WWYD
The member says:
"I had to leave before my last appointment."
What's the best documentation?
A. Move goal to Low
B. Close goal
C. Document barrier, discuss next steps, maintain follow-up
C. Document barrier, discuss next steps, maintain follow-up
A member declines every intervention offered.
Can you still pass audit?
Yes.
If appropriate interventions were offered and the member declined, documentation of the offer and refusal can still support the care plan.
You begin a medication review.
The member immediately says: "Nothing has changed with my medications."
What is the best response?
A. Accept the statement and move on
B. Verify medication name, dose, and frequency as required
C. Skip OML because the member sounds confident
B. Verify medication name, dose, and frequency as required
A member stating "nothing changed" does not replace the medication review process. Medication verification is still expected when a review is required.
A member tells you:
"I don't really have time to discuss my exercise goal today."
What should you do?
A. Delete goal
B. Keep goal High and document member-driven reason for deferring
C. Close goal
B. Keep goal High and document member-driven reason for deferring
Which is stronger?
A. Discussed transportation benefit.
B. Offered three-way call with transportation vendor. Member declined assistance and accepted benefit phone number.
B. Offered three-way call with transportation vendor. Member declined assistance and accepted benefit phone number.
Why? It demonstrates active intervention.
During review OML shows:
Member states:
What should you do?
A. Leave OML unchanged
B. Update OML and investigate discrepancy
C. Assume the member is mistaken
B. Update OML and investigate discrepancy
The purpose of the review is to identify discrepancies and update information appropriately.
Previous action plan: Attend cardiology appointment.
Current call, member states:
"I missed it because my wife was hospitalized."
What should happen next?
A. Repeat the exact same action plan
B. Document the barrier, discuss new plan, update interventions
C. Close the goal because the appointment was missed
B. Document the barrier, discuss new plan, update interventions
A condition is perfectly controlled.
Should the goal automatically be closed?
No.
Control of a condition does not automatically eliminate documentation requirements.
You verify all prescription medications.
The member then says:
"I also take Ibuprofen every day."
What should you do?
A. Ignore OTC medications
B. Update and verify OTC medications as part of the review
C. Only document it if prescribed
B. Update and verify OTC medications as part of the review
A member cannot get to specialist appointments.
You provide the transportation vendor phone number.
The member says:
"I don't really understand how to use that benefit."
What is the strongest intervention?
A. Educate the member on how to use the benefit and document benefit education only
B. Educate on the benefit and offer assistance coordinating transportation
C. Re-educate the member and ask if they now understand
B. Re-educate on the benefit and offer assistance coordinating transportation
What causes more audit failures?
A. Missing interventions
B. Forgetting follow-up on previous care plans
Both are major drivers, but failure to follow up on previous goals, referrals, appointments, and action plans is one of the most common retrospective audit findings.
A C-SNP member has Diabetes as a qualifying chronic condition.
The member reports:
What would you do?
A. Close the Diabetes AOF
B. Leave Diabetes Open Low with documentation describing how the condition is being managed
C. Remove Diabetes from the ICP because it is controlled
B. Leave Diabetes Open Low with documentation describing how the condition is being managed
Final Boss Question--AKA DAILY DOUBLE
You review a chart and see:
Six months later, the next note says:
"Member doing well. Continue plan."
What is the biggest audit concern?
There is no documented follow-up regarding the outcome of the previous interventions. Did the member attend the PCP appointment? Did transportation help? Was the article received? Were PDMR recommendations addressed? The audit wants to see the progression of the member's story and outcomes, not just that interventions were originally provided.