13-004 Code Vt. R. 13-150-004-X - DEPARTMENT OF MENTAL HEALTH MDICAID REGULATIONS

CLINIC SERVICES - MENTAL HEALTH

Section 1

Medicaid payment for covered services is limited to Community Mental Health Centers that are facilities established for the purpose of providing outpatient mental health care. In order for a Community Mental Health Center to be eligible for participation under the Medicaid State Plan, it must agree to comply with appropriate Federal regulations and to perform and bill for services, maintain records and adhere to the supervision, regulations, standards and the medicaid guideline requirements of the Commissioner of Mental Health pursuant to 18 V.S.A., Chapter 177, Section 7401(2), (4) and (15); and 18 V.S.A., Chapter 207, Sections 8907 through 8913. A center is considered enrolled for participation in the Medicaid program when it has a signed provider agreement for services with the Department of Mental Health.

Section 2

In order for a service to be eligible for reimbursement, it must meet the following conditions:

2.1. The service must be delivered within a community mental health center program which has been approved by the Commissioner of Mental Health.

2.2. The service must be provided by a Vermont Medicaid enrolled physician directly affiliated with the center, or prescribed by a physician directly affiliated with the center and provided by a mental health or mental retardation professional on the staff of the center considered by the prescribing physician to be a competent therapist or practitioner.

2.2.1. Prescription is a physician's authorization of treatment as indicated by physician signature on an Individual Treatment Plan (ITP), Individual Program Plan (IPP) or Individual Plan of Care (IPC) before delivery of service except for initial contacts. No more than three (3) visits will be reimbursed before a physician's prescription of an ITP is required. A physician's prescription on an IPC or an IPP is required within thirty (30) calendar days of the date of the first billable session. These plans (ITP, IPC and IPP) and the process of treatment must be periodically reviewed by a physician.

2.3. Service to be provided must be prescribed by the physician in the ITP, IPC or IPP.

2.4. The service must be documented.

2.4.1. Documentation of services provided must be legible and state clearly the services provided. There must be a separate progress note for each billed session of psychotherapy, group therapy, chemotherapy, emergency care and/or day hospital. A weekly summary progress note is required to document billed day treatment sessions.

2.4.2. All entries in the case record must indicate the type of service rendered, the date of service and the amount of time spent with the client.

Section 3

The clinic services which are eligible for Title XIX reimbursement are defined as follows:

3.1. Psychotherapy is a method of treatment of mental disorders using the interaction between a therapist and a patient (client) to promote emotional or psychological change to alleviate mental disorder. Psychotherapy also includes couple therapy and family therapy when only one family is being treated.

3.1.1. The service is reimbursed on a per one-half hour basis. Reimbursement is limited to a maximum of two hours per day and no more than seven hours per week per client.

3.2. Group Therapy is a method of treatment of mental disorders using the interaction between a therapist(s) and two or more patients (clients) to promote emotional or psychological change to alleviate mental disorders. Group Therapy may, in addition, focus on the client's adaptational skills involving social interaction and emotional reactions to reality situations. Group Therapy also includes multiple family or multiple couples therapy.

3.2.1. This service is reimbursed on a per half-hour basis. Reimbursement is limited to a maximum of two hours per day and no more than ten hours per week per client. A group therapy session must be a minimum of two half-hours (one hour) in duration.

3.3. Day Hospital is an intensive service provided in clinic facilities that provides active treatment which can reasonably be expected to lead to full or partial recovery of the patient (client). Day Hospital services are provided as an alternative to inpatient care for clients with mental illness of an acute and/or episodic nature. A variety of treatment modalities is available, including individual, group and family therapy, chemotherapy and treatment-related activity programs.

3.3.1. The service is reimbursed on a per session basis. A session must last at least two hours. Reimbursement is limited to one session per day and no more than seven sessions per week. No other service except Diagnosis and Evaluation and/or Emergency Care will be reimbursed for a client on a day that a Day Hospital service has been provided.

