SEAS™Arkansas

Medicaid Claiming and Compliance

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CAS has successfully deployed SEAS at more sites than any other Special Education Management Solution!

• Over 2,200 School Districts use SEAS

• SEAS installed in 38 U.S. States, D.C.

• Smallest single district has 1 IEP (MO)

• Largest single district has 9,100 (FL)

• 90% of districts in AR use SEAS

• Medicaid Solutions in 10 States Nationally

• Approximately 100 AR Districts use our Medicaid Solution

• MITS and CAS Partners

What is Medicaid?

•Medicaid is a federally funded, health insurance program for low Medicaid is a federally funded, health insurance program for low income and needy people.income and needy people.

•It is for children under age 22, and is called the Early & Periodic It is for children under age 22, and is called the Early & Periodic Screening, Diagnosis and Treatment (EPSDT) Program.Screening, Diagnosis and Treatment (EPSDT) Program.

•53 million Americans depend on Medicaid53 million Americans depend on Medicaid

•Medicaid spending reached over $300 billion, surpassing Medicaid spending reached over $300 billion, surpassing MedicareMedicare

•Increased state Medicaid spending, coupled with increased Increased state Medicaid spending, coupled with increased unemployment, threaten states’ ability to maintain current unemployment, threaten states’ ability to maintain current service levelsservice levels

What is School Based Claiming?

Federal program for school related services often times referred to as School-Based Fee For Service (FFS)

The federal program allows schools to seek reimbursement for Medicaid-covered services provided to children in Special Education.

The federal agency that oversees this program is the Centers for Medicare and Medicaid Services (CMS)

Each state has its own CMS approved version (State Plan) of FFS School Based program; most states are participating

Each State Medicaid agency has responsibility to oversee this program. Some States outsource this (Arizona, etc.)

Arkansas School Based Claiming Facts

Medicaid (DMS-640) requires a separate application for each service provided.

Services must be listed in an Individualized Education Program (IEP). SBMH services are the only services that can be billed to Medicaid without requiring an IEP.

• Arkansas school districts are able to offer: Occupational Therapy (OT),

Physical Therapy (PT), Speech/Language Pathology (SLP), School-Based Mental Health (SBMH), Private Duty Nursing (PDN), Targeted Case Management (TCM), and

Personal Care (PC).

• 504 Services can not be billed through Medicaid

Schools have the right to Medicaid Recoveries

• Need to Recover All Revenues• Schools have the right to bill Medicaid for services in

the educational setting if:

the child is Medicaid eligible on the date of services the District has written parental consent the service is approved in the State Plan the medical services are in the IEP (scope,

frequency, and duration) all medical services are documented with progress

reports the provider is Medicaid certified at the time

services rendered

… but it can be an intimidating process

• CMS and the Federal Government consider School-Based Claiming a “High Risk” program

They do not believe schools have demonstrated the ability to document that they have met all requirements of this program

and because of this, some states (i.e. Tennessee, New Mexico, Ohio) have elected not to participate…

…denying districts of their federal right to revenue for reimbursements for services delivered.

Districts need an ‘electronic safety net’• CMS and OIG Audit history shows that the vast majority of

districts and States do not pass routine audits• Funds are required to be paid back, even when the service

may be legitimate, simply because: Lack of documentation, especially years after the billing

when an audit is performed No electronic checks, no self-audits or formal reporting

mechanism No systematic checks in place to ensure delivery of IEP

“promises” match what is billed Units billed do not always match IEP and/or provider logs No documentation to verify the provider was certified during

time of services Services were not sufficiently documented to ensure that

services prescribed in the IEPs were delivered Services billed and paid were not approved in the state plan

SEAS DSCtop Manages Medicaid Recovery and

Compliance

SEAS™ Medicaid Recovery Keys• SEAS DSCtop Suggestions

Compliance First – Medicaid Recoveries Ease of Use for Providers Parental Consent SIS, IEP and Medicaid Solutions interface IEP Goals and Objectives to be integrated Automated Eligibility Updates Prescriptions and Prior Authorizations Financial and Administrative Reports Needed by

Districts– Accountability and Reconciliation

SEAS™ Arkansas Medicaid KeysParental Consent:

• Required by IDEA.

• If you have SEAS this document should be included with the forms packet when developing the IEP.

• Only logged Medically Necessary sessions, for Medicaid eligible kids, with parental consent of yes. Within SEAS this is documented in the “Eligibility Update Screen.”

Eligibility Benefit Information:

• Claims cannot be processed without primary care physician information.

• If eligible, the Medicaid and primary care physician information will populate the necessary fields for successful claims.

• This information needs to match the information reported on the DMS-640 form.

Prescription Updates:

• Have you entered the prescription start and end dates for OT, PT and Speech services? This can be accomplished by entering the prescription start and end dates in Prescription Update.

Prior Authorization:

• Have you entered Prior Authorization Number, Start and End Dates for services requiring prior authorization (Personal Care, Private Duty Nursing, and School Based Mental Health)?

SEAS™ Arkansas Medicaid Keys

• Medical Necessity: To be considered medically necessary, the following

condition must be met: 1) The services must be considered under accepted standards of

practice to be a specific and effective treatment for the patient’s condition;

2) The services must be of such a level of complexity, or the student’s condition must be such that the services required can be safely and effectively performed only by or under the supervision of a qualified speech and language pathologist;

3) There must be reasonable expectation that therapy will result in meaningful improvement or reasonable expectation that therapy will prevent a worsening of the condition.

A diagnosis alone is not sufficient documentation to support the medical necessity of therapy. The student’s diagnosis must clearly establish and support that the prescribed therapy is medically necessary.

SEAS Revenue Recovery is automatically populated when students enroll in Special Education with an active IEP.

Multiple providers can be linked to the same student simultaneously.

Once a student has been selected, the provider is directed to this unique documentation screen which prevents entries on holidays, weekends and in the future.

The goals and objectives for this student will be automatically populated from the IEP.

The system validates the type, frequency and time of the sessions

The system provides an area to document the clinical notes according to the dates and services provided.

When a student in your caseload masters a goal, you can deactivate it so it does not appear in future months.

SEAS Revenue Recovery and Compliance

• Built-in accountability, validation and compliance rules

• Focus is on Providers Ease of Use

• Data is automatically populated to promote staff efficiency

• Backed by Exceptional Medicaid Service and Technical Teams to support your needs

• One of the many commitments we make to our customers

QUESTIONS

The MITS Help Desk staff:866/280-8300, option 1 or 870/367-4837

Jeanie Donaldson - jdonaldson@se2.k12.ar.us Jamie Rawls - jamie.rawls@se2.k12.ar.us Janell Harris - janell.harris@se2.k12.ar.us  CASDianne Cole(877) 221-7327 (toll-free)http://www.computerautomation.com

Thank You!

CAS(877) 221-7327 (toll-free)http://www.computerautomation.com