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Personal Care Assistants


Medica DUAL Solution members (Medica's Minnesota Senior Health Options product) ... Minnesota State Legislature has made several changes to improve oversight of PCA ... – PowerPoint PPT presentation

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Title: Personal Care Assistants

Personal Care Assistants
  • May 19, 2006

PCA May 1, 2006 Changes
  • Effective May 1, 2006, Medica implemented three
    changes for PCA services
  • Statement of Need
  • Flexible Use
  • Claims Payment
  • Today, we will review these changes, as well as
    the reasons behind the changes.
  • Additionally, we will cover
  • Completing the 485
  • Medica DUAL Solution Care Coordinator

PCA General Info
  • Medica provides coverage for PCA services for
  • Medica DUAL Solution members (Medicas Minnesota
    Senior Health Options product)
  • Medica Choice CareSM members
  • Medica MinnesotaCare Children and pregnant women

PCA General Info
  • PCAs assist members who need help with personal
    care. Examples of services PCAs provide
  • - Dressing
  • - Bathing
  • - Toileting
  • - Mobility

PCA General Info
  • Assessment must be done by a public health nurse
    before services will be authorized.
  • Assessment is arranged by Medica.
  • Medica Nurse Case Managers determine coverage,
    based on the assessment, for Medica Choice Care
    and eligible Medica MinnesotaCare members.
  • Medica Care Coordinators (through designated Care
    System) determine coverage, based on the
    assessment, for Medica DUAL Solution members.

Special Investigation Unit (SIU)
Case Identification
  • Primary Sources
  • Internal Referrals
  • External Referrals
  • Law Enforcement
  • Members
  • Providers
  • Brokers
  • Data Mining
  • Fraud Software

Cost of Fraud
  • Financial Impact According to the NHCAA,
    approximately 3 percent or 51 billion of
    Americas 1.7 trillion annual health care
    expenditures is estimated to be fraudulent.

State/Federal Requirement
  • An Annual Anti-Fraud Plan must be filed with the
    Minnesota Department of Human Services.
  • Suspected fraud cases involving Medicaid
    recipients must be referred to DHS within 24
  • All other suspected fraud cases must be referred
    to law enforcement
  • DOC, FBI, OIG, DOJ, Licensing Board
  • Federal law requires that all health plans have a
    designated Information Exchange Coordinator.
  • DOH requires that all health plans have an SIU to
    investigate any alleged fraud involving
    employees, officers and directors.
  • Medicare Part D reporting requirements.

Investigation Process
  • Investigation
  • Internal/External Review
  • Review and send acknowledgment to
  • referral source.
  • Review for prior investigations and/or
  • Open investigation and review claims history and
    billing patterns.
  • Obtain relevant information from licensing boards
    and law enforcement agencies.
  • Investigation may include
  • Provider/member interviews
  • Review of documents and/or
  • Surveillance
  • Prepare a final report summarizing the

Investigation Process
  • Resolution Options
  • Report suspected fraud to government
  • agencies for criminal investigation.
  • Refer to state licensing boards.
  • Pursuit not feasible close case.
  • Education document in provider file.
  • Recommendations to pertinent departments (Network
    Management, Credentialing, Legal, Operations,
  • Administrative Remedy
  • Member/Provider holds
  • Corrective Action Plan
  • Dismissal from network
  • Negotiated settlement.
  • Civil litigation.

Evidence of the Problem
  • Claims Cost Increase

Evidence of the Problem
  • Anecdotal Evidence
  • Reports from Care Systems and Care Coordinators
    of abuses in the system
  • Members being coached by agencies
  • Members being pressured by family members as PCA
    revenue is a source of family income
  • Billing for services not provided
  • Letter sent by an anonymous home care nurse to
    the CEOs of all health plans

May 1, 2006 Changes
PCA May 1, 2006 Changes
  • Minnesota State Legislature has made several
    changes to improve oversight of PCA services.
  • Changes not designed to restrict or reduce
    appropriate PCA services.
  • Medica has implemented some of these changes.

Statement of Need
PCA May 1, 2006 Changes
  • As of May 1st, a signed Physician Statement of
    Need form is required before Medica will
    authorize services or pay claims for PCA
  • Form will be owned by Minnesota Council of Health
  • Form is required for new requests of PCA
    services, as well as for requests to renew
    authorization for PCA services.
  • Medica will arrange for an assessment by a public
    health nurse.

PCA May 1, 2006 Changes
  • Once assessment completed, Medica will summarize
  • Assessment summary and Statement of Need form
    will be sent to members primary care physician.
  • Unlike the process for fee for service Medical
    Assistance, Medica will arrange for the physician
    to sign the Statement of Need.

