Medicaid MH-TCM Review Finds Inadequate Documentation

Family Preservation Services -
Florida

Medicaid Mental Health Targeted Case
Management Technical Assistance
Review

Presented by Kerri Pawlak
and Cheryl Buss (LCSW)

October 11, 2011
1

Agency Certification
Requirements
Every enrolled Medicaid Mental Health
Targeted Case Management (MH-TCM)
location must be Certified by the local
Area Medicaid office before Medicaid
reimbursable services can be delivered
from the service location.
Certification is awarded after the provider
location has been successful (100%
compliance) in passing the Certification
Review.
July 2006 MH-TCM Coverage and Limitations
Handbook, pages1-5 and 1-6
2

Results of the Certification of the
Naples Location
Certification Tool is broken down into
two domains:
Administrative Targeted Case
Management (TCM) Review (54.54%)
Compliance
Programmatic Targeted Case
Management (TCM) Review (40%)
Compliance

3

Findings from a Review of the
MH-TCM Program in Naples
Programmatic Findings from the Review:
It was unclear whether the TCM met educational
requirements because she had a foreign diploma.
Four of 10 clients did not appear to meet
minimum standards to receive MH-TCM services.
Caseloads were always maintained within
Medicaid policy parameters.
Services were always rendered by agency
certified case managers, but were not always
rendered in accordance with Medicaid policy.
Case Management Assessments were
inadequate and did not address all components
required.

4

MH-TCM Program at Naples
Programmatic Findings from the review
(contd)
Two of 10 Assessments did not document
a home visit with the client.
The Assessment was dated by the
recipient, case manager and treatment
team members on different dates, with the
supervisor being the first to sign, as
opposed to the case manager.
Service Plans did not contain measurable
goals and objectives or include the
amount, frequency and duration of
services.
5

MH-TCM Program at Naples
Programmatic Findings from the review
(contd)
One Service Plan was inadequately
documented.
Progress notes did not meet documentation
requirements, adequately justify the length of
time spent, nor did they consistently link
services to the Service Plan or Review.
MH-TCM services rendered in conjunction with
other Medicaid reimbursable service, when
rendered to provide/communicate critical
information that assists the recipient often
exceeded the two units per event limit.
Documentation was not entered in the record
timely.

6

Medical Necessity
All Medicaid services must be medically
necessary.
Clear and comprehensive documentation of all
assessments, home visits, recipient
interactions, and contacts with collateral
sources should adequately show the
strengths/needs of the recipient /natural
support system.
Documentation is the key to
justifying/supporting the medical necessity of
the service being provided.
If the information is not documented, an auditor
cannot allow reimbursement of the service.

7

What is MH-TCM
Supportive services which assist
individuals to obtain needed medical,
financial, insurance benefits,
employment, social, educational
and/or other services to appropriately
address their needs
It is not the provision of direct
therapeutic medical or clinical services
July 2006 MH-TCM Coverage and
Limitations Handbook, pages 2-7 and 2-8

8

Accomplishing the Goal
of MH-TCM
Identify the persons problem(s) by
assessing the person to determine that
persons needs.
Create a Service Plan to outline the
strategy for assisting the client in achieving
his/her goals.
Advocate for your client by linking the client
to the services outlined in their service
plan.
Organize and monitor service delivery to
evaluate the recipients progress.

Handbook, page 2-17

9

Recipient Certification
Childrens and Adult Recipient MH-TCM
Certifications
The recipient certification form should document
initial eligibility for MH-TCM services.

Appendix I-K:
Recipients are certified by the Case Manager and
the Case Management Supervisor
Certifications must be completed within 30 days
of initial date of service.
It is possible that a referred client may not meet
eligibility criteria, even if the referral source
wants the individual to receive MH-TCM.

Handbook, pages 2-3 through 2-5
10

On-going Eligibility
The Service Plan Review is a process
conducted to ensure that services, goals
and objectives remain appropriate to the
recipients needs and to (re)assess
recipient progress and continued need for
MH-TCM.
The activities, discussion and review
process must be clearly documented.
Minimally, the Review is signed by the
recipient, the MH-TCM and the MH-TCM
supervisor.
Handbook, page 2-16

11

Covered Services*
Conducting the MH-TCM Assessment and Service
Plan in accordance with the handbook.
Service Plan implementation with the client/family.
Assessing service plan effectiveness.
Linking, facilitating, coordinating and monitoring
services delivered as defined in the Service Plan.
Advocate for delivery of medically necessary
services, as identified from the Service Plan.
Documenting the delivery of MH-TCM.
Providing access to resources during moments of
crisis.
Staffing(s) with the recipient treatment team or
one-on-one with the psychiatrist, psychiatric ARNP,
physician, therapist, teacher, attorney, GAL or other
collateral.
Handbook, page 2-17
12

Covered Services
TCM billed in conjunction with another
Medicaid service when communicating critical
client info.
This cannot exceed two units per event.
Coordination of aftercare upon discharge from
a residential/inpatient facility when the facility
is not paid a discharge planning per diem.
Participating in the clients individualized
Treatment Plan Development/Review
process.
Time billed must be clearly justified as time
dedicated to the recipient.
Providing MH-TCM services during the last
90 days of a childs BHOS stay.

