Frequently Asked Questions (FAQs) Regarding BQA Memo 04-005 Clinical Collaboration instead of Supervision

• A. The Department issued a statewide variance to allow collaboration in BQA memo 04-005. Certified psychotherapy clinics do not need to request a variance to permit collaboration.

  Certified outpatient mental health clinics that intend to implement clinical collaboration must notify their program certification specialist in writing.

  The narrative should include the timeline for transition from the requirements established in HFS 61.97 (3) and detail the policy and procedure for implementation of a collaborative practice protocol within the certified clinic.

• A. The proposal to switch to a collaborative protocol should be provided to the Division of Quality Assurance behavioral health certification  specialist. 
  
  A list of surveyors and contact information was attached to the statewide variance notice. There are several reasons why the surveyor needs to be notified, including, but not limited, to:
  • To determine the degree of consistency of proposals within each region and for Department review of statewide implementation; 
  • For confirmation of timelines for clinic transition; 
  • To have Department staff available for consultation during the transition period.

3. Q. Does someone who only sees four patient hours per week still need one hour per month collaboration time?

• A. Yes, either one-hour per month or one hour for every 120 clock hours of face-to-face mental health services is required.

4. Q. Will I get a written notice of approval?

• A. This statewide variance does not require correspondence back to the clinic as would be customary with other waiver or variance requests.
  
  You will be notified if the Department does not approve your proposal or if the Department requires additional qualifying information in order to consider your proposal.

5. Q. Am I correct in assuming that each staff person with a Master’s degree is required to attend?

• A. Certified Clinic professional staff as outlined in section 3 of DDES-BQA-04-005 must participate in the process of collaboration unless the certified clinic continues to meet the supervision requirements established in DHS 61.97 (3) (exit DHS).
  
  This section includes all licensed staff providing psychotherapy.

• A. Yes. A Department goal with this variance is to ensure the certified clinic has established a good/quality Quality Improvement system. 
  
  All staff who provide psychotherapy should participate in a collaborative process to ensure the quality of the system and support colleague’s efforts at the provision of quality care.

7. Q. Does this mean we no longer need to have a psychiatrist or psychologist on staff?

• A. The psychiatrist and/or psychologist are required staff identified in DHS 61.96 (exit DHS). The psychiatrist or psychologist is also required to provide 2 hours of psychotherapy for each 40 hours of therapy provided within the clinic as required in DHS 61.97(2) (exit DHS).
  
  This variance was specific to the role of collaboration and did not change any staff requirements in outpatient psychotherapy clinics.

8. Q. If a Master’s level clinician misses a meeting because of sickness or vacation, is that okay?

• A. The Department recognizes there may be short-notice circumstances that impact scheduling of collaboration meetings. Clinic policy may provide the guidelines necessary for reestablishing collaboration opportunities.

9. Q. If I have a relevant Master’s degree, previous clinical experience, but no license because I’m not currently practicing (e.g. an administrator in the clinic), can I become a collaborator?

• A. If you have a Master’s degree in the behavioral sciences, previous clinical experience and are part of the staff of the entity you may participate in the review.
  
  However, only staff identified as "qualified staff" in BQA memo 04-005 may be recorded as evidence of clinical collaboration.

10. Q. Do we need to involve a staff member with a Masters in Social Work (MSW) in reviews/collaboration?

• A. An MSW is not required to participate in all reviews/ collaboration. A qualified MSW that is identified as clinical staff participates in the collaboration if the certified clinic has approval for a collaborative practice by the Department.

11. Q. Now that I can collaborate with other Master’s level therapists, do I still need an MSW coming to my clinic?

• A. The requirement to have an MSW in a certified clinic has not changed. The Department is currently reviewing this requirement to determine if it will be maintained.

12. Q. Are professionals who practice in more than one location able to combine the clinical collaboration received in each practice setting?

• A. Each certified clinic is required to have evidence of compliance with supervision or collaborative practice specific to clients receiving services in that clinic. Qualified staff may collaborate about care provided at a branch of a certified clinic as well.
  
  Staff who may provide services in more than one certified clinic must meet the requirements for collaboration in each certified entity.

13. Q. Can I participate in collaboration to earn my 3,000 hours of post-master’s clinical experience?

• A. Yes, as long as those who participate in the collaboration are qualified clinical staff.

14. Q. Do the new clinical collaboration regulations replace the requirement for social workers to obtain physician (MD) case supervision on intake and every 90 days?

• A. The requirement of review at intake and at least once every 90 days for patients receiving one or less therapy sessions per week has not changed and was not included in the statewide variance.
  
  The Department will monitor the QI systems established and will provide feedback for future rule language development. This variance does not limit the review to the psychiatrist or psychologist.
  
  A clinic could continue to follow that practice outlined in DHS 61 (exit DHS) or establish guidelines in the collaborative practice protocol that includes the necessary review.

15. Q. Treatment plans---Will we need to formally review the plans every 3 months or can they be developed with the patient (obtaining their informed consent) and be in effect for 15 months without quarterly review?

• A. This variance does not change the requirement for review of client care. The variance allows the opportunity for a collaborative review as an option for clinics to consider.
  
  Note: The Department’s intent for DHS 94.03 (exit DHS) that permits an informed consent document to be valid for 15 months was:
  • to have the informed consent renewed annually, 
  • and/or to provide additional time for providers to obtain the consent via mail from a guardian or other legal representative who lives out-of-town.

