Medicaid 101: Basic Training for Medicaid MH/DD/SA Providers

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Medicaid 101:Medicaid 101:Basic Training for Medicaid Basic Training for Medicaid

MH/DD/SA ProvidersMH/DD/SA Providers

WakeWake

December 2007December 2007

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IntroductionIntroduction

• IntroductionsIntroductions

• Medicaid is a federal and state entitlement Medicaid is a federal and state entitlement program that pays for medical assistance program that pays for medical assistance for certain individuals and families with for certain individuals and families with low incomes and resources.low incomes and resources.

• Federal - Centers for Medicare and Federal - Centers for Medicare and Medicaid Services (CMS) Medicaid Services (CMS)

• State – Division of Medical Assistance State – Division of Medical Assistance (DMA)(DMA)

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Department of Health and Human Services Department of Health and Human Services (DHHS)(DHHS)

• Division of Medical AssistanceDivision of Medical Assistance– Fees and ratesFees and rates– PolicyPolicy– Maintain files (insurance, provider, eligibility)Maintain files (insurance, provider, eligibility)

• Division of MH/DD/SADivision of MH/DD/SA– Provision of services through LME endorsed Provision of services through LME endorsed

providersproviders– State funded servicesState funded services

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• Mission StatementMission Statement– The Mission of the Department of Health The Mission of the Department of Health

and Human Services is to provide and Human Services is to provide efficient services that enhance the efficient services that enhance the quality of life of North Carolina quality of life of North Carolina individuals and families so that they have individuals and families so that they have opportunities for healthier and safer lives opportunities for healthier and safer lives resulting ultimately in the achievement resulting ultimately in the achievement of economic and personal independence.of economic and personal independence.

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Goals of this TrainingGoals of this Training

• To better understand Basic Medicaid policy To better understand Basic Medicaid policy and the role of the Qualified Professional and the role of the Qualified Professional in the delivery of services as they apply to:in the delivery of services as they apply to:– Provider Endorsement Provider Endorsement – Provider EnrollmentProvider Enrollment– The Role of the LMEThe Role of the LME– Medicaid ServicesMedicaid Services– Proactive InterventionsProactive Interventions– Authorizations and Utilization ReviewAuthorizations and Utilization Review

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Goals of this Training (cont.)Goals of this Training (cont.)

– Basic Medicaid Documentation Basic Medicaid Documentation RequirementsRequirements

– Billing and PaymentBilling and Payment– Quality Management/Self MonitoringQuality Management/Self Monitoring– AppealsAppeals– Pitfalls to AvoidPitfalls to Avoid– Fraud and Abuse in MedicaidFraud and Abuse in Medicaid

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Provider EndorsementProvider Endorsement

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• Endorsement is a verification and quality Endorsement is a verification and quality assurance process using statewide criteria assurance process using statewide criteria and procedures.and procedures.

• The endorsement process provides the LME The endorsement process provides the LME with the objective criteria to determine the with the objective criteria to determine the competency and quality of Medicaid competency and quality of Medicaid providers.providers.

• Endorsement purpose is to assure that Endorsement purpose is to assure that individuals receive Medicaid services and individuals receive Medicaid services and supports from providers that comply with supports from providers that comply with state and federal laws and regulations.state and federal laws and regulations.

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• Endorsement is an LME functionEndorsement is an LME function• Required for the provision of Required for the provision of

enhanced and residential servicesenhanced and residential services• Each service requires a separate Each service requires a separate

endorsementendorsement• For more information or to initiate For more information or to initiate

the endorsement process contact the endorsement process contact your local LME.your local LME.

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Provider EnrollmentProvider Enrollment

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Enrolling as a Medicaid ProviderEnrolling as a Medicaid Provider• All providers must enroll directly with All providers must enroll directly with

DMADMA

• Enrollment application packages are Enrollment application packages are available on DMA’s websiteavailable on DMA’s website

• Enrollment takes about six to eight weeksEnrollment takes about six to eight weeks

• Notified by mail when enrollment is Notified by mail when enrollment is completecomplete

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• Licensed providers must be enrolled with Licensed providers must be enrolled with Medicaid in order to be a North Carolina Medicaid in order to be a North Carolina Medicaid provider.Medicaid provider.

• Enrollment is open to all providers who Enrollment is open to all providers who meet the qualifications and receive meet the qualifications and receive endorsement from the LME endorsement from the LME

• Providers should contact DMA Provider Providers should contact DMA Provider Enrollment at 919-855-4050 for further Enrollment at 919-855-4050 for further information.information.

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Reporting changes In StatusReporting changes In Status• An enrolled provider must use the An enrolled provider must use the

Medicaid Provider Change FormMedicaid Provider Change Form

• Examples of some changes:Examples of some changes:

• Address changeAddress change

• Phone number changePhone number change

• Tax ID number changeTax ID number change

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Provider Enrollment AgreementProvider Enrollment Agreement• When an application for enrollment was submitted, the When an application for enrollment was submitted, the

provider agreed to follow Medicaid rules. It is a 22 page provider agreed to follow Medicaid rules. It is a 22 page application in order to get as much information as possible, to application in order to get as much information as possible, to meet the requirements of CMS and State and to provide the meet the requirements of CMS and State and to provide the applicant the expectations of participation with NC DMA.applicant the expectations of participation with NC DMA.

• All questions on the applications must have been answered All questions on the applications must have been answered honestly.honestly.

• Signature-Signature-““I certify that the above information is true and correct. I further I certify that the above information is true and correct. I further

understand that any false or misleading information may be understand that any false or misleading information may be cause for denial or termination of participation as a Medicaid cause for denial or termination of participation as a Medicaid Provider.”Provider.”

- 1A: “Comply with federal , state laws, regulations, state - 1A: “Comply with federal , state laws, regulations, state reimbursement plan and policies governing the services…”reimbursement plan and policies governing the services…”

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Provider Enrollment Provider Enrollment

• B 10: DMA may terminate this B 10: DMA may terminate this agreement…agreement…

- The provider is determined to have The provider is determined to have violated Medicaid rules or regulationsviolated Medicaid rules or regulations

- The provider fails to provide The provider fails to provide medically appropriate health care medically appropriate health care services, etc.services, etc.

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Provider Enrollment Provider Enrollment

• C 1-14 further outlines the provider C 1-14 further outlines the provider responsibilities to follow rules and responsibilities to follow rules and regulationsregulations

• Electronic Claims Submission Electronic Claims Submission AgreementAgreement

- Another signature attesting to - Another signature attesting to understanding of the rules and understanding of the rules and requirements of Medicaid.requirements of Medicaid.

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The Role of the LMEThe Role of the LME

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The Role of the LMEThe Role of the LME

• Functions include:Functions include:– EndorsementEndorsement– Record reviewRecord review– Ongoing monitoringOngoing monitoring– Client specific reviews and care coordinationClient specific reviews and care coordination– DMA expects that providers will accept LMEs in DMA expects that providers will accept LMEs in

their offices/facilities just as if DMA contacted their offices/facilities just as if DMA contacted the provider agency.the provider agency.

