Medicaid School-Based Claiming

Annual Regional Compliance Training

February 2013

www.pcgeducation.com

Agenda

• What is the MSBC Program?

• Compliance Overview

• Documentation Requirements

• Preparing for a Compliance Review

• Updated DSC Compliance Model

• Common Findings

• Tips for a Successful Review

• Resources

• Questions

• Review Game

What is the Medicaid School Based

Claiming (MSBC)Program? • Direct Service Claiming (DSC) and Medicaid Administrative Claiming (MAC)

are two reimbursement components in the MSBC program

• DSC Claiming

• Allows Local Education Agencies (LEAs) to receive Medicaid reimbursement based on

actual costs to provide Medicaid allowable services to students who are Title XIX

eligible

• Medical services include: behavioral health, occupational, physical, and speech

therapies, audiology, nursing, school-based health aides, evaluation, and transportation

services

• DSC Reimbursement is received through interim payments and annual cost

settlement

• LEAs complete the Annual DSC Cost Report to determine the actual cost of

providing direct services compared to the interim payments received

• LEA will be required to reimburse money if they received more in interim

payments throughout the year than their actual cost

• LEA will receive the difference of their cost and the total annual interim payments

if their costs exceed reimbursement received

What is the MSBC Program?

• MAC Claiming

• Allows LEAs to receive reimbursement for Medicaid administrative and

outreach activities that are done routinely within the school setting

• MAC reimbursement is received through quarterly cost reporting

• Salaries and benefits are reported for full/part time employees, Purchased

Professional Services (PPS) costs are reported for contractors

• Costs are submitted in a claim filed with Arizona Health Care Cost

Containment System (AHCCCS) every quarter and LEA reimbursement is

determined by these factors:

• Costs

• RMTS results

• Unrestricted Indirect Cost Rate (UICR)

• Medicaid Eligibility Rate (MER)

• Does not impact annual cost settlement

Compliance Overview • Periodic compliance reviews

• PCG conducts periodic compliance reviews to verify that appropriate supporting

documentation is maintained by LEAs

• All participating LEAs will be reviewed at least once every three years

• DSC reviews

• PCG reviews the supporting documentation that is maintained by the LEA to

substantiate interim direct service payments for approved claims

• PCG pulls a sample of paid claims for a selected period of time

• PCG verifies supporting documentation for paid claims

Supporting Documentation

IEP with a valid prescription of service Clinical Notes/Service Logs

Certification or Licensure Evaluation (if the claim is an evaluation)

Summary Report Attendance Reports

Compliance Overview

• Quarterly Cost Reporting reviews

• All participating LEAs will be reviewed at least once every three years

• Quarterly cost reporting reviews verify the LEA’s certified costs reported for the

quarter under review using system generated or substantiating reports for the

following:

• Salaries

• PPS costs

• Employer paid benefits

• Cost data from documentation is entered into compliance review tool and used to

regenerate that quarter’s claim

• Variances identified between original claim and claim regeneration result in either

additional reimbursement to LEA, or recoupment in the form of a prior period

adjustment made to a future claim submission

Audience Participation

• How long does the LEA need to maintain documentation for the MSBC

program?

• Maintain records for a minimum of five (5) years from the date of payment

• Records under review by a state or federal agency must be maintained

until review has been finalized even if the time period of records

exceed 5 years

• What is the purpose of a Quarterly Cost Reporting review?

