> > School-Based ACCESS Program 2013 Fall Regional Training Barry C. Decker, Bureau of Policy,...

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School-Based ACCESS Program

2013 Fall Regional Training

Barry C. Decker, Bureau of Policy, Analysis and Planning

Pam Tressler, Bureau of Program Integrity


AGENDA

Overview Participant Roles CMS Financial Management Review Services Requirements Documentation Verification

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AGENDA (cont.)

Provider Screening Audit/Reviews Self-audits Self-disclosures Corrective Action Plans Results of CMS Audit BPI Findings

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AGENDA (cont.)

Contact Information Questions

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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

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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.)

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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.)

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Administrative services• Services provided by the LEAs that are

in support of direct services

OVERVIEW (cont.)

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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

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• 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.)

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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

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• 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.)

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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.)

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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

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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.

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SERVICES (cont.)

MA Provider Agreement• LEAs must comply with all Federal Medicaid

and State rules and regulations

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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

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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)

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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)

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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

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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.

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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

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>www.dpw.state.pa.us > 23


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)

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DOCUMENTATION (CONT)

• Daily logs (Easy Trac)o If on behalf of or not electronically

documented the original paper document must be retained

• Attendance recordso Studento Provider

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• Keys for acronyms/abbreviations used

• Provider licenses and/or certifications

• Evaluation reports

• Transportation logs

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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

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• 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)

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• Must document progress for each session, change in diagnosis, treatment and response to treatment

• Must be dated and signed

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Reminder for LEAs using a third partyvendor or on behalf of entries

• You must maintain the original documents

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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

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VERIFY (cont)

Parental consent

•On file

•Appropriately marked/checked

•Signed & dated

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VERIFY (cont)

Medical Practitioner Authorization Form(MPA)/Prescription

•On file

•Valid for that DOS

•Contains the health-related service

•Duration

•Frequency

•Signed/Dated33


VERIFY (cont)

• Provider meets the appropriate qualifications (valid license, CPR, first aid)

• Provider is not paid with IDEA funds

• Daily log o Completedo Signed/Supervisory signature if necessary

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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

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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.

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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.

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SELF AUDITS (cont)

Self Audit Protocol can be assessed at:

www.dpw.state.pa.us/PartnersProviders/MedicalAssistance/DoingBusiness/FraudAbuse/003670226.htm

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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

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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

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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.

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SELF DISCLOSURES (cont)

Send Self Audits/Self Disclosures to BPI at:

Department of Public Welfare, Office of Administration, Bureau of Program IntegrityP.O. Box 2675, Harrisburg, PA 17105-2675

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CORRECTIVE ACTION PLANS

A CAP is:• A written step-by-step plan of action

developed to achieve targeted outcomes for resolution of identified problems

• Requested by BPI as a component of its review when violations are identified

• BPI will either accept a provider’s CAP or request revisions

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The ultimate goal is to incorporate a CAP into an LEA’s everyday operations in an effort to:

• Comply with state and federal regulations;• Ensure quality, accessible, timely services;• Achieve measurable improvement in the

highest priority areas;

• Eliminate repeated deficient practices

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CAPs must include at a minimum:• Specific policies and procedures

developed to address the issue• Specific measures taken or to be taken to

ensure compliance• Timeline for the measures• Date(s) of implementation• Responsible person/persons• Follow-ups to ensure compliance

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RESULTS OF CMS AUDIT

Missing documentation

• IEP• Daily progress note• Parental Consent• Medical Practitioners Authorization • Attendance Record• Transportation Logs

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RESULTS OF CMS AUDIT (cont)

Incomplete Documentation/Didn’t Meet Requirements

• Daily log must include the providers name and be signed

• Units billed not equal to units documented• More units billed than medically necessary• IEP did not specify group vs individual• Service not listed on IEP

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RESULTS OF CMS AUDIT (cont)

• MPA signed post date of service• Provider not licensed on date of service• One way transport paid for round trip

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BPI FINDINGS

Findings:•Licensing Problems•Signatures•PCS•Documentation

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CONTACT INFORMATION

Barry Decker, BPAP

717-772-6341

[email protected]

Pam Tressler, BPI

717-705-6873

[email protected]

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QUESTIONS

Questions?

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