Applies to ICF/MRs
Posted September 10, 2002
Please contact Jerri Lynn Ward for more information.
Recently, we have seen more requests for increases in level of need (LON) rejected by the Texas Department of Mental Health and Mental Retardation (TDMHMR). As a provider, you need to know that there are a few simple strategies you can utilize to help ensure that your LON request will be granted. This article discusses two methods for increasing the chances of getting TDMHMR to approve an LON appropriate for the consumer.
Many times, the stated reason for a denial relates to a lack of documentation. This can be remedied by appealing the decision, as the appeals process gives the provider the opportunity to provide additional documentation and to clarify any confusion regarding the request. My experience shows me that most providers who are denied an LON increase can benefit from the appeals process. Even if unsuccessful, the LON appeals process can show you what you can do the next time to make sure your request is approved. Accordingly, the two strategies for increasing your LON success rate are to make sure that your documentation is in order and to appeal the decision if the LON is denied. These decisions are appealable through a relatively simple process afforded by TDMHMR. I urge providers to take advantage of it.
Documenting
LON increases can be denied for a variety of reasons. Some common reasons are:
- the behavior is not dangerous enough to support a behavior increase
- the behavior management plan is not in order
- the ICAP is improperly scored
- the consumer record does not support the level of need requested.
While each of these seems to be a different justification for denial, there is one common element: documentation. For example, in one particular case, TDMHMR stated that the ICAP was improperly scored. TDMHMR believed that the supporting documentation did not support the scoring in the Problem Behaviors Section of the ICAP. Why? Because the information in the consumer=s file did not show that the consumer=s self-injurious behavior was dangerous enough to support a classification of Aextremely dangerous.@ Had there been regular documentation in the form of incident reports or other notes describing the severity of the behavior, the chances of receiving an LON 9 would have been much greater. What you the provider can learn from this example is that documentation can make or break your appeal. Without it, there is no Aproof@ that the behaviors actually happened.
Do not hesitate to fully describe how unmanageable a particular consumer=s behavior is. Preferably, fill out an incident report for each and every event. TDMHMR does not like checklists, so go ahead and describe the behavior each and every time it happens.
Providers and staff can be at a disadvantage because they deal with consumers every day and become accustomed to seeing certain behaviors from them. It is easy to get used to seeing the same behavior every day and get lax about documenting it. Documenting repeated behavior can be tedious and lose priority when you have about a thousand other things to do (and I=m sure you know what I mean!) I cannot stress enough, though, how critical it is to get your staff to document each and every behavior. Just telling TDMHMR what happened in your request is not enough; behaviors need to be documented in the consumer=s record every time they happen. Also, make sure that the behavior management plan reflects all of the elements as required in the ICAP. Thorough, consistent documentation will greatly increase your chances of getting the LON approved.
Appealing the Denial
If your request is denied, despite your best efforts to document the necessity for an increase in a consumer=s LON, take advantage of the appeals process that TDMHMR offers. Here is a summary of how it works:
After you submit the packet in support of the LON request, and your request is denied, you will receive a letter from TDMHMR. In the past, these letters stated the reason for the denial, however, TDMHMR no longer gives reasons. This letter will inform you that you have the right to request reconsideration of the LON. At this point, it is important to follow through with this request. Make sure to include any information that the reviewer requests, especially if it was missing from the first packet.
If TDMHMR Utilization Review (UR) denies the request again, you have the right to request an appeal of the decision. After you make this request, you will be notified of the TDMHMR attorney assigned to the case, and the matter will be set for a hearing before the Administrative Law Judge. During this time, you can set up a meeting with the UR reviewers to discuss exactly what their concerns are with the requested LON. These meetings can be very helpful. Sometimes the reviewers have concerns that are not readily apparent. Once these concerns are addressed, you and TDMHMR can fully discuss the reasonableness of the LON. Frequently, these matters can be resolved without the necessity of a hearing once the communication lines are open.
Conclusion
You are the care takers for the consumers. Don=t short change them or yourselves with incomplete documents. While it may be time consuming, it can pay off in the end. Most often, the behavior happens, but the documentation does not support it. With thorough documentation, you give TDMHMR the opportunity to give you the level of need you and your consumers deserve. And remember, take the time and effort to appeal the decision and meet with TDMHMR if the LON is denied. At the very least, you may learn something that could help you in the future.
All information in this article is informational only and is not legal advice. Should you have any questions or a situation requiring advice, please contact an attorney.
Copyright 2004 by Garlo Ward, P.C., all rights reserved
Austin, Texas 78752-3714 USA
Telephone: 512-302-1103
Facsimilie: 512-302-3256
Email: Info@Garloward.com