Personal Care Assistants

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Personal Care Assistants

• May 19, 2006

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PCA May 1, 2006 Changes

• Effective May 1, 2006, Medica implemented three
  changes for PCA services
• Statement of Need
• Flexible Use
• Claims Payment
• Today, we will review these changes, as well as
  the reasons behind the changes.
• Additionally, we will cover
• Completing the 485
• Medica DUAL Solution Care Coordinator

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PCA General Info

• Medica provides coverage for PCA services for
• Medica DUAL Solution members (Medicas Minnesota
  Senior Health Options product)
• Medica Choice CareSM members
• Medica MinnesotaCare Children and pregnant women

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PCA General Info

• PCAs assist members who need help with personal
  care. Examples of services PCAs provide
• - Dressing
• - Bathing
• - Toileting
• - Mobility

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PCA General Info

• Assessment must be done by a public health nurse
  before services will be authorized.
• Assessment is arranged by Medica.
• Medica Nurse Case Managers determine coverage,
  based on the assessment, for Medica Choice Care
  and eligible Medica MinnesotaCare members.
• Medica Care Coordinators (through designated Care
  System) determine coverage, based on the
  assessment, for Medica DUAL Solution members.

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Special Investigation Unit (SIU)
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Case Identification

• Primary Sources
• Internal Referrals
• External Referrals
• Law Enforcement
• Members
• Providers
• Brokers
• Data Mining
• Fraud Software

8
Cost of Fraud

• Financial Impact According to the NHCAA,
  approximately 3 percent or 51 billion of
  Americas 1.7 trillion annual health care
  expenditures is estimated to be fraudulent.

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State/Federal Requirement

• An Annual Anti-Fraud Plan must be filed with the
  Minnesota Department of Human Services.
• Suspected fraud cases involving Medicaid
  recipients must be referred to DHS within 24
  hours.
• All other suspected fraud cases must be referred
  to law enforcement
• DOC, FBI, OIG, DOJ, Licensing Board
• Federal law requires that all health plans have a
  designated Information Exchange Coordinator.
• DOH requires that all health plans have an SIU to
  investigate any alleged fraud involving
  employees, officers and directors.
• Medicare Part D reporting requirements.

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Investigation Process

• Investigation
• Internal/External Review
• Review and send acknowledgment to
• referral source.
• Review for prior investigations and/or
  complaints.
• Open investigation and review claims history and
  billing patterns.
• Obtain relevant information from licensing boards
  and law enforcement agencies.
• Investigation may include
• Provider/member interviews
• Review of documents and/or
• Surveillance
• Prepare a final report summarizing the
  investigation.

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Investigation Process

• Resolution Options
• Report suspected fraud to government
• agencies for criminal investigation.
• Refer to state licensing boards.
• Pursuit not feasible close case.
• Education document in provider file.
• Recommendations to pertinent departments (Network
  Management, Credentialing, Legal, Operations,
  etc.)
• Administrative Remedy
• Member/Provider holds
• Corrective Action Plan
• Dismissal from network
• Negotiated settlement.
• Civil litigation.

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Evidence of the Problem

• Claims Cost Increase

13
Evidence of the Problem

• Anecdotal Evidence
• Reports from Care Systems and Care Coordinators
  of abuses in the system
• Members being coached by agencies
• Members being pressured by family members as PCA
  revenue is a source of family income
• Billing for services not provided
• Letter sent by an anonymous home care nurse to
  the CEOs of all health plans

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May 1, 2006 Changes
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PCA May 1, 2006 Changes

• Minnesota State Legislature has made several
  changes to improve oversight of PCA services.
• Changes not designed to restrict or reduce
  appropriate PCA services.
• Medica has implemented some of these changes.

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Statement of Need
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PCA May 1, 2006 Changes

• As of May 1st, a signed Physician Statement of
  Need form is required before Medica will
  authorize services or pay claims for PCA
  services.
• Form will be owned by Minnesota Council of Health
  Plans.
• Form is required for new requests of PCA
  services, as well as for requests to renew
  authorization for PCA services.
• Medica will arrange for an assessment by a public
  health nurse.

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PCA May 1, 2006 Changes

• Once assessment completed, Medica will summarize
  information.
• Assessment summary and Statement of Need form
  will be sent to members primary care physician.
• Unlike the process for fee for service Medical
  Assistance, Medica will arrange for the physician
  to sign the Statement of Need.

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PCA May 1, 2006 Changes

• If, based on review, the ordering physician is
  not the members primary care physician, summary
  and Statement of Need will be sent to physician
  identified by Medica as members primary care
  physician.
• Primary care physician should review and sign
  Statement of Need and return to Medica.
• Physicians review should make sure the
  information in the summary is consistent with
  their records and that the services will meet
  their patients needs.
• If the information is not consistent, the
  physician should contact Medica or the Care
  Coordinator.

