Transcript Slide 1

Family Preservation Services - Florida
Medicaid Mental Health Targeted Case
Management Technical Assistance Review
Presented by Kerri Pawlak
and Cheryl Buss (LCSW)
October 11, 2011
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Agency Certification Requirements
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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
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Results of the Certification of the
Naples Location
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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
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Findings from a Review of the MHTCM 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.
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Findings from a Review of the MHTCM Program at Naples
Programmatic Findings from the review (cont’d)
 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.
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Findings from a Review of the MHTCM Program at Naples
Programmatic Findings from the review (cont’d)
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.
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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.
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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
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July 2006 MH-TCM Coverage and
Limitations Handbook, pages 2-7 and 2-8
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Accomplishing the Goal
of MH-TCM
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Identify the person’s problem(s) by assessing
the person to determine that person’s 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 recipient’s progress.
July 2006 MH-TCM Coverage and Limitations
Handbook, page 2-17
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Recipient Certification
Children’s 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.
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July 2006 MH-TCM Coverage and Limitations
Handbook, pages 2-3 through 2-5
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On-going Eligibility
The Service Plan Review is a process conducted
to ensure that services, goals and objectives
remain appropriate to the recipient’s 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.
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July 2006 MH-TCM Coverage and Limitations
Handbook, page 2-16
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Covered Services*
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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-onone with the psychiatrist, psychiatric ARNP, physician,
therapist, teacher, attorney, GAL or other collateral.
July 2006 MH-TCM Coverage and Limitations
Handbook, page 2-17
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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 client’s individualized
Treatment Plan Development/Review process.
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◦ Time billed must be clearly justified as time
dedicated to the recipient.
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Providing MH-TCM services during the last 90
days of a child’s BHOS stay.
July 2006 MH-TCM Coverage and Limitations Handbook,
page 2-17
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Service Restrictions
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Provision of direct care services
◦ Offering clinical services, transportation, etc.
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Performing Administrative Functions:
◦ Copying, mailing, faxing, checking recipient eligibility
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Discharge planning when covered by a
residential facility’s per diem rate.
◦ Medicaid reimburses d/c planning 60-days prior to
discharge from a state mental health facility.
Ineligible Medicaid recipients
 FACT recipients
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July 2006 MH-TCM Coverage and Limitations
Handbook, pages 2-8, 2-9 and 2-11
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Service Restrictions
Home & Community Based Waiver Clients
 Institutionalized Recipients
◦ Jails, Prisons, Detention Centers, ICF-DDs, etc.
 Institution for Mental Diseases
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◦ Hospital/other institution with 17 or more beds, engaged
in providing diagnosis, treatment and care to individuals
with behavioral diseases (i.e.-some CSU’s)
Supervision is not a billable MH-TCM activity.
 Incomplete Certification Form, Assessment,
Service Plan.
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July 2006 MH-TCM Coverage and Limitations
Handbook, pages 2-9 and 2-11
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Service Restrictions
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No Recipient Contact (direct contact is required)
◦ Messages on machines, notes on the client’s door and
e-mail messages are not reimbursable.
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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.).
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Transportation
◦ Medicaid does not reimburse case managers for
transporting recipients.
July 2006 MH-TCM Coverage and Limitations
Handbook, page 2-11 and 2-12
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Service Restrictions
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.
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◦ 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
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Service Restrictions
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.
July 2006 MH-TCM Coverage and Limitations
Handbook, page 2-10
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Documentation Components
Required documentation for each Case
Management Record:
Certification Form
MH-TCM Assessment
Service Plan and Reviews
 Service documentation with
required elements
July 2006 MH-TCM Coverage and Limitations
Handbook, pages 2-2, 2-4, 2-12, 2-15, 2-16, 2-20
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Documentation Components
Requirements for Case Management Notes:
 Recipient’s 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, person’s life/support system, custody or
educational/ employment placement
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Inclusion of MH-TCM’s name, original (handwritten or
electronic) signature, title and date.
◦ Photocopied signatures are not allowed.
July 2006 MH-TCM Coverage and Limitations
Handbook, page 2-20
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Documentation Components
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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 recipient’s progress related to
the Service Plan;
◦ Justify the time spent providing MH-TCM
services.
◦ Document MH-TCM substitution, when rendered.
July 2006 MH-TCM Coverage and Limitations
Handbook, page 2-20
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Purpose of Documentation
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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.
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Assessment and Service Planning
Linkage Advocacy
Continuous Review &
Adjustment of
Services
Client Needs
Collateral Input.
Services/Tx.
Case
Manager
Assessment & Service Planning
MH-TCM Assessments
Assessment must be completed within 30days of client referral.
 A home visit must occur prior to
completion of the initial assessment.
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July 2006 MH-TCM Coverage and
Limitations Handbook, page 2-12
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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:
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◦ 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
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MH-TCM Assessments*
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Assessment documentation must reflect that
the following information sources were used:
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Recipient’s own perception of his/her situation
The referral source; Recipient’s 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.
July 2006 MH-TCM Coverage and Limitations Handbook,
pg. 2-13
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Assessment Documentation
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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.
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The assessment must be reviewed, signed and dated by
the MH-TCM and their supervisor prior to completion
of the Service Plan.
July 2006 MH-TCM Coverage and Limitations Handbook,
pg. 2-14
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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 recipient’s status,
progress, needs or present functional level.
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July 2006 MH-TCM Coverage and
Limitations Handbook, page 2-12
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Service Plan Elements
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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.
July 2006 MH-TCM Coverage and
Limitations Handbook, page 2-15
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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.
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July 2006 MH-TCM Coverage and
Limitations Handbook, page 2-15
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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.
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Service Plan Reviews
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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
recipient’s 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.
July 2006 MH-TCM Coverage and
Limitations Handbook, page 2-15
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Examples of non-reimbursable
MH-TCM Services
The following are from past and present MH-TCM FPS
documentation:
 Children’s Case Management notes documented
provision of services which were directed to the
child’s 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 child’s foster parents,
and there was not documented need for MH-TCM.Duplication of services is not allowable.
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Examples of non-reimbursable
MH-TCM Services
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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.
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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.
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Examples of non-reimbursable
MH-TCM Services
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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.
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QUESTIONS????
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Helpful Links/Resources
Medicaid Summary of Services Link:

http://ahca.myflorida.com/Medicaid/flmedicaid.sh
tml
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
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Helpful Links/Resources
Agency for Healthcare Administration
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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
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www.dcf.state.fl.us
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Contact Information
Kerri Pawlak
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Area Eight Medicaid Behavioral Health
Specialist
239-335-1272
E-mail: [email protected]
Cheryl L. Buss, LCSW
Area Eight Medicaid Utilization Management
Specialist
 239-335-1259
 E-mail: [email protected]
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