Louisiana Coordinated System of Care: Treatment Record …

1 Quality Improvement Department Magellan Health in Louisiana December 2015 Louisiana Coordinated System of Care: Treatment Record Reviews Objectives Define what Treatment Record Reviews (TRR) are and identify why they are important review the process and procedures related to a Treatment Record review review specific monitoring activities for: Coordinated System of Care clinical Practice Guidelines Fraud, Waste and Abuse Unlicensed Direct Care Staff Identify Resources that can be used in preparation for reviews 2/08/2016 2 Treatment Record Reviews Treatment Record review Monitoring What is a TRR? Definition: A Treatment Record review (TRR) is a review conducted as part of Magellan s Quality Assurance Program. The purpose of the review is to monitor Treatment Record documentation and Record keeping practices as required by Magellan for members in the Coordinated System of Care.

2 2/08/2016 Treatment Record Reviews 4 Why is Quality Documentation Important? Reasons that providers should keep accurate and comprehensive records of the services provided: from legal Liability (if it is not documented, it did not happen). evidence of Medical Necessity Criteria for purposes of financial reimbursement. a mechanism for internal Quality Assurance monitoring. compliance with federal and state Fraud, Waste and Abuse regulations (Affordable Care Act). with Continuity of Care for members. 2/08/2016 Treatment Record Reviews 5 Process and Procedures of TRR The following areas will be discussed: Participation Requirements Triggers for Treatment Record Reviews Types of Treatment Record Reviews Record Preparation Submitting Records On-site Reviews Results Performance Improvement Plans 2/08/2016 Treatment Record Reviews 6 Participation Requirements Participation in the Treatment Record review is a contractual obligation.

3 Section of the Magellan contract states: Provider AGREES to cooperate and participate with all announced or unannounced internal and external quality assessment reviews, utilization review /management, and grievance procedures, or other similar programs established by Magellan and DHH-OBH, or its designee. Contracted providers are required to submit records without charges to Magellan. Section of the Magellan contract states: If copies of Members medical records are requested by Magellan or Payer for appeals or any utilization, grievance, claims payment or quality review , Facility AGREES to provide the medical records WITHOUT charges. 2/08/2016 Treatment Record Reviews 7 Triggers A Treatment Record review can occur for two reasons: 1. As part of a Quality of Care Concern Investigation: If a quality of care concern is identified, a Treatment Record review can be conducted at anytime and no advance notification is required.

4 2. As part of standard quality reviews: Magellan conducts Record reviews of random providers to monitor and ensure quality documentation and Treatment practices. Providers are generally chosen the month prior to the review to ensure adequate resources. 2/08/2016 Treatment Record Reviews 8 Types of review : Onsite vs. Desktop 9 Magellan will send a request letter identifying if the Treatment Record review is an on-site or desk-top review . : Providers are sent a request letter specifying the type and number of charts that should be submitted to Magellan for review . Approximately 10 business days are given for the provider to submit records. The chart review takes place at the Magellan office and the communication of results takes place telephonically and through a written report. : Similar to a desktop review , providers are sent a request letter for the type and number of records to be reviewed; however in an on-site review , Magellan requests that charts are in central location for review onsite.

5 2/08/2016 Treatment Record Reviews When preparing records, it is important that documentation is submitted or available for all of the required elements. This includes: Member Rights and Confidentiality Documents Initial Assessments/Evaluations Treatment Plans Progress Notes Labs Medical logs Discharge Plan If onsite review , it is not necessary to print documents that are stored electronically as long as a computer is provided to access the records. Helpful Tip: If documents are located in 2 files ( paper file, electronic file), create a list for the clinical reviewer of where the documents can be found. 10 Record Preparation 2/08/2016 Treatment Record Reviews In accordance Health Insurance Portability and Accountability Act (HIPAA) regulations, Magellan handles all Treatment records with the highest level of confidentiality.

6 Please securely submit Treatment Records to: Fax: 1- 888-656-3857 or Email: Attention: Stephanie Akers 10 Submitting Records for a Desktop TRR 2/08/2016 11 Treatment Record Reviews On-Site review 12 When: The clinical reviewer will contact the provider to schedule the review . clinical reviewer will indicate the date of the review . Exceptions can be given regarding date of review under special circumstances; however, there are limits due to the volume of reviews scheduled each month. Where: A clinical reviewer will arrive at the provider s location at the agreed upon time to review the records. Who: It is generally helpful to have a clinical manager and/or administrative supervisor on-site on the day of the review . 2/08/2016 Treatment Record Reviews Procedure: A brief introduction takes place and then reviewer can be escorted to work station to review the charts.

7 If a provider s records are stored electronically, computer access is needed. It is helpful for the provider to have a guide to the chart to assist the reviewer to locate relevant documentation. Reviewer will ask for assistance if documentation can not be located or is ambiguous. Once the review is complete, then a brief informal exit interview will be conducted. 13 On-Site review 2/08/2016 Treatment Record Reviews After the review 14 Once the review takes place, the reviewer will input, aggregate, and analyze data. The minimum performance threshold for items, sections, and the aggregate total score is 80% compliance. It is determined by dividing the total number of items that were in compliance by the total number of items scored. The clinical reviewer will identify strengths and opportunities for improvement based on data analysis and clinical impression.

8 Final Reports are sent to the provider, which summarize the results and identify any required follow up actions if applicable. 2/08/2016 Treatment Record Reviews Types of Improvement Plans 15 There are two types of improvement plans that could be required as result of scores that fall below the minimum performance threshold (80%): Performance Improvement Plan Applies to all providers. Can be given if the TRR overall aggregate score falls below 70% or serious Quality of Care Concerns are identified during review . Requires a written action plan be sent of the provider s intent to modify processes and procedures to address deficiencies AND a follow-up review to monitor progress. Performance Improvement Plan Applies to all providers. Can be given if the TRR overall aggregate score falls between 79%- 70% or if TRR sections or items score below 80%.

9 Require a written action plan be sent of the provider s intent to modify processes and procedures to address deficiencies. There is no follow up review for this type of improvement plan 2/08/2016 Treatment Record Reviews Treatment Record review Scoring Procedures 16 Scoring Guidelines Minimal deficiencies: Treatment Record aggregate score of 80 to 100%. No remediation or written response is required. Moderate deficiencies: Treatment Record aggregate score of 70 to 79% or Sections and/or Items scoring under 80%. Requires an Informal Performance Improvement Plan to be submitted. This is a written response on the provider s intent to incorporate recommendations into the documentation process. It is requested that the plan be submitted within 30 calendar days. No follow up review is required once the plan is accepted.

10 Serious deficiencies: Treatment Record aggregate score 0 to 69%. Requires a Formal Performance Improvement Plan to be submitted. This is a written response on the provider s intent to address deficiencies and a timeline for implementation of actions. It is required that the plan be submitted within 30 calendar days. A follow up review will be conducted in approximately 3 months from the date of submission to ensure corrective actions have been implemented 2/08/2016 Treatment Record Reviews General Member Rights and Confidentiality Initial Evaluation Individualized Treatment Planning Ongoing Treatment Addendum for Children Coordination of Care Discharge Planning/Process Medication Management Cultural Coordinated System of Care clinical Practice Guidelines Fraud, Waste and Abuse Adverse Incident 17 Treatment Record review Auditing Tool The following sections will be reviewed as part of your Treatment Record review : Please access the specific elements for each section at the Magellan of Louisiana website.