• LMEs may receive Medicaid payment for LMEs may receive Medicaid payment for “acting” as agents of DMA“acting” as agents of DMA

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Service DefinitionsService Definitions

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Medicaid Services – Basic Medicaid Services – Basic BenefitBenefit

• Basic Benefits Basic Benefits – Available to all Medicaid recipientsAvailable to all Medicaid recipients– Outpatient benefits Outpatient benefits

Adults – age 21 and over - (8 Adults – age 21 and over - (8 unmanaged visits)unmanaged visits)

Children – under age 21 - (26 Children – under age 21 - (26 unmanaged visits)unmanaged visits)

– Inpatient hospitalizationInpatient hospitalization

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Outpatient Behavioral Health Outpatient Behavioral Health ServicesServices• Assessment, treatment (individual medical Assessment, treatment (individual medical

evaluation and management, including evaluation and management, including medication management, individual and medication management, individual and group therapy, behavioral health group therapy, behavioral health counseling), family therapy and counseling), family therapy and psychological testingpsychological testing– 26 unmanaged visits for recipients under age 2126 unmanaged visits for recipients under age 21– 8 unmanaged visits for recipients aged 21 and 8 unmanaged visits for recipients aged 21 and

overover– Services delivered by physicians, licensed Services delivered by physicians, licensed

clinicians, nurse practitioners, clinical nurse clinicians, nurse practitioners, clinical nurse specialists, certified clinical supervisors, licensed specialists, certified clinical supervisors, licensed clinical addictions specialistsclinical addictions specialists

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Inpatient Behavioral Health Inpatient Behavioral Health ServicesServices

– Hospital setting 24 hours a dayHospital setting 24 hours a day– Nursing and medical care provided under the Nursing and medical care provided under the

supervision of a psychiatrist or a physiciansupervision of a psychiatrist or a physician– Continuous treatment for recipients with acute Continuous treatment for recipients with acute

psychiatric or substance abuse problemspsychiatric or substance abuse problems• Inpatient Hospital Substance Abuse Inpatient Hospital Substance Abuse

TreatmentTreatment– Licensed 24 hour inpatient setting, licensed Licensed 24 hour inpatient setting, licensed

community hospital or licensed facilitycommunity hospital or licensed facility• Inpatient Hospital Psychiatric TreatmentInpatient Hospital Psychiatric Treatment

– Licensed 24 hour inpatient setting or State Licensed 24 hour inpatient setting or State operated facilityoperated facility

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Medicaid Services – Enhanced Medicaid Services – Enhanced BenefitBenefit

– MH/SA Services for AdultsMH/SA Services for Adults•Community Support – Adults (MH/SA)Community Support – Adults (MH/SA)•Mobile Crisis Management (MH/DD/SA)Mobile Crisis Management (MH/DD/SA)•Diagnostic/Assessment (MH/DD/SA)Diagnostic/Assessment (MH/DD/SA)•Community Support Team (CST) (MH/SA)Community Support Team (CST) (MH/SA)•Assertive Community Treatment Team (ACTT)Assertive Community Treatment Team (ACTT)•Psychosocial RehabilitationPsychosocial Rehabilitation•Partial HospitalizationPartial Hospitalization•Professional Treatment Services in Facility-Professional Treatment Services in Facility-

Based Crisis ProgramBased Crisis Program

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– Substance Abuse Specific Treatment Substance Abuse Specific Treatment ServicesServices•Substance Abuse Intensive Outpatient Substance Abuse Intensive Outpatient

Program Program

•Substance Abuse Comprehensive Outpatient Substance Abuse Comprehensive Outpatient Treatment ProgramTreatment Program

•Substance Abuse Non-Medical Community Substance Abuse Non-Medical Community Residential TreatmentResidential Treatment

•Substance Abuse Medically Monitored Substance Abuse Medically Monitored Community Residential TreatmentCommunity Residential Treatment

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– Substance Abuse Specific Detox Substance Abuse Specific Detox ServicesServices•Ambulatory DetoxificationAmbulatory Detoxification

•Non-Hospital Medical DetoxificationNon-Hospital Medical Detoxification

•Medically Supervised or ADATC Medically Supervised or ADATC Detoxification/Crisis StabilizationDetoxification/Crisis Stabilization

•Outpatient Opioid TreatmentOutpatient Opioid Treatment

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– Services for Children (up to age 21)Services for Children (up to age 21)•Diagnostic/Assessment (MH/DD/SA)Diagnostic/Assessment (MH/DD/SA)•Community Support – Children/Adolescents Community Support – Children/Adolescents

(MH/SA)(MH/SA)•Mobile Crisis Management (MH/DD/SA)Mobile Crisis Management (MH/DD/SA)• Intensive In-Home ServicesIntensive In-Home Services•Multisystemic Therapy (MST)Multisystemic Therapy (MST)•Child and Adolescent Day Treatment (MH/SA)Child and Adolescent Day Treatment (MH/SA)•Partial HospitalPartial Hospital•SAIOPSAIOP

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– Developmental Disability ServicesDevelopmental Disability Services•Diagnostic/Assessment (MH/DD/SA)Diagnostic/Assessment (MH/DD/SA)

•Mobile Crisis Management (MH/DD/SA)Mobile Crisis Management (MH/DD/SA)

•Targeted Case Management Targeted Case Management

•Community Action Program (CAP)Community Action Program (CAP)

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Enhanced MH/SA Enhanced MH/SA ServicesServices

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Enhanced MH/SA Services - Enhanced MH/SA Services - AdultsAdults

• Community Support – Adult (MH/SA)Community Support – Adult (MH/SA)– Services support independent community Services support independent community

functioning/development of critical living and functioning/development of critical living and coping skills for recipients 21 and oldercoping skills for recipients 21 and older

– Direct and indirect periodic service provided in Direct and indirect periodic service provided in any location by QP, AP and Paraprofessional staffany location by QP, AP and Paraprofessional staff

– Authorization up to 780 units for a 90-day period, Authorization up to 780 units for a 90-day period, based on the medical necessity – not intended to based on the medical necessity – not intended to remain at this level of intensity long termremain at this level of intensity long term

– Clinical HomeClinical Home

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Enhanced MH/SA Services – Enhanced MH/SA Services – Adults and ChildrenAdults and Children

• Mobile Crisis Management (MH/DD/SA)Mobile Crisis Management (MH/DD/SA)– Crisis response, stabilization and prevention to Crisis response, stabilization and prevention to

divert individuals from inpatient psychiatric divert individuals from inpatient psychiatric and detoxification servicesand detoxification services

– Direct and periodic service provided 24/7/365 Direct and periodic service provided 24/7/365 outside the agency’s facility by a Team of outside the agency’s facility by a Team of practitioners (QP; CCAS, CCS or CSAC; practitioners (QP; CCAS, CCS or CSAC; Psychiatrist access; QP or AP with DD Psychiatrist access; QP or AP with DD experience; Paraprofessionals with experience; Paraprofessionals with competency in crisis management)competency in crisis management)

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Enhanced MH/SA Services – Enhanced MH/SA Services – Adults and ChildrenAdults and Children

• Diagnostic/Assessment (MH/DD/SA)Diagnostic/Assessment (MH/DD/SA)– Evaluation of MH/DD/SA condition that Evaluation of MH/DD/SA condition that

results in issuance of D/A report with a results in issuance of D/A report with a recommendation for servicesrecommendation for services

– Direct periodic service provided in any Direct periodic service provided in any location by a Team of clinicians (2 QPs; location by a Team of clinicians (2 QPs; one MD, DO, NP, PA or Licensed one MD, DO, NP, PA or Licensed psychologist)psychologist)

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Enhanced MH/SA Services - Enhanced MH/SA Services - AdultsAdults• Community Support Team (CST) (MH/SA)Community Support Team (CST) (MH/SA)

– Intensive service for recipients to assist with Intensive service for recipients to assist with rehabilitative and recovery goals. May exhibit high use rehabilitative and recovery goals. May exhibit high use of psychiatric hospital or crisis, risk factors, medication of psychiatric hospital or crisis, risk factors, medication refractory, co-diagnosis of SA, legal, homeless, suicidal, refractory, co-diagnosis of SA, legal, homeless, suicidal, inappropriate public behavior, self harm, inappropriate public behavior, self harm, cognitive/behavioral/ medical conditions, lower level of cognitive/behavioral/ medical conditions, lower level of care inappropriatecare inappropriate