Handbook,
page 2-17

13

Service Restrictions
Provision of direct care services
Offering clinical services, transportation, etc.
Performing Administrative Functions:
Copying, mailing, faxing, checking recipient
eligibility
Discharge planning when covered by a
residential facilitys per diem rate.
Medicaid reimburses d/c planning 60-days prior
to discharge from a state mental health facility.
Ineligible Medicaid recipients
FACT recipients
Handbook, pages 2-8, 2-9 and 2-11

14

Home & Community Based Waiver Clients
Institutionalized Recipients
Jails, Prisons, Detention Centers, ICF-DDs, etc.
Institution for Mental Diseases
Hospital/other institution with 17 or more beds,
engaged in providing diagnosis, treatment and care
to individuals with behavioral diseases (i.e.-some
CSUs)
Supervision is not a billable MH-TCM activity.
Incomplete Certification Form, Assessment,
Service Plan.
Handbook, pages 2-9 and 2-11
15

No Recipient Contact (direct contact is
required)
Messages on machines, notes on the clients door
and e-mail messages are not reimbursable.
Non-Duplication of Services
No reimbursement for simply being present
during a face-to-face therapeutic activity.
Services provided which duplicate what is already
being provided, regardless of the funding source
(i.e.-services coordinated by family/CBC worker,
etc.).
Transportation
Medicaid does not reimburse case managers for
transporting recipients.

Handbook, page 2-11 and 2-12

16

Statewide Inpatient Psychiatric Pgm (SIPP)
TCM can be rendered the last 180 days of
SIPP.
Clinical information must be provided by the
TCM to the SIPP at time of admission.
MH-TCM must attend monthly treatment
team meetings and remain in contact with
the therapist, relevant collaterals, family &
the child.
Staff can attend by phone when clients are
placed outside the district
This must be justified in the clinical record

July 2006 MH-TCM Coverage and Limitations Handbook,
page 2-10

17

SIPP Restrictions Continued
The MH-TCM follows up with the
recipient for two months after
discharge to collect SIPP outcome
data.
Services are limited to 8 hours/mo.
during the SIPP stay; this is
increased to 12 hours/mo. in the last
month of care.

Handbook, page 2-10

18

Documentation Components
Required documentation for each Case
Management Record:
Certification Form
MH-TCM Assessment
Service Plan and Reviews
Service documentation with
required elements

Handbook, pages 2-2, 2-4, 2-12, 2-15, 2-16, 2-20

19

Requirements for Case Management Notes:
Recipients name;
Date of service w/beginning & end times;
Detail of the services provided;
Setting where service was rendered (home,
office, etc.);
Updates when there is a significant change in:
Residence, inpatient/state mental hospital placement,
mental status, persons life/support system, custody
or educational/ employment placement
Inclusion of MH-TCMs name, original
(handwritten or electronic) signature, title and
date.
Photocopied signatures are not allowed.
Handbook, page 2-20

20

Detailed Case Notes Must:
Clearly link the case management activity with
one or more identified, reimbursable Service
Plan activities;
Refer to Service Plan Objectives;
Describe the recipients progress related to
the Service Plan;
Justify the time spent providing MH-TCM
services.
Document MH-TCM substitution, when
rendered.
Handbook, page 2-20

21

Purpose of Documentation
There is connection between the
assessment, service planning, TCM
activities and treatment services
provided. Everything is coordinated
through the MH-TCM Service Plan
and MH-TCM documentation allows
an auditor to understand the service
planning and implementation process.

22
Linkage Advocacy
S
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.

Client Needs
C
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a
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a
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I
n
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t
.

Assessment & Service
Planning

Continuous Review &
Adjustment of
Services
Case
Manager
Assessment and Service
Planning

MH-TCM Assessments
Assessment must be completed within
30-days of client referral.
A home visit must occur prior to
completion of the initial assessment.

