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Provider Training, Optum SLCoApril 2012

Provider NetworkConfidential property of Optum. Do not distribute or reproduce without express permission from Optum.2

Agenda 1.Documentation 2.Medicaid Provider Manual 3.Client Rights 4.Notice of Action 5.Timely Access 6.Fraud, Waste and Abuse 7.LEIE reporting requirements 8.ProviderConnect 9.Updates– Recovery Plus– OQ/YOQ– Mental Health Event RecordConfidential property of Optum. Do not distribute or reproduce without express permission from Optum.3

CLINICAL DOCUMENTATIONConfidential property of Optum. Do not distribute or reproduce without express permission from Optum.4

Clinical Documentation- GeneralClinical documentation in the consumerrecord is: vital and requiredfor the provision of quality care andreimbursement for services rendered.Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.5

Purposes of Clinical Documentation Recording what was done, by whom, to whom, when, where, why and withwhat results; To serve as the basis for care planning and continuity of care by an individualpractioners To serve as the basis for continuity of care by the care team To facilitate coordination of clinical care To comply with legal, regulatory, and institutional guidance and standards To facilitate quality assurance and utilization review To provide risk management and malpractice protectionConfidential property of Optum. Do not distribute or reproduce without express permission from Optum.6

Elements of Good Clinical Documentation Be factual, internally consistent, concise, and accurate and not includeeditorial comments, speculation or meaningless phrases; Be written concurrently, or as close as possible, to the time care wasgiven; Be written from first-hand knowledge; Be signed with the care-givers name and professional credentials: When required, signature of supervising professional including nameand professional credentialsConfidential property of Optum. Do not distribute or reproduce without express permission from Optum.7

Consequences of Deficient Documentation It has been argued that the quality of Poor documentation could lead to:care a client receives is reflected inthe quality of the documentation ofthe care, and that a direct relationship The omission or duplication oftreatment;between the two exists. Inappropriate care decisions; Inability to evaluate the effectivenessof care/treatment; and Responding ineffectively todeterioration in a client’s healthstatus. Non-paymentConfidential property of Optum. Do not distribute or reproduce without express permission from Optum.8

Treatment Planning: A Person Centered ApproachPerson-Centered Planning turns the focus away from the system and places it onthe individual.Strengths, preferences and an individualized system of support are identified toassist the individual achieve functional, meaningful goals and objectives.Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.9

Person Centered PlanningAll person centered planningapproaches share three basicfeatures: the focus of planning should be oneveryday events and activities inwhich the individual participates; family and connections within thecommunity are more important thanthe services currently available; and planning must be done w/ theindividual and a group of people whoknow the individual well and arecommitted to helping the individualachieve their goalsConfidential property of Optum. Do not distribute or reproduce without express permission from Optum.10

Treatment PlansTherapy is a process in which you treat a client who is dealing withmental health and/or substance abuse issues.A treatment plan is:– necessary to pinpoint the exact issues the client wants toaddress and the ways in which they will be tackled;– a dynamic document that incorporates the voice of client;It sets specific goals that allow both the client and you and to assessprogress.It acts as an important road map, providing guidance on the road to thegoals and instructions on how to reach them.Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.11

S.M.A.R.T. Goals Specific I want to improve my self esteem Measureable I want to graduate from high schoolby the end of 2013 with a 3.0 GPA. Attainable I want to be less depressed? Realistic Timely I want to get my PO off my back bythe end of this month by attending mytherapy appointments, not usingillegal substances, taking mymedication as prescribed and meetingon Wednesdays at 11:00 with him.Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.12

Effective Treatment Planning Set S.M.A.R.T. Goals Develop specific steps with your client foreach of the goals. Discuss the steps with the client, making appropriate changes as needed. Create a timeframe for the treatment plan. Along with the client, decide howlong each goal should take. Record the plan Have your client sign the completed treatment plan form. This signifies his buyin to the plan. Review the plan regularly and make adjustments.Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.13

Coordination of Care Medicaid consumers with mental health and substance abuse disordersoften need care from numerous doctors, nurses, clinicians, certifiedpeer specialists and other professionals in multiple settings of care. These consumers often transition between hospitals, residentialtreatment facilities, day treatment, intensive outpatient programs, inhome health agencies, and doctors’ offices in order to obtain theservices they need. Studies have shown that such transitions can jeopardize client safetyand quality of care as a result of incomplete and/or inaccurate transferof information, leading to possible to adverse medication events,exacerbation of symptoms and the inability of consumers and familiesto recognize and react to signs of their illness. Coordination of care is key in reducing risk and fostering optimaloutcomes.Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.14

