School-Based ACCESS Program 2013 Fall Regional Training

1. School-Based ACCESS Program 2013 Fall Regional Training Barry C. Decker, Bureau of Policy, Analysis and Planning Pam Tressler, Bureau of Program Integrity

2. AGENDA Overview Participant Roles CMS Financial Management Review Services Requirements Documentation Verification

3. AGENDA (cont.) Provider Screening Audit/Reviews Self-audits Self-disclosures Corrective Action Plans Results of CMS Audit BPI Findings

4. AGENDA (cont.) Contact Information Questions

5. History of SBAP Began in 1992 Involves: Centers for Medicare and Medicaid Services (CMS), Department of Public Welfare (DPW) Pennsylvania Department of Education (PDE) LEAs Public Consulting Group (PCG) OVERVIEW

6. School-Based ACCESS Program (SBAP) involves the State Medicaid Agency which through Local Education Agencies (LEA) are able to receive reimbursement for direct and administrative service costs. OVERVIEW (cont.)

7. Direct Services Face-to-face medically necessary services provided by the LEA Services must be properly documented in the Individualized Education Program (IEP) Authorized/prescribed by currently licensed practitioner OVERVIEW (cont.)

8. Administrative services Services provided by the LEAs that are in support of direct services OVERVIEW (cont.)

9. Those involved in SBAP: Centers for Medicare and Medicaid Services (CMS) Department of Public Welfare (DPW) Bureau of Policy, Analysis and Planning Bureau of Program Integrity Bureau of Financial Reporting PARTICIPANT ROLES

10. Pennsylvania Department of Education (PDE) Bureau of Special Education Bureau of Early Intervention Services LEAs School districts, charter schools, intermediate units, approved private schools, vocational-technical schools, and pre-school early intervention programs Public Consulting Group (PCG) PARTICIPANT ROLES (cont.)

11. Financial Management Review (FMR) Began in January 2012 Met with CMS in May 2012 Changes effective July 1, 2012 Daily Progress Note required Discontinuance of billing for IEP Meetings as direct service Discontinuance of billing for collateral services as part of direct service Allow for one way transportation billing CMS FMR

12. State Plan Amendment Cost-based payment methodology Cost reconciliation Random Moment Time Study (RMTS) State Administrative Claiming Plan RMTS FMR Draft Report CMS FMR (cont.)

13. FMR Findings/Requests: State Plan Amendment Approved payment methodology Discontinue of billing for IEP meetings as direct service Discontinuance of billing for collateral services as part of direct service Fully document the service Identify individual or group in IEP CMS FMR (cont.)

14. CMS FMR (cont.) Direct services are face-to-face Use a procedure code to identify evaluations Units of service billed must not be more than the units that are medically necessary and authorized Billed units must be documented

15. SERVICES SBAP Direct Services Services provided by school-based service providers that are provided or purchased by LEAs enrolled in the Medical Assistance (MA) Program to MA-eligible beneficiaries 3-21 years of age for whom the service is medically necessary and documented in the IEP.

16. SERVICES (cont.) MA Provider Agreement LEAs must comply with all Federal Medicaid and State rules and regulations

17. SERVICES (cont.) Assistive Technology Devices (ATD) 42 CFR 440.70(b)(3) Only authorized/prescribed by a physician (MD or DO) LEA obtains from medical supplier Nursing Services 42 CFR 440.60(a) RN or LPN

18. SERVICES (cont.) Nurse Practitioner Services 42 CFR 440.166 Certified Registered Nurse Practitioner (CRNP) Known as physician service in SBAP Occupational Therapy Services 42 CFR 440.110(b) Orientation, Mobility and Vision Services 42 CFR 440.130(d)

19. SERVICES (cont.) Personal Care Services 42 CFR 440.167 Known as PCA service in SBAP One-to-one direct service Activities of daily living Physical Therapy Services 42 CFR 440.110(a)

20. SERVICES (cont.) Physician Services 42 CFR 440.50(a) Psychological, Counseling and Social Work Services 42 CFR 440.50(a) and 42 CFR 440.130(d) Known as psychological, social work and psychiatric services in SBAP

21. SERVICES (cont.) Special Transportation Services 42 CFR 440.170(a) Speech, Language and Hearing Services 42 CFR 440.110(c) Known as: audiology services; speech, language and hearing services; and teacher of the hearing impaired services.

