Reduction, Appropriate Use and Justification of Case Management Units
The Medicaid Services Unit-ADvantage Administration (MSU-AA) met with members of the Home and Community Based Services (Provider) Council to discuss cost saving measures due to the DHS budget allocation, that would potentially avert an implementation of an enrollment freeze for applicants to receive ADvantage services. An imposed enrollment freeze would cause a waiting list of ADvantage applicants as well as disallow closed Members to reactivate closed or pended eligible cases. The Provider Council presented several options for cost-savings that would have a lesser impact to Members and applicants. The discussions resulted in agreeing to the following: Effective immediately, Case Management units (T1016), will be authorized at 175 units per year. Authorization of 175 units represents about a 15% increase above the average Case Management units that were billed during FY17. Limiting authorizations at this level will contribute to generating the much needed cost savings to continue to operate the ADvantage Program without jeopardizing enrollment to eligible applicants. Requests received for Case Management units after this date that request more than 175 units will be authorized at the 175 units limit. All Case Management units will be systematically prorated and converted to meet the new guideline, and a Conversion Provider Report will be sent through SmarterMail to all Providers, after August 1, 2017.
This change will require careful planning on the part of the Case Manager to ensure that Case Management units are used appropriately and efficiently in order to maintain coverage of the Member through the end of the Service Plan year. To support the appropriate use of the 175 authorized units, and to reduce the likelihood of additional units requests, Case Management Providers are encouraged to closely review the billable vs. non-billable activities below, and ensure usage of T1016 strictly adheres to these guidelines. Unit adjustments that occur when a Member transfers Case Management Providers will be prorated, utilizing a set amount of units based on the amount of time the Member has remaining in their service plan year.
Requests for Increase Above 175 Case Management Units
Requests for increases above 175 Case Management units must be related to exceptional circumstance(s) and will be stringently reviewed for cost-effectiveness Professional documentation detailing the extraordinary circumstances and Case Management units used must be reported on the attached Case Management Unit Increase Justification Form. The requests for Case Management units, above the 175 authorization limit, should be a rare occurrence and will require extensive justification. All justifications must be submitted electronically, with a corresponding addendum, via Provider Question. Please allow 60 days processing time for review of justification documentation. Please note that we will not accept requests via fax or mail. Those received in this manner will be shredded and no notification will be sent to the Provider.
Billable Case Management Activities
A billable Case Management activity is any task or function that only an ADvantage Case Manager, because of skill, training or authority, can perform on behalf of a Member.
All billable activities must be based on actual clock-time used to complete an activity.
- Scheduling the interdisciplinary team, or IDT, meeting
- Facilitating the IDT meeting
- Researching service options outside the ADvantage program
- Obtaining information or documents required for service authorization that the Member and/or family is (are) unable to obtain without assistance, such as prescriptions, prices, HCPCS codes, etc.
- Obtaining service plan authorization
- Arranging for and initiating service implementation
- Coordinating both formal and informal supports
- Member advocacy
- Monitoring contacts with the Member
- Monitoring contacts with other supports if the Member is unable to provide reliable information
- Reviewing intermittent skilled nursing evaluations
- Revising the service plan to meet changing Member needs
Non-Billable Case Management Activities
A non-billable Case Management activity is actions that do not require the skill, training or authority of a Case Manager in order to be completed.
Practices, such as billing a set number of units per activity (billing two (2) units for each phone call, two (2) units for review of each RN evaluation, etc.) are disallowed.
- Activities completed by anyone other than a certified ADvantage Case Manager
- Services provided by more than one Case Manager at the same time
- Clerical tasks, such as mailing, copying, filing, faxing, preparing packets, etc.
- Unsuccessful attempts to contact the Member or collateral supports
- Drive time
- Supervisory activities
- Activities specific to Quality Assurance and Improvement (QAI), even if completed by the Case Manager. This may include time spent in case review and for completing agency-required documentation solely for Continuous Quality Improvement (CQI) purposes
- Correcting Case Manager errors
- However, time spent correcting errors made by MSU-AA are billable.
- Time spent at staff meetings
- Time spent at case conferences
- Exception: Time spent to staff a Member’s individual case for the purpose of problem-solving is a billable activity. In the event this case staffing occurs during a meeting where multiple Members’ issues are discussed, only the time spent for discussion of the particular Member’s issue may be billed for that Member.
- Contacts with support staff within the Case Manager’s Provider agency, such as checking to see if a document was faxed, if a prescription was received, if a call was returned, etc.
- Time spent on duplicate documentation, such as completing monthly monitoring on an agency-specific form, then restating the same information in a narrative format in the Member’s record
- Time spent for visits and/or phone calls unrelated to the Member’s person-centered service plan, even if those contacts are with the Member and/or collateral supports
- Example: Member calls Case Manager to tell her that her daughter came to visit with her family, they stayed over for Thanksgiving. Daughter did all the cooking, they had turkey, ham and all the fixings, etc.
- Monitoring contacts with other supports if the Member is able and willing to provide reliable information
- Time spent providing direct medical, social, educational or other services (paying a Member’s bills, scheduling medical appointments, arranging transportation, educating on diabetes self-management, etc.)
- Educating a Member about the ADvantage program, services, requirements, etc., is a part of Case Management services. Specific education needs should be performed by the most appropriate entity. For example, diabetes self-management education would be most appropriately provided by the skilled nurse
- Time spent for billing, claims and collection activities
- Scheduling and/or supervising personal care services
We appreciate all of your dedication to providing quality services to ADvantage Program Members. We are looking at other cost-savings options for the programs. Please expect additional notifications of such items.
If you have any questions regarding the information provided above, please feel free to contact us via SmarterMail at: email@example.com