Department of Medical Assistance Services IFDDS Support Coordination Training

1
Department of Medical Assistance Services
IFDDS Support Coordination Training

• Utilization Review
• November 2004

2
What to Expect During a Utilization Review

• Department of Medical Assistance Services

3
What Generates a Review

• Statewide Sample
• A computer generated list is created and reviews
  are scheduled randomly.
• Complaints
• DMAS receives a concern regarding services from a
  constituent.

4
Utilization Review

• Unannounced
• May be on-site or desk review
• May include
• observation of service delivery,
• face to face or telephone interviews with the
  consumer and caregivers.
• Usually 1 3 days in length
• depends on size of review sample

5
Utilization Review (contd)

• Upon Arrival, Analyst Will
• Request charts be gathered together in a central
  location.
• Secure a workplace to conduct the review.

6
Utilization Review (contd)

• During the review
• Analyst may ask questions regarding your
  documentation.
• Analyst will let you know how long the review
  will last and time of the Exit Conference.

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7
Utilization Review (contd)

• Exit Conference will occur on the last day of the
  review.
• You may have any of your staff attend.

8
Items to be Reviewed

• Assessments
• Consumer Service Plan (CSP)
• Supporting Documentation (457)
• Quarterly/Semiannual Reports
• Patient Pay

9
Items to be Reviewed

• Individual records
• Appropriate data, contact notes, or progress
  notes
• Personnel files

10
Patient-Pay Requirements

• If there is a patient-pay, and the provider is
  designated to collect any portion of it, it must
  be indicated on the HCFA-1500.
• A copy of the current DMAS-122 (completed by DSS)
  should be in the consumers record.

11
Terminations

• Terminations of single Waiver services should be
  reflected on notification letters to consumers.
• Terminations of all Waiver services should be
  reflected on a completed DMAS-122.

12
Report Contents

• Technical Assistance
• Issues not in compliance with Medicaid policy
  that should be addressed by the provider
• Overpayment
• Situations in which the provider has failed to
  comply with federal and state regulations or
  policy guidelines.
• If licensure issues are found, the appropriate
  licensing agency will receive a copy.

13
Possible Overpayment Reasons

• No documentation in the support coordination
  record that the consumer meets
• eligibility criteria
• functional criteria

14
Possible Overpayment Reasons (contd)

• Absence of adequate documentation to support
  services billed or the need for service
• Unqualified staff delivering the service
• Patient-pay errors

15
Other Options

• Reconsideration
• Request will be reviewed and response letter sent
  to provider.
• If denial is upheld, provider has the right to
  appeal.

16
Other Options (contd)

• Appeals
• Informal Fact Finding Conference (IFFC)
• Provider may request within 30 days of receipt of
  reconsideration decision.
• Formal Evidentiary Hearing
• Request must be made within 30 days of receipt of
  IFFC decision.

17
Recent Findings Trends (contd)

• Essential components to a CSP include
• Social Assessment
• primary goals and measurable outcomes desired by
  the consumer
• supporting documentation for each DD Waiver
  Service (including support coordination),
• a signature page or documentation of agreement by
  those participating in the development and
  implementation of the CSP.

18
Recent Findings Trends

• CSP is reviewed by the support coordinator and
  updated annually and whenever changes or service
  modifications occur.
•  
• Social assessment completed no earlier than one
  year prior to start date of services and updated
  annually.
•  
• Documentation that demonstrates consumers
  receiving DD Waiver services are receiving any
  necessary medical care.

19
Recent Findings Trends

• Quarterly Reviews
• Should accurately reflect the individuals
  response for that quarter
• Documentation of reviewing this information with
  individual

20
Recent Findings Trends

• Monthly SC contact notes
• Staff signatures, dates, month and year
  documented entry. Individual full name or
  Medicaid number need to be on all documents
• Health and safety needs to be documented in CSP.

21
Recent Findings Trends

• No whiteout, errors must corrected by a drawing a
  line through them.
• Service plans not approved by DMAS
• DMAS-122 missing in file
• Records not addressing side effects of
  Medications
• Billing for SC without providing SC services

22
Recent Findings Trends

• SC acting as employer on behalf of individual
  cannot be a Service Facilitator