ASSURING YOUR TCM PROGRAM IS
IN COMPLIANCE
Presented by Patricia Calloway and
Pat Ericsson
TCM Conference April 2017
Topic for discussion
Case
Manager qualifications
Agency qualifications
Program policies
Audit file
Best practices
Agency Qualifications
Must have system of coordination
between programs
 Demonstrate experience in providing case
management
 Employ staff with CM qualifications
 Have or establish referral systems for
linkages

Agency Qualifications – Cont’d
5 year minimum of providing CM to target
group
 Admin capacity to ensure quality of services
 Financial management capacity to comply with
OMB A-87
 Capacity to document and maintain case
records to meet regulation standards
 Ability to evaluate quality and effectiveness

Case Manager Qualifications
 RN
or PHN with active license
 Bachelor’s degree with agency approved CM
training
 Documentation of initial and annual time
survey training
 Duty statements
 NPI
 Documentation of case management training
for Non – RN/PHNs
Program Policies
Part of the Annual Participation Prerequisite:
 Performance Monitoring Plan/Nonduplication/Care Coordination
 Freedom of Choice
 Fee Mechanism
 Managed Care MOU
Program Policies - continued
Policies
 Annual
Participation Prerequisite
 subcontractors
 Provider
Participation Agreement
 Signature Authority
 MEDS Access
 Sub program codes
 Third Party Liability
Program Policies - continued
Policies
 TCM Payment System
 Time Surveys
 Confidentiality
 Duty Statements
 Payment by invoice
 Quality Assurance
 Chart audit and peer review
Audit File
 Organizational
Charts
 Duty Statements/Job Description
 Case Management Qualifications
Billable vs Non-billable
 Encounter Logs

Best Practices

Best Practices
 Duty
Statements
 Client satisfaction
 Grievance procedure
Required Documentation
 Red Flags
 Resources

Alameda County Public Health Nursing : Patient
Experience
“Excellent! I like
her, she was right!
I’d recommend
xxxx. She is very
helpful and I love
her to death!”
“She really
helped me.
Very nice”
“Everything was
good, very
satisfied”
“They are my
best friends”
“xxx goes above
and beyond. I
can’t say enough
good things
about her”
“She is excellent!
Best nurse
around! So
understanding!”
“Professional,
super nice, really
sweet”
took her time and
explained
everything. She
was very good”
“Was very
helpful, they
helped me a lot”
“She was on top
of everything”
“Yes, very
helpful. I got to
know a lot of
things”
“xxx. She is nice,
helpful – Tell her
I said ‘hello’”
“Staff is very
friendly and the
nurse answered
all my questions”
“This helps lots of
people”
“Very nice, very
helpful . I am
very happy”
“Good worker,
helped me a lot.
Kept me from
stressing out”
“It’s been great!”
“Every staff RN
PHN service was
sufficient”
“Helpful to me,
“Definitely
recommend, I
really enjoy
working with
xxx”
“I had 2 strokes. I
needed a new
pharmacy and
delayed meds
because medical
needs to do that in
the clinic”
“She was great,
very helpful. She
is the right
resource, and
was helped right
away!”
“It’s great service.
Provided good
information and
literature”
“She really helps
me. I want her to
come back”
“I am going to
move out of
state, and the
nurses gave me
really good
references!”
“She was very
helpful and she
was really nice”
“Always helpful
to provide more
information. Xxx
was very nice”
“Timing of visits
can be off;
otherwise happy
with services”
Freedom of Choice
Must
Best
have a Freedom of Choice policy
Practice: Note on assessment form
that Freedom of Choice was explained
Freedom of Choice

Client must be told:
Services are voluntary
May go to a different TCM provider
May request a different CM
May terminate TCM services at any time
Fee Determination and Waiver
It must be documented that the client was
reviewed for a fee for TCM services
 Each LGA or TCM provider must have an
income-based scale to determine if client
must pay a fee
 There are no state or federal parameters

Fee Determination and Waiver
If it is determined that the client must pay a
fee, the fee may be waived by the Case
Manager
Client has a communicable disease
CM determines client will not continue in
the Program and could be detrimental
to the client
Billable vs. Non-Billable
A billable encounter is:
 Face-to-face visit with Medi-Cal client
 In TCM target group
 During which case manager renders one
or more TCM service components.
Performance Monitoring Plan
LGA must submit their Performance Monitoring
Plan with their Annual Participation Prerequisite.
 Details how LGA will ensure case
management service will not be duplicated
 Details your Quality Assurance Plan
Quality Assurance


No formal requirements exist – each LGA
should determine its own QA protocols
LGAs develop a written policy for
reviewing TCM cases
Quality Assurance
Best Practices
 Include criteria, sample methodology, and
frequency of reviews
 May involve coordinator’s review, supervisor
review and/or peer review
 Include periodic checks to assure that client case
documentation, encounter logs, and billings are
consistent in details

Common Documentation Errors



Not clearly identifying the TCM service that was
provided
Not identifying one of the four TCM
service components
Billing for a TCM encounter when a TCM service
has not been documented
Common Documentation Errors



Not addressing who, what, when, where and why
Not clearly distinguishing individual care plans,
assessments and progress notes within family
charts
Not clearly identifying how a client meets the
Target Population criteria
Red Flags for Auditors
Not using TCM words in case file
documentation
 Making frequent client visits without
documenting client outcomes or new needs
 Documenting multiple home visits where
no new information was received or new
referrals made

Red Flags for Auditors
Needs identified on the Assessment are not
the same needs identified in the Care Plan
 Using local agency acronyms without a key to
full names or meanings
 Illegible writing
 Documenting for a family versus an individual

Resources
State Website
 LGA Website
TCM FAQs
 MAA/TCM Regional Meetings
 TCM Guidelines Workgroup
 Annual Conference

Resources-FAQs

View the complete FAQ document:
https://sites.google.com/site/calgacons
ortiumworkgroups/home/tcmworkgroup/tcm-faqs
TCM FAQs
TCM FAQs
Questions