According to an article on NJ.com, the U.S. Department of Health and Human Services examination of 100 claims submitted by the state of New Jersey for reimbursement of outpatient mental health Medicaid services revealed only 8 complied with federal and state requirements. New Jersey may have to reimburse Medicaid $95 million dollars.
Typical case management software for behavioral/mental health includes case notes, but clinicians are focused on care not on system functionality, as they should be. The clinician is completing their role by inputting the case notes, but case notes are unstructured data. They may document what issues and actions were taken for the day, but do not necessarily provide a means for rule compliance, such as adding or approving a service needed by the patient to the plan. Technology should support making the clinician and caseworker’s job easier not harder. Case management software that allows authorized users to add services on an ad hoc basis within business rule limits and authority can provide the oversight the US Department of Health is recommending.
To avoid these types of audit and compliance dilemmas, health, and human services agencies can implement systems that include provider collaboration and business rule technology. With a collaborative case management system and business rule technology, only approved services would be displayed to the provider and allowed to be submitted for reimbursement. The provider then has a vested interest in assuring that the delivered services are included in the system and approved prior to being submitted to Medicaid for reimbursement.
Treatment of individuals needs to be fluid and easily documented, but oversight is improved with business rules that put limits on the services/dollars that can be added after the overall plan is approved, so flexibility cannot be abused. Business rule technology allows limits to be set based on multiple criteria to provide the greatest granularity and flexibility giving the provider or caseworker the ability to add a service to the plan or case in an ad hoc manner within a specified dollar amount or type of service.
Additional oversight can be added by including business analytics of ad hoc services added within an aggregate amount per patient, by caseworker and provider to surface trends or indicators of rule abuse or fraud.
Click to learn more about HHS Case Management and business rule technology. RSM US LLP is a leading provider of audit, tax and consulting services focused on the middle market. We guide our clients through business challenges by understanding their needs and bringing together the right team to address them. With 9,000 professionals and associates in 86 cities nationwide and access to more than 38,300 people in 120 countries through our membership in RSM International, we can meet your needs wherever in the world you do business.
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by Pat Hayes for RMS