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Personal Care Assistants

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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


1
Personal Care Assistants
  • May 19, 2006

2
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

3
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

4
PCA General Info
  • PCAs assist members who need help with personal
    care. Examples of services PCAs provide
  • - Dressing
  • - Bathing
  • - Toileting
  • - Mobility

5
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.

6
Special Investigation Unit (SIU)
7
Case Identification
  • Primary Sources
  • Internal Referrals
  • External Referrals
  • Law Enforcement
  • Members
  • Providers
  • Brokers
  • Data Mining
  • Fraud Software

8
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.

9
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
    hours.
  • 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.

10
Investigation Process
  • Investigation
  • Internal/External Review
  • Review and send acknowledgment to
  • referral source.
  • Review for prior investigations and/or
    complaints.
  • 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.

11
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,
    etc.)
  • Administrative Remedy
  • Member/Provider holds
  • Corrective Action Plan
  • Dismissal from network
  • Negotiated settlement.
  • Civil litigation.

12
Evidence of the Problem
  • Claims Cost Increase

13
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

14
May 1, 2006 Changes
15
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.

16
Statement of Need
17
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
    services.
  • Form will be owned by Minnesota Council of Health
    Plans.
  • 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.

18
PCA May 1, 2006 Changes
  • Once assessment completed, Medica will summarize
    information.
  • 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.

19
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
    physician.
  • 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
    Coordinator.

20
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.

21
Interim Statement of Need
  • Statement of Need form is different than DHS
    form.
  • Current form is an interim form, until MN Council
    of Health Plans form is finalized.

22
Interim Statement of Need
23
Flexible Use Option
24
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.

25
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
    on
  • - Individual Needs
  • - Preferences
  • - Abilities
  • - Past Use of PCA hours

26
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
    use
  • - Example authorization is 2 hours day and 4
    hours are performed, only 2 will be paid unless
    authorization states flexible use.

27
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.

28
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
    required.
  • 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.

29
Claims Payment
30
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
    denied.
  • Claims will be denied with reason code
  • - 941 PCA Services not approved
  • Denial is provider liability, denied charges may
    NOT be billed to member.

31
PCA May 1, 2006 Changes
  • Services must be provided in accordance with the
    authorization.
  • Services outside the authorization will be denied
    reason code 941.

32
Changes to Utilization Management Policy
33
PCA May 1, 2006 Changes
  • Background
  • ?Definitions
  • - Change in definition of Personal Care
    Assistant
  • - Change in definition of Flexible Use of
    PCA Hours

34
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
    II
  • - Verbiage added

35
PCA May 1, 2006 Changes
  • Coverage Issues
  • ?Bullets added
  • References
  • ?References added

36
Reminders
37
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

38
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
    coverage).

39
Completing the Home Health Certification and Plan
of Care (485) form
40
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41
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42
Medica DUAL Solution Care Coordinator
43
DUAL Solution Care Coordinator
  • Role of the Care Coordinator
  • Communication with the Care Coordinator
  • County Partners

44
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