BILL ANALYSIS Ó
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|SENATE RULES COMMITTEE | SB 296|
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UNFINISHED BUSINESS
Bill No: SB 296
Author: Cannella (R)
Amended: 8/28/15
Vote: 21
SENATE HEALTH COMMITTEE: 9-0, 4/15/15
AYES: Hernandez, Nguyen, Hall, Mitchell, Monning, Nielsen,
Pan, Roth, Wolk
SENATE APPROPRIATIONS COMMITTEE: 7-0, 5/28/15
AYES: Lara, Bates, Beall, Hill, Leyva, Mendoza, Nielsen
SENATE FLOOR: 40-0, 6/1/15
AYES: Allen, Anderson, Bates, Beall, Berryhill, Block,
Cannella, De León, Fuller, Gaines, Galgiani, Glazer, Hall,
Hancock, Hernandez, Hertzberg, Hill, Hueso, Huff, Jackson,
Lara, Leno, Leyva, Liu, McGuire, Mendoza, Mitchell, Monning,
Moorlach, Morrell, Nguyen, Nielsen, Pan, Pavley, Roth, Runner,
Stone, Vidak, Wieckowski, Wolk
ASSEMBLY FLOOR: 79-0, 9/2/15 - See last page for vote
SUBJECT: Medi-Cal: specialty mental health services:
documentation requirements
SOURCE: California Council of Community Mental Health
Agencies
DIGEST: This bill limits the scope of the service billing
documentation requirements that the Department of Health Care
Services (DHCS) may apply when conducting an audit of Medi-Cal
specialty mental health (SMH) services, as specified. This bill
also requires DHCS to consider further revisions to its service
billing documentation requirements and to prepare, in
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consultation with counties, providers, and other stakeholders,
and to submit to the Legislature a proposal to accomplish
specified objectives.
Assembly Amendments delete the requirement for DHCS to develop a
single set of service billing documentation requirements, after
consulting counties, providers, and other stakeholders, and
instead require DHCS to limit the scope of service billing
documentation requirements, when auditing Medi-Cal SMH services,
to criteria specified in state regulations, letters, and
directives; federal Medicaid terms and conditions; and in the
state's Medicaid State Plan.
ANALYSIS:
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 limit the scope of any service billing
documentation requirements to criteria clearly and explicitly
set forth in any of the following: a) regulations,
interpretive letters, and compliance directives sent by DHCS
to counties in a previous fiscal year; b) federal terms and
conditions of the Medicaid Program; and c) the Medicaid State
Plan.
2)Requires an audit requirement that does not meet the criteria
in 1) above to be considered an advisory finding only for
which no disallowance can be made, unless DHCS modifies its
regulations to make the audit requirement explicit, or
provides an interpretive letter or other written clarification
to counties that clearly prescribes the requirement.
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3)Prohibits DHCS from requiring a county or county contract
provider to copy or reenter any unchanged information from a
patient's existing care record into any subsequent progress
note, assessment, or treatment plan for that patient, unless
explicitly required by a federal directive.
4)Requires a DHCS regulation, interpretive letter, compliance
directive, or audit requirement relating to service billing
documentation to allow counties and county contract providers,
when documenting a patient's treatment, to incorporate by
reference any information from the patient's entire case
record, including, but not limited to, assessments, treatment
plans, evaluations, and progress notes.
5)Requires DHCS to consider further revisions to its service
billing documentation requirements to minimize the time and
paperwork required of counties and providers, consistent with
federal standards, and to eliminate duplicative or obsolete
requirements.
6)Requires DHCS to submit a proposal to the Legislature, to
accomplish the requirements in 5) above, in the same fiscal
year that DHCS submits to the federal Centers for Medicare and
Medicaid Services (CMS) its proposal to revise the billing
method for mental health services from the current practice of
billing by the minute to a system that provides for greater
documentation streamlining, including, but not limited to, a
capitated system. Requires DHCS, in preparing the proposal, to
consult with counties, providers, and other stakeholders.
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
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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
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.
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.
3)State SMH service reimbursement. In order to receive
reimbursement for SMH services, the current contracts that
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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
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.
4)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%) and
2012-2013 (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, Diagnostic, and
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Treatment 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.
5)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.
6)Opposition. The opposition listed below is based upon the
previous version.
FISCAL EFFECT: Appropriation: No Fiscal
Com.:YesLocal: No
According to the Assembly Appropriations Committee, potential
administrative staff costs to DHCS in the range of several
hundred thousand dollars in staff costs for at least one to two
years.
SUPPORT: (Verified9/2/15)
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California Council of Community Mental Health Agencies (source)
American Association for Marriage and Family Therapy California
Division
California Chapter of the American College of Emergency
Physicians
California Coalition for Mental Health
Mental Health America of California
Pacific Clinics
Steinberg Institute
OPPOSITION: (Verified9/2/15)
Department of Finance
ARGUMENTS IN 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
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.
ASSEMBLY FLOOR: 79-0, 9/2/15
AYES: Achadjian, Alejo, Travis Allen, Baker, Bigelow, Bloom,
Bonilla, Bonta, Brough, Brown, Burke, Calderon, Campos, Chang,
Chau, Chávez, Chiu, Chu, Cooley, Cooper, Dababneh, Dahle,
Daly, Dodd, Eggman, Frazier, Beth Gaines, Gallagher, Cristina
Garcia, Eduardo Garcia, Gatto, Gipson, Gomez, Gonzalez,
Gordon, Gray, Grove, Hadley, Harper, Roger Hernández, Holden,
Irwin, Jones, Kim, Lackey, Levine, Linder, Lopez, Low,
Maienschein, Mathis, Mayes, McCarty, Medina, Melendez, Mullin,
Nazarian, Obernolte, O'Donnell, Olsen, Patterson, Perea,
Quirk, Rendon, Ridley-Thomas, Rodriguez, Salas, Santiago,
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Steinorth, Mark Stone, Thurmond, Ting, Wagner, Waldron, Weber,
Wilk, Williams, Wood, Atkins
NO VOTE RECORDED: Jones-Sawyer
Prepared by:Reyes Diaz / HEALTH /
9/2/15 18:56:24
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