BILL ANALYSIS Ó
SB 296
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Date of Hearing: June 30, 2015
ASSEMBLY COMMITTEE ON HEALTH
Rob Bonta, Chair
SB
296 (Cannella) - As Amended April 20, 2015
SENATE VOTE: 40-0
SUBJECT: Medi-Cal: specialty mental health services:
documentation requirements.
SUMMARY: Requires the Department of Health Care Services (DHCS)
to develop a single set of billing 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. Specifically, this
bill:
1)Requires DHCS to consult with counties, providers, and other
stakeholders to develop the billing documentation
requirements,
2)Requires that the billing documentation requirements:
a) Minimize time and paperwork required of counties and
providers
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b) Are consistent with federal law
c) Eliminate duplicative or outdated requirements
3)Prohibits a county from requiring additional billing
documentation for Medi-Cal SMH services after the standards
required by this bill are adopted.
EXISTING LAW:
1)Establishes the Medi-Cal program, administered by DHCS, under
which qualified low-income individuals receive health care
services.
2)Establishes, under the terms of a federal Medicaid waiver, a
managed care program providing Medi-Cal SMH services for
eligible low-income persons administered through local county
mental health plans (MHPs) under contract with the state.
3)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.
FISCAL EFFECT: According to the Senate Appropriations
Committee, likely one-time costs up to $150,000 to consult with
stakeholders, develop the documentation guidelines, and adopt
regulations (General Fund and federal funds).
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COMMENTS:
1)PURPOSE OF THIS BILL. According to the author, this bill is
necessary because it would address concerns of 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. The author further states that 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. The author concludes that this bill would end this
pattern by creating a single set of documentation requirements
developed by the state, in consultation with counties and
providers, that should limit audit disallowances and is
designed to be the minimum documentation requirements
necessary to comply with federal law and other applicable
state laws.
2)BACKGROUND.
a) Specialty Mental Health 1915(b) waiver. Specialty
Medi-Cal mental health services are provided under the
terms of the federal Medicaid Medi-Cal Specialty Mental
Health Services Consolidation 1915(b) waiver program. The
waiver established a managed care program for specialty
mental health services separate from the overall Medi-Cal
program. Medi-Cal beneficiaries must receive specialty
mental health services though county-operated MHPs. County
MHPs provide services directly or through contracts in the
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local community using a combination of county funds,
realignment revenues and Mental Health Services Act funds.
Counties pay for services locally, incurring certified
public expenditures, which the state then uses as the state
match to claim federal Medicaid reimbursement and the
state, in turn, returns the federal funds to the county
MHPs. The Medi-Cal Specialty Mental Health Services
Consolidation waiver has been in place since the mid-1990s
and was just submitted for renewal by DHCS to the Centers
for Medicare and Medicaid Services for a new five-year
term, from July 1, 2015, through June 30, 2020.
During regular monitoring 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.
b) 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
a diagnosis, a treatment plan with objectives/interventions
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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:
i) The need for authorization or the need for service;
ii) Risk (e.g. the Los Angeles County Blue Ribbon
Commission mandate to assess for self-harm vulnerability
risk);
iii) The need for ongoing flex funds for a particular
client; or,
iv) 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.
c) DHCS billing disallowances. In a presentation document
DHCS shared at the California Mental Health Directors
Association All Directors Meeting on January 9, 2014, DHCS
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noted that in fiscal years (FY) 2007-13, disallowance rates
for outpatient chart reviews of a sampling of MHPs
increased, with the most notable increase occurring between
FYs 2011-12 (26%) and 2012-13 (36%). 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 Early and Periodic
Screening, Diagnosis, and Treatment (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% 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)SUPPORT. The sponsors of the bill, California Council of
Community Mental Health Agencies, state that paperwork
reduction is one great way of increasing the efficiency of our
health care system while actually helping to improve outcomes.
The sponsors state that this bill achieves that by requiring
DHCS to develop a single set of service documentation
requirements for the provision of SMH services. The
California Chapter of the American College of Emergency
Physicians state in support of this bill that individual
counties across the state have their own documentation
requirements, adding 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
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morale of mental health workers.
4)RELATED LEGISLATION.
a) AB 1018 (Cooper) requires DHCS and the California
Department of Education to convene a joint task force to
examine the delivery of mental health services to children
eligible for EPSDT services and for services required by
the federal Individuals with Disabilities Education Act.
AB 1018 is pending in the Senate Education Committee.
b) AB 1299 (Ridley-Thomas) transfers responsibility for
providing or arranging mental health services for foster
youth from the county of original jurisdiction to the
foster child's county of residence. This bill is pending
in the Senate Human Services Committee.
5)AMENDMENTS. The Committee suggests technical amendments to
address a code conflict with AB 1018 (Cooper).
REGISTERED SUPPORT / OPPOSITION:
Support
California Council of Community Mental Health Agencies (sponsor)
American Association for Marriage and Family Therapy, California
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Division
California Chapter of the American College of Emergency
Physicians
California Coalition for Mental Health
Mental Health America of California
Pacific Clinics Advancing Behavioral Healthcare
Steinberg Institute
Opposition
None on file.
Analysis Prepared by:Paula Villescaz / HEALTH / (916)
319-2097
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