• To substantiate cost reported by verifying supporting documentation for

the quarter claim under review

Documentation Requirements

• Individualized Education Program (IEP)

• Duration of the IEP covers date of service

• The service must be prescribed by THE qualified medical provider

• The IEP must be signed AND dated by the qualified medical provider

• The IEP must contain outcome oriented goals for the service type under review

• The IEP must contain scope, frequency, and duration for the service under

review

• IEP must be legible and free of alterations / errors

Documentation Requirements

• The LEA must maintain certification / licensure for all qualified medical

providers to cover:

• Date the provider rendered a service

• Date the provider signed the IEP

• Clinical note, service log, or trip log

• Describes service provided on date of claim

• Reflects the student on the claim and includes a unique identifier

• Signed AND dated by the appropriate qualified provider

• Signature and date of rendering provider AND signature and date of

supervisor when supervisory is required

• Trip log must also document the mileage transported

Documentation Requirements

• Summary Report

• Covers the date of service on the claim

• Reflects the student on the claim and includes a unique identifier

• Signed AND dated by the appropriate, qualified medical provider

• Signature and date of rendering provider AND signature and date of

supervisor when supervisory is required

• Evaluation Report

• Shows that the evaluation was performed by an appropriately qualified medical

provider

• Reflects the student on the claim and includes a unique identifier

• Attendance records

• Attendance records must show that the student attended school on date of

service

Documentation Requirements

• Quarterly Cost Reporting

• Effective July 1, 2012 Centers for Medicare and Medicaid Services (CMS)

approved AHCCCS’s request to report all quarterly costs on a cash basis

• Depending on quarter under review documentation will need to substantiate

reporting requirements at the time

• July-September and October-December 2011 quarters were reported

on an accrual basis

Cash Basis Accrual

Salaries and Benefits Based on pay date Based on start and end dates of

the pay period

PPS Based on invoice paid date Based on dates of service

Documentation Requirements

• Documentation used to report salaries and benefits for full and part-time

employees must include the following:

• Account code structure

• Participant’s full name as it is displayed on the roster

• Pay dates/Date of Service

• Documentation for PPS must be invoices that:

• Specifically identify the participant by name

• Full name must be displayed as it is on the roster

• Pay dates/Date of Service

• Must display the account code from which the revenues were paid

Audience Participation

• Who is qualified to prescribe a speech service within the IEP?

• A qualified Speech-Language Pathologist (SLP) licensed by the Arizona

Department of Health Services

• How often should the qualified medical provider sign a summary report?

• Summary reports should be signed and dated by the provider each time an

entry is made

• Why does the account code structure need to be displayed on cost

reporting documentation?

• In order for PCG to determine which costs are associated with federal

funds or non-allowable functions

• Why do PPS invoices need to display a participant’s name as it exists on a

roster?

• Costs need to be associated with an individual

Preparing for a Compliance Review • Preparation checklist*

• IEP with the qualified medical provider signature(s) for each student covering the

date of service

• Progress reports completed after the date of service

• Clinical notes, service logs, trip logs describing the service provided on date of

claim

• Evaluation reports performed by an appropriately qualified medical provider

• Attendance records covering dates of service

• Qualified Medical Provider table*

• List of provider types that are qualified to prescribe services and sign the IEP for

the MSBC program

• Services the qualified medical provider can prescribe on the IEP

*Included in the training packet

Audience Participation

• What documentation should be submitted for an evaluation claim?

• Evaluation report, resulting IEP, licensure for provider, and attendance

record

• Who is qualified to prescribe behavioral / mental health services?

• Licensed Clinical Social Worker, Licensed Marriage and Family Therapist,

Licensed Professional Counselor, Licensed Psychiatrists, and / or

Licensed Psychologist

Updated DSC Compliance Model

• Updated DSC compliance model effective January – March 2013 (JM13)

• Better aligns review process to cost-based rates

• Proactive approach

• Regional annual trainings

• Quarterly trainings

• Strategic interventions

• LEA responsibility

• Dual certified Corrective Action Plan (CAP)

• Check-in calls

• PCG validated self re-assessments

Updated DSC Compliance Model • Overview of updated DSC compliance model

• Proactive Measures

• Annual Regional Compliance Trainings

• PCG will conduct “live” regional trainings every JM quarter

• Trainings will focus on proactive communication of current information

• Aim is to increase LEA compliance based on relevant findings

• Answer LEA specific questions on program compliance

• Mandatory focused trainings based on findings

• Strategic interventions based on LEA findings during their DSC

compliance review

• Customized training based on individual LEA findings

• Detailed explanation of each finding

• Documentation required to satisfy program requirements

• Aimed to guide LEA in creating Corrective Action Plan (CAP)