3.4. Emergency Care is a method of care provided for persons experiencing an acute mental health crisis as evidenced by (1) sudden change in behavior with negative consequences for wellbeing (2) a loss of usual coping mechanisms, or (3) presenting a danger to self or others. Emergency care includes diagnostic and psychotherapeutic services such as evaluation of the client and circumstances leading to the crisis, crisis counseling, screening for hospitalization, referral and follow-up. Emergency services are intensive, time-limited and are intended to resolve or stabilize the immediate crisis through direct treatment, support services to significant others, or arrangement of other more appropriate care.

3.4.1. Emergency Care must include, as one component a face-to-face contact with the Medicaid eligible client.

3.4.2. The service is reimbursed on a per one-half hour basis. Reimbursement is limited to three hours per day and 12 hours per week per client.

3.5. Chemotherapy (Med Check) is prescription by a physician or qualified nurse (as defined in the Nurse Practice Act of 26 V.S.A., Chapter 28) of psychoactive drugs to favorably influence or prevent mental illness. Chemotherapy also includes the monitoring and assessment of patient reaction to prescribed drugs.

3.5.1. The service is reimbursed on a per session basis. Reimbursement is limited to one session per day and no more than four sessions per calender week.

3.6. Day Treatment is a service provided in the clinic facility, with a variety of treatment modalities available to promote emotional or psychological change to alleviate the effects of mental disorder. In addition, Day Treatment may have the goal of preventing deterioration of the patient's (client's) emotional or physical functions. Day Treatment services are provided for patients (clients) characterized by chronic disability and dependency. Services available include supportive counseling, preventive or restorative physical exercise, vocationally habilitative services, recreational therapy and instruction in self-care relating to health maintenance.

3.6.1. This service is reimbursed on a per session basis. A session must last at least two hours. Reimbursement is limited to one session per day and no more than seven sessions per week. All other services except day hospital may be reimbursed on the same day.

3.7. Diagnosis and Evaluation is a service related to identifying the extent of a patient's (client's) condition. It may take the form of a psychiatric and/or psychological and/or psychosocial and/or developmental and/or social assessment, including the administration and interpretation of psychometric tests. It may include: an evaluation of the client's attitudes, behavior, emotional state, personality characteristics, motivation, intellectual functioning, memory and orientation; an evaluation of the client's social situation relating to family background, family interaction and current living situation; an evaluation of the client's social performance, community living skills, self-care skills and prevocational skills; and/or an evaluation of strategies, goals and objectives included in the development of a treatment plan, program plan or plan of care consistent with the assessment findings as a whole.

3.7.1. This service is reimbursed on a per one-half hour basis. Reimbursement is limited to 30 hours per calendar year per client. In instances where these limits are not adequate, extensions on a case by case basis may be obtained from the Department of Mental Health with prior written authorization.

3.8. Transportation: If no other transportation is available, payment for transportation to and from the previous seven clinic services only is reimbursed. (See 3.1 through 3.7 above)

3.8.1. Reimbursement is limited to two one-way trips per day.

Section 4 Exclusion and Prohibitions

4.1. Day Hospital and Day Treatment are not reimbursable if provided at Project Independence.

4.2. Mental Health clinic services cannot be reimbursed when provided in skilled nursing (Level I) or intermediate care (Level II) facilities. However, if a client is a resident of either type of facility and is seen at a mental health facility, the services provided may be billed.

4.3. Physicians and psychologists serving as community mental health center staff members may not concurrently provide private services to their community mental health center clients and bill for those services under the Medicaid program.

4.4. No reimbursement will be made for services provided in the facilities of the Vermont State Hospital or the Brandon Training School.

Section 5 Monitoring

5.1. Audit Procedure

5.1.1. Annual Title XIX Field Audits will be performed by the Department of Mental Health for each community mental health center. Statistical, financial and clinical data will be audited in conjunction with the fiscal agent's reports to verify the allowability of payments made by the fiscal agent.

5.1.2. In addition, Desk Audits will be conducted at the Department of Mental Health. If the desk audits reveal substantial utilization over statewide norms, or other unusual patterns, special field audits may be conducted.

