Chpater 2 page 15 states that "Each therapy session must contain the dated co-signature of the supervising provider within one business day from the date the service was rendered.... "   However, Chapter 4, page 4 states "Each therapy session must contain the co-signature of the supervising qualified Medicaid enrolled providers on the date the service was rendered..." Also in Chapter 4, page 4 there is the same statement from Chapter 2, page 15 "Each therapy session must contain the dated co-signature of the supervising provider within one business day from the date the service was rendered.... "  Are LMHPs expected to sign on the date the service is rendered or within one business day?

I would strongly recommend that the criteria for the components of a psychiatric evaluation under the Psychiatric Services Manual and the components of a Comprehensive Needs Assessment under the CMHRS Services Manual should be alligned.  This is especially critical for individuals coming into services with CSBs through regional reinvestment projects who are being referred to bridge appointments with our pshyciatrists.  If an individual is seen for a psychiatric evaluation by a psychiatrist, they should not need to undergo a seperate Comprehensive Needs Assessment is there is a need for these individuals to receive CMHRS services.

Psychiatric Services Manual; Chapter IV, under the section for outpatient services (pages 31 - 39); page 32 starts the changes with "Physician Direction of Mental Health Clinic" he majority of the guidelines are outlined on page 33.  

I would like to respond to the noted above changes in the Manual which affect patients and private providers adversely.

1.The notices were not posted in a timely manner for providers to reply to the posting. Few professionals have knowledge of these new changes.

2. The state of Virginia allows licensed providers (LCSW, LPC, etc) the right to practice autonomously. The changes listed forces the provider to have a medical doctor sign off on documents that the provider can legally do on their own in Virginia. Naturally this takes more time and paperwork.

3. The physician must sign off on a referral then it must be authorized by the MCO before the client is seen. Once again this takes time and more red tape for the provide and then the client. What if the client needs mental health assistance asap?

4. The new changes also takes the right to choose a physician from the client. What if the client does not prefer the physician that is affiliated with the mental health practice?

5. These changes affect the rural communities in a negative manner.  In rural Virginia there are very few mental health providers, and this will inhibit them even more by not allowing them the autonomy to practice without medical input on each case.

6. Why have the proposed changes been kept so quiet and the Medicaid recipients not been notified of these changes?

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Physician Direction of Mental Health Clinics

The requirement (chapter IV pages 32 – 33) for a physician to ‘assume professional responsibility… have a face to face visit with the individual, prescribe the type of care provided, and … periodically review the need for continued care’ will have a negative impact regarding outpatient therapy services being available in rural areas of the Commonwealth.  The reimbursement rate for outpatient therapy is one of the lowest rates for all services, and  the provider must be a licensed clinical professional (or staff working on licensure with weekly supervision by a licensed staff).  This low reimbursement rate for licensed staff is already a burden for providing therapy services.  Fiscal challenges exist without the addition of financially supporting the requirement of a physician to be part of the process (including conducting a face to face interview) for everyone receiving outpatient therapy.  FY 18 we served over 325 children/adolescents with mental health diagnoses through outpatient therapy services (assessment, individual, and/or family therapy).  Of those served, approximately 90% were Medicaid customers.   If these guidelines become effective, I’m uncertain if we will be able to provide outpatient therapy; and unfortunately, there are few private providers in our rural area.  I am concerned therapy will no longer be available for Medicaid recipients in rural Southwest Virginia.  We will need a list of local providers who will meet these new requirements to assist with referrals if they become effective.  Currently, we coordinate services with Primary Care Providers, and refer therapy cases in need of medical assessment / care to physicians or medical providers as part of the treatment process.  We have several medical providers that refer their patients to us for treatment while they provide mental health medications. If a regular Family Nurse Practitioner could provide the oversight and complete the face to face interview (and other requirements) in the place of a physician; it would cause a fiscal burden, but improve the likelihood that providers continue to offer these needed services. Please reconsider the requirement to have physicians direct outpatient therapy services. 

Physician Direction of Mental Health Clinics

This Community Services Board operates in a very rural area of the Commonwealth.  Outpatient therapy is one of the core services that our CSB offers.  It is a service that often times prevents the need for more intensive and more restrictive services.  Requiring a physician to provide oversight, including conducting a "face-to-face visit with the individual, prescribe the type of care provided, and if services are not limited by the prescription, periodically review the need for continued care,"  would place extreme financial and workforce development burdens on providers.  In an area that is impoverished, and in an ongoing drug epidemic, placing such extreme requirements will restrict the areas ability to provide quality, lesser restrictive treatment to our population.

The Psychiatric Services Manual, does not appear to reference "Comprehensive Needs Assessment", as does the CMHRS Manual.  Does this mean if and individual needs outpatient counseling, case management services and intensive in home services at the same initial encounter with the CSB, that more than one "assessment document/intervention, must be completed?

1 comment and 1 question:

Regs state Providers must report any knowledge of adverse outcomes for an individual currently receiving services or who have been discharged from services within 180 days of the incident.