Updated DSC Compliance Model • Dual certified CAP

• Required for all non-compliant standards

• “Dual-certified” means certified by two LEA representatives

• Special Education Director – AND

• Finance Director

• Outlines LEA responsibility

• Involves finance to increase interdepartmental knowledge and

coordination

• “Check-in” calls with LEAs requiring a follow-up review

• PCG will conduct periodic phone calls to assist in necessary changes

• LEA will be required to submit internal evidence of change

• Procedural documents

• Trainings

• E-mails

Updated DSC Compliance Model

• Sample size

• Initial DSC Compliance reviews have been reduced

• PCG confirmed self re-assessment

• Large LEA sample size = 25 claims

• Medium sample size = 20 claims

• Small sample size = 15 claims

Claims Threshold LEA Size Claim Sample

More than 5,000 Large 124

500 – 4,999 Medium 62

Less than 500 Small 31

Updated DSC Compliance Model • Sampling Methodology

• Total number of claims reviewed for each CPT code is directly proportional

to claiming history

• Reviews would directly reflect service types and claim history of each LEA

• Would likely reduce LEA preparation time and cost

• Example of proportional claim sample:

20

CPT code Percentage of total claims Number of claims reviewed

92508 (speech) 45% 56

97110 (OT) 20% 25

S5125 (H/A) 15% 18

A0120 (Trans) 20% 25

Total 124

Updated DSC Compliance Model • Scoring

• Each standard and the final overall score will fall into one of two categories:

• Compliant = 90% and greater

• Non-compliant = below 89.9%

• Non-compliant standards

• Mandatory focused training within 30 working days of finalization of review

• Dual certified CAP due 15 working days after focused training

Updated DSC Compliance Model

• Non-compliant final overall score

• Mandatory focused training within 30 working days of finalization of review

• Dual certified CAP due 15 working days after focused training

• Periodic check-in calls by PCG to assist and confirm compliance

• PCG validated self-reassessment 6 months after CAP submittal

• LEA will be supplied a sample from PCG

• LEA conducts a self-reassessment based on initial standards identified

as being non-compliant

• LEA sends review tool AND all supporting documentation to PCG

• PCG will validate submitted findings within 20 business days

• If necessary PCG will pull an additional claim sample for review by

provider or service types

Updated DSC Compliance Model

• Non-compliant PCG validated self-reassessment

• Possible removal from the MSBC program

• Reimbursement of all funds associated with current fiscal year

• Inability to participate in annual cost settlement

• In order to re-participate in the MSBC program the LEA would be required

to:

• Undergo pre-approval of IEPs and other supporting documentation

• Provide a dual certified CAP

• Completion of mandatory trainings

• Sign a new participation agreement

Updated DSC Compliance Model

Compliance Review Score LEA Responsibility

Non-compliant Individual Standard

Scores

Dual-certified CAP

Update internal procedures

Non-compliant Final Overall Scores

Dual-certified CAP with periodic check-in calls

Update internal procedures

Mandatory focused trainings

Self re-assessment validated by PCG

Non-compliant PCG Confirmed Self

Re-assessment Final Scores

Removal from the MSBC Program

Reimbursement of all funds associated with current

fiscal year

Inability to participate in annual cost settlement

24

Updated DSC Compliance Model

• Recoupment

• Due to PCG within 30 days after finalization of review

• Tied to specific claim findings that may include (but are not limited to):

• Claim line under review only

• Claims within that IEP duration for the service type under review

• All claims within the IEP duration for ALL service types

• No recoupment at all

Audience Participation

• With the changes to the DSC compliance review model, did any of the

actual program requirements change?

