for Mental Health Services Provided in a Residential Treatment Facility for Eligible Individuals Under 21 Years of Age

State RequirementsState Requirements

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PA PROMISe• PA PROMISe Provider Handbooks

http://www.dpw.state.pa.us/publications/forproviders/promiseproviderhandbooksandbillingguides/index.htm

• Mental Health Requirementshttp://www.dpw.state.pa.us/provider/mentalhealth/index.htm

• PA Recovery (for information by level of care)http://www.parecovery.org

Contractual RequirementsContractual Requirements

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Managed Care Organization (VBH-PA)• Provider Manual

www.vbh-pa.com Documentation Guide (All providers) Provider Information Section Provider Information

• Quality Audit Tools• Best Practices

• VBH-PA Fraud and Abuse Webpagehttp://www.vbh-pa.com/fraud_abuse.htm

Framework of RTF Service Delivery

Framework of RTF Service DeliveryFramework of RTF Service Delivery

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Practice Standards:http://www.vbh-pa.com/provider/info/clinical_ut/RTF_BestPracticeStandards.pdf• As defined by OMHSAS, RTF are childcare facilities that are licensed

under Chapter 3800 of 55 PA Code and certified by OMHSAS.• RTF provide treatment within the continuum of psychiatric and

therapeutic inventions, intended for children and adolescents whose psychiatric services cannot be addressed through services delivered in the community.

• The goal is to develop standards and outline best practice guidelines for treatment of children in RTF. The standards are intended to support, not replace, licensing, accrediting, and credentialing regulations.


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Program Design• Trauma Informed

RTF makes continuous effort to develop and sustain a trauma informed culture

• Evidence Based Interventions are reflective of evidence based practices

• Recovery Focused The program will support children and families in achieving their

potential for functioning


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Treatment (as defined by Program Description)• Treatment Milieu

Regular/daily activities provide opportunities for treatment and therapeutic activities

• Individual Therapy Weekly and scheduled sessions that are one-to-one therapy

• Family Therapy Weekly and scheduled sessions that are family-focused therapy

• Group Therapy According to daily programming, there should be group therapy

and psycho-education groups


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Treatment (as defined by Program Description)• Requires program description that addresses the following:

Visitation Should be in regular contact with family Therapeutic Leaves Skill Building Opportunities for Community Participation Regular contact with Treatment Team Medication administrating and monitoring

Documentation Requirements

Documentation RequirementsDocumentation Requirements

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Member Record Requirements according to 3800.243:• Each child’s record shall include:

Personal information including: • The name, sex, admission date, birth date and Social Security Number• The race, height, weight, color of hair, color of eyes and

identifying marks • The dated photograph of the child taken within the past year• Language or means of communication spoken and understood by the child and

the primary language used by the child’s family, if other than English. • Religious affiliation• The name, address and telephone number of the person to contacted in the

event of an emergency


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Health records Dental, vision and hearing records Health and safety assessments ISPs Restrictive procedure plans Restrictive procedure records relating to the child Reports of reportable incidents


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Consent to treatment, as specified in § 3800.19 Court order, if applicable. Admission and placement information specified in § 3800.222 and

3800.223 (relating to description of services; and admission) Signed notification of rights, grievance procedures and

applicable consent to treatment protections specified in §3800.31 (relating to notification of rights).

Service records of the contracting agency. Education records.


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All RTF records must include the following documentation requirements:• Treatment/Service Plan• Progress Note (Individual, Group, and Family) • Discharge Plan/Summary

VBH-PA Minimum Documentation Requirements for Payment• http://www.vbh-pa.com/fraud/pdfs/Minimum-Provider-

Documentation-Standards-for-Payment.pdf


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Individualized Treatment Plans• There must be a individualized treatment plan for payment,

and must meet following: Individualized per the comprehensive psychiatric evaluation/ISPT Measurable goals and objectives with specific timeframes Expected frequency and duration of services Signed and dated by the treatment team and

psychologist/director Member/parent/guardian involvement with treatment plan

including signature


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Individualized Treatment Plans• Additionally, the treatment plan should:

Be recovery focused Developed collaboratively with family and supports Link strengths and needs from assessments Identify length of expected treatments Discharge planning Crisis/relapse plans Include activities that promote community-based integration

• The progress notes must reflect the treatment plan goals, objectives, and interventions