– Direct and indirect periodic service provided in any Direct and indirect periodic service provided in any location by a Team of practitioners (3 person team location by a Team of practitioners (3 person team including 1.5 QP; and other including 1.5 QP; and other QP/AP/Paraprofessional/Certified Peer Support Specialist) QP/AP/Paraprofessional/Certified Peer Support Specialist)


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Enhanced MH/SA Services - Enhanced MH/SA Services - AdultsAdults• Assertive Community Treatment Team (ACTT)Assertive Community Treatment Team (ACTT)

– Service for SPMI, co-occurring disorders, dual and triple Service for SPMI, co-occurring disorders, dual and triple diagnosed to promote symptom stability, appropriate diagnosed to promote symptom stability, appropriate use of medication, restore personal community living use of medication, restore personal community living and social skills, promote and maintain physical health, and social skills, promote and maintain physical health, access entitlements, housing, work and social access entitlements, housing, work and social opportunities, promote highest possible level of opportunities, promote highest possible level of functioning in the communityfunctioning in the community

– Direct and indirect periodic service provided in any Direct and indirect periodic service provided in any location by an Interdisciplinary Team trained in ACTT location by an Interdisciplinary Team trained in ACTT (QPs, psychiatrist, RNs, AP, CCS/CCAS/CSAC, Certified (QPs, psychiatrist, RNs, AP, CCS/CCAS/CSAC, Certified Peer Support Specialist)Peer Support Specialist)


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• Psychosocial RehabilitationPsychosocial Rehabilitation– Skill and resource development for adults with Skill and resource development for adults with

psychiatric disabilities (SPMI) to increase psychiatric disabilities (SPMI) to increase functioning and ability to live as independently functioning and ability to live as independently as possible with minimal professional as possible with minimal professional intervention. Supports functional, social, intervention. Supports functional, social, educational and vocational goalseducational and vocational goals

– Day/night facility service provided five hours or Day/night facility service provided five hours or more/day, five days/week, day or night by QP, more/day, five days/week, day or night by QP, AP and Paraprofessional staffAP and Paraprofessional staff

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Enhanced MH/SA Services – Enhanced MH/SA Services – Adults and ChildrenAdults and Children• Partial HospitalizationPartial Hospitalization

– Short term service to prevent hospitalization or Short term service to prevent hospitalization or to step down from inpatient facility: therapy, to step down from inpatient facility: therapy, recreational therapy, community living skills, recreational therapy, community living skills, coping skills, medical servicescoping skills, medical services

– Physician involvement in diagnosis, treatment Physician involvement in diagnosis, treatment planning, and admission/dischargeplanning, and admission/discharge

– Day/night facility service provided four Day/night facility service provided four hours/day, five days/wk, (may or may not be hours/day, five days/wk, (may or may not be hospital based) by a Team: social workers, hospital based) by a Team: social workers, psychologists, therapists, case managers, or psychologists, therapists, case managers, or other MH/SA paraprofessional staff, MD other MH/SA paraprofessional staff, MD supervisedsupervised

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• Professional Treatment Services in Professional Treatment Services in Facility-Based Crisis ProgramFacility-Based Crisis Program– Alternative to hospitalization, MH/SA, Alternative to hospitalization, MH/SA,

intensified short-term, medically supervised intensified short-term, medically supervised 24 hour residential facility with 16 beds or 24 hour residential facility with 16 beds or less to alleviate acute or crisis situationsless to alleviate acute or crisis situations

– Assess, monitor, stabilize acute symptomsAssess, monitor, stabilize acute symptoms– Under direction of a physicianUnder direction of a physician

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Enhanced MH/SA Services - Enhanced MH/SA Services - Substance Abuse – Adults and Substance Abuse – Adults and ChildrenChildren• Substance Abuse Intensive Outpatient Substance Abuse Intensive Outpatient

Program (SAIOP)Program (SAIOP)– Structured individual and group addiction Structured individual and group addiction

activities to assist recipients to begin recovery activities to assist recipients to begin recovery and learn skills for recovery maintenanceand learn skills for recovery maintenance

– Licensed facility service provided three Licensed facility service provided three hours/day, three days/week by CCS, CCAS, hours/day, three days/week by CCS, CCAS, CSAC, QPs/APs for SA, and Paraprofessional CSAC, QPs/APs for SA, and Paraprofessional staffstaff


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Enhanced MH/SA Services - Enhanced MH/SA Services - Substance Abuse - AdultsSubstance Abuse - Adults

• Substance Abuse Comprehensive Substance Abuse Comprehensive Outpatient Treatment Program (SACOT)Outpatient Treatment Program (SACOT)– Time limited, multi-faceted approach treatment Time limited, multi-faceted approach treatment

to achieve and sustain recoveryto achieve and sustain recovery– Day and evening periodic licensed facility Day and evening periodic licensed facility

service provided a minimum of four hours/day, service provided a minimum of four hours/day, five days/week by CCS/CCAS/CSAC, QP/AP for five days/week by CCS/CCAS/CSAC, QP/AP for SA, and Paraprofessional staff and access to SA, and Paraprofessional staff and access to psychiatrist when neededpsychiatrist when needed


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Enhanced MH/SA Services - Enhanced MH/SA Services - Substance Abuse AdultsSubstance Abuse Adults

• Substance Abuse Non-Medical Community Substance Abuse Non-Medical Community Residential TreatmentResidential Treatment– 24 hour residential recovery program for adults 24 hour residential recovery program for adults

who provide/have potential to provide primary who provide/have potential to provide primary care for their minor children without 24 hour care for their minor children without 24 hour medical/nursing monitoring (may provide medical/nursing monitoring (may provide services to individuals with their children in services to individuals with their children in residence and/or to pregnant women)residence and/or to pregnant women)

– Short term service (thirty days per twelve Short term service (thirty days per twelve month period) provided by CCS/CCAS/CSAC, month period) provided by CCS/CCAS/CSAC, QP/AP for SA, and paraprofessional staffQP/AP for SA, and paraprofessional staff

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• Substance Abuse Medically Monitored Substance Abuse Medically Monitored Community Residential TreatmentCommunity Residential Treatment– Non Hospital 24 hour rehabilitation facility Non Hospital 24 hour rehabilitation facility

with 24 hour medical/nursing monitoring with 24 hour medical/nursing monitoring – Short term service (thirty days per twelve Short term service (thirty days per twelve

month period) provided by physicians, RN, month period) provided by physicians, RN, CCS/CCAS/CSAC, QP/AP in SA, and CCS/CCAS/CSAC, QP/AP in SA, and paraprofessional staffparaprofessional staff

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Enhanced MH/SA Services – Enhanced MH/SA Services – Detoxification Services – Adults Detoxification Services – Adults and Childrenand Children• Ambulatory DetoxificationAmbulatory Detoxification

– Outpatient medically supervised evaluation, Outpatient medically supervised evaluation, detoxification and referral services to achieve detoxification and referral services to achieve safe/ comfortable withdrawal and transition to safe/ comfortable withdrawal and transition to ongoing treatmentongoing treatment

– Ten day maximum licensed facility service Ten day maximum licensed facility service provided by physicians, RN, and appropriately provided by physicians, RN, and appropriately licensed and credentialed staff and counselors, licensed and credentialed staff and counselors, QP/AP for SA under supervision of CCAS or CCSQP/AP for SA under supervision of CCAS or CCS

