Naomi Weinstein, MPH Vice President, Innovations, ICL Noah Isaacs, - - PowerPoint PPT Presentation

The Managed Care Technical Assistance Center of New York

Naomi Weinstein, MPH

Vice President, Innovations, ICL

Noah Isaacs, MPA

Project Manager, ICL

What is MCTAC?

MCTAC is a training, consultation, and educational resource center that offers resources to all mental health and substance use disorder providers in New York State.

MCTAC’s Goal:

Provide training and intensive support on quality improvement strategies including business, organizational and clinical practices, to achieve the overall goal of preparing and assisting providers with the transition to Medicaid Managed Care.

Who is MCTAC?

MCTAC Partners

Naomi Weinstein, MPH Vice President of Innovations Noah Isaacs, MPA Project Manager, Educator

Two remaining Utilization Management webinars

• Client Education
• Family Engagement

Applied Learning Discussions of case examples

• Two OMH-specific
• Two OASAS-specific

Please complete evaluations so we know how to improve series in the future

• Connecting the dots of UM, Medical Necessity and Documentation
• Why documentation is important
• What good documentation looks like from the managed care lens

• How MCO decides if specific health care services, or specific level of care

are appropriate for coverage under an enrollee’s plan

• Primary purpose: ensure services are necessary, appropriate, and cost-

effective

• Helps maintain fidelity and integrity of service provisions while meeting UM

standards and requirements

• Required for reimbursement
• Reflects optimal care for clients/consumers

• Written record of clinical assessments, plans, and services
• Expresses clearly a client’s “story” of their time in a specific program
• Opportunity to actively involve client in treatment and capture their

view of progress toward recovery

• Information to support authorizations, concurrent review, and

appropriate discharge

• Demonstrates medical necessity
• If it is not written down, it didn’t happen

Medical Necessity

Documentation and Authorization

• You wouldn’t think it was fair if you agreed to pay for one

thing, and then learned that your money was being used to pay for something else. Health Insurers feel the same way. They want to make sure their money is being used as it was intended.

• Medical necessity is the criteria used to ensure this.
• Care that is reasonable, necessary, and/or

appropriate, based on evidence-based clinical standards of care.

• There is a diagnosis to treat
• Intervention provided is appropriate for the person’s

condition/illness/ functional deficit

• Intervention considered effective for the condition/illness (pre-

authorization)/Intervention is working (re-authorization)

• Intensity, frequency, and duration of the intervention is neither

excessive nor too restrictive

• Person is able to benefit from the intervention
• There are active interventions/services being provided

Because medical necessity is integral to Utilization Management, it is vital that documentation reflect medical necessity throughout.

• Assessments
• Treatment Plans (and updates)
• Progress notes
• Discharge plans

Assessment

Physical Emotional/ Behavioral Social

• Balanced – strengths and deficits
• Symptoms and functioning both
• Symptoms should be connected to how they impact person
• If issue raised during assessment, it should be addressed in

the treatment plan and in services, and should appear in progress notes

• Substance abuse – must include LOCADTR

Assessment Goal Setting

• Provides rationale for services
• When client developed, shows client is engaged and

wants services

• Points towards an end point of services – when
• bjectives are achieved, may be able to step down
• Allows for outcomes measurement, which helps MCOs

determine efficacy

• Goals: Statement of what the client wants to accomplish
• Should be person-centered
• Written in action-oriented and behavioral language
• Easily understood by any reader (including the client)
• Should not be too many objectives
• Is it effective? Read objective aloud and ask:
• At the end of a specific time period, can you definitively say

whether the objective was accomplished?