5.1.3. The Department shall issue a written report of findings, corrective action and recommendations within forty-five (45) days of completion of the onsite field audit. The provider may, within ten (10) days, request a meeting with the Director of Mental Health Services or the Director of Mental Retardation Services to discuss the report of findings and to negotiate an amicable settlement if there is a discrepancy. The provider may bring evidence, witnesses and representation of choice to the meeting as desired, or may submit a written statement to the Director for consideration in the decision.

5.1.4. If the audit reveals an error rate, defined as noncompliance or billing errors, exceeding five percent of the total transactions audited by the Division of Mental Health and/or five percent of the total transactions audited by the Division of Mental Retardation exclusive of transportation, the Department of Mental Health will call for a complete self-audit for all transactions in programs operating under the auspices of that division from the date of the previously "passed" audit. If a significant number of errors fall into a specific program area, only that program area will need self-audit. Upon receipt of notification of an error rate exceeding five percent, the community mental health center will have forty-five (45) working days to complete the self-audit before the Department of Mental Health returns to verify self-audit. At the completion of the self audit, the Department of Mental Health will return to verify the self-audit. If it is determined that the community mental health center continues to be over the five percent allowable error rate, the community mental health center will be subject to the sanctions listed in 6.2. below. If at the end of the original 45 day period the community mental health center has not completed its self-audit, the Department of Mental Health may suspend Medicaid payments. Resumption of payment will require Department of Mental Health approval. The Department of Mental Health may return to do a complete audit. The Department of Mental Health will send their findings to the Medicaid Provider Fraud Unit, the Department of Social Welfare and the Agency of Human Services.

Section 6 Sanctioning

6.1. Sanctions may be imposed by the Department of Mental Health against a provider for one or more of the following reasons:

6.1.1. Presenting or causing to be presented for payment any false or fraudulent claim for care or services, including billing for care not rendered;

6.1.2. Submitting or causing to be submitted false information for the purpose of obtaining greater compensation than that to which the provider is legally entitled;

6.1.3. Submitting or causing to be submitted false information for the purpose of meeting prior authorization requirements;

6.1.4. Submitting a false or fraudulent application to obtain provider status;

6.1.5. Failing to disclose or make available to the Department of Mental Health or its authorized agent records of services provided to Medicaid recipients and records of payments received for those services;

6.1.6. Failing to provide and maintain services to Medicaid recipients within accepted medical community standards as adjudged by a body of peers.

6.1.7. Failing to comply with the terms of the provider certification agreement printed on the Medicaid claim form;

6.1.8. Overutilizing the Medicaid program by inducing, furnishing or otherwise causing a recipient to receive care and services not required by the recipient;

6.1.9. Rebating or accepting a fee or portion of a fee or charge for a Medicaid patient referral;

6.1.10. Conviction of a criminal offense related to the practice of medicine resulting in death or injury to patients;

6.1.11. Failing to meet and maintain substantial compliance with all State and Federal regulations and statutes, applicable to the provider's profession, business or enterprise;

6.1.12. Termination or suspension from participation in Medicare;

6.1.13. Documented practice of billing or collecting from the recipient an amount in addition to that received from Medicaid for that care or service;

6.1.14. Failing to correct deficient provider operations after receiving written notice of these deficiencies from the Department of Mental Health, other responsible State agencies, or their designees;

6.1.15. Formal reprimand or censure by an association of the provider's peers for unethical practices;

6.1.16. Presenting or causing to be presented for payment a disproportionate number of claims which are rejected or denied due to submission errors made by the provider or his agent. In this context, disproportionate is determined in relation to providers of similar services;

6.1.17. Discovering and refunding a disproportionate number of errors during a post-payment review or annual audit;

6.1.18. Being convicted under any law relating to the Medicaid program or under any law of general applicability for acts arising out of the Medicaid program.

6.2. Sanctions - one or more of the following sanctions may be invoked against providers based upon the grounds specified in 6.1.