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Enhanced MH/SA Services – Enhanced MH/SA Services – Detoxification Services - AdultsDetoxification Services - Adults

• Non-Hospital Medical DetoxificationNon-Hospital Medical Detoxification– Medical and nursing professionals in 24 hour Medical and nursing professionals in 24 hour

medically supervised evaluation and withdrawal medically supervised evaluation and withdrawal management in a facility affiliated with a management in a facility affiliated with a hospital or in a freestanding facility of 16 beds hospital or in a freestanding facility of 16 beds or lessor less

– Short term licensed facility service (not more Short term licensed facility service (not more than thirty days in a short-term period) provided than thirty days in a short-term period) provided by physicians, RN, appropriately licensed and by physicians, RN, appropriately licensed and credentialed staff, CCS/CCAS/CSAC, QP/AP in SA credentialed staff, CCS/CCAS/CSAC, QP/AP in SA and paraprofessional staffand paraprofessional staff

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Enhanced MH/SA Services – Enhanced MH/SA Services – Detoxification Services - AdultsDetoxification Services - Adults

• Medically Supervised or ADATC Medically Supervised or ADATC Detoxification/ Crisis StabilizationDetoxification/ Crisis Stabilization– 24 hour medically supervised evaluation and 24 hour medically supervised evaluation and

withdrawal management in a permanent withdrawal management in a permanent facility with inpatient beds (fewer than 16)facility with inpatient beds (fewer than 16)

– Short term service (not more than 30 days in a Short term service (not more than 30 days in a twelve month period) provided by physicians, twelve month period) provided by physicians, psychiatrists, RN, appropriately licensed and psychiatrists, RN, appropriately licensed and credentialed staff, CCS/CCAS/CSAC, QP/AP for credentialed staff, CCS/CCAS/CSAC, QP/AP for SA and paraprofessional staffSA and paraprofessional staff

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• Outpatient Opioid TreatmentOutpatient Opioid Treatment– Methadone treatment, rehabilitation and Methadone treatment, rehabilitation and

medical services for patients with opiate medical services for patients with opiate addiction disorders addiction disorders

– Periodic service provided in a licensed Periodic service provided in a licensed Opioid Treatment Program by RN, LPN, Opioid Treatment Program by RN, LPN, pharmacist, or physician under 10A pharmacist, or physician under 10A NCAC 27G .3600.NCAC 27G .3600.

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Enhanced MH/SA Services - Enhanced MH/SA Services - ChildrenChildren

• Community Support – Community Support – Children/Adolescents (MH/SA)Children/Adolescents (MH/SA)– Psychoeducational/supportive services Psychoeducational/supportive services

for children age 3-20 and their caregivers for children age 3-20 and their caregivers to assist with rehabilitative and recovery to assist with rehabilitative and recovery goalsgoals

– Direct and indirect periodic service Direct and indirect periodic service provided in any location by QP, AP and provided in any location by QP, AP and paraprofessional staffparaprofessional staff


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• Intensive In-Home ServicesIntensive In-Home Services– Time limited family preservation intervention to Time limited family preservation intervention to

stabilize living arrangement, promote stabilize living arrangement, promote reunification or prevent use of out-of-home reunification or prevent use of out-of-home therapeutic resources for youth through age 20therapeutic resources for youth through age 20

– Direct and indirect periodic service delivered Direct and indirect periodic service delivered primarily in the family’s home (any location) by primarily in the family’s home (any location) by a Team: licensed professional and minimum of 2 a Team: licensed professional and minimum of 2 staff who are APs or provisionally licensed staff who are APs or provisionally licensed (CCS/CCAS/CSAC needed if focus is SA), team (CCS/CCAS/CSAC needed if focus is SA), team leaderleader


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• Multisystemic Therapy (MST)Multisystemic Therapy (MST)– Behavioral therapy model for treating youth and Behavioral therapy model for treating youth and

their families, designed for 7-17 year olds who their families, designed for 7-17 year olds who have antisocial, aggressive/violent, delinquent have antisocial, aggressive/violent, delinquent behaviors, are at risk for (or returning home behaviors, are at risk for (or returning home from) out of home placement, or have SED or from) out of home placement, or have SED or substance abusesubstance abuse

– Direct and indirect periodic service provided Direct and indirect periodic service provided primarily in the home (any location) by a Team of primarily in the home (any location) by a Team of practitioners: 1 master’s level QP and 3 QPspractitioners: 1 master’s level QP and 3 QPs


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• Child and Adolescent Day TreatmentChild and Adolescent Day Treatment– Structured treatment service program for children Structured treatment service program for children

20 or younger: MH/SA interventions in the context 20 or younger: MH/SA interventions in the context of a treatment milieu to enhance capacity to of a treatment milieu to enhance capacity to function in inclusive setting or to be maintained in function in inclusive setting or to be maintained in community based services; reintegrate into school community based services; reintegrate into school or transition into employmentor transition into employment

– Facility based day/night service provided minimum Facility based day/night service provided minimum three hours/day, minimum two days/week by QPs, three hours/day, minimum two days/week by QPs, APs and Paraprofessionals (CCS/CCAS/CSAC if SA)APs and Paraprofessionals (CCS/CCAS/CSAC if SA)

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Residential Treatment Residential Treatment ServicesServices• Treatment in a structured, therapeutic, Treatment in a structured, therapeutic,

supervised environment for under age supervised environment for under age 2121– Level I: low to moderately structured family Level I: low to moderately structured family

settingsetting– Level II: moderate to highly structured Level II: moderate to highly structured

family or program settingfamily or program setting– Level III: highly structured program settingLevel III: highly structured program setting– Level IV: physically secure, locked program Level IV: physically secure, locked program

settingsetting

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Psychiatric Residential Psychiatric Residential Treatment Facilities (PRTF) - Treatment Facilities (PRTF) - for for

children under the age of 21children under the age of 21

– Non Acute inpatient facility care for Non Acute inpatient facility care for recipients under 21 years of agerecipients under 21 years of age

– 24 hour supervision and specialized 24 hour supervision and specialized interventionsinterventions

– Program operates under the direction of Program operates under the direction of a board-eligible or certified child a board-eligible or certified child psychiatrist or general psychiatrist with psychiatrist or general psychiatrist with experience in the treatment of childrenexperience in the treatment of children

– May be hospital basedMay be hospital based

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Medicaid Services – Medicaid Services – Developmental DisabilitiesDevelopmental Disabilities

– Developmental Disability ServicesDevelopmental Disability Services•Targeted Case ManagementTargeted Case Management

– DD services habilitative versus DD services habilitative versus rehabilitative rehabilitative

– Services covered under the CAP MR/DD Services covered under the CAP MR/DD WaiverWaiver

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Clinical HomeClinical Home

• Nine services that can be accessed directly by Nine services that can be accessed directly by Screening Triage and Referral (STR)Screening Triage and Referral (STR)– Intensive In-Home (IIH)Intensive In-Home (IIH)– Multisystemic Therapy (MST)Multisystemic Therapy (MST)– Assertive Community Treatment Team (ACTT)Assertive Community Treatment Team (ACTT)– Community Support Team (CST)Community Support Team (CST)– Substance Abuse Intensive Outpatient Program (SAIOP)Substance Abuse Intensive Outpatient Program (SAIOP)– Substance Abuse Comprehensive Outpatient Treatment Substance Abuse Comprehensive Outpatient Treatment

(SACOT)(SACOT)– Targeted Case Management (TCM)Targeted Case Management (TCM)– Community Support Child/Adolescent (CS-Child/Adolescent)Community Support Child/Adolescent (CS-Child/Adolescent)– Community Support Adult (CS-Adult)Community Support Adult (CS-Adult)