16. Q. Does this requirement also apply to an Alcohol and Other Drug Abuse (AODA) / Community Substance Abuse Services (CSAS) outpatient program? If not, why not?

• A. This variance is specific to requirements identified in DHS 61.97 (3) (exit DHS) that are established for outpatient psychotherapy clinics. AODA/CSAS protocols are not currently being reviewed.

17. Q. In designing a treatment plan for dually diagnosed clients, do I still need supervision from a Certified Clinical Supervisor (CCS) who does not have a Master’s degree?

• A. The requirements for the provision of services under DHS 75 (exit DHS) are not impacted by this variance. If the clinic is certified under HFS 75 and providing services to dual diagnosed clients mental health and AODA professionals may need to be involved in the review.

18. Q. Can we stop listing the supervising physician on insurance claims?

• A. The variance does not address or change billing protocol or requirements.

19. Q. Can clinical collaboration be obtained from qualified licensed professionals practicing at other locations?

• A. Yes. This practice is encouraged for small, certified clinics in order to bring other professional perspectives into the collaborative process.
  
  Each clinic should establish business associates agreements (45 CFR 164.502 and 164.504 (exit DHS) with qualified professionals from other clinics to ensures patient rights and confidentiality are maintained and compliance with HIPAA requirements.

20. Q. Are the new variance regulations concerned about which party in the clinical collaboration activity poses the questions or receives the feedback?

(i.e. Does an equal exchange of clinical information between two or more professionals count as clinical coordination?)

• A. Staff shall document the collaboration by signature and date in regularly maintained clinical records. The names of the persons who participate in the collaboration and the time they spend on collaboration are documented.
  
  The patient clinical record should reflect case collaboration has occurred. One goal of the collaborative process is to have a reasonably equitable distribution of case review among clinicians participating.

21. Q. Is it allowable for clinical collaboration to be general clinical treatment information, and not specific to the treatment of a particular patient?

• A. Certified clinics must distinguish between general staff meetings that may discuss clinical practice from individual case collaboration. Client focused collaboration meets the requirements of the variance.

22. Q. We assume that clinical collaboration that takes place over the telephone is allowed by the regulation. Is this correct?

• A. There may be circumstances that necessitate collaboration regarding a specific case and these episodes are permitted. Utilization of telephone collaboration should not be the routine or customary practice for the staff in the certified clinic.

23. Q. What do we need to do to document the collaboration process? Do collaboration reviews need to be documented in the clinical record? May we maintain a separate log or record?

• A. Staff shall document the collaboration by signature and date in regularly maintained clinical records for each client. The documentation regarding collaboration may include a progress note regarding:
  • Referrals of the client to outside resources;
  • Descriptions of significant events that are related to the client’s service plan and contribute to an overall understanding of the consumer’s ongoing level and quality of functioning;
  • Evidence of the client’s progress, including response to services, changes in condition and changes in services provided;
  • Observation of changes inactivity level or in physical, cognitive or emotional status and details of any related referrals;
  • Reports of treatment or other activities from outside resources that may be influential in the clinic’s service planning.

24. Q. When the collaboration is anonymous, is it essential to note that fact in the record?

• A. Collaboration involves representatives of a treatment team and should not be anonymous. Those participating in the collaboration and their recommendations should be recorded.

25. Q. If this variance does not constitute granting a variance of the Medicaid requirement, what are the Medicaid requirements? Where could I find information on the Medicaid requirements?

• Since the publication of BQA Memo 04-005, the Division of Health Care Finance has provided notification that Wisconsin Medicaid will automatically grant a waiver of the Medicaid requirement of supervision when an agency receives a variance under HFS 61, Wis. Admin. Code to permit "clinical collaboration" in certified outpatient mental health clinic settings in lieu of supervision.

  The April 2004 Wisconsin Medicaid and BadgerCare update provides this notice.

26. Q. If our clinic changes to a collaboration process, do we still need to look at the medical necessity issue for discharge? If so, how can we process the discharge decision without a physician present?

• A. If the entity that provides reimbursement for services requires physician participation in the discharge, the certified clinic should adhere to those requirements.

27. Q. Do we still need a prescription for treatment/referral for psychotherapy per WI Admin Code HFS 61.97 (5)?

• A. The requirement for an order for treatment has not changed. The Department is exploring options for addressing concerns about this requirement.
  
  There are HFS code requirements for a physician’s prescription for outpatient mental health therapy for which the Department may consider a waiver/variance.
  
  However, there is a State statutory requirement for a physician’s prescription for Medicaid recipients to receive outpatient mental health therapy, which the Department cannot waive.
  
  At minimum this issue will be addressed to the extent that the Department is able to in the re-write of HFS 35.

28. Q. Will we need any signatures from supervisors or clinical collaborators on our Intake Notes, Treatment Plan, and Discharge Summaries? We now have our Ph.D. psychologist or physician sign all of these documents.

• A. The Outpatient Psychotherapy Clinic Administrative Code outlines minimum standards for the provision of services. Each entity will develop policy and procedure for their collaborative practice.
  
  If the entity determines certain signatures add value to the process of collaboration those signatures should be part of the clinic protocol.
  
  If a clinic does participate in the variance, the clinic policy/ procedure should detail how these signatures will be secured as evidence of review. The surveyor will review the policy and monitor compliance through the record review process.

29. Q. How can I secure a copy of this BQA memo?

• A. BQA Memo 04-005 can be downloaded at the following: http://dhs.wisconsin.gov/rl_DSL/Publications/04-005.htm

Last Updated: February 17, 2009