6.2.1. Exclusion from participation in the Medicaid program;

6.2.2. Suspension from participation in the Medicaid program;

6.2.3. Deferment or offsetting of payments to a provider;

6.2.4. Transfer to a closed-end provider agreement not to exceed 12 months;

6.2.5. Mandatory attendance at provider information sessions;

6.2.6. Required prior authorization of service;

6.2.7. 100% review of the provider's claims prior to payment;

6.3 Rules concerning the imposition and extent of sanctions.

6.3.1. When the staff of the Department of Mental Health determines that grounds for sanctioning exist and a provider sanction is being considered, the Department will advise the provider in writing of the discrepancy noted. The contact with the provider will set forth in the case of mandatory sanctions, the extent and reason for the sanction, or, in cases of discretionary sanctions:

i. The nature of the discrepancy or inconsistency;

ii. The dollar value, if any, of such discrepancy or inconsistency;

iii. The method of computing such dollar value;

iv. That one or more sanctions may be taken;

v. That the provider may, within 10 days, request a meeting with the Director of Mental Health Services or the Director of Mental Retardation Services to negotiate an amicable settlement of the discrepancy or request a commissioner's conference to be heard in the matter;

vi. That the provider may bring evidence, witnesses and representation of choice to either the meeting or conference as desired, or may submit a written statement to the Director or Commissioner for consideration in the decision to impose sanctions;

vii. That if a meeting or conference is not requested within 10 days, the decision regarding imposition of sanctions will be made based upon information at hand.

6.3.2. Simultaneous with taking action to advise the provider as above, the Department may defer payments on pending and future claims pending resolution of the discrepancy and shall so advise the provider if this action has been taken.

6.3.3 If a mutually agreeable settlement is negotiated with the Director of Mental Health or the Director of Mental Retardation, formal sanction is discontinued at this point. If not, at any point in the negotiation, at the discretion of either party, a Commissioner's Conference may be requested to resolve the issue. If the provider prefers to bypass negotiation with the Director of Mental Health or Mental Retardation and, within 10 days, does request a Commissioner's Conference in the matter at dispute, or negotiations are unsuccessful and a conference is requested, a date shall be set, with notice sent to all parties, and the conference conducted within 20 days from the date of request. The purpose of the conference shall be to assure that the Commissioner has all pertinent information at hand prior to making a decision regarding imposition of sanction. The provider may utilize any records, witnesses or other information which will be helpful in achieving this purpose and may utilize legal or other representation in the presentation. The conference will be recorded and pertinent records retained by the Department at least until the end of the appeal hearing. If, after written notice as provided in a. above, there has been no request from the provider for either a Director's Meeting or Commissioner's Conference at the end of 10 days, this shall be noted and the Commissioner shall proceed, on the basis of information at hand, to the imposition of sanctions as outlined in the following section.

6.4. Imposition of Sanctions

The decision as to discretionary sanctions to be imposed shall be made by the Commissioner of Mental Health.

6.4.1. The following factors shall be considered in determining discretionary sanctions to be imposed:

a) seriousness of the offense;

b) extent of the violations;

c) history of prior violations;

d) prior imposition of sanctions;

e) prior provision of provider information and training;

f) provider willingness to adhere to program rules;

g) agreement to make restitution;

h) actions taken or recommended by peer groups or Licensing Boards; and

i) whether a lessor sanction will be sufficient remedy.

6.4.2. The following mandatory sanctions shall be applied by the Commissioner effective as of the date of action requiring the sanction:

a) When a provider has been suspended or terminated from the Medicare program, imposition of the same sanction as that imposed by Medicare is mandatory upon the Commissioner by Federal regulation. The only appeal is to the Medicare sanctioning authority.

b) When a provider has been convicted of a violation under 33 V.S.A., Chapter 26, Subchapter 5 or under any Vermont statute of general applicability, and said conviction arises from or is directly related to the Medicaid program (33 V.S.A., Chapter 36), that the provider will be suspended from further participation in the Medicaid program for a period of four years unless such suspension is specifically waived or reduced by the Secretary of Human Services.

c) When a provider has failed to retain licensure, certification or registration which is required by State or Federal law for participation in the Medicaid Program, suspension from participation shall be imposed.