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Clinical HomeClinical Home• Clinical HomeClinical Home

– The clinical home is considered the service best able to provide continuity of care for a recipient in the system. The Qualified Professional at the Clinical Qualified Professional at the Clinical Home provides the following:Home provides the following:•Development and updating of the Person-Development and updating of the Person-

Centered Plan and Crisis PlanCentered Plan and Crisis Plan•Obtaining Authorizations (ITR/ORF2/CTCM)Obtaining Authorizations (ITR/ORF2/CTCM)•Completing the Consumer Admission Form Completing the Consumer Admission Form

(State Only)(State Only)•Completing the NC-TOPPS & NC-SNAPCompleting the NC-TOPPS & NC-SNAP•Serving as a First Responder (24/7)Serving as a First Responder (24/7)

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Proactive InterventionsProactive Interventions

• ““Proactive Interventions” is an aggressive and Proactive Interventions” is an aggressive and organized effort to fulfill each person’s fullest organized effort to fulfill each person’s fullest capacity. It requires an integrated, individually capacity. It requires an integrated, individually tailored program of services directed to achieving tailored program of services directed to achieving measurable, behaviorally-stated objectives.measurable, behaviorally-stated objectives.

• Integrated program of therapiesIntegrated program of therapies– Behavioral programming: positive reinforcement for Behavioral programming: positive reinforcement for

appropriate behaviorappropriate behavior– Psycho-educational programming: curriculum, games, Psycho-educational programming: curriculum, games,

experiential education, therapeutic recreationexperiential education, therapeutic recreation– Generalization of skills: natural and designedGeneralization of skills: natural and designed

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Access to Enhanced Medicaid Access to Enhanced Medicaid ServicesServices

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Comprehensive Clinical Comprehensive Clinical AssessmentAssessment• Alternative to the Diagnostic Assessment

as a means to gather the clinical and diagnostic information necessary to develop the PCP.

• Purpose is to give the Qualified Professional completing the PCP the assessment information necessary to complete the PCP.

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Comprehensive Clinical Comprehensive Clinical AssessmentAssessment• Required elements:

– chronological general health and behavioral health history;– biological, psychological, familial, social, developmental and

environmental dimensions and identified strengths and weaknesses in each area;

– description of the presenting problems, precipitating events, symptoms, and current medications;

– strengths/problem summary; – evidence of recipient or family participation;– analysis and interpretation of the assessment information

with an appropriate case formulation;– diagnoses on all five (5) axes of DSM-IV; and– recommendations for additional assessments, services,

support, or treatment based on the Comprehensive Clinical Assessment.

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Comprehensive Clinical Comprehensive Clinical AssessmentAssessment• Services for Children

– Involve the Child and Family Team as appropriate – assess the strengths of the child/youth and their family– utilize information such as reports from psychological

testing and/or Individualized Education Plans

• Mental Health

– identify the clinical services appropriate to treat the diagnosed condition

– incorporate principles of education, wellness and recovery in partnership with the consumer

– work directly with the clinical home provider

6161

Comprehensive Clinical Comprehensive Clinical AssessmentAssessment• Developmental Disabilities Services

– persons with a developmental disability have multiple disabilities necessitating a comprehensive approach often requiring a variety of clinical assessments (e.g., intellectual assessment, psychiatric assessment, physical evaluation, educational/vocational assessment, PT/OT evaluation).

– identify the person’s current functioning status and needed supports for the PCP

• Substance Abuse Services– The information gathered in the comprehensive clinical

assessment should be utilized to determine the appropriate level of care using the ASAM Patient Placement -2 as a clinical guide. The ASAM level of care recommendation should be included in the disposition of the comprehensive clinical assessment.

6262

EARLY AND PERIODICSCREENING, DIAGNOSTIC,

ANDTREATMENT (EPSDT)

6363

EARLY AND PERIODICSCREENING, DIAGNOSTIC, AND

TREATMENT (EPSDT)

• Provides for medical and dental screenings and medically necessary health care to correct or ameliorate a defect, physical or mental illness, or a condition identified through a screening.

• Services have to be medically necessary.Services have to be medically necessary. • Any proper request for services for a recipient

under 21 years of age is considered a request for EPSDT services.

• Does NOT eliminate the need for prior approval if prior approval is required.

• For more information review the training material For more information review the training material found at: found at: http://www.dhhs.state.nc.us/mhddsas/training/access-care/http://www.dhhs.state.nc.us/mhddsas/training/access-care/epsdt-mhddsa6-07training-3.pdfepsdt-mhddsa6-07training-3.pdf

http://www.dhhs.state.nc.us/mhddsas/training/access-care/epsdt-mhddsa6-07training-3.pdf

http://www.dhhs.state.nc.us/mhddsas/training/access-care/epsdt-mhddsa6-07training-3.pdf

6464

Authorizations and Authorizations and Utilization ReviewUtilization Review

6565

Authorizations and Utilization Authorizations and Utilization ReviewReview

• Prior Authorization is required for all Prior Authorization is required for all services.services.– Exceptions (one time pass though)Exceptions (one time pass though)

• 8 hours of Targeted Case Management 8 hours of Targeted Case Management • 4 hours of Community Support – Adult to complete the 4 hours of Community Support – Adult to complete the

Introductory PCPIntroductory PCP• 8 hours of Community Support – Child to complete the 8 hours of Community Support – Child to complete the

Introductory PCPIntroductory PCP• Unmanaged basic benefit visits Unmanaged basic benefit visits

• Refer to the specific service definition for Refer to the specific service definition for utilization management and authorization utilization management and authorization requirements. requirements.

6666

Authorizations and Utilization Authorizations and Utilization ReviewReview

• Value Options is the DMA contracted agency Value Options is the DMA contracted agency to provide authorization and utilization to provide authorization and utilization review. For more information:review. For more information:– Call Value Options at Call Value Options at 888-510-1150888-510-1150– Refer to the Value Options website at Refer to the Value Options website at

http://www.valueoptions.comhttp://www.valueoptions.com• Piedmont Piedmont Piedmont Cardinal Health PlanPiedmont Cardinal Health Plan

– If a recipient's eligibility is in Cabarrus, Rowan, If a recipient's eligibility is in Cabarrus, Rowan, Stanley, Union or Davidson counties, please call Stanley, Union or Davidson counties, please call Piedmont Behavioral Health at : Piedmont Behavioral Health at :

1-800-939-59111-800-939-5911• State Funded Services are authorized State Funded Services are authorized

through the LMEthrough the LME

http://www.valueoptions.com/

6767

Basic Medicaid Basic Medicaid Documentation Documentation RequirementsRequirements

6868

Basic Medicaid Documentation Basic Medicaid Documentation ElementsElements

• For any Medicaid service, not just For any Medicaid service, not just MH/DD/SA, there must be:MH/DD/SA, there must be:– Assessments and clinical Assessments and clinical

recommendations justifying the course recommendations justifying the course of treatment, or service being of treatment, or service being rendered rendered

– Treatment Plan/PCPTreatment Plan/PCP– Service OrderService Order– Progress notes or other documentation Progress notes or other documentation

that proves delivery of servicethat proves delivery of service

6969

Basic Medicaid Documentation Basic Medicaid Documentation RequirementsRequirements

• Enter information that is:Enter information that is:– AccurateAccurate– TimelyTimely– ObjectiveObjective– Specific, Concise, DescriptiveSpecific, Concise, Descriptive– ConsistentConsistent– Substantive and pertinentSubstantive and pertinent– ClearClear

7070


All service notes must contain the following All service notes must contain the following elements:elements:

• Individual’s name, record number and Individual’s name, record number and Medicaid ID number must be on every Medicaid ID number must be on every service note pageservice note page

• Full date of service (month, day, year)Full date of service (month, day, year)• Name of the service that was providedName of the service that was provided• Purpose of contact (tied to PCP goals)Purpose of contact (tied to PCP goals)• Description of the Description of the

interventions/treatment/supportinterventions/treatment/support

7171


Service Note elements (cont.)Service Note elements (cont.)

