[NYAPRS Enews] NY's OMIG to Review Clinic, Day Treatment, CR, Case Management, PMHP Payments

[Matt Canuteson]

NYAPRS Note: In its third full fiscal year of operation, the NYS Office of the Medicaid Inspector General (OMIG) has recently prepared a comprehensive work plan that includes several mental health Medicaid programs it will be examining in the coming year, including clinics, continuing day treatment, community residences, case management, COPS and CSP and the Prepaid Mental Health Plan. Following are details from the OMIG's plan.

 

OFFICE OF MENTAL HEALTH

The New York State Office of Mental Health (OMH) has as its mission to promote the mental health of New Yorkers. Of particular focus for OMH is mental health service provision for adults with serious mental illness and children with severe emotional disturbances. OMH's policy is to refer all matters relating to suspected Medicaid fraud, waste and abuse to the OMIG as such cases are identified.

 

Clinic Restructuring

OMH has undertaken a multi-year initiative to restructure the way in which the state delivers and reimburses publicly-supported mental health services. The goal is to develop a system of quality care that responds to the individual needs of adults and children and delivers care in appropriate

settings.

Clinic restructuring represents the first phase of this transformation process. Parallel initiatives are tackling the many challenges facing support services for children, rehabilitation and support services for adults, inpatient services, and the treatment of co-occurring disorders in both mental

health and substance abuse clinics. The key elements of clinic restructuring include the following:

·         A redefined and more responsive set of clinic treatment services and greater accountability for outcomes. "Clinic" is defined as a level of care with specific services. These services should enhance consumer engagement and support quality assessment and treatment. Clinic treatment should be part of a coordinated and accountable system of recovery and resiliency, which includes other Medicaid reimbursable and non-Medicaid specialty services, such as case management, day and vocational services.

·         Redesigned Medicaid clinic rates and phase-out comprehensive outpatient programs (COPs). Medicaid payment rates will be based on the efficient and economical provision of services to Medicaid clients. OMH will establish peer groups for payment, and payments will be comparable for similar services delivered by similar providers across service systems. Payments will also include adjustments for factors that influence the cost of providing services. The new system will eliminate rate add-ons such as COPs. OMH is committed to integrating clinic restructuring with DOH's new outpatient

·         reimbursement methodology called ambulatory patient groups (APGs), which will replace New York's current "threshold visit" methodology for reimbursement.

·         HIPAA-compliant procedure-based payment systems with modifiers to reflect variations in cost. The federal Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Act requires the use of a HIPAA-compliant billing system. Billing codes for clinic services will be HIPAA-compliant with modifiers to reflect differences in resources and related costs (e.g., service location, night and weekend hours, language other than English, among other factors).

·         Provisions for indigent care. The New York State Constitution gives the state a special responsibility to care for "persons suffering from mental disorder or defect and [for] the protection of the mental health of the inhabitants." 

Assuring access to outpatient clinic services is essential to meeting this objective while also reducing the demand for other high cost services such as inpatient care. Currently, OMH clinics receiving COPs payments are required to serve all clients regardless of ability to pay. As part of restructuring, OMH will work to develop a comprehensive strategy for funding mental health outpatient services for the uninsured. 

 

Standards Of Care

OMH recently released standards of care for clinic treatment. These guidelines are a first step in articulating the basic tenets of good clinical care and accountability. These fundamentals of care should be occurring in all clinics now, as well as in our redesigned clinic of the future.

 

Continuing Day Treatment Reimbursement Methodology

As part of the New York State Office of Mental Health's financial management plan relating to the 2008-09 state budget, the level of Medicaid reimbursement for continuing day treatment (CDT) programs was reduced, effective January 1, 2009. To implement this reduction, OMH issued emergency regulations effectuating this reduction from January 1 through March 31, 2009.

The enacted 2009/10 budget included a temporary restoration of the previously reduced funding for non-Article 28 CDTs, effective from April 1, 2009 through June 30, 2010.

Effective April 1, 2009, the regulation also provided for a change in the reimbursement methodology for CDTs, from one based upon hours of attendance to a modified threshold rate, designed to more closely correlate the amount of reimbursement to the level of services received.

CDT programs have historically been reimbursed for visits in durations of one, two, three, four, or five hours. At least one service per visit must be provided, regardless of the duration of the visit. While Article 31 and Article 28 CDT programs are licensed under the same regulations, they have been reimbursed differently. Article 31 providers have been paid rates based on daily visit duration and the individual consumer's cumulative CDT use during a calendar month. Article 28 providers have been reimbursed based on a "threshold" visit, as long as the visit is at least one hour in duration.

