Medicaid Compliant Documentation
Answered
I was recently audited by medicaid and all 40 of my claims were deemed "insufficient" in terms of what is called "General Medical Record Documentation Requirements"
I have placed a call to the auditor to obtain more specific information about what was missing that caused my notes to be deemed "insufficient" I am not certain whether they will return my call or answer my question. So.....
From the Medicaid Provider Manual, these are the topics that must be covered.
As you read this list, has anyone treating clients on Medicaid actually been audited and passed the audit? If so, I would really like (need) to know how you managed to provide all of this information in SimplePractice. As it stands, if I cannot successful appeal the audit department's decision, I will be required to pay back several thousand dollars in claims that were initially paid.
I need a system in place NOW that will allow me to provide all required information in compliant form.
Any help and advice would be greatly appreciated
Here are the required items:
- (Mandatory) All entries are legible to individuals other than the author, dated (month, day, and year), and signed by the performing provider.
- (Mandatory) Medicaid-enrolled providers must submit claims with their own TPI except when under the agreement of a substitute provider or locum tenens.
- (Mandatory) Each page of the medical record documents the patient’s name and Texas Medicaid number.
- (Mandatory) A copy of the actual authorization from HHSC or its designee (e.g., TMHP) is maintained in the medical record for any item or service that requires prior authorization.
- (Mandatory) Allergies and adverse reactions (including immunization reactions) are prominently noted in the record.
- (Mandatory) The selection of evaluation and management codes (levels of service) is supported by the client’s clinical record documentation. Providers must follow either the 1995 or 1997 Documentation Guidelines for Evaluation and Management Services published by CMS, when selecting the level of service provided.
- (Mandatory) The history and physical documents the presenting complaint with appropriate subjective and objective information.
- (Mandatory) The services provided are clearly documented in the medical record with all pertinent information regarding the patient’s condition to substantiate the need and medical necessity for the services.
- (Mandatory) Medically necessary diagnostic lab and X-ray results are included in the medical record and abnormal findings have an explicit notation of follow-up plans.
- (Mandatory) Necessary follow-up visits specify time of return by at least the week or month.
- (Mandatory) Unresolved problems are noted in the record.
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HI, I'm so sorry this happened to you. I just took a training on documentation and many of the things that were covered (and mandated by medicare audit) are not incorporated in Simple Practice. It's really scary, b/c I assumed that Simple Practice would ensure compliance! The trainers name is Beth Rontal, LICSW.
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Agreed, this is a huge gap in services that I was hoping this system provided.The EHR program that I had before ensured compliance if form was completed correctly (I don't know if I would have switched over had I known). Let's create the forms and find a way to "share" with each other.
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Hi Patrick, SimplePractice offers full customization on your Note and Form templates. We recommend adjusting your Note and Form templates to include the fields required by insurance payers, and reach out to insurance payers individually for clarification on their requirements. Rhonda, we're working on updating the print layout of progress notes to help make documentation easier to understand and more readable when responding to an audit.
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Gillian,
I don't think the input note template is the issue. I think the printed report is the issue. Medicaid guidelines mandate that every page of a progress note have the date of service, client name, and page numbers (e.g. Page 1 of 2). Users of Simple Practice are not able to modify the format or fields of the printed report.
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Hi Patrick, thanks for clarifying - we're working on updating our print Progress Note layout, and welcome your feedback on our Ideas board here: https://simplepractice.uservoice.com/forums/918553/suggestions/36553009
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Did you have the exact session time documented in your notes? I just went through an audit and because the time on the note was generated by the scheduled time they are asking for me to pay back everything. I am beside myself about this. Is this something Simple Practice is aware of? Have others had this issue?
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Cherie,
My documentation was like yours, using the system generated time for each session. The problem I have is that I don’t know if I was penalized for that because the audit department has refused to provide me those details. I recently appealed my audit and I am waiting for their decision. I may know more then. Crazy.
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I am just getting started in my practice and I am using Simple Practice as well. One issue I see is that as Medicaid Providers we need a way to get an actual signature (not just a checkbox). I can't find a way on the forms I am creating to get the system to insert and actual online signature requirement besides the checkbox method. I probably am missing this in the platform can anyone shed light on this issue?
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Hi Everyone, thank you all for alerting us to this issue! Until recently, our alternative workflow of customizing Progress Note and Intake Form Templates to include information like a client's Medicaid Number and the exact start and stop time of their appointment held up in audits. We really appreciate you sharing your experiences with us, we hear you and want to make sure you're getting paid for services rendered. I'm sorry to be responding so late to some of your comments. I've relayed your concerns to our Product Team and they're currently looking into how to best address the documentation requirements mentioned in this thread. I'll let you know of any updates I hear from them, but in the meantime, continue to customize your Progress Note and Intake Form Templates to include information Medicaid requires that's missing from our default documentation. Go to your Settings > Notes & Forms, select each template that you frequently use to edit them and add fields for appointment start and stop times, as well as the client's Medicaid Number. All documents in your client's Medical Record should have the client's name on each page, the page count, the client's date of birth and the clinician's information. If the eSignature provided by our system isn't meeting Medicaid requirements, you can print the documents and add wet signatures. Our eSignatures hold up legally, but if this isn't your experience when submitting to Medicaid audits, please let us know. Thank you again!
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