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PCA May 1, 2006 Changes

• Once Medica has received the signed Statement of
  Need, PCA services will be considered.
• Medica will not accept Statements of Need that
  were not initiated by Medica (including Care
  System Care Coordinator).
• Determination will be made based on medical
  necessity, as defined by MN Rule 9505.0175,
  subpart 25 MN Rule 4685.0100, subpart 9b and
  Medicas PCA UM Policy.

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Interim Statement of Need

• Statement of Need form is different than DHS
  form.
• Current form is an interim form, until MN Council
  of Health Plans form is finalized.

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Interim Statement of Need
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Flexible Use Option
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PCA May 1, 2006 Changes

• With flexible use, a member may use the hours as
  they choose within the authorization period.
• - Example member is authorized 2 hours of PCA
  services a day, for a total of 14 hours a week.
  Can use 14 hours within week, as needed per day.
• As of May 1st, flexible use will only be
  authorized if requested for a specific purpose.

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PCA May 1, 2006 Changes

• Request for flexible use must be made at time of
  prior authorization request.
• The public health nurse assessment agency will
  consider the request for flexible use when doing
  the assessment.
• Authorization for flexible use will be made based
  on
• - Individual Needs
• - Preferences
• - Abilities
• - Past Use of PCA hours

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PCA May 1, 2006 Changes

• Flexible use can only be authorized up to
  six-months at a time (by MN Statute).
• Authorization must specifically state flexible
  use
• - Example authorization is 2 hours day and 4
  hours are performed, only 2 will be paid unless
  authorization states flexible use.

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PCA May 1, 2006 Changes

• Unused hours cannot be carried over into a new
  six-month period.
• If flexible use is authorized, PCA Agency RN must
  develop care plan specifically outlining how
  flexible use will be applied.
• PCA agency must monitor the hours used and report
  any problems to Medica.
• Failure to appropriately monitor use of hours
  will result in non-authorization of additional
  hours to supplement an authorization exhausted
  prior to the end date.

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PCA May 1, 2006 Changes

• If there is a change in situation or medical need
  for increased services, agency or member can
  request a re-evaluation. Supporting clinical
  documentation from primary care physician will be
  required.
• Hours do not have to be divided evenly
• - Example Member receives 800 total service
  units in one year. Member may receive 500 units
  in one six-month period and 300 units in the
  second six-months of the year.

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Claims Payment
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PCA May 1, 2006 Changes

• As of May 1st, Medica will pay claims for PCA
  services in accordance with the authorization.
• If PCA Agency fails to obtain prior
  authorization, claims for PCA services will be
  denied.
• Claims will be denied with reason code
• - 941 PCA Services not approved
• Denial is provider liability, denied charges may
  NOT be billed to member.

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PCA May 1, 2006 Changes

• Services must be provided in accordance with the
  authorization.
• Services outside the authorization will be denied
  reason code 941.

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Changes to Utilization Management Policy
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PCA May 1, 2006 Changes

• Background
• ?Definitions
• - Change in definition of Personal Care
  Assistant
• - Change in definition of Flexible Use of
  PCA Hours

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PCA May 1, 2006 Changes

• Medical Necessity Criteria
• ?Section II
• - Was Written Documentation
• - Became new section Authorization of
  Flexible Use of PCA Hours
• ?Section III
• - Written Documentation moved from Section
  II
• - Verbiage added

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PCA May 1, 2006 Changes

• Coverage Issues
• ?Bullets added
• References
• ?References added

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Reminders
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Record Keeping

• Record keeping is a requirement of the law.
• Medica has the same expectation of record keeping
  as the Department of Human Services.
• Criminal background check for each employed PCA
• Verbiage surrounding this requirement has been
  added to the PCA Utilization Management policy
• Specific documentation must be kept on file for
  10 years
• Medica-approved physician statement of need
• Service plan
• Care plan
• Daily written records detailing actual services
  provided amount of time spent providing

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PCA Medica Advantage SolutionSM Choice

• Claims for members enrolled on Medica Advantage
  SolutionSM Choice do not need to be submitted
  under the 79000 group number.
• PCA Services are not a covered service under the
  Medicare portion of the members coverage.
• Claims may be submitted directly to the group
  number beginning with 59XXX (members Medicaid
  coverage).

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Completing the Home Health Certification and Plan
of Care (485) form
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Medica DUAL Solution Care Coordinator
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DUAL Solution Care Coordinator

• Role of the Care Coordinator
• Communication with the Care Coordinator
• County Partners

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