6.5. Scope of Sanction

6.5.1. A sanction may be applied to all known affiliates of a provider, provided that each decision to include an affiliate is made on a case by case basis after giving due regard to all relevant facts and circumstances. The violation, failure or inadequacy of performance may be imputed to a person with whom the provider is affiliated where such conduct was accomplished within the course of his official duty or was effectuated by him with the knowledge or approval of such person.

6.5.2. Suspension or exclusion from participation of any provider shall preclude such provider from submitting claims for payment, either personally or through claim submitted by any clinic, group, corporation or other association to the Department of Mental Health or its fiscal agent for any services or supplies provided prior to the effective date of the suspension or exclusion.

6.5.3. No clinic, group, corporation or other organization that is a provider of services shall submit claims for payment to the Department of Mental Health or its administrative agent for any services or supplies provided by a person within such organization who has been suspended or excluded from participation in the Medicaid program except for those services and supplies provided prior to the effective date of the suspension or termination.

6.5.4. When the provisions of Section 6.1 above are violated by a provider of services the Department of Mental Health may suspend or terminate such organization or any individual within said organization who is responsible for such violation.

6.6. Notice of Sanction

6.6.1. When a provider has been sanctioned, the Commissioner of Mental Health or his/her designee shall notify the provider, the Department of Social Welfare, and the Agency of Human Services in writing of the sanction imposed. The letter will also notify the provider of his right of appeal. The provider shall also be notified when a decision is made to take no sanctions.

6.6.2. When a provider's participation in the Medicaid program has been suspended or terminated, the Commissioner or his/her designee may notify the recipients for whom the provider has submitted claims for services, that such provider has been suspended or terminated.

Section 7 Right of Appeal

7.1. The rights of appeal from mandatory sanctions are limited to the appeal rights inherent in the originating authority; i.e., the Medicaid sanctioning authority, the courts, or licensing authority as appropriate to the cause for sanction. A provider may appeal a discretionary sanction within 10 days after notice of such sanction by requesting a hearing of the Secretary of the Agency of Human Services. Unless a timely request for hearing is received by the Secretary, the sanctions shall be considered final and binding. The sanctions imposed shall be suspended pending the outcome of the hearing. However, if payment on pending and future claims has been deferred pending resolution of the discrepancy, such deferment shall be continued. A hearing on the appeal shall be conducted within 30 days of the request, by the Secretary or a hearing officer appointed by the Secretary, under the same rules of conduct as are in current use for hearings before the Human Services Board.

Section 8 Payments and Conditions of Reimbursement

Medicaid payment for mental health clinic services will be made at the lower of the actual charge or the Medicaid rate on file. The provider must accept, as payment in full, the amounts received from Medicaid.

8.1. Except for transportation services, payment rates will be established based on an aggregated state-wide cost by service. The Department of Mental Health retains sole authority to set payment rates.

8.2. Transportation is reimbursed on a cost related fee basis established for each provider.

Section 9 Third Party Liability

Medicaid is the payor of last resort, after all third party medical resources have been applied. A third party is defined as one having an obligation to meet all or any portion of the medical expense incurred by the recipient for the time such service was delivered. Such obligation is not discharged by virtue of being undiscovered or undeveloped at the time a Medicaid claim is paid; it then becomes an issue of recovery. Some examples of third party medical resources are:

a. Medicare (providers must accept assignment)

b. Health insurance, including health and accident but not that portion specifically designated for "income protection" which has been considered in determining recipient and veteran programs, workers' compensation, etc.

c. Liability for medical expenses as agreed or ordered in negligence suits support settlements, trust funds, etc.

Notes

13-004 Code Vt. R. 13-150-004-X

Effective Date: July 1, 1986 (SOS Rule Log # 86-24)