• Total amount of time spent performing the service Total amount of time spent performing the service (required for all periodic services and many others)(required for all periodic services and many others)

• Effectiveness of the interventionsEffectiveness of the interventions

• Proper signature of person who provided the serviceProper signature of person who provided the service– For professionals signature must include For professionals signature must include

credentials, degree, or licensurecredentials, degree, or licensure– For paraprofessionals, signature must include the For paraprofessionals, signature must include the

person’s title (position)person’s title (position)

7272

Documentation ResourcesDocumentation Resources

• For more details about documentation For more details about documentation refer to:refer to:– Medicaid Clinical Policy and Service Medicaid Clinical Policy and Service

Definitions found at: Definitions found at: http://www.dhhs.state.nc.us/dma/bh/8A.pdfhttp://www.dhhs.state.nc.us/dma/bh/8A.pdf

– Service Records Manual found at: Service Records Manual found at: http://www.dhhs.state.nc.us/mhddsas/statspuhttp://www.dhhs.state.nc.us/mhddsas/statspublications/manualsforms/aps/apsm_serv-recorblications/manualsforms/aps/apsm_serv-record-manual-10-07.pdfd-manual-10-07.pdf

– Person-Centered Plan Instruction Manual Person-Centered Plan Instruction Manual found at: found at: http://www.dhhs.state.nc.us/mhddsas/traininghttp://www.dhhs.state.nc.us/mhddsas/training/access-care/pcp6-29-07manual.pdf/access-care/pcp6-29-07manual.pdf

http://www.dhhs.state.nc.us/dma/bh/8A.pdf

http://www.dhhs.state.nc.us/mhddsas/statspublications/manualsforms/aps/apsm_serv-record-manual-10-07.pdf



http://www.dhhs.state.nc.us/mhddsas/training/access-care/pcp6-29-07manual.pdf

http://www.dhhs.state.nc.us/mhddsas/training/access-care/pcp6-29-07manual.pdf

7373

Billing and PaymentBilling and Payment

7474

Billing and PaymentBilling and Payment

Billing to and Payment FromBilling to and Payment From• Electronic Data Systems (EDS) is the fiscal agent Electronic Data Systems (EDS) is the fiscal agent

contracted by DMA to:contracted by DMA to:– Process claims for enrolled Medicaid providers according Process claims for enrolled Medicaid providers according

to DMA’s policies and guidelinesto DMA’s policies and guidelines– Establish and maintain a presence with the Medicaid Establish and maintain a presence with the Medicaid

provider community through:provider community through:• Provider seminarsProvider seminars• On-site visits to providers for assistance with billing issuesOn-site visits to providers for assistance with billing issues• For detailed instructions on billing refer to the Basic For detailed instructions on billing refer to the Basic

Medicaid Billing Guide Medicaid Billing Guide http://www.dhhs.state.nc.us/dma/bulletin/BasicMedBillingGhttp://www.dhhs.state.nc.us/dma/bulletin/BasicMedBillingGuide0407.pdfuide0407.pdf and the EDS website and the EDS website http://www.EDS.comhttp://www.EDS.com

http://www.dhhs.state.nc.us/dma/bulletin/BasicMedBillingGuide0407.pdf

http://www.dhhs.state.nc.us/dma/bulletin/BasicMedBillingGuide0407.pdf

http://www.eds.com/

7575

Quality Management/Assurance Quality Management/Assurance (QM/QA)(QM/QA)

7676

Quality Quality Management/AssuranceManagement/Assurance

What is Quality … What is Quality … Management, Assurance, Management, Assurance,

Improvement, etc. ?Improvement, etc. ?

7777


What is the goal of Quality … What is the goal of Quality … Management, Assurance, Management, Assurance,

Improvement, etc. ?Improvement, etc. ?

7878


What is the role of the Qualified What is the role of the Qualified Professional in Quality … Management, Professional in Quality … Management,

Assurance, Improvement, etc. ?Assurance, Improvement, etc. ?

7979


• Are you doing things right?Are you doing things right?– EfficiencyEfficiency– ProductiveProductive

• Are you doing the right thing?Are you doing the right thing?– EffectivenessEffectiveness– Best/Evidenced Based PracticesBest/Evidenced Based Practices

• Are you looking at yourself?Are you looking at yourself?– Self-MonitoringSelf-Monitoring

8080


Are you doing things right?Are you doing things right?

• Record keepingRecord keeping– CompleteComplete– AccurateAccurate– requires intensive QM to prevent requires intensive QM to prevent

paybacks.paybacks.

8181



• BillingBilling– Complete Complete – AccurateAccurate– TimelyTimely

8282


Are you doing things right?Are you doing things right?• Practice ManagementPractice Management

– EfficientEfficient– Cost effectiveCost effective

• StaffStaff– LicensingLicensing– CertificationCertification– PrivilegingPrivileging

8383



• Service DeliveryService Delivery– AccessibleAccessible– Culturally competentCulturally competent– EfficientEfficient

8484


Are you doing the right thing?Are you doing the right thing?

• Most appropriate serviceMost appropriate service

• At the right timeAt the right time

• With the right personWith the right person

8585


Are you doing the right thing?Are you doing the right thing?• Medical Necessity:Medical Necessity:

– A clinical decision as to if a service will benefit A clinical decision as to if a service will benefit the individual.the individual.

– The responsibility of the Qualified ProfessionalThe responsibility of the Qualified Professional• SupervisionSupervision

– Staff should be under the supervision of a Staff should be under the supervision of a licensed professional according to clinical need licensed professional according to clinical need and requirementsand requirements•Service DefinitionsService Definitions•Certification and/or LicensureCertification and/or Licensure

– Policy on supervision requiredPolicy on supervision required

8686


Are you doing the right thing?Are you doing the right thing?

• referring to other agencies or to referring to other agencies or to other services when indicatedother services when indicated

• offering choice of providers vs. self- offering choice of providers vs. self- referringreferring

• balance between clinical, regulatory, balance between clinical, regulatory, and QA functionsand QA functions

8787


Are you looking at yourself?Are you looking at yourself?

• Utilization:Utilization:– monitor utilization patternsmonitor utilization patterns– establish clinical review process for establish clinical review process for

“high need” recipients.“high need” recipients.

• Risk ManagementRisk Management

8888


Are you looking at yourself?Are you looking at yourself?

• Incident monitoringIncident monitoring– Critical Incident ReportsCritical Incident Reports

• Licensed facilities are required to report critical Licensed facilities are required to report critical incidents to the LME and DMH/DD/SASincidents to the LME and DMH/DD/SAS

• Deaths must also be reported to the Division of Deaths must also be reported to the Division of Facility ServicesFacility Services

• Incident in depth report form located at: Incident in depth report form located at: http://facility-services.state.nc.us/mental_health/pdf/chttp://facility-services.state.nc.us/mental_health/pdf/crdeathrep.pdfrdeathrep.pdf

8989


Are you looking at yourself?Are you looking at yourself?• QQuality improvement committee

– Quality improvement plan– Quality improvement studies

• OutcomesOutcomes– What is the effect of your treatment?What is the effect of your treatment?– NCTOPPSNCTOPPS

• Endorsement– Quality of provider organization and of the

services major part of LME endorsement

9090


Pitfalls to AvoidPitfalls to Avoid

9191


Pitfalls to AvoidPitfalls to Avoid• Prior Authorization does not guarantee payment for all Prior Authorization does not guarantee payment for all

units/hours authorizedunits/hours authorized– Billing may not occur if documentation is not complete or Billing may not occur if documentation is not complete or

timelytimely– Billing may not occur if the person is not present for the Billing may not occur if the person is not present for the

delivery regardless of making a trip to the person’s home or delivery regardless of making a trip to the person’s home or other location. other location.