The new reimbursement methodology entails changing Medicaid reimbursement for CDT programs to "half-day" and "full-day" visits. Reimbursement for a full-day visit requires a minimum of four hours of attendance and the provision of at least three services. Reimbursement for a half-day visit requires a minimum of two hours of attendance, and the provision of at least one service. This methodology will apply to both Article 31 and Article 28 providers. Article 31 CDT programs will continue to have three rate tiers, with different rates for half-days and full days based on the cumulative monthly hours of attendance totaling 1 through 40 hours, 41 through 64 hours, and 65 plus hours. This is equivalent to the current three-tier rate structure based on five-hour days. Article 28 CDT programs will have different half-day and full-day rates with two tiers reflecting cumulative monthly hours of attendance of 1through 40 hours, and 41 plus hours. For both Article 31 and Article 28 CDT programs, all crisis, collateral, group

collateral and pre-admission services that meet the regulatory minimums for program attendance and service provision will now be reimbursed as half-day visits, without regard to actual duration of attendance. These hours will not be counted toward the monthly cumulative hours for

purposes of determining which rate tier to assign regular visits.

 

Community Residence Rehabilitation Services

The OMIG will review payments made for rehabilitative services provided to residents, both child and adult, of community-based residential programs in accordance with 14 NYCRR § 593. 

OMH licenses these programs for adults with mental illness and children and adolescents with serious emotional disturbances. The OMIG is focusing on Medicaid recipients residing in community residences. Rehabilitative service providers will be reviewed for compliance with regulations relating to service authorization requirements. In addition, the OMIG will assess provider adherence to program documentation and staffing requirements.

 

Case Management Services

Case management is a process which assists persons eligible for Medicaid to gain access to necessary services in accordance with goals contained in a written case management plan. 18 NYCRR § 505.16 provides details of the regulatory requirements for case management services. 

The OMIG will review providers of case management services to ensure that the procedural requirements for service provision are met and that those services have been billed correctly and have supporting documentation for the claimed units of service.

 

Ninety-Day Billing Exception Codes

The Medicaid program requires a provider to submit claims for services to eligible recipients within 90 days from the date of discharge or service. Claims submitted after 90 days are denied unless the provider submits a 90-day exception code on the claim.

The OMIG data mining activities identified numerous inaccuracies where claims were submitted after 90 days with invalid exception codes. For example, claims for administration services were submitted with exception code 10 (delay the prior authorization process). No prior authorization

is required for such services. The OMIG will expand its review of Medicaid payments for claims submitted by providers after the date of discharge or services utilizing exception codes. Generally our review period will cover July 1, 2003 through December 31, 2005.

The OMIG will select a sample of claims submitted with the exception codes and request that the hospital provide underlying documentation to support late claim submission.

 

OMH COPS-Managed Care Recoveries

The MCO submits an encounter to DOH for those services paid by the MCO to a network provider, and the comprehensive outpatient program services (COPS) supplemental payment is subsequently billed on a fee-for-service (FFS) basis by the network provider who rendered the service. A COPS-only payment is made if the MCO-enrolled recipient received a covered service from a medical health provider within the MCO network; in that case, the MCO is required to submit encounter data to DOH. The OMIG will match COPS supplemental payments with MCO encounter information. If the network provider cannot provide documentation that a managed care service was provided, the OMIG will recover the COPS payment.

 

COPS/CSP-Overpayment Recoveries

The OMIG and the OMH performed a review of mental health providers who received COPS/CSP (community support programs) overpayments for the four years ended November 31, 2005. COPS are supplemental payments in addition to the provider's Medicaid rate. The amount of COPS reimbursement that a provider can receive is limited to a threshold amount and any COPS received in excess of that amount can be recouped. CSP payments in excess of a formulated reimbursement rate are also subject to recovery. Recoveries of COPS and CSP overpayments will be for the period of local fiscal year (LFY) 2002/3-2004/5 for New York City providers and county year (CY) 2003-2005 for the rest of the state.

 

Outpatient Services

The OMIG will review Medicaid payments for outpatient mental health services to determine if providers claimed reimbursement in accordance with 14 NYCRR §§ 587 and 588. This review will include clinic, continuing day treatment, partial hospitalization, and intensive psychiatric rehabilitation program. Prior OMIG audits identified significant non-compliance with regulations relating to treatment plans and program documentation requirements. Additionally, the OMIG will identify instances where a pharmacological service was billed (unbundled) by providers as a separate procedure and instances where unlicensed physicians were approving treatment plans.

 

Prepaid Mental Health Plan

The OMH monitors the Prepaid Mental Health Plan (PMHP) through a governing body that includes two members of the commissioner's cabinet, the physician medical director for adult services, the director of state operations finance, a representative of the OMH counsel's office, key members of the state facility program operations staff, and representatives for recipient/consumers and component facility administration.

The governing body convenes quarterly to review the operation of PMHP, including specific data regarding fiscal and operational issues. Enrollment patterns, service use, and available service options for consumers are reviewed to strengthen the quality of comprehensive mental health treatment and recovery services that are available and delivered at state psychiatric center outpatient service sites throughout New York State.

 

http://www.omig.state.ny.us/data/images/stories/work_plan/omig_work_plan_2009_2010.pdf

 

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