Post Payment Review
August 30, 2012
Dear DHS/DMH Community Mental Health Providers,
The purpose of this communication is to provide a summary of trends in FY12 provider monitoring and an update on FY13 procedures. Revised FY13 monitoring tools and protocols will be available in the DHS/DMH Provider Manual at www.dhs.state.il.us/page.aspx?item=60857.
In FY12, all providers who scored below 90% on their Post Payment Review the previous year received a Post Payment Review (PPR). On average, providers statewide scored 96% or better on nine of the eleven PPR criteria. The most common reason claims were disallowed was because either a valid MHA or ITP could not be located. The average statewide overall score was 73% and a quarter of providers reviewed scored 90% or higher this year. Since all reviewed had previously scored under 90%, this represents a significant achievement by these providers. Also, the number of providers scoring less than 60% has steadily dropped in the last four years (21% of providers reviewed in FY12 and FY11, compared to 27% in FY10, compared to 34% in FY09). Great improvements!
Because it has been two years now since we have been in to monitor some providers, we will return for Post Payment Reviews to all providers that were not reviewed in FY10 or in FY11.
In FY12, DHS/DMH performed Clinical Practice and Guidance (CPG) reviews at those providers who received a score of 3 out of 5 or below in the FY10 review and a sample of other providers. The CPG reviews went very well overall, with an average statewide score of 4 out of 5. The biggest challenges were documenting primary health care coordination (item #11), documenting that treatment builds on the identified strengths of the consumer (item #12), and documenting moving an individual toward natural supports in the community (item #9).
Two items were developed specifically for the review of non-Medicaid records in the FY12 CPG reviews. These items were to assess linkage to natural supports and entitlement applications, and providers scored 80% on average on these two items. Considering the funding constraints for services to clients without Medicaid benefits, we believe this performance to be very positive.
Reviewers saw a variety of excellent approaches to documentation practices, chart organization, and quality improvement in the past year. In addition to what was noted above, some highlights include:
The Mental Health Assessment report and Individual Treatment Plan included the date and name of supporting documents to make it easier to identify the referenced document in the chart.
The Mental Health Assessment provided a dedicated section on natural supports, including family members and community supports.
The Individual Treatment Plan included a section on "significant life events" that included events such as illnesses, changes in housing, or deaths in the family. It was clear that this section was updated frequently and used in making treatment decisions.
Many providers with issues identified during a previous monitoring review began making needed changes to their documentation and practices immediately and did self-checks periodically during the year to verify that the changes were maintained. In this way, the next monitoring review found those issues resolved and the score was much higher.
We encourage providers to share these kinds of best practices with each other to ensure all can benefit from each other's innovative ideas.
Provider Monitoring in Fiscal Year 2013
DHS/DMH will continue to perform Post Payment Reviews. The PPR tool was changed slightly with the addition of two quality indicators: "Documentation is sufficiently detailed corresponding to time billed" and "MHA contains sufficiently detailed information to guide clinical treatment." The purpose of these indicators is quality improvement and the identification of training needs. They will not affect the PPR score and poor performance will not require a formal Plan of Improvement. If documentation is so poorly detailed that the claim is not valid, the claims will be disallowed per the usual practice.
In addition to the plans of improvement of individual items not meeting thresholds in Post Payment Reviews, plans of improvement will also be required for a total PPR score of less than 70%. An overall low score on PPR indicates that a provider should implement a larger quality improvement strategy to address a low overall performance. This will be in addition to the individual plans of improvement required by specific items. Because consistently poor performance on Post Payment Review could affect a providers Medicaid certification, this change was needed to ensure improvements after a review indeed improve the quality of documentation.
Clinical Practice and Guidance (CPG) reviews have for several years provided important information on clinical practices and recovery focus. Due to resource constraints at the state level, CPG reviews will not be a part of the standard reviews in FY13. However, DHS/DMH staff may still perform a CPG review if they believe it is the best way to understand clinical and recovery practices at a community provider. If this is necessary, DHS/DMH regional staff will notify a provider in advance.
DHS/DMH will perform fidelity reviews of Assertive Community Treatment (ACT), Community Support Team (CST), and Individual Placement and Support (IPS) services in FY13. In addition, we may monitor providers on utilization management issues or other clinical issues that arise. All monitoring efforts will be guided by the principles of minimal administrative impact to providers.
We are thrilled at the improvements we have seen through monitoring and want to congratulate providers who have made these great strides. Thank you for your continued work in providing excellent services.
Jacqueline J. Manker
DHS/DMH, Associate Director for Community Services