BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 296
---------------------------------------------------------------
|AUTHOR: |Cannella |
|---------------+-----------------------------------------------|
|VERSION: |April 7, 2015 |
---------------------------------------------------------------
---------------------------------------------------------------
|HEARING DATE: |April 15, 2015 | | |
---------------------------------------------------------------
---------------------------------------------------------------
|CONSULTANT: |Reyes Diaz |
---------------------------------------------------------------
SUBJECT : Medi-Cal: specialty mental health services:
documentation requirements.
SUMMARY : Requires the Department of Health Care Services (DHCS) to
develop a single set of documentation requirements, with
consultation from various entities as specified, for the
provision of specialty mental health (SMH) services by January
1, 2017, for use commencing July 1, 2017. Requires DHCS to
update the documentation requirements no less than every two
years, unless more frequent updating is required, as specified.
Prohibits counties from requiring additional documentation for
SMH services, unless required by funding sources.
Existing law:
1.Establishes the Medi-Cal program, administered by DHCS, under
which qualified low-income individuals receive health care
services.
2.Requires DHCS to create a standardized set of documentation
standards and forms in order to facilitate the receipt of
medically necessary SMH services by a foster child who is
placed outside of his or her county of original jurisdiction.
This bill:
1.Requires DHCS to consult with counties, providers, national
experts, other states, and other stakeholders to develop a
single set of service documentation requirements for the
provision of SMH services.
2.Requires the documentation requirements to: a) minimize time
and paperwork required of counties and providers, consistent
with federal standards and practices of other states; b)
eliminate duplicative or outdated requirements; and c) reflect
SB 296 (Cannella) Page 2 of ?
outcome reporting requirements developed pursuant to the
performance outcome system for Early and Periodic Screening,
Diagnosis, and Treatment (EPSDT) mental health services.
3.Requires DHCS to complete the documentation requirements by
January 1, 2017, for use commencing July 1, 2017, and to
update the documentation requirements no less than every two
years through a stakeholder process, unless changes in the
Medicaid state plan or other federal rules require more
frequent updating.
4.Prohibits a county from requiring additional documentation,
after DHCS adopts the standard requirements, for SMH services
that go beyond DHCS's requirements unless it is necessary for
counties to comply with requirements from funding sources that
are used to pay for the services.
5.Makes findings and declarations about the amount of time
paperwork documentation takes in the state because counties
have added documentation requirements based on the fear that
state audits will result in billing disallowances. States the
necessity for DHCS to develop a single set of documentation
requirements to limit audit disallowances.
FISCAL
EFFECT : This bill has not been analyzed by a fiscal committee.
COMMENTS :
1.Author's statement. According to the author, SB 296 is
necessary because it would get rid of the concern from mental
health officials and the community agencies they contract with
that the state's interpretation of the guidelines in audits
might disallow some services if the additional documentation
were not included. While the state guidelines on billing are
not much different from other states, counties have added so
many requirements that it takes up to 20 minutes of
documentation to prepare progress notes on things like
psychotherapy, while in other states it takes five minutes.
This costs manpower and money to the state and counties. SB
296 would end this pattern by creating a single set of
documentation requirements developed by the state, in
consultation with counties and providers, that limits audit
disallowances to circumstances clearly spelled out in the
requirements, and is designed to be the minimum documentation
requirements necessary to comply with federal law and other
SB 296 (Cannella) Page 3 of ?
applicable state laws.
2.CMS requirements for reimbursement. Behavioral health services
must meet specific requirements for reimbursement. Documented
services must:
a. Meet that state's Medicaid program rules;
b. To the extent required under state law, reflect
medical necessity and justify the treatment and clinical
rationale (each state adopts its own medical necessity
definition);
c. To the extent required under state law, reflect
active treatment;
d. Be complete, concise, and accurate, including the
face-to-face time spent with the patient (for example,
the time spent to complete a psychosocial assessment, a
treatment plan, or a discharge plan);
e. Be legible, signed, and dated;
f. Be maintained and available for review; and,
g. Be coded correctly for billing purposes.
Centers for Medicare and Medicaid Services (CMS) states that a
reason for documenting medical services is to comply with
federal and state laws, which require proper support for
billed claims. In addition, CMS states that documentation done
well can help protect a behavioral health practitioner from
billing disallowances.
1.State SMH service reimbursement. In order to receive
reimbursement for SMH services, the current contracts that
counties have with the state require medical necessity to be
met for the service as documented on an assessment with an
International Classification of Diseases or Diagnostic and
Statistical Manual of Mental Disorders diagnosis, a treatment
plan with objectives/interventions and client participation,
and progress notes with the intervention and response of the
client. According to the County Behavioral Health Directors
Association of California (CBHDAC), counties, as the
contracting entity with mental health plans (MHPs), need to
have the ability to impose greater documentation to meet
requirements based on:
a. The need for authorization or the need for service;
b. Risk, (e.g. the Los Angeles County Blue Ribbon
Commission mandate to assess for self-harm vulnerability
SB 296 (Cannella) Page 4 of ?
risk);
c. The need for ongoing flex funds for a particular
client; or
d. Documentation-related practice mandates (entering
data into the Managing and Adapting Practice [MAP]
database dashboard at the end of each MAP session).
