Clinical Practice-Establishing Benefits

Establishing Benefits

The Los Angeles County Department of Mental Health (DMH) is committed to providing the highest quality mental health services to indigent consumers for whom it has statutory responsibility. These are consumers who have the most serious mental problems and are not eligible for any medical financial benefits. In order to meet this commitment, DMH must ensure that its limited indigent care resources are used in the most efficient way consistent with proper clinical care for this population. It must also ensure that indigent resources are used exclusively for those who are not entitled to benefits from other sources, such as Medi-Cal. Using DMH indigent resources wisely will therefore depend on reliably and quickly establishing certain fiscal and clinical data during the interview. This data will determine two important facts:

  1. The individual is medically indigent; and
  2. The individual is part of the priority indigent population that we serve.

All DMH directly operated and contracted clinics must determine these facts. However, past clinic practices suggest that there are multiple ways to obtain the necessary data. The methodologies outlined below are designed as guides to an efficient process and may be especially useful in situations where current practice must be enhanced. Elements of the algorithms and tools may be specifically adopted by some parts of the DMH system, but are not uniformly mandated.

Algorithms for Establishing Benefits

Algorithm for Determination of Follow-Up after Screening Assessment Visit

The manner in which we use the data to efficiently determine medical indigency and priority population status is by using a decision-making algorithm: “Algorithm for determination of follow up after screening assessment visit.” This algorithm is meant to be a decision instrument for using specific information in order to determine eligibility for clinic services. It does not reflect a specific clinic procedure for establishing the required information or a particular sequence in which information is to be obtained. It is expected that there may be some variance in actual clinic procedures to obtain necessary fiscal and clinical information.

Screening Assessment for Establishing Fiscal and Clinical Data

The initial screening assessment must quickly and reliably establish the fiscal and clinical data necessary to support decision-making. Obtaining this data must have priority during the first visit.

The essential information components of initial screening assessment include:

  1. Fiscal information: Presence/absence of existing benefit (e.g. Medi-Cal); data necessary to determine benefits eligibility and complete and application when there is no existing benefit.
  2. Clinical information: Data (diagnosis, functional level, and supporting information) necessary to establish presence/absence of benefit (e.g. Medi-Cal)-associated medical necessity criteria and/or identification as priority/non-priority population.
  3. State-mandated information: Data required for appropriate billing for clinical assessment and any other associated services.

The essential process and outcome components of initial screening assessment include:

  1. Establish presence/absence of acute crisis.
  2. Establish benefits status.
  3. For those without benefits, establish information necessary to determine benefit eligibility and make application.
  4. For those without benefits but with benefit eligibility, and for those with benefits, establish information sufficient to meet billing requirement (standard assessment).
  5. For those with benefits, establish information sufficient to determine medical necessity.
  6. For those without benefits, establish identification as priority/non-priority population.

A variety of forms and instruments may aid clinicians and clinic financial screening personnel during the initial screening assessment. During the first stages of adoption of these new processes, existing forms and instruments will be adapted to the purpose. With time and experience, newer more specific tools may be developed.

The instruments include: financial benefits form, financial benefits application information form, financial benefits application tracking form, financial benefits application, clinic assessment form, level of function assessment form, disposition form.

Clinic-Centered Benefits Eligibility Assessment and Application Process

This term denotes the process by which each clinic assesses consumers for benefits eligibility and helps the consumer to complete and send applications as necessary. The process may include both elements of fiscal screening and reimbursable clinical services. This process may be standardized at a departmental level, and may allow for specific variations. Reimbursable clinical services incident to benefits establishment may continue as necessary to complete the process.

Related Information