VNPP



Responses to 2015 VNPP Conference and DMAS Town Hall QuestionsQ #OriginCategoryQuestionResponse1VNPP StaffingMHSS Supervision of QMHP:? Manual use to state "The QMHP must meet face to face with the LMHP or LMHP-E supervisor to review the ISP at least quarterly.? This review must be documented in the client record. This is no longer in the updated version of the manual.? So if this above is no longer in the manual then LMHPs no longer have to provider face to face supervision quarterly with the DSPCMHRS manual Chapter II pgs. 8 – 19 - Staffing and supervision requirements per service is reflected in this text.CMHRS manual Chapter IV pg. 65 #4 – Every three months, the LMHP, QMHP-A or QMHP-C shall review the ISP with the individual, modify as appropriate, and update the ISP. This review shall be documented in the record, as evidenced by the dated signatures of the LMHP, QMHP-A or QMHPC and the individual. The ISP must be rewritten annually.2VNPPStaffingIIH Supervision of QMHP: Manual use to state:An LMHP or an LMHP-S/R must provide clinical supervision at regular interval.? The full-time work schedule is 32 hours or more per week.? Full time LMHP or the LMHP S/R may supervisor up to 10 staff; Half time staff whose work schedule 16 to 31.9 hour per week may supervise up to five supervises.? If a supervisor works less than half time, the supervision limit is two counselors. The LMHP or LMHP-S/R must provide clinical supervision weekly, with the individual face to face supervision occurring at least every other week.? Group supervision may occur on the other weeks.? If the supervision is on leave for one episode that is more than two weeks, a substitute supervisor must provide clinical supervision. Supervision for clinical staff must be documented by LMHP or LMHP-S/R...A supervision log or note must be placed in individuals file... LMHPs are encouraged to adhere to clinical supervision tenets within their cop of practice and profession's guidelines. A QMHP may only provide administrative supervision.? The LMHP or LMHP-S/R must provide clinical supervision...CMHRS manual Chapter II pgs. 8-19 - Staffing and supervision requirements per service is reflected in this text.CMHRS manual Chapter VI pgs. 12-13 –The clinical supervisor (LMHP or LMHP Supervisee or Resident) must be available for consultation as needed, around the clock every day including weekends and holidays.All staff qualifications and supervision requirements are deferred to DBHDS.Since these supervision parameters for IIH are then no longer in the manual then only the above is applicable about being available for consultation around the clock. We looked at the DBHDS regs and do not see anything about supervision requirements.3MHSS regulatory town hall public commentsStaffingSupervision definitions:?Providers asking for?clarification of the different types of supervision.? At one workgroup I believe the three that were agreed upon by all was administrative supervision, service supervision, and clinical supervision.? I have a rough outline of what the different definitions for those are based on various workgroup discussions which we can send to Brian. See number 1 and 2 above. Refer to DBHDS.So I guess they are not going to clarify it any more than what is already in the manual. And again, I do not see anything about supervision in DBHDS regs. Maybe I am missing something? 4VNPPStaffingQMHP-E:?This?appears to be an?oversight that QMHP-Es are not able to provide MHSS although they are able to provide IIH.? (Note: I believe a while back Brian checked and did?not see where this is?a regulation so it is rather a manual oversight that could be updated.) QMHP-E’s are not currently allowed to provide MHSS. QMHP-E’s will be able to provide MHSS upon implementation of the Final MHSS regulations. This has been corrected in the pending final regulations. The emergency Regulations omitted the QMHP-E. This is good and what was said, but good to have in writing. 5VNPPDocumentationSignature requirements (Chpt VI): Manual states: "Providers shall be required to maintain documentation detailing all relevant information about the Medicaid individuals who are in providers' care. Such documentation shall fully disclose the extent of services provided in order to support providers' claims for reimbursement for services rendered. This documentation shall be written, signed, and dated at the time the services are rendered or within one business day from the time the services were rendered" Concern: For those providers who aren't on electronic systems, writing, dating, and signing the session note the same day (or within one business day) that the session took place is not difficult. DSPs write their notes, sign and date them, and then bring them all to the office all at once. For these providers, who are not on an electronic system, they would simply have to have as part of their internal policy, that the DSP sign the note within 24 hours although may not be directly monitored if notes are turned in all at once. However, for those providers who use electronic records and don't have the electronic signature option, they would find it very cumbersome and an increased financial burden, to have all their DSPs come in every day to sign off on the notes that they submit electronically. Electronic records systems already cost providers a significant amount. Providers would then have to incur and additional cost if they were required to have DSPs come to the office each day to sign off on notes as per DOL standards providers would have to pay DSPs for this travel time and time spent signing notes. If the state would like to see more providers using electronic record systems, this would cause providers to be even more reluctant to do so. It would make more sense for DSPs to submit the notes electronically the day (or within 24 hrs) of the session, but then to come to the office prior to billing/payroll (for example) to then sign off on the notes all at once. They should be able to ethically sign off on the note and date it the date of the session (or within 24 hrs of the session) because the electronic record system would have record of the date it was submitted. CMHRS Manual Chapter VI pg. 13 Daily Service DocumentationProviders shall be required to maintain documentation detailing all relevant information about the Medicaid individuals who are in providers' care. Such documentation shall fully disclose the extent of services provided in order