– Billing may not occur if the recipient and provider are not Billing may not occur if the recipient and provider are not actively engaged in the implementation of the strategies actively engaged in the implementation of the strategies and/or curricula used to address the goals of the plan. and/or curricula used to address the goals of the plan.

– Authorizations do not transfer from provider to provider. New Authorizations do not transfer from provider to provider. New authorizations are required.authorizations are required.

• PCP/Treatment PlanPCP/Treatment Plan– PCP/Plan should not be signed prior to the plan meeting date PCP/Plan should not be signed prior to the plan meeting date – PCP/Plans are valid when the consumer/legally responsible PCP/Plans are valid when the consumer/legally responsible

person and the person who developed the plan sign and date person and the person who developed the plan sign and date itit

9292


Pitfalls to Avoid (cont)Pitfalls to Avoid (cont)• No Canned DocumentationNo Canned Documentation

– Progress Notes that look the same for other recipients or Progress Notes that look the same for other recipients or day after day the same words day after day the same words

– PCPs/Treatment Plans that look the same for other PCPs/Treatment Plans that look the same for other recipientsrecipients

Progress Notes should not be preprinted or Progress Notes should not be preprinted or predatedpredated

• The progress note should match the goals on the The progress note should match the goals on the plan and the plan should match the needs of the plan and the plan should match the needs of the recipient. There should be clear continuity recipient. There should be clear continuity between the documentationbetween the documentation

• Progress Notes must provide enough detail and Progress Notes must provide enough detail and explanation to justify the amount of billing.explanation to justify the amount of billing.

9393


Pitfalls to Avoid (cont)Pitfalls to Avoid (cont)• Claims ProcessingClaims Processing

– Errors in claims processing delay your claimErrors in claims processing delay your claim• can usually be corrected since these are commonly can usually be corrected since these are commonly

data entry errorsdata entry errors

– Primary fraudulent issue is the lack of payback Primary fraudulent issue is the lack of payback of funds when errors in documentation or of funds when errors in documentation or service delivery have been found.service delivery have been found.• Recipient no longer Medicaid eligibleRecipient no longer Medicaid eligible• Location of service negates billing for MedicaidLocation of service negates billing for Medicaid

– Requires close communication between Requires close communication between everyone involved in the care and billingeveryone involved in the care and billing

9494


Pitfalls to Avoid (cont)Pitfalls to Avoid (cont)• No “stamped” signaturesNo “stamped” signatures

• White Out is not acceptable on any White Out is not acceptable on any records.records.

• Making service receipt conditional of Making service receipt conditional of getting all services from providergetting all services from provider

9595


Pitfalls to Avoid (cont)Pitfalls to Avoid (cont)• Recipients from an agency all have Recipients from an agency all have

the same hours/units requestedthe same hours/units requested

• Business Plan should account for not Business Plan should account for not being able to bill 100% of everything being able to bill 100% of everything donedone– Some non-billable activities are factored Some non-billable activities are factored

into the rateinto the rate

9696


RULES

9797


RULES FOR MENTAL HEALTH, DEVELOPMENTAL DISABILITIES, AND SUBSTANCE ABUSE FACILITIES AND SERVICES 10A NCAC 27G.0201 states:

• The governing body shall develop and implement written policies for the following:– review of medical recordsreview of medical records– risk managementrisk management– quality assurance and quality improvement committee– written quality assurance and quality improvement plan;– methods for monitoring and evaluating the quality and

appropriateness of client care, including delineation of client outcomes and utilization of services

9898


Governing Body Policies (Cont.)

– professional or clinical supervision– strategies for improving client care;– review of staff qualifications and a

determination made to grant treatment/habilitation privileges;

– review of all fatalities in residential programs.

9999

AppealsAppeals

100100

AppealsAppeals

• Every Medicaid recipient has appeal rights that can apply to situations in which a recipient is:– denied a requested service; or – informed that a current service will be reduced,

suspended, or terminated.

• If services are being denied, reduced, suspended or terminated, the recipient will receive an letter detailing their appeal rights

101101

AppealsAppeals

•Two hearing options:– informal hearing by the DHHS

Hearing Office– formal or evidentiary hearing by the

Office of Administrative Hearings (OAH) in Raleigh

102102

Fraud and AbuseFraud and Abuse

103103

Fraud and AbuseFraud and Abuse

• False Claims Act (FCA)- handoutFalse Claims Act (FCA)- handout--Knowingly presents or causes to be presented to…Knowingly presents or causes to be presented to…

a false or fraudulent claim for payment or a false or fraudulent claim for payment or approval;approval;

-Knowingly makes, uses or causes to be made or -Knowingly makes, uses or causes to be made or used a false record or statement to get a false used a false record or statement to get a false claim…claim…

-Conspires to defraud the Government by getting a -Conspires to defraud the Government by getting a false or fraudulent claim paid or approved…false or fraudulent claim paid or approved…

-Knowingly makes, uses or causes to be made or -Knowingly makes, uses or causes to be made or used a false record or statement to…an obligation used a false record or statement to…an obligation to pay or transmit money..to pay or transmit money..

• False Claims Act (FCA) – False Claims Act (FCA) – http://www.cms.hhs.gov/smdl/downloads/SMD032http://www.cms.hhs.gov/smdl/downloads/SMD032207Att2.pdf207Att2.pdf

http://www.cms.hhs.gov/smdl/downloads/SMD032207Att2.pdf

http://www.cms.hhs.gov/smdl/downloads/SMD032207Att2.pdf

104104

Fraud and Abuse (cont.)Fraud and Abuse (cont.)

• Knowing (and knowingly) mean that a Knowing (and knowingly) mean that a person, with respect to information (1) person, with respect to information (1) has actual knowledge of the has actual knowledge of the information, (2) acts in deliberate information, (2) acts in deliberate ignorance of the truth or falsity of the ignorance of the truth or falsity of the information; or (3) acts in reckless information; or (3) acts in reckless disregard of the truth or falsity of the disregard of the truth or falsity of the information, and no proof of specific information, and no proof of specific intent to defraud is required.intent to defraud is required.

105105


• 31 USC 3729. While the FCA imposes 31 USC 3729. While the FCA imposes liability only when the claimant acts liability only when the claimant acts “knowingly,” it does not require that “knowingly,” it does not require that the person submitting the claim have the person submitting the claim have actual knowledge that the claim is actual knowledge that the claim is false.false.

106106

Abuse and Fraud (cont.)Abuse and Fraud (cont.)

• It is incumbent upon all providers to It is incumbent upon all providers to become familiar with potential areas of become familiar with potential areas of fraud and abuse.fraud and abuse.

• Fraud may be often interpreted to mean Fraud may be often interpreted to mean intentional deception in this regard, it can intentional deception in this regard, it can also entail unintentional patterns of also entail unintentional patterns of errors. Work must be completed with errors. Work must be completed with utmost accuracy and soundness of utmost accuracy and soundness of judgement.judgement.