Comment: It is not within the means of a provider to continue to be aware of or track adverse events of consumers once they have been discharged from services . This requirement puts an unjust burden on the provider and will likely be a requirement that the provider will always be out of compliance. It would make better sense to have this be an expectation of the Care Coordination activities of the Health Plans.

Question: Based on the additional language added that addresses physician directed services and Community Mental Health Clinics, it appears that the current MH Clinic Manual will likely be retired effective 08/01 and all psychaitric services will fall under the Psychiatric Manual effective 08/01. Is this accurate?  If this is accurate, are there any contracting implications ? Will this affect any current contracts based on whether, as an agency, we are contracted as physician directed under the current MH Clinic Manual or contracted as not under the current Psychiatric Manual? Please clarify and advise.

Comment: Chapter IV, pp. 31-34 – Outpatient Psychiatric Services: The requirement for a physician to ‘assume professional responsibility… have a face-to-face visit with the individual, prescribe the type of care provided, and … periodically review the need for continued care’ will have a negative impact regarding outpatient therapy services being available in rural areas of the Commonwealth.  I am concerned individual and family therapy will no longer be available for Medicaid recipients in rural southwest Virginia.  Please reconsider the requirement to have physicians direct outpatient therapy services.  We do coordinate services and refer therapy cases in need of medical assessment and / or services as part of the treatment process.   If a regular Family Nurse Practitioner could provide the oversight and complete the face-to-face assessment and other requirements in the place of a physician, it would improve the likelihood that providers continue to offer these needed services.

Comment: Chapter IV, pp. 32 & 33 – Physician Direction of MH Clinics: The last paragraph on page 32 indicates that there must be direct personal supervision of a physician present whereas the second paragraph on p. 33 indicates that the physician does not have to be on the premises. These two paragraphs needs to be reconciled.

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Chpt 2 page 15

"each patient’s care must be under the supervision of a physician directly affiliated with the clinic. To meet this requirement, a physician must see the patient at least once, prescribe the type of care provided, and, if the services are not limited by the prescription, periodically review the need for continued care"

"physician must assume professional responsibility for the services provided and assure that the services are medically appropriate"

This would greatly impact CSB's abilities to provide timely outpatient counseling services and be a huge burden on rural communities who are already struggling with providing enough available doctor time to cover clients who are in need of medication management. This requirement would be very restricting to whom we could provide outpatient therapy services to.

Chapter IV, pp. 32 & 33 – Physician Direction of MH Clinics: The last paragraph on page 32 indicates that there must be direct personal supervision of a physician present whereas the second paragraph on p. 33 indicates that the physician does not have to be on the premises. These two paragraphs needs to be reconciled.  However, if page 32 stands then CMCSB will be faced with reducing and/or eliminating our clinic services due to only having a part-time psychiatrist and full time Nurse Practitioners.  This would have a major adverse effect on the individuals we serve.  Plus the Virginia General Assembly increased the scope of practice for Nurse Practitioners this year and I recommend that these regulations reflect that so we (CMCSB) can continue providing our current level of clinic services. 

The proposed language requires an initial plan of care to be completed prior to services starting.  How can this be done and be person centered which means that it is developed in collaboration with the individual?  Typically this would be done during the first service appointment.

Outpatient therapy is one of the primary services that our CSB offers. Requiring physician direction as described in the manual that includes but not limited to, a "face-to-face visit with the individual, prescribe the type of care provided, and if services are not limited by the prescription, periodically review the need for continued care,"  would place a financial as well as a workforce barrier on us as well as many other agencies that provide this service. I would ask that this is reconsidered. 

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The requirement for Physician directed services has been added to this manual.  This requirement will place an extraordinatory burden on the CSB's when we are already faced with a workforce shortage in psychiatry.  If this language remains it will result in increased barriers to care and limited access at a time when the state is encouraging initiatives that improve access..  There is barely sufficient psychiatry and/or nurse practitioner availability in the rural areas of our state to meet the medication needs for those we serve.  I encourage you to strongly reconsider this requirement in this manual.

Section VI, page 10 -the language in this section indicates that all services require a comprehensive needs assessment which must be completed "face to face by an LMHP, LMHP-S, LMHP-R, or LMHP-RP.” This contradicts Chapter 4 in the CMHRS provider manual which indicates that Case Management services assessment can be conducted by QMHPs.  Please clarify.

The requirement for Physician directed services has been added to this manual.  This requirement will place an extraordinatory burden on the CSB's when we are already faced with a workforce shortage in psychiatry.  If this language remains it will result in increased barriers to care and limited access at a time when the state is encouraging initiatives that improve access..  There is barely sufficient psychiatry and/or nurse practitioner availability in the rural areas of our state to meet the medication needs for those we serve. And if this must stay, it does not appear to allow us the ability to provide even three sessions or thirty days (whichever is soonest) before the F2F evaluation  I encourage you to strongly reconsider this requirement in this manual.

Chapter II

1. Pg. 16, Adverse Outcomes: Suggest that the reporting requirements align with the DBHDS serious incident reporting requirements which do not require providers to report incidents for individuals who have been discharged from their services.  Providers should not be required to monitor and report adverse outcomes for individuals who have been discharged from their services. The treatment relationship has ended and reporting incidents would be a violation of the individual’s privacy.