tosupport providers' claims for reimbursement for services rendered. This documentation shall be written, signed, and dated at the time the services are rendered or within one business day from the time the services were rendered.The daily notes shall also include, at a minimum:the name of the service rendered,the date of the service rendered,the signature and credentials of the person who rendered the service,the setting in which the service was rendered, andthe amount of time or units/hours required to deliver the service.Providers are not reimbursed for administrative duties.Refer to the 8/20/2004 Medicaid Memo on electronic signatures for a reference on using electronic health records and requirements for “e-signatures”. It does not relate to timeliness standards but it defines how providers must use any electronic medical record and document signatures. This is still problematic for those using electronic signatures. I mean clearly we know that providers are not reimbursed for admin duties, but it still seems ridiculous to have it signed within one business day. It is actually encouraging providers to not use electronic records. Is there anything more we can do about this? The memo does not say anything to help with the timing factor. 6MHSS regulatory town hall public commentsDocumentationLMHP doing the ISP – QMHP-A was accidently left out (already been addressed)An LMHP, QMHP-A, or QMHP-C are currently able to develop an ISP. This has been corrected in the pending final regulations. The emergency Regulations omitted the QMHP-E and the LMHP “types”. Good that it has been corrected!7VNPPServiceService Coordination payment: Providers would like to know if they will be able to bill for service coordination if this is performed when not providing direct face to face services with the client.? There are times?when such coordination is not done in the presence of a client especially with children's services (i.e. IIH). Please note the following came from a provider with reference to this: “There is conflicting information about whether service coordination is a billable activity for CMHR services. I spoke to “Tricia” at Magellan who said these activities were billable as long as they were listed in the ISP. The current manual continues to restrict billing for face-to-face services for MHSS and CS. This conflicts what Tricia says.”Care coordination between different providers is required and must be documented in the ISP and Progress Notes. Care Coordination serves to help align services to prevent duplication and is intended to complement the service planning and delivery efforts of each service. Providers must collaborate and share information among other health care providers and individuals who routinely come in contact with the individual, i.e. PCPs, Case Managers, Probation Officers, Teachers, etc. and who are involved with the individual’s health care and overall wellbeing in order to improve care.Service coordination is built into the service and not a separate billable service. Only face to face contacts and services to the individual are billable.The conflicting information by Magellan has been addressed.So they are not apparently going to update the manual per our conversations with them and Magellan last August in making the various “coordination” definitions more clear. But probably more to the point they are not paying for any of what the providers are supposed to be doing as service coordination. 8VNPPServiceService Coordination definitions:? There is much confusion of the varies terms being used by DMAS, Magellan, DBHDS with regards to service coordination, care coordination, case management.? At one point it was discussed that these terms be defined out clearly in the manual and Brian Campbell had suggested going a webinar on what service coordination should look like for service providers so not to overlap?with the other types of coordination.?(NOTE:?I think a definition that was?proposed at one point when with Brian?for service coordination was something like: "Proving linking coordination for services geared toward the individual meeting ISP goals").? See above and refer to CMHRS Manual Chapter IV pgs. 9-11 Same as above9MHSS regulatory town hall public commentsServiceCare Coordination: The response states, "Care coordination or service coordination activities are a requirement for all CMHRS service providers as part of the service being rendered. Reimbursement for MHSS is limited to the duration of Face to Face service delivery encounters." So would a provider not be able to bill for care coordination under MHSS if not with the client? And if not, would this also be the case for IIH or TDT for instance, in which it would not be clinically in the best interest of the child/adolescent to be involved in such a conversation and therefore it not be time spent face to face. Care coordination is provided by any and all entities that are involved in a member’s care. Service coordination is a part of all CMHR services. Refer to CMHRS Manual Chapter IV pg. 11 and defined in 12VAC30-50-130.Service Provider Care Coordination is done in the spirit of collaboration with the treatment team and is meant to support the member on his or her path of recovery.Service Provider Care Coordination includes:Assisting the individual to access and appropriately utilize needed services and supports;Assisting them to overcome barriers to being able to maximize the use of these resources;Actively collaborating with all internal and external service providers;Coordinating the services and supports provided by these individuals (including family members and significant others involved in the consumer’s life);Assessing the effectiveness of these services/supports;Preventing duplication of services or the provision of unnecessary interventions and supports; andRevising the service plan as clinically indicated and to ensure that service planning is consistent with other services being provided to the individual.Care coordination between different providers is required and must be documented in the ISP and Progress Notes. Care Coordination serves to help align services to prevent duplication and is intended to complement the service planning and delivery efforts of each service. Providers must collaborate and share information among other health care providers and individuals who routinely come in contact with the individual, i.e. PCPs, Case Managers, Probation Officers, Teachers, etc. and who