• NO!!! All program requirements remain the same

• Who, within your LEA, is required to sign the dual-certified Corrective Action

Plan?

• The Special Education Director and a Finance Director

Common Findings • Related Services

• THE qualified medical provider for each service type did not sign and date the

IEP

• Make sure each service type has a qualified medical provider signing for

services

• Verify that each signature is fully executed (handwritten date)

• LEA did not maintain certification / licensure of medical provider(s)

• Collect, maintain and store certification and licensure for all providers

• Supply certification / licensure to cover the prescribing provider to cover their

signature date

• Supply certification / licensure to cover the rendering provider to cover the

date of service

Common Findings • Clinical notes did not contain all required elements

• Check for completeness of clinical notes

• Make sure clinical notes contain a brief description of services rendered

• Verify that clinical notes contain a unique student identifier in addition to

the student’s name

• Review internal processes

• Verify that clinical notes are being entered by the provider who

rendered the service

• Review approval process when supervisory signatures are required

• Health aide / Nursing

• THE qualified medical provider for each service type did not sign and date the

IEP

• A qualified nurse MUST prescribe nursing services

Common Findings

• IEP did not contain scope, frequency, and / or duration for the service under

review

• Verify that nursing is prescribed within the IEP

• Double check the frequency as prescribed to the student

• Frequency for nursing MUST include a time increment

• Billed units exceeded prescribed number of minutes

• Verify that the prescription is complete and valid for nurses services

• Verify that the nursing prescription contains a valid scope, frequency,

and duration

• All billed units would exceed a prescription if there is not one present

• Clinical notes do not contain all required elements

Common Findings

• Check for completeness of clinical notes

• Clinical note for nursing services must include a description of services

rendered

• Transportation

• IEP did not contain documentation that student required specialized

transportation due to a need for an adaptive vehicle or because of behavioral

need

• Locate the statement of need within all IEPs for students who claim

transportation

• Verify that statement clearly indicates WHY student requires specialized

transportation

• LEA did not maintain certification / licensure of the bus driver

• Collect, maintain, and store licensure for all bus drivers and substitutes

Common Findings

• Driver’s licensure must cover the date of transport (may not be current

license)

• Evaluations

• Each evaluation is not substantiated by the resulting evaluation report and/or IEP

• Evaluations are only reimbursable if they result in another DSC covered

service

• Evaluations are event-based services and can only be billed ONCE

Common Findings

• Quarterly Cost Reporting

• PPS invoices supplied do not identify participant by name

• LEA must coordinate with vendor to obtain invoices that display participant’s

full name

• Incorrect reporting of federal and non-federal revenues

• Make sure all federal funds are reported accurately within the cost reporting

system

Tips for a Successful Review

• DSC

• LEAs should conduct internal periodic self-reviews on a sample of student files

• Establish a procedure for reviewing and or accepting incoming IEPs from other

LEAs

• Draft a checklist once IEPs are drafted to ensure completeness of all

requirements before billing

• Quarterly Cost Reporting

• Maintain all documentation used to certify quarterly cost reports

• Make sure all documentation for full/part-time participants include account code

structures, participant names, and pay dates and/or dates of service

• PPS invoices should clearly identify the participant by full name

Resources • PCG Program website: https://web.pcgus.com/azschools/

• Program Handbook

• Trainings

• PCG posts all training presentations to the program website

• There are several recorded presentations on the website for those who would like to

listen to the presentation

• PCG Post newsletters

• Review Tools

• Azaudit@pcgus.com

• All e-mail correspondence related to DSC and MAC compliance reviews

• AHCCCS website: www.azahcccs.gov

• AMPM

• The AHCCCS Medical Policy Manual (AMPM) chapter 700 provides detailed

information on general requirements, covered services, and required records

Questions

• Questions?

• Compliance Review Jeopardy

Public Consulting Group, Inc.

101 N. 1st Ave., Suite 1800, Phoenix, Arizona 85003

(602) 324-5090, www.publicconsultinggroup.com