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Mental Health Care and Regulatory Compliance within the Long-Term Care Setting
ACT psychology and
psychiatry providers assist facility staff in helping residents
attain or maintain the highest practicable level of physical,
mental, and psychosocial well-being.
As your mental health provider and active member of nursing
facility teams, ACT helps facilities meet OBRA requirements and
provide quality care.
ACT strives to ensure that
services provided to long-term care residents are medically
necessary and that our marketing, administrative, and billing
practices are compliant with Federal, State, Local and Payer
regulations. Assurance
of compliance not only benefits our patients, but also benefits
facilities since there may be some facility liability when practices
are not compliant with these regulations.
The following Medicare practice
guidelines and federal regulations apply to psychiatric and
psychological services.
Referral for Services
In 1996, a report by the Office
of the Inspector General pointed out that, among practices that may
be suggestive of fraud or abuse and should be questioned is “case
finding” (practitioners requesting unlimited access to resident
medical records). Nursing
facility staff cannot directly refer residents for psychiatric
services, as Medicare requires that the attending physicians make
the referrals.
ACT staff work with
facility staff to help them identify needs of residents that can be
addressed through our services.
A written order by the physician is required for initiation
of services for residents of nursing facilities. In Rest Homes/
Assisted Living Facilities, a doctor’s order is preferred, but not
required.
Consents
Before submitting a claim to
Medicare, the provider must obtain the written signature of
the patient or health care power of attorney authorizing the release
of information necessary to process the claim.
Patient authorizations may be signed in advance of need, but
written signatures are required; verbal or telephone consents do
not comply with Medicare standards.
In nursing facilities,
Medicare requires the written order of the attending
physician for psychiatric and psychological services.
Unless co-signed by the physician, Medicare does not accept
the orders of nurse practitioners or physician assistants.
Verbal orders do not comply with Medicare rules.
Free Services
Provision of free services of
significant value or services at below market value to induce
referral of patients could be considered a violation of the Federal
Anti-kickback Statute. Such
services could include extensive free in-service training for
facility staff or provision of pro-bono services to facility
residents.
ACT
does make brief staff training available to its contracted
facilities, but limits free in-service training to one 20-30 minute
session per quarter to ensure that the value of free services does
not violate anti-kickback regulations.
ACT will gladly provide more extensive, formal staff training
on a facility paid basis to support our customers.
ACT is also happy to provide contact information for your
local, state funded Geriatric Specialty Team that provides free
training on-site through the Local Management Entity (LME) in your
area.
Co-Payments
Medicare requires billing of
co-pays, even for people who receive Medicaid.
Marketing even the intention to generally waive collection of
Medicare coinsurance/deductible amounts is unlawful and may violate
laws pertaining to false claims and kickbacks.
Waivers made for the majority, i.e., more than 50% of
Medicare patients for any reason other than disproportionate billing
costs are unlawful, unless reasonable collection efforts were made.
While
ACT does not utilize collection agents, ACT does make reasonable
efforts to collect the amount designated as patient responsibility.
Many dually eligible nursing facility residents are able to
receive assistance in payment through the Unmet Medical Needs
program, accessed through their DSS caseworker.
Appropriate Psychotherapy
Services
Psychotherapy services,
including behavior management, are not covered when documentation
indicates that dementia has produced a severe enough cognitive
defect to prevent establishment of a relationship with the therapist
which would allow insight-oriented therapy to be effective.
Individual and group psychotherapy are inappropriate
treatments for patients with advanced dementia or profound mental
retardation.
As part of their initial assessment, ACT psychologists evaluate each
patient’s cognitive ability to ensure that psychotherapy services
are planned only for those patients who would reasonably be expected
to benefit from these services.
Frequency & Duration of Psychotherapy
The usual and customary
outpatient standard is for weekly services.
Utilization of services should be consistent with local,
acceptable, community standards of practice.
Individual patients with a high acuity of symptoms (i.e.
suicidality) might require more frequent sessions; justification for
increased frequency should be explicitly documented in the clinical
record to support medical necessity.
As patients improve and approach discontinuation of therapy,
services are typically provided at reduced frequency.
Medicare does not place
arbitrary limits on the number of services or length of the course
of treatment. However,
Medicare does require that the rationale for any departure
from the plan or extension of therapy needs to be documented in the
medical record. In
situations when prolonged treatment, in excess of 20 sessions for
example, has no evident benefit, it would be considered not
medically necessary and not payable by Medicare.
Practice standards call for treatments to be discontinued
when it becomes clear that the patient has reached maximum benefit.
OBRA Compliance and Psychiatry
The medical regimen must be
consistent with the resident's assessment and the interdisciplinary
care plan.
ACT psychiatry providers ensure
that psychotropic medications are prescribed consistent with patient
medical diagnoses. Dosage
reductions are attempted unless medically contra-indicated.
When it is necessary to exceed Beers criteria, the medical
necessity for the exceptions is well-documented
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Tuberculosis
ACT requires all clinicians to
obtain a TB test on a yearly basis.
Since this requirement was initiated at the beginning of
2004, several people have asked why it is necessary.
Health care workers in general are more at risk of coming in
contact with TB germs then the rest of the population.
Testing should be done to determine if you have been exposed
to TB germs or if you pose a risk to others.
Here is some general information about TB.
TB is a disease that is spread
from person to person through the air.
It usually affects the lungs, but it can also affect other
parts of the body, such as the brain, kidneys or spine.
TB germs are put into the air when a person with TB of the
lungs or throat coughs or sneezes.
When a person inhales air that contains TB germs, he or she
may become infected. People
with a TB infection do not feel sick and do not have any symptoms.
However, they may develop TB disease at some time in the
future. The symptoms of
TB disease include feeling sick or weak, weight loss, fever and
night sweats. The symptoms of TB of the lungs include coughing, chest pain
and coughing up blood. Other
symptoms depend on the part of the body that is affected.
Latent TB infection is not TB
disease. People with
latent TB infection have the germ that causes TB in their bodies but
the germs are inactive. They
cannot spread the germs to others.
However, these people do face the possibility of developing
the disease in the future.
If a tuberculin skin test
results are positive, you should have a chest radiograph as part of
the initial evaluation. If
the chest radiograph is negative, repeat chest radiographs are not
needed unless symptoms develop.
A positive reaction to the tuberculin skin test usually means
that the person has been infected the TB germ.
It does not mean that the person has TB disease.
People who have a positive reaction to the skin test but who
do not have the TB disease cannot spread the germs to others.
There are drugs to treat the infection and prevent it from
developing into TB disease.
A person that has been
identified positive for TB disease can be treated.
Taking several drugs for a 6 to 12 month period can cure TB
disease. It is very
important that people who have TB disease take the drugs exactly as
prescribed by their medical doctors.
Stopping the drug too soon or not taking it correctly may
result in germs that are still active resistant to those drugs.
TB that is resistant to drugs is harder to treat.
If you think you have been
around someone who has TB disease, you should go to your doctor or a
local health department for tests.
It is important to remember that people with TB infection but
not TB disease cannot spread the germs to other.
However, seeking medical advice for the treatment of TB
infection to prevent future problems or TB disease for cure is
imperative.
Source:
CDC Centers for Disease Control and Prevention.
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