PCA May 1, 2006 Changes
  • If, based on review, the ordering physician is
    not the members primary care physician, summary
    and Statement of Need will be sent to physician
    identified by Medica as members primary care
  • Primary care physician should review and sign
    Statement of Need and return to Medica.
  • Physicians review should make sure the
    information in the summary is consistent with
    their records and that the services will meet
    their patients needs.
  • If the information is not consistent, the
    physician should contact Medica or the Care

PCA May 1, 2006 Changes
  • Once Medica has received the signed Statement of
    Need, PCA services will be considered.
  • Medica will not accept Statements of Need that
    were not initiated by Medica (including Care
    System Care Coordinator).
  • Determination will be made based on medical
    necessity, as defined by MN Rule 9505.0175,
    subpart 25 MN Rule 4685.0100, subpart 9b and
    Medicas PCA UM Policy.

Interim Statement of Need
  • Statement of Need form is different than DHS
  • Current form is an interim form, until MN Council
    of Health Plans form is finalized.

Interim Statement of Need
Flexible Use Option
PCA May 1, 2006 Changes
  • With flexible use, a member may use the hours as
    they choose within the authorization period.
  • - Example member is authorized 2 hours of PCA
    services a day, for a total of 14 hours a week.
    Can use 14 hours within week, as needed per day.
  • As of May 1st, flexible use will only be
    authorized if requested for a specific purpose.

PCA May 1, 2006 Changes
  • Request for flexible use must be made at time of
    prior authorization request.
  • The public health nurse assessment agency will
    consider the request for flexible use when doing
    the assessment.
  • Authorization for flexible use will be made based
  • - Individual Needs
  • - Preferences
  • - Abilities
  • - Past Use of PCA hours

PCA May 1, 2006 Changes
  • Flexible use can only be authorized up to
    six-months at a time (by MN Statute).
  • Authorization must specifically state flexible
  • - Example authorization is 2 hours day and 4
    hours are performed, only 2 will be paid unless
    authorization states flexible use.

PCA May 1, 2006 Changes
  • Unused hours cannot be carried over into a new
    six-month period.
  • If flexible use is authorized, PCA Agency RN must
    develop care plan specifically outlining how
    flexible use will be applied.
  • PCA agency must monitor the hours used and report
    any problems to Medica.
  • Failure to appropriately monitor use of hours
    will result in non-authorization of additional
    hours to supplement an authorization exhausted
    prior to the end date.

PCA May 1, 2006 Changes
  • If there is a change in situation or medical need
    for increased services, agency or member can
    request a re-evaluation. Supporting clinical
    documentation from primary care physician will be
  • Hours do not have to be divided evenly
  • - Example Member receives 800 total service
    units in one year. Member may receive 500 units
    in one six-month period and 300 units in the
    second six-months of the year.

Claims Payment
PCA May 1, 2006 Changes
  • As of May 1st, Medica will pay claims for PCA
    services in accordance with the authorization.
  • If PCA Agency fails to obtain prior
    authorization, claims for PCA services will be
  • Claims will be denied with reason code
  • - 941 PCA Services not approved
  • Denial is provider liability, denied charges may
    NOT be billed to member.

PCA May 1, 2006 Changes
  • Services must be provided in accordance with the
  • Services outside the authorization will be denied
    reason code 941.

Changes to Utilization Management Policy
PCA May 1, 2006 Changes
  • Background
  • ?Definitions
  • - Change in definition of Personal Care
  • - Change in definition of Flexible Use of
    PCA Hours

PCA May 1, 2006 Changes
  • Medical Necessity Criteria
  • ?Section II
  • - Was Written Documentation
  • - Became new section Authorization of
    Flexible Use of PCA Hours
  • ?Section III
  • - Written Documentation moved from Section
  • - Verbiage added

PCA May 1, 2006 Changes
  • Coverage Issues
  • ?Bullets added
  • References
  • ?References added

Record Keeping
  • Record keeping is a requirement of the law.
  • Medica has the same expectation of record keeping
    as the Department of Human Services.
  • Criminal background check for each employed PCA
  • Verbiage surrounding this requirement has been
    added to the PCA Utilization Management policy
  • Specific documentation must be kept on file for
    10 years
  • Medica-approved physician statement of need
  • Service plan
  • Care plan
  • Daily written records detailing actual services
    provided amount of time spent providing

PCA Medica Advantage SolutionSM Choice
  • Claims for members enrolled on Medica Advantage
    SolutionSM Choice do not need to be submitted
    under the 79000 group number.
  • PCA Services are not a covered service under the
    Medicare portion of the members coverage.
  • Claims may be submitted directly to the group
    number beginning with 59XXX (members Medicaid

Completing the Home Health Certification and Plan
of Care (485) form
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Medica DUAL Solution Care Coordinator
DUAL Solution Care Coordinator
  • Role of the Care Coordinator
  • Communication with the Care Coordinator
  • County Partners

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