22. REQUIREMENTS Medical Authorization Practitioner’s orders must be documented on: Prescription or SBAP Medical Practitioner Authorization Form Practitioner’s orders must be: Concurrent with the IEP and obtained at least annually or whenever there is a change to a student’s MA-covered service

24. DOCUMENTATION LEAs must maintain any and all relevant documents to the services claimed. Parental Consent (signed, checked and dated) IEP MPA/Order/Prescription (signed and dated)

25. DOCUMENTATION (CONT) Daily logs (Easy Trac) If on behalf of or not electronically documented the original paper document must be retained Attendance records Student Provider

26. DOCUMENTATION (CONT) Keys for acronyms/abbreviations used Provider licenses and/or certifications Evaluation reports Transportation logs

27. DOCUMENTATION (CONT) Records must comply with MA Regulations (55 Pa.Code§ 1101.51) Record Retention Pennsylvania – records must be maintained for a minimum of 4 years from the date of service (55 Pa.Code §1101.51(e)) Federal – require documents to be maintained for six years

28. DOCUMENTATION (CONT) Fully disclose the nature and extent of services rendered Readily available for review or copying Must be legible Alterations must be dated and signed Plans must be part of the record (IEP, treatment plan, evaluations and reports)

29. DOCUMENTATION (CONT) Must document progress for each session, change in diagnosis, treatment and response to treatment Must be dated and signed

30. DOCUMENTATION (CONT) Reminder for LEAs using a third party vendor or on behalf of entries You must maintain the original documents

31. VERIFY LEA’s should verify: IEP Is on file Valid for that date of service (DOS) Contains the health-related service Service is within the duration/frequency

32. VERIFY (cont) Parental consent On file Appropriately marked/checked Signed & dated

33. VERIFY (cont) Medical Practitioner Authorization Form(MPA)/Prescription On file Valid for that DOS Contains the health-related service Duration Frequency Signed/Dated

34. VERIFY (cont) Provider meets the appropriate qualifications (valid license, CPR, first aid) Provider is not paid with IDEA funds Daily log Completed Signed/Supervisory signature if necessary

35. PROVIDER SCREENING Medical Assistance Bulletin #99-11-05 Provider Screening of Employees and Contractors for Exclusion from Participation in Federal Health Care Programs Effective Date August 15, 2011

36. PROVIDER SCREENING (cont) You cannot be paid by Medicare, Medicaid, or other Federal healthcare programs for items or services furnished, ordered or prescribed by an excluded individual or entity. “Furnished” refers to items or services provided or supplied, directly or indirectly.

37. PROVIDER SCREENING (cont) An excluded individual or entity cannot be part of a task that is reimbursed by Federal program dollars, which includes: Claims submittal Any service, including those not directly related to patient care Payment from a Federal program cannot cover salaries, expenses, or fringe benefits

38. PROVIDER SCREENING (cont) Exclusion may be imposed on an individual or entity that is not: Enrolled in Medicare or Medicaid Involved in submitting claims Involved in recipient care

39. PROVIDER SCREENING (cont) Potential consequences of employing an excluded provider include: Repayment of claims Penalty of up to $10,000 for each item or service claimed Assessment of three times the amount claimed for each item or service Exclusion

40. PROVIDER SCREENING (cont) Exclusions are documented on the following databases: List of Excluded Individuals/Entities (LEIE) at http://www.oig.hhs.gov/fraud/exclusions.asp System for Award Management (SAM) at www.sam.gov Medicheck List at http://www.dpw.state.pa.us/learnaboutdpw/fraudandabuse/medicheckprecludedproviderslist/index.htm

41. PROVIDER SCREENING (cont) Protect yourself and your company Develop policies and procedures for screening all employees and contractors Develop and maintain auditable documentation of screening efforts Periodically conduct self-audits to determine compliance with this requirement

42. PROVIDER SCREENING (cont) Check Federal and State Databases: Before hiring or contracting with an individual or entity Monthly thereafter This maybe a good time to verify licenses with the Department of State

43. PROVIDER SCREENING (cont) If you discover an excluded individual? Immediately self report any discovered exclusion to the Bureau of Program Integrity This can be done via e-mail through the MA Provider Compliance form at the following link: http://www.dpw.state.pa.us/learnaboutdpw/fraudandabuse/maprovidercompliancehotlineresponseform/index.htm

44. AUDITS/REVIEWS Who can conduct audits/reviews? Centers for Medicare & Medicaid Services (CMS) Office of Inspector General (OIG) Payment Error Rate Measurement (PERM) Medicaid Integrity Contract (MIC) Bureau of Program Integrity (BPI) PCG

45. SELF AUDITS Self-Auditing activities include: Periodic self auditing of service delivery and billing Reconciliation of MA claims with the amount received Review of regulation/requirements to ensure that services were rendered and billed correctly

46. SELF AUDITS (cont) Pennsylvania’s voluntary MA Provider Self Audit Protocol provides a mechanism for disclosure and repayment of improper MA payments and provides guidance on the preferred methodology.

47. SELF AUDITS (cont) Self Audit Protocol can be assessed at: www.dpw.state.pa.us/PartnersProviders/MedicalAssistance/DoingBusiness/FraudAbuse/003670226.htm

48. SELF AUDITS (cont) Help you to: Identify incomplete/inaccurate documentation Promote a commitment to comply with rule/regulations Prevent/detect criminal conduct and violations Avoid penalties

49. SELF AUDITS (cont) Benefits Identify overpayments Identify underpayment Identify services you could be billing for Identify individuals that might not be submitting time appropriately DPW isn’t standing over you shoulder conducting the review

50. SELF DISCLOSURES LEAs are encouraged to self disclose billing errors and violations identified Providers have a legal and ethical commitment to return inappropriate Medicaid payments.