Limitations Handbook, page 2-12

24

MH-TCM Assessment Elements*
Presenting problem(s) including history, self
assessment;
Psychosocial history;
Psychiatric and medical history;
Recipient current and potential strengths;
Strengths/resources available through natural support
system;
Educational placement, adjustment and progress;
Relationship with family and significant others;
Identification and effectiveness of received services;
Identification of services to assist client in reaching his
goals;
Assessment of service needs in the following areas:
Mental Health; Alcohol/drug abuse; Family support
and education; Education, Vocational/Job training;
Housing, Food, Clothing or Transportation; Medical
and Dental; Legal assistance; Development of
environmental supports; Assistance with Financial
Resources.
July 2006 MH-TCM Coverage and Limitations Handbook, pg. 2-
13

25

MH-TCM Assessments*
Assessment documentation must reflect
that the following information sources were
used:
Recipients own perception of his/her situation
The referral source; Recipients family/friends;
Other care providers serving the recipient;
Information from previous treating providers,
after a release of information is obtained.
If collateral/other provider information is not
obtained, documentation must justify this in
the record.
pg. 2-13

26

Assessment Documentation

An identifiable and dated document in the record;
Contains information from initial screening and
other sources: copies of evaluations, discharge
summaries and other gathered data;
Documentation of the home visit done prior to
the completion of the assessment;
Justification for lack of a home visit is required with
sign-off by the case management supervisor.
A face-to-face evaluation with the client still must
occur.
The assessment must be reviewed, signed and
dated by the MH-TCM and their supervisor prior to
completion of the Service Plan.

pg. 2-14

27

MH-TCM Assessment Updates
MH-TCM Assessments must be
updated annually.
It is not recommended that Assessment
Updates cite No Change or Status
Unchanged as this does not document
assessment of the recipients status,
progress, needs or present functional
level.


28

Service Plan Elements
Single identifiable document (not also the tx
plan).
It is individualized to the recipient.
It requires measurable goals/objectives
consistent with the MH-TCM assessment.
It must be developed and finalized by the
supervisor within 30 days after intake.
Developed in partnership with and signed by
the recipient, (guardian, if applicable), TCM
and supervisor.

29

Service Plan Elements
The Service Plan describes needed
services and indicates how needs will be
met.
The plan identifies timeframes for goal
achievement.
It includes short and long-term goals.
It identifies who will be responsible for
providing specific assistance/services,
and should be consistent with the
treatment plan.


30

Service Planning
The Service Plan should:
Be a working, functional tool used to plan
services that address client needs.
Reflect assessment findings and case
monitoring activities (i.e.-home visits,
communication with treatment providers/
collateral sources, and ongoing face-to-face
interactions with the client).
Through these activities the client and
case manager can evaluate
needs/goals, and make adjustments to
the Service Plan.
31

Service Plan Reviews
Service Plan must be reviewed at least
every six months and documented in the
record;
Revisions are done as significant events
occur.
Reviews must include a re-evaluation of the
recipients eligibility for ongoing TCM.
Documentation must indicate client still
meets criteria to receive TCM services.
The activities, discussion and review process
must be clearly documented.
The recipient, TCM, supervisor (and legal
guardian, if applicable) must sign and date the
Review.


32

Examples of non-reimbursable
MH-TCM Services
The following are from past and present MH-TCM
FPS documentation:
Childrens Case Management notes
documented provision of services which were
directed to the childs parent(s) instead of being
directed toward the child-Services should be
rendered to the recipient, and should meet
their individualized needs as identified from
the MH-TCM Assessment and Service
Plan/Reviews.
Services were managed by the childs foster
parents, and there was not documented need for
MH-TCM.-Duplication of services is not
allowable.
33

MH-TCM Services
Case manager did not document regression of
child and evidence of TCM eligibility was not
clearly indicated; however, other
documentation showed that the child was
referred for a QE and required SIPP admission
-documentation did not justify on-going
TCM eligibility although services were
needed.
Documentation contained discussion between the
TCM and supervisor regarding what the TCM
would be doing in the future. No active service
provision was documented-MH-TCM did not
provide a billable service and documented
receipt of supervision.

34

MH-TCM Services
Some documentation in a clinical file
referred to how the boys were doing
(client was in foster care with his
brother).-Documentation should be
reflective of services and needs
specific to the client.
Client was identified to have
developmental disabilities (DD), though it
was not determined whether the
individual was in the DD waiver-
Recipients cannot receive TCM and
Waiver services at the same time.

35
QUESTIONS????
36

Helpful Links/Resources
Medicaid Summary of Services Link:
http://ahca.myflorida.com/Medicaid/flmedica
id.shtml
Medicaid Fiscal Agent Website:
http://mymedicaid-florida.com
Get handbooks and enrollment forms here
Magellan Medicaid Administration
(MMA):
https://florida.fhsc.com/
Get monitoring guidelines and MMA Power
Point presentations here

37

Helpful Links/Resources
Agency for Healthcare Administration
www.fdhc.state.fl.us
Sign up for Medicaid Health Care Alerts
See Agency announcements, publications,
notices
Make a public record request
Report fraud
Department of Children and Families
www.dcf.state.fl.us

38

Contact Information
Kerri Pawlak
Area Eight Medicaid Behavioral Health
Specialist
239-335-1272
E-mail:
kerri.pawlak@ahca.myflorida.com
Cheryl L. Buss, LCSW
Area Eight Medicaid Utilization
Management Specialist
239-335-1259
E-mail:
cheryl.buss@ahca.myflorida.com

39

Medicaid MH-TCM Review Finds Inadequate Documentation

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