Coordination of CareCommon components of care coordination include: Planning treatment strategies Monitoring outcomes and resource use Coordinating visits with treatment partners Organizing care to avoid duplication of diagnostic tests and services Sharing information among health care professionals, family, and otherpersonnel Facilitating access to services Planning hospital discharges Training of caregivers and family Ongoing reassessment and refinement of a care planConfidential property of Optum. Do not distribute or reproduce without express permission from Optum.15

Coordination of CareIn an effort to provide the best care to the consumer, every attemptshould be made to obtain previous and current records from other caregivers.Documentation in the clinical record should include appropriate releaseof information forms, calls and/or letters to providers requesting theinformation and clinical notes indicating the information has beenreceived and reviewed by appropriate staff. IIn situations where the consumer refuses to sign a release ofinformation, documentation should reflect this decision.Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.16

MEDICAIDConfidential property of Optum. Do not distribute or reproduce without express permission from Optum.17

MEDICAIDConfidential property of Optum. Do not distribute or reproduce without express permission from Optum.18

Medicaid Provider Manual Primary Care vider.html Pre-paid Mental Health entalHealth1-12.pdf Substance bstanAbuse1-10.pdfConfidential property of Optum. Do not distribute or reproduce without express permission from Optum.19

MEDICAID MANUAL REVIEWConfidential property of Optum. Do not distribute or reproduce without express permission from Optum.20

CLIENT RIGHTSConfidential property of Optum. Do not distribute or reproduce without express permission from Optum.21

Client RightsYou have the right to: Get mental health care regardless ofyour race, color, national origin,disability (mental or physical), sex,religion or age. Receive information on the PrepaidMental Health Plan in a languageand format that is easily understood Take part in treatment decisionsabout your mental health care,including the right to refusetreatment. Be free from restraint or seclusion ifit is used these ways:– To coerce (force) ordiscipline– As a reaction (to retaliate)or for convenience– As specified in federalregulations on the use ofrestraint and seclusion Get information on the Prepaid MentalHealth Plan. Be treated with respect and dignity. Have your privacy protected. Get information on all treatmentchoices in a way that is clear and youcan understand.Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.22

Client Rights Get a copy of your mental healthrecord. You may also ask that it beamended or corrected.If you have been treated unfairly ordiscriminated against for any reason,please call any of the numbers listedbelow: Medicaid’s Constituent Services: 1877-291-5583 The Federal Office for Civil Rights: 1800-368-1019, ocrmail@hhs.gov (email), www.hhs.gov/ocr (website), or1-800-537-7697 (TDD)Optum SLCo Complaints Hotline1-877-370-8953Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.23

Client RightsThe Client Rights need to be posted in your office & the client must sign theacknowledgement form indicating they have reviewed the memberhandbook and understand their rights. The signed acknowledgment formmust be in the client record.Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.24

NOTICE OF ACTIONConfidential property of Optum. Do not distribute or reproduce without express permission from Optum.25

Notice of ActionIf either of the below circumstancesexist, and IF the consumer does notfind the alternative arrangementsacceptable, a Notice of Action mustbe issued to the consumer, by theprovider responsible for the Action. A provider denies, refuses, orreduces services to a consumer. A provider does not offer aconsumer’s first appointment withinthe required amount of time foremergency, urgent, or non-urgentcare.Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.26

TIMELY ACCESSConfidential property of Optum. Do not distribute or reproduce without express permission from Optum.27

Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.28

Initial Contacts/Timely AccessPurposeWhat is considered an initial contact? Requirement by the State of Utah toensure timely access to services. When the client contacts you by voicemessage or live call. In order to ensure the requirement isbeing met, OptumHealth must gatherthis data.What is considered an initial contactTimely Access Guidelines Emergent-contact within 1 hour if faceto face, 30 minutes if by phone Urgent-first appt scheduled within 5days of initial contact. Non-urgent-first appt scheduled within14 days of initial contact.What happens if only appointment availableoutside of timely access window? Client accepts: make notation on spreadsheet Client declines: suggest contact withOptumHealth SLCo Client expresses dissatisfaction withappointment offered and wants to continueservices at your agency: NOA must becompleted.Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.29

FRAUD, WASTE & ABUSEConfidential property of Optum. Do not distribute or reproduce without express permission from Optum.30

FRAUD, WASTE AND ABUSEConfidential property of Optum. Do not distribute or reproduce without express permission from Optum.31