2. Pg. 14, Provider Qualifications for OP Psychiatric Services: DMAS allows LMHP-Rs, LMHP-Ss, and LMHP-RPs to provide OP Psychiatric Services under the direct supervision of an LMHP. However, not all the Medicaid MCOs allow or reimburse for services provided by an LMHP-R, LMHP-S or LMHP-RP under the LMHP, unless the provider is with a CSB. Would recommend that language be included in this Manual to refer providers to the MCO before utilizing LMHP-R, LMHP-S, or LMHP-RP to provide OP services.

3. Page 15, Mental Health Clinic requirements:  Including the Mental Health Clinic provider manual information into the Psychiatric Services Manual is now confusing.  Perhaps some language could be added to differentiate between what qualifies as a Mental Health Clinic versus a group OP practice/agency providing OP Psychiatric Services?

Chapter IV

1. Page 31 – If OP psychiatric services will now be allowed to be provided in the school setting to cover the counseling component of the TDT program, suggest adding the school as an allowed place of service.

2. Page 31 – Including the Mental Health Clinic requirements under the OP Psychiatric Services section is very confusing and implies that all OP providers are subject to these physician-directed requirements. Perhaps the Mental Health Clinic specific information could be moved to its own section.

3. Page 37 – “The individual must participate and be compliant with treatment (e.g. some individuals with intellectual disabilities [ID] or children may not have the ability to understand the treatment).”.  In the Psychiatric Services Provider Manual, it indicates that children may not have the ability to understand the treatment of OP psychiatric services, yet in the CMHRS Provider Manual, individual, group and/or family counseling, which can be provided through Outpatient psychiatric services, are a REQUIRED component of the services provided to children (TDT and IIH specifically) and providers can be cited for not providing those components of the CMHRS services. There seems to be a contradiction here on whether counseling/OP psychiatric services are appropriate for children.  In all cases, shouldn’t clinical necessity and appropriateness of the service be determined by the LMHP completing the Assessment or Diagnostic Interview? Can this be clarified in both manuals?

4. Page 39, Telemedicine Services:

   • The LMHP-R, LMHP-S, and LMHP-RP are not listed as eligible “remote providers” in the May 13, 2014 Medicaid Memo.  As the Psychiatric Services Manual includes these as Providers, under the supervision of the LMHP, can they also provide Telemedicine Services?  Please clarify here or perhaps updates are needed to the May 13, 2014 Memo.

   • “Schools” are not listed as an approved “originating site” in item g. of Attachment A of the May 13th Memo.  If DMAS is going to allow the school-setting to be a reimbursable setting for OP Psychiatric Services to cover the counseling component of the TDT service, can it also be an approved “originating site” for the use of Telemedicine?

5. Care Coordination – Recommend that some language be included on the requirement for Care Coordination with any concurrent CMHR and other services.  Counseling is a required component of many of the CMHR services which may be provided as OP services and if OP providers are not obligated to coordinate services with other providers this may impede the CMHRS provider’s ability to comply with their requirements for care coordination.

Chapter VI

1. Page 4, Notes for therapy sessions: The first paragraph indicates that if the therapy session was conducted by a Resident of Supervisee, the progress note must be signed by the LMHP on the same day as the therapy session. The last paragraph indicates the note must be signed within one-business day from the date of service. Please correct for consistency.

2. Can the Comprehensive Needs Assessments, described in the CMHRS Provider Manual, be utilized as, or in lieu of, the Psychiatric Diagnostic Evaluation/Interview for OP Psychiatric Services?

Psychiatric Manual

It looks like in Chapter 2 of proposed Psychiatric Manual, we are being instructed to ensure that therapy notes which are written by unlicensed providers  are signed by licensed supervisor within the next business day. However, in Chapter 6, the Utilization of this regulation and how we will be audited is being held to a more stringent standard. Chapter 6 would require that all co-signatures of licensed providers be gained on the day that the service is rendered. I would ask that this be considered to ensure that the next business day be the expectation when it comes to utilization and audit. Thanks.

Adverse Outcomes:

Providers must report any knowledge of adverse outcomes for an individual currently receiving services or who have been discharged from services within 180 days of the incident.  Providers should  submit  all  of  the  following  information  to  Magellan  of  Virginia  or  the  MCO:  Individual’s name and Medicaid number; facility/provider  name,  address  and  National Provider Identifier (NPI) number; name(s) of staff involved (if applicable); detailed description of  the  incident,  including  the  dates  and  location  of  the  incident; outcome,  including  the person(s) notified; current location and status of the individual; steps taken to ensure continued safety for the individual.

 This requirement places a burden on the CSB  to monitor clients whom have been closed to services. There is a challenge posed to provide oversight to clients in whom we are no longer serving. Where does the knowledge of this information need to originate from? Are we to monitor the local newspaper, or gain this by word of mouth? Which sources should we deem as reliable for making such a report to Magellan? I feel that this requirement is out of the CSB’s oversight scope, once the client has been closed to agency services.Please reconsider. Thanks.