are involved with the individual’s health care and overall wellbeing in order to improve care.Service coordination is built into the service and not a separate billable service. Service billing units are limited to face to face contacts with the individual per emergency regulations 12VAC30-60-143.10VNPPServiceCase Management question on SRA: There have been some Magellan Care Managers that?have been contacting providers stating that the member must have case management or be referred to case management with regards to MHSS authorizations.? As discussed, MHSS does not require that the member receive case management services.? Additionally, there are some CSBs who are not taking referrals for case management or the member does not want to seek case management services with a particular CSB.? The suggestion was to create a dialogue box on the SRA form under this question so that the provider can explain why or why not a referral has been made.? Additional training with Magellan Care Managers was also suggested. Case Management is a standalone service and it is a member’s choice if they want to obtain that service. Members/providers should pursue case management if there is evidence to support the need for the service. The member still has the right to refuse the service. The SRA should reflect “choice” not a mandatory requirement. Magellan is offering two training events related to this topic in April and July. However, a specific training on this topic has also been requested for March. Magellan will send out a notice about the training events.Good this is in writing now and Magellan staff is fully aware.11VNPPServiceDescription of VICAP time frames which are contrary: Providers finding that the time frames described are very unclear. Chpt IV pg 13 -14 esp #6 and #11 in which the difference between those situations in confusing. Use of the word at-risk (pg 14 #9)?– Confusing for providers. (Note: There was an alternative word/definition for the use of at-risk discussed in a meeting with Brian to separate out “imminent harm” from “harm happening in the very near future should this service not be put into place.”)???The VICAP is good for 30 days. The timeframe does not change based on whether #6 or #11 in the CMHR Manual Chapter IV is applied.Also refer to pg. 14 #9If the independent assessment is greater than 30 days old, a new ICA must be obtained prior to the initiation of IIH services, TDT, or MHSS for individuals younger than 21 years of age. If the child was screened and determined to be “at risk” for physical injury, the service provider must complete the intake within 14 days from when the individual was deemed “at risk” of physical injury. Refer to the IIH and TDT service requirements for more detail.It appears that regardless of #6 and #11 situations, it all has to still be done within 30 days of the VICAP which is still hard to do. The definition of “at risk” is found within the CMHRS manual Chapter IV, pages 2 and 6.? The definition can also be found in the IIH and TDT sections within the same chapter.? IIH is found on pages 26-27 and TDT is found on pages 32-33.Still problematic but doesn’t look like it is changing. 12MHSS regulatory town hall public commentsServiceCrisis stabilization requiring authorization – do we know how long this authorization process will take?Crisis stabilization continues to be a registration (12VAC30-50-226). Also refer to provider for registration and service authorization support.This was changed for the final MHSS regulations based on stakeholder comment.They are saying that it will stay at registration which is good. 13MHSS regulatory town hallpublic commentsBilling/ClaimsWill claims be denied if the specific hours per week on the ISP are exceeded? -- The responses to this was "all services must be defined in the ISP or they will be subject to retraction." There is confusion here in that the "services" are specified in the ISP. However the typical average amount of hours/week are also defined in the ISP and at times may have to be exceeded if clinical need presents itself. I feel that if hours are exceeded but are justified through the session note, then those hours should not be retracted. It would be ideal if it could be stated that should hours be exceeded beyond what the ISP specifies, that this should typically only occur in rare circumstances and not be the norm, and that this be clearly justified in the session note to avert possible retractions. And of course if this begins to occur more regularly a provider would need to justify an increase in the hours/week based on clinical need and then update the ISP accordingly. For any CHMR service, the ISP needs to reflect the elements in the CMHRS manual Chapter VI pgs. 10-11. All hours of service must be justified in the progress notes. If the service authorization is at the maximum amount allowed for the service, then all hours beyond the maximum will be denied for those claims. However, if additional hours are needed for the service, then the ISP needs to reflect the increase need of the member and the provider would need to contact Magellan and speak with a care manager about the situation and how to adjust the current authorization and obtain more units for the member.14MHSS regulatory town hall public commentsBilling/Claims15 minute unit -- DMAS has clearly stated that they will not be changing the unit structure and this was an oversight, but then in some of the responses it states that the unit structure for the assessment would change to this 15 minute unit: "A 15 minute unit value would be applied to the assessment/services specific provider intake in a cost neutral manner." So is the SSPI going to change to a 15 minute unit increment and if so will a provider be able to bill beyond an hour for an assessment since they often take much longer than that? There have not been any changes made to the unit structure for MHSS. The proposed regulations contained, in error, a reference to a 15 minute unit. The unit value will not be changed in the final regulations.Service Units and Maximum Service Limitations (refer to CMHRS manual Chapter. IV pg. 69)One unit = 1 to 2.99 hours per dayTwo units = 3 to 4.99 hours per dayThree units = 5 to 6.99 hours per daFour units = 7+ hours per dayTime may be accumulated to reach a billable unit. Service delivery time must be added consecutively to reach a billable unit of service. ................
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