107107


• Degrees of DMA interventionDegrees of DMA intervention-Warning letter-Warning letter-Suspension of enrollment-Suspension of enrollment-Termination-Termination-Withhold of payment-Withhold of payment• DMA has the authority and obligation to:DMA has the authority and obligation to:-revoke a provider’s participation-revoke a provider’s participation-recoup payment and-recoup payment and-report any potential fraud to the Attorney General’s -report any potential fraud to the Attorney General’s

OfficeOffice

108108

Fraud and AbuseFraud and Abuse• Investigation of Fraud and AbuseInvestigation of Fraud and Abuse

– May be planned or unannouncedMay be planned or unannounced– Three agencies that typically reviewThree agencies that typically review

1.1. DMH/DD/SA may monitor compliance with regulations DMH/DD/SA may monitor compliance with regulations and determine financial payback for deficiencies. and determine financial payback for deficiencies. Results are forwarded to DMA. Results are forwarded to DMA. – This may begin with the LME’s involvement and reviewThis may begin with the LME’s involvement and review

2.2. DMA is the official Medicaid agency in NC, on behalf of DMA is the official Medicaid agency in NC, on behalf of CMS. DMA may initiate its own investigation or CMS CMS. DMA may initiate its own investigation or CMS may initiate an investigation. The investigation may initiate an investigation. The investigation determines compliance with all regulations in determines compliance with all regulations in implementing the State’s agreement with CMS. DMA implementing the State’s agreement with CMS. DMA has the authority to revoke a provider’s participation, has the authority to revoke a provider’s participation, recoup payment and report any potential fraud to the recoup payment and report any potential fraud to the Attorney General’s OfficeAttorney General’s Office

109109

Fraud and AbuseFraud and Abuse3.3. The State’s AG’s office and the US Attorney’s Office The State’s AG’s office and the US Attorney’s Office

have the authority to investigate and prosecute have the authority to investigate and prosecute potential Medicaid fraud as contained in the Federal potential Medicaid fraud as contained in the Federal False Claim Act, Federal Civil Monetary Penalty Law False Claim Act, Federal Civil Monetary Penalty Law and Medical Assistance Provider False Claims Act and Medical Assistance Provider False Claims Act (State criminal and civil law). (State criminal and civil law).

– These three typically represents a hierarchy These three typically represents a hierarchy depending on the nature and source of the depending on the nature and source of the complaint. Agencies collaborate and complaint. Agencies collaborate and communicate findings. communicate findings.

– The finding of fraud does not require an The finding of fraud does not require an intent of wrongdoing, however, it is more intent of wrongdoing, however, it is more than a simple mistake. than a simple mistake.

– The lack of knowledge is not a defense for The lack of knowledge is not a defense for fraud. fraud.

110110

ResourcesResources

111111

ResourcesResources

• Review DMA Web SiteReview DMA Web Site– Provider Information: Provider Information:

http://www.dhhs.state.nc.us/dma/prov.htmhttp://www.dhhs.state.nc.us/dma/prov.htm• Monthly Medicaid Bulletins, Clinical policy, billing Monthly Medicaid Bulletins, Clinical policy, billing

guide, check schedules, Fee Schedules, guide, check schedules, Fee Schedules, Administrative rules, etc. Administrative rules, etc.

• Service Definitions, Implementation MemosService Definitions, Implementation Memos

• Division of MH/DD/SA Web siteDivision of MH/DD/SA Web site– http://www.ncdhhs.gov/mhddsas/index.hhttp://www.ncdhhs.gov/mhddsas/index.h

tmtm– Joint DMA/DMH Implementation MemosJoint DMA/DMH Implementation Memos– RulesRules– Service Records ManualService Records Manual

http://www.dhhs.state.nc.us/dma/prov.htm

http://www.ncdhhs.gov/mhddsas/index.htm

http://www.ncdhhs.gov/mhddsas/index.htm

112112

ResourcesResources• Medicaid State Plan at: Medicaid State Plan at:

http://www.dhhs.state.nc.us/dma/sp.htmhttp://www.dhhs.state.nc.us/dma/sp.htm

• DMA Clinical Coverage Policy 8-A, DMA Clinical Coverage Policy 8-A, “Enhanced Mental Health and Substance “Enhanced Mental Health and Substance Abuse Services”, can be found at the Abuse Services”, can be found at the following link: following link: http://www.dhhs.state.nc.us/dma/bh/8A.pdhttp://www.dhhs.state.nc.us/dma/bh/8A.pdff

• Basic Medicaid Billing Training (all Basic Medicaid Billing Training (all providers should attend) Information can providers should attend) Information can be located at be located at http://www.dhhs.state.nc.us/dma/home.hthttp://www.dhhs.state.nc.us/dma/home.htmm

http://www.dhhs.state.nc.us/dma/sp.htm



http://www.dhhs.state.nc.us/dma/home.htm

http://www.dhhs.state.nc.us/dma/home.htm

113113

ResourcesResourcesValueOptions ValueOptions http://http://

www.valueoptions.comwww.valueoptions.com

• Provider Relations: 888-510-1150Provider Relations: 888-510-1150

EDS Website at: EDS Website at: http://www.eds.comhttp://www.eds.com

• EDS Provider Services: 1-800-688-EDS Provider Services: 1-800-688-6696 or 919-851-88886696 or 919-851-8888– Provider Training at: Provider Training at:

www.ncdhhs.gov/mhddsas/videoconferewww.ncdhhs.gov/mhddsas/videoconference/basic-medicaid-chris-ferrell.pdfnce/basic-medicaid-chris-ferrell.pdf



http://www.eds.com/

http://www.ncdhhs.gov/mhddsas/videoconference/basic-medicaid-chris-ferrell.pdf

http://www.ncdhhs.gov/mhddsas/videoconference/basic-medicaid-chris-ferrell.pdf

114114

Medicaid ContactsMedicaid Contacts

• Clinical Policy (919-855-4260)Clinical Policy (919-855-4260)

• Behavioral Health Care Section (919-Behavioral Health Care Section (919-855-4290)855-4290)

•Marcia Copeland, ChiefMarcia Copeland, Chief

•Marie Britt RN, BC, MS - 910-674-4226Marie Britt RN, BC, MS - 910-674-4226

•Bert Bennett, Ph.D. - 336-724-4539Bert Bennett, Ph.D. - 336-724-4539

• Recipient Services - (919-855-4000)Recipient Services - (919-855-4000)

• Program Integrity – (919-647-8000)Program Integrity – (919-647-8000)

• Provider Services – (919-855-4050)Provider Services – (919-855-4050)

115115

Division of MH/DD/SADivision of MH/DD/SA

• Community Policy Management (919-715-Community Policy Management (919-715-1294)1294)– Christina Carter, Implementation Manager Christina Carter, Implementation Manager – Dick Oliver, LME Team Leader Dick Oliver, LME Team Leader – Bonnie Morell, Best Practice and Community Bonnie Morell, Best Practice and Community

Innovations TeamInnovations Team

• Resource and Regulatory Mgmt. (919-881-Resource and Regulatory Mgmt. (919-881-2446)2446)– Jim Jarrard, Accountability Team LeaderJim Jarrard, Accountability Team Leader

• Advocacy and Customer Service (919-715-3197)Advocacy and Customer Service (919-715-3197)– Chris Phillips, ChiefChris Phillips, Chief

116116

EVALUATION & QUESTIONS EVALUATION & QUESTIONS

Medicaid 101: Basic Training for Medicaid MH/DD/SA Providers

Documents

dma provider enrollment

provider enrollment

provider enrollment

provider enrollment

enrolled provider

provider responsibilities

provider agency

requirements of medicaid