Information on Required Provider Monitoring
LME/MCOs are required by statute (NC GS § 122C-111) to monitor public mental health, intellectual/developmental disability and substance abuse services. Types of monitoring include routine monitoring utilizing the State-mandated DHHS North Carolina Monitoring Process for LME/MCOs, and targeted monitoring to address grievances, complaints or quality of care concerns. All providers with the exception of those providing only hospital, ICF-MR or therapeutic foster care services are monitored.
Routine monitoring is conducted at a minimum of every two years using the tools and process developed by the Department of Health and Human Services through the NC DHHS-LME/MCO-Provider Collaboration Workgroup. Information regarding monitoring requirements and the monitoring process is available on the provider monitoring page of the NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services (DMH/DD/SAS) website. The monitoring tools are available here on the DMH/DD/SAS website.
The State of North Carolina has made changes to the provider monitoring process. As stated in the LME-MCO Communication Bulletin #J254, while providers who are fully accredited by an accrediting body (CQI, COA, CARF, The Joint Commission) will no longer require a “routine” monitoring, the every two-year post-payment review will continue. As a result of this change some items were added to the post-payment review for ALL agencies (accredited and non-accredited) and licensed independent practitioners. Those items are:
- Is there evidence the provider agency meets the access standards related to appointment availability (emergency, urgent and routine need)?
- Is there evidence the provider agency meets the access standards related to Office Wait Time (scheduled, walk-ins and emergency)?
- Is there evidence the provider agency provides physical access, reasonable accommodations, and accessible equipment for enrollees with physical or mental disabilities?
- The question regarding coordination of care has been moved from the routine monitoring tool to the post-payment tab.
Practitioner solo and group practices as well as agencies which provide only outpatient behavioral health services are monitored using the DHHS Review Tool for Routine Monitoring of Licensed Independent Practitioners. All other providers are monitored with the DHHS Review Tool for Routine Monitoring of Provider Agencies using the sub tools required by the services which that agency provides. Routine monitoring may be comprised of a routine monitoring tool and a post-payment review or a post-payment review alone. Only the post-payment review tool is completed for providers of services provided only in licensed facilities which are monitored annually by DHSR.
The provider monitoring tools have been revised and the new tools were implemented October 1, 2015. Most revisions were minor. The major changes were the addition of a post payment review for therapeutic foster care which will begin with claims dates October 1, 2015 or later, and changes to the site visit tools for new unlicensed sites and unlicensed AFLs. You can access a presentation An Update on Routine Provider Monitoring which describes the changes to the tools.
Each tool contains detailed guidelines which describe the compliance criteria for each item on the tool and the citation for the regulations, State service definitions or clinical coverage policy on which the criteria are based. To obtain inter-rater reliability within Alliance and between LME/MCOs, monitoring tools are scored according to guideline requirements. To prepare for a review it is strongly recommended that providers self-audit using the monitoring tools and guidelines.
Providers are expected to be familiar with the regulatory and service definition requirements cited in the guidelines. These include but are not limited to:
Clinical Coverage Policies located on the Division of Medical Assistance (DMA) website. Behavioral Health Policies are Section 8.
State-Funded Service Definitions located on the DMH/DD/SAS website.
State Regulations located on the DMH/DD/SAS website.
The documents located under the State Regulations section of this page include the Administrative Rules governing MH/IDD/SAS services, Confidentiality Rules, Client’s Rights and Records Management and Documentation requirements.
Monitoring tools are scored in accordance with the guidelines provided with the tools. The tools score automatically and note when providers have not met threshold standards. Providers who have not met the threshold defined on the tool or who demonstrate systemic compliance issues will be issued a statement of deficiencies and will be required to submit a plan of correction. In addition, any claim date of service cited out of compliance on the post- payment review shall be identified as an overpayment and require a payback to Alliance through the recoupment process. If the provider disagrees with the monitoring action taken, plan of correction, or recoupment, they may request reconsideration as outlined in their results letter.
Follow up with providers who are required to complete a plan of correction will follow the DHHS Policy and Procedure of the Review, Approval and Follow-Up of Plan(s) of Correction (POC), Policy N. ACC002, Revision Date 12/10/2008.
Failure to submit an acceptable Plan of Correction or substantially minimize or eliminate deficiencies will be presented to the Alliance Corporate Compliance Committee and may result in sanction up to and including termination from the Network. Access a presentation on Developing an Effective Plan of Correction as well as an Introduction to Quality Management.
Providers may request technical assistance regarding the Review or Plan of Correction requirements and processes from the provider monitoring team. Technical assistance will not include previewing provider information to determine if it meets compliance criteria.