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Progress Notes• Requirements for family, group, and individual therapy

sessions: Name or Medical Assistance identification number Date of service Start and stop times of service Reason for the session or encounter Treatment goals addressed Current symptoms and behaviors Interventions and response to treatment Next steps and progress in treatment Narrative with the clinical justification to support utilization Clinician’s signature, credentials, and signature date


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Discharge Plan• ISPT meeting within 45 days• Identification of lead clinician• Identification of legal guardianship• Identification of triggers for potential relapse• Identification of family supports• Ensure initial outpatient and medical management

appointments• Arrangements for education• 30-day follow up

Compliance Audits

AuditsAudits

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VBH-PA Program Integrity Audits• Routine Audits

Scheduled or standard data validation audits, and claims sampling, of contracted providers to ensure compliance with documentation, laws, regulations and billing requirements. The purpose of these audits will also be to monitor providers for possible fraud and abuse. Control assessments, compliance programs, and policies and procedures will be monitored and analyzed for inconsistencies, risk, etc.

• Audit procedures will be followed for routine auditshttp://www.vbh-pa.com/fraud/pdfs/Audit_Process.pdf

AuditsAudits

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Audit Process• Audit notification • Pre-audit conference call with provider• Entrance meeting with provider for on-site reviews (1st day of

audit)• Preliminary exit meeting with provider for on-site reviews (last

day of audit)• Exit conference call with provider• Report to provider• Provider audit response (CAP or reconsideration)

http://www.vbh-pa.com/fraud/pdfs/Audit_Appeals_Process.pdf

AuditsAudits

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Audit Tools• Service Description and Delivery Evaluations• Compliance and Control Assessments• Claims Documentation and Validation Audits• Clinical and Treatment Plan Evaluations and Technical

Assistance

Audit Exceptions• http://www.vbh-pa.com/fraud/pdfs/Program-Integrity-Exceptions-

and-Findings.p

Audit Exceptions and FindingsAudit Exceptions and Findings

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Clinical Findings • No valid treatment plan for date of service• Incomplete treatment plan for date of service• Progress note does not state reason for the encounter• Progress note does not state treatment plan goals and

objectives• Progress note does not reference symptoms or behaviors• Progress note does not have next steps in treatment• Progress note does not state intervention• Progress note or narrative is a duplication or almost a

duplication of previous note or narrative


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Payment Documentation Findings• No progress note for date of service• No consent to treatment• No narrative (must fully disclose services provided)• Progress note is illegible• Inaccurate units billed• Progress note does not have start and stop times• Progress note is not signed and/or dated by clinician• Overlapping services• Correction to note or encounter is not initialed and/or dated• Services are bundled in one note (needs to be in separate

notes)


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Other Audit Findings• Activities that are not included in the service class grid for that

particular service code• Service not provided according service description • Service does not include require individual, group, and family

therapy• Clinician does not meet requirements to provide service• Clinician excluded from participation• Progress notes that do not fully describe or misrepresent the

services provided (Provider Prohibited Act)

Provider Self-Audits

Provider Self-AuditsProvider Self-Audits

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Benefits• Good faith disclosures and cooperation with OIG and AG can

result in the following outcomes: Provides evidence of a robust compliance program Allows for integrity agreements instead of exclusion Allows for lower multiplier and single damages Prevents suspension of future payments Reduces OIG investigations


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DPW Self-Audit Protocol:• Outlined specific procedures to follow on the following

webpage:http://www.dpw.state.pa.us/learnaboutdpw/fraudandabuse/medicalassistanceproviderselfauditprotocol/S_001151

• DPW requires providers to return overpayments within 60 days of identifying overpayments

• For PA HC PSR, providers should conduct self-audits and return overpayments to BH-MCO (VBH-PA)

• Acceptance of payment by the MA Program does not constitute agreement as to the amount of loss suffered


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VBH-PA Self- Audit and Disclosure Process• http://www.vbh-

pa.com/fraud/pdfs/Provider_Self_Audit_Referral_Form.pdf

Questions???Melissa S. Hooks, DHCE(c), MS, AHFI, CFE

Director of Program IntegrityValue Behavioral Health of Pennsylvania

[email protected](724)744-6513

http://www.vbh-pa.com/fraud_abuse.htm

Documents

Search for Compliance - Beacon Health Options€¦ · Search for Compliance Additional Topics for Residential Treatment Facilities Melissa S. Hooks Director of Program Integrity