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2/6/2006 12:00:00 AM


Attached is a notice from NASW regarding HHS’s interest in looking at mental health services. Please take a moment to review your documentation and billing procedures and insure services are documented and bill properly.

HHS Audits to Target Behavioral Health

According to NASWNEWS (Vol.50, No. 8, September 2005), a decision has been made by the U.S. Department of Health and Human Services’ Office of Inspector General (OIG) to step up audits of Medicaid mental health services this year and could affect social workers in a number of settings.

In its fiscal year 2005 workplan, the OIG outlines plans to audit a number of programs for fraud and abuse.  Among them are five areas of Medicaid mental health services: rehabilitation services for persons with mental illness; community mental health centers; nursing home residents with mental illness and mental retardation; claims for residents of institutions for mental diseases; Medicaid services for mentally disabled persons.

Mary Thornton, a behavioral health care industry consultant with expertise in Medicaid compliance, suspects that recent reports of poor documentation and confusion over CPT (current procedural terminology) codes in both inpatient and outpatient mental health services may have been the catalysts for this.

“OIG is actively looking for fraud and abuse situations,” said NASW Senior Policy Associate Mirean Coleman.  “In the process, however, people are being punished for innocent errors.” 

Mary Thornton said social workers should prepare for the fact that the OIG will evaluate Medicaid treatment plans using three main criteria:  they must be current, they must be signed by the appropriate parties, and they must clearly show that a service was medically necessary.

Documentation needs to be done on a timely basis and done clearly.  In addition to better documentation, social workers need to know what services Medicaid covers and which CPT codes are appropriate for these services.  It’s important you understand definitions of services and the limits and boundaries of those services.  Read your state Medicaid newsletters and other provider correspondence to keep abreast of new information and changes.  Also, social workers in all mental health settings should have a formal set of policies and procedures to address compliance issues.

If you have any questions regarding Medicaid coverage or services, call the Center for Medicare and Medicaid Services at 1-877-267-2323 or go on their website at  You can also contact the New York State Department of Health Medicaid Program at 1-800-522-5518 or go onto their website at

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