Simple and Specific Measurable Actionable and Achievable Realistic Time Limited

Assessment Goal Setting Service Plan

• Must connect back to assessment findings (and diagnosis)
• Clinical information supporting medical necessity
• Lays out the specific requirements for services
• Guidelines for how MCOs will look at care
• Should point towards criteria for discharge/step-down/completion
• Service plan updates should tie to progress, emerging needs, and

services other than listed in original plan

• WHO will provide the service, i.e., name and job title
• WHAT: what kind of service and what modality (individual v.

group)

• WHEN: how often the service is scheduled (could include

days and times)

• WHERE the services are being provided
• WHY: intent and purpose of each specific intervention

Assessment Goal Setting Service Plan Service Delivery

Progress Notes should link back to goals/objectives in service plan

• Progress made and/or challenges encountered
• Refer to specific goals/objectives, and barriers in

Treatment Plan

• Interventions used and how they help promote goal

achievement

• Any significant life events (both accomplishments and

difficulties)

• Confirmation that services are being provided as defined in

the plan (or updated plan)

• How person is using services to achieve goals
• Should be linked back to a specific goal in the treatment plan
• Focuses on actual interventions by staff, rather than
• bservations of clients
• Client’s point of view should be included
• Should document all communication with other providers,

services, medical professionals, family, collaterals – all care coordination

• Give clinicians guidance on what to

focus on

• Saves time
• Increases likelihood that provider will

discuss long-term plan for discharge

Client's Presentation/Mental Status: New Developments/Progress Made since last session: Interventions/EBPs Utilized and Client's Response to Intervention: Complex Care Provided (if applicable): Plan for Next session

Assessment Goal Setting Service Plan Service Delivery Discharge

• Treatment plan objectives should have built-in

criteria identifying when the treatment has been successful, and step-down/completion is appropriate.

• Good to utilize the SMART formula so discharge

criteria is clear to all.

Assessment Goal Setting Service Plan Service Delivery Discharge

Progress Notes should link back to goals/objectives in service plan

• Writing should be clear
• Not all details, just important facts
• Documentation should be appropriate for duration of service
• Document all communication with collaterals, other providers
• Collaborate with client to enhance person-centered practice
• Watch out for auto-populate and “cut + paste” mistakes
• Make sure documentation completed in timely fashion
• Still need to satisfy state regulations (OMH, OASAS)

Strengths Symptoms

Who should be calling?

• Ideally, a clinician familiar with the client
• If not a clinician, strong documentation is key

Goal: Keep it simple

• Have information available and prepare in advance of

the call

• Expect to be engaged, to have a conversation with

the MCO

• r
• May request documentation

later

• Likely to require documentation

for some authorizations

• Even phone authorizations

require information found in documentation

?

• Why is this treatment necessary?
• What else has been tried and why hasn't it been sufficient?
• Would she be successful in a lower level of care (why or

why not)?

• How does this treatment fit into the bigger picture of her

recovery?

• What are you looking for in determining treatment goals

success – how is this being documented?

• For admissions and continuing stays, MCOs must follow

state utilization management guidelines.

• As a provider make sure you are familiar with these
• To review OMH regulations: Click HERE
• To review OASAS regulations: Click HERE

MCOs are required by CMS to respond to authorization requests within 3 business days

• Clock starts ticking at first request for authorization (even if

you and MCO are playing phone tag)

• That means if you haven’t provided much specific information

with the request, you might get a denial Tip: MCO voicemails are private and confidential. When leaving a message, include as much info about the client as possible to increase the likelihood of a quick authorization.

• Review documentation on existing clients, focusing on:
• Clear, concise language
• Complete notes
• Reflects medical necessity
• Progress notes reflect goals and objectives
• Make sure process is in place for new clients

Before you go, please take a minute to complete the survey (in the comments section to the right)

• Attend next utilization series events
• Next Webinar: Client Education (January 5)
• Applied Learning Discussion (December 15)
• OASAS programs – 12 noon
• OMH programs – 1 pm

Before you go, please take a minute to complete the survey (in the comments section to the right)

• Please email any questions, comments, or suggestions to

mctac.info@nyu.edu with the subject line “Documentation webinar”

• Questions from this webinar and next week’s will be answered

at the Applied Learning Discussion on December 15th

• OASAS at noon
• OMHat 1pm

Before you go, please take a minute to complete the survey (in the comments section to the right)