If counties have additional documentation requirements,
according to CBHDAC, it is usually based on other funding
requirements and/or special interests by the boards of
supervisors, Blue Ribbon Commissions, courts, or other state
departments.
2.DHCS billing disallowances. In a presentation document DHCS
shared at the California Mental Health Directors Association
All Directors Meeting on January 9, 2014, DHCS noted that in
Fiscal Years (FY) 2007-2013, disallowance rates for outpatient
chart reviews of a sampling of MHPs increased, with the most
notable increase occurring between FYs 2011-12 (26 percent)
and 2012-2013 (36 percent). DHCS noted that the increase may
have been attributed to the inclusion of children/adolescents
data in the sample. Prior to FY 2011-12, the triennial
outpatient chart samples consisted of adults only, and there
were separate EPSDT chart audits conducted. In addition, with
the inclusion of children/adolescents and the resulting Day
Treatment Intensive (DTI) and Day Rehabilitation (DR) paid
claims in the same sample, DHCS notes that the disallowance
rates increased. DHCS's presentation document also noted that
90 percent of the DTI and DR claims were disallowed in FY
2011-12. Primary reasons for disallowances were due to
provider documentation error, such as lack of required service
components, no documentation of attendance, absence of
required progress notes, medical necessity not substantiated,
and not meeting program Medi-Cal certification requirements.
3.Concerns with existing SMH 1915(b) waiver. DHCS administers a
Section 1915(b) Freedom of Choice federal waiver to provide
SMH services using a managed care model of service delivery.
The SMH waiver program has been in effect since 1995, with a
total of eight waiver terms approved by CMS to date. The
eighth waiver term was approved by CMS for two years only
(July 1, 2013, through June 30, 2015), instead of the five
years initially requested by DHCS. CMS stipulated that DHCS
needed to continue with regular monitoring activities with
CMS, including monthly calls. During the monthly monitoring
SB 296 (Cannella) Page 5 of ?
calls and in ongoing communications, CMS has asked questions
on specific areas of the SMH waiver. CMS reviews MHP triennial
and External Quality Review Organization reports and raised
concern about the findings and continued noncompliance with
specific waiver requirements. CMS believes that significant
improvement is needed in identified areas and expects the
state to closely monitor, ensure, and provide evidence of
compliance. In addition to a number of identified areas of
focus, CMS has expressed concern about the ongoing elevated
inpatient and outpatient disallowance rates resulting from
chart reviews (i.e., disallowed claims under the Medi-Cal
program). Due to past deficiencies, CMS is requiring the state
to provide oversight to ensure that the Medi-Cal claims
submitted by MHPs for SMH services meet medical necessity
criteria for reimbursement and that the documentation in the
medical records provided contains the required evidence of
medical necessity. CMS has requested that DHCS explore
establishing a process to enact fines, sanctions and
penalties, or corrective actions as a way to ensure
compliance.
4.Lack of evidence-based/best practice service provision for
behavioral health. The Technical Assistance
Collaborative/Human Services Research Institute's final report
in February 2012, California Mental Health and Substance Use
System Needs Assessment, notes that the percent of individuals
reported to be receiving an evidence-based practice service
was low: only one percent in 2010, down from two percent in
2009. It also notes that there is a variability among counties
in the use and training of staff in state-of-the-art and
evidence-based and recovery-oriented treatment; there is a
need to address better preparation of physical health
providers to engage and treat people with behavioral health
needs; and there is still disproportionate access to
behavioral health services on the part of certain ethnic
populations-compounded by the relative lack of
cultural/linguistic capacity among providers and practitioners
in the state.
5.Support. Supporters of this bill argue that paperwork
reduction is one great way of increasing the efficiency of the
health care system while helping to improve outcomes. The
California Chapter of the American College of Emergency
Physicians states that individual counties across the state
have their own documentation requirements, adding
SB 296 (Cannella) Page 6 of ?
substantially to the amount of time Medi-Cal providers spend
documenting their services. The American Association for
Marriage and Family Therapy California Division argues that
paperwork overload contributes to workplace fatigue and that
this bill will improve the morale of mental health workers.
6.Policy comment.
a. This bill requires DHCS to develop a single set of
documentation requirements for the provision of SMH
services, which raises questions about a county's ability
to require or collect information related to
evidence-based practice implementation or other best
practice assessments. The sponsor of this bill states
that the intent is to limit county requirements for
documentation of compliance with billing rules, which is
not indicated in this bill. The author may wish to
clarify this intent.
b. This bill makes findings and declarations about a
national expert's review of counties' documentation
requirements and determination that it takes an average
of 20 minutes to prepare progress notes in California
compared to an estimated five minutes in other states
and, therefore, proposes to limit the amount of
documentation a county can require. According to DHCS,
disallowances generally occur because of a provider's
inability to accurately document service provision as
required, and not because of excessive paperwork
requirements. According to counties, all documentation
required serves a critical purpose. The author may wish
to consider whether relaxing documentation requirements
is the right solution at a time when CMS is closely
monitoring the state because of concerns about the
state's high disallowance rate, including lack of proper
documentation.
SUPPORT AND OPPOSITION :
Support: California Council of Community Mental Health Agencies
(sponsor)
American Association for Marriage and Family Therapy
California Division
California Chapter of the American College of
Emergency Physicians
Mental Health America of California
SB 296 (Cannella) Page 7 of ?
Steinberg Institute
Oppose: None received.
-- END --