Clinical Documentation Review:

Compliance Risk Assessment and Risk Attenuation Planning

Purpose

Provider organizations nationally are concerned about their ability to survive a state or federal documentation audit and/or payer audits in the new value-based environment. This concern has been heightened in recent years due to devastating financial takebacks which have occurred as part of the Medicaid, Medicare, and commercial managed care audit process. Increasingly, payers are tying reimbursement to the quality of the documentation, with evidence of Medical Necessity and the Golden Thread in documentation being an expected measure for CCBHCs and beyond.

Process

Documentation Review

  • 1-hour kick-off meeting with the project team to review roles, responsibilities, and timeframes.

  • Consultant review of state, local, and other documentation standards used in local auditing, internal clinical documentation policies, procedures, and guidelines, internal documentation audit tools, and documentation forms and formats including intake assessment/assessment updates/treatment plans/treatment plan reviews/progress notes (including any specialized note formats such as group, individual, etc.), and relevant outcome measurements.

  • Expert consultant review of 10-15 provided clinical records selected via guidelines provided by the consultant, with additional chart reviews possible depending on the scope of the consultation.

  • Deliverables

    • Detailed report of findings based on the review of materials submitted, including prioritized recommendations for risk attenuation.

    • 2-hour Leadership major findings review and Q&A session with expert consultant, leading to action plans and steps for immediate initiation.

    • 3 hours available for Staff documentation training based on specific findings for the organization with changes and clinical actions that can be made immediately post-training to improve documentation quality and lower risk.

Timeframe: 3 months

Outcomes:

  • Generate a significant risk reduction.

    Significant time savings related to time spent on documentation processes versus what is happening now.

    Enhanced documentation quality, improved client outcomes, and greater group practice processes unification.

Individual Center Cost

Varies according to scope of work; contact MTM for a more detailed discussion

MTM Team

LMHC, MCAP, QCS
Workforce Development & Process Change Consultant