POUGHKEEPSIE CITY SCHOOL DISTRICT PUPIL PERSONNEL DEPARTMENT S MEDICAID BILLING COMPLIANCE PROGRAM AND PROCEDURES

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1 POUGHKEEPSIE CITY SCHOOL DISTRICT PUPIL PERSONNEL DEPARTMENT S MEDICAID BILLING COMPLIANCE PROGRAM AND PROCEDURES INTRODUCTION This Poughkeepsie City School District Medicaid Billing Compliance Program was developed in response to New York State Office of the Medicaid Inspector General s requirement that all entities that submit Medicaid claims or receive payment for Medicaid covered services at $500,000 or greater during any 12-month develop a comprehensive system of oversight for Medicaid billing, reporting and practices. SCHOOL DISTRICT COMPLIANCE OFFICER Responsibility for monitoring the School District s Compliance Program is delegated to the Assistant Superintendent for Pupil Personnel and many of the responsibilities associated with the daily oversight are assigned to the Junior Accountant assigned to the Pupil Personnel Department. The Compliance Officer shall report directly to the District s Superintendent of Schools and shall periodically report to the Board of Education on the District s Compliance Program. The duties of the Compliance Officer shall include, but not be limited to: 1. overseeing and monitoring compliance activities; 2. reporting regularly to the Superintendent and periodically to the Board of Education; 3. establishing procedures to improve efficiency and to reduce vulnerability to fraud, abuse and waste; 4. ensuring that the Compliance Program is implemented and evaluated periodically; 5. developing, coordinating, and participating in a training program that focuses on elements of the Compliance Program, and seeks to ensure that all appropriate non-employees have access to training information, and all employees, service providers, administrators, appointees, associates and executive and governing body members of the Board of Education receive formal training so that they are knowledgeable of, and compliant with, pertinent federal and State requirements;

2 6. educational and training programs shall occur at least annually and shall be made a part of the orientation for any new employee, service provider, administrator, and Board of Education member. 7. training materials shall be posted on the Poughkeepsie City School District Medicaid web link, thus available to all parents and external agencies that interface with the school district. 8. coordinating internal and external auditing of all compliance requirements on a periodic basis; 9. establishing and administering a reporting system that is available to report any suspected illegal conduct or other conduct that violates applicable law, regulation, or School District guidelines; 10. developing and publishing notices that encourage the reporting of all suspected fraud and other improprieties without fear of retaliation and guidance on how to report; 11. investigating any report or allegation concerning possible unethical or improper business practices and monitoring subsequent action and compliance; l2. monitoring any and all fraud alerts issued by the Office of the Medicaid Inspector General; 13. monitoring the website of the Office of the Medicaid Inspector General for Compliance Program guidelines, including any Compliance Program template, and revising the School District s Compliance Program if necessary; and COMMUNICATION An open line of communication between the Compliance Officer and all School Supportive Health Services Program (SSHSP) providers is critical to the successful implementation and operation of the Compliance Program. There is an open door, confidential, complete anonymity, and non-retribution assurance to all employees, service providers administrators, and Board of Education members to encourage good faith reporting of potential compliance issues. This assurance is documented in Policy Methods for reporting concerns will be listed in the Medicaid Compliance web link located on the Poughkeepsie City School District home page. Concerned parties may report electronically or complete an anonymous form to be sent via interoffice or post mail to the Compliance Officer.

3 Reports that suggest violations of the Compliance Program will be maintained by the Compliance Officer in a log and will be investigated promptly by the Compliance Officer to determine their validity. The Compliance Officer will report the findings to the Superintendent and Board of Education for possible further investigation of and possible corrective action regarding each compliance issue. Identifying and reporting compliance issues may also be made directly to the New York State Department of Health or the Office of the Medicaid Inspector General. The School District will not penalize, discriminate, or retaliate against anyone who in good faith discloses a practice that violates any law, regulation, or guideline, initiates, cooperates or participates in an investigation, or objects to or refuses to participate in any activity, policy or practice that violates any law, regulation, or guideline. COMPLIANCE Billing for Medicaid eligible school services will be done in compliance with all applicable state and federal laws and regulations. Specifically, no bill for reimbursement shall be submitted unless it was actually performed and documented by the service provider. The District is committed to maintaining the accuracy of every claim it processes and submits. Any false, inaccurate, or questionable claims should be reported immediately to the District s Medicaid Compliance Officer. False billing is a serious offense. Federal and State rules prohibit knowingly and willfully making or causing to be made any false statement or representation of a material fact in an application for benefits or payment. It is also unlawful to conceal or fail to disclose the occurrence of an event affecting the right to payment with the intent to secure payment that is not due. In addition to criminal penalties, the Federal False Claims Act permits substantial civil monetary penalties against any person who submits false claims. The Act provides a penalty of triple damages as well as fines up to $10,000 for each false claim submitted. The persons involved in submitting false claims (as well as the District) may be excluded from participating in the Medicaid programs. Numerous other federal laws prohibit false statements or inadequate disclosure to the government and mandate exclusion from Medicaid programs. It is illegal to make any false statement to the federal government, including statements on Medicaid claim forms. It is illegal to use the U.S. mail to scheme to defraud the government. Any agreement between

4 two or more people to submit false claims may be prosecuted as a conspiracy to defraud the government. The District promotes full compliance with each of the relevant laws by maintaining a strict policy of ethics, integrity, and accuracy in all its financial dealings. Each employee and professional, including outside consultants, who is involved in submitting charges, preparing claims, billing, and documenting services is expected to maintain the highest standards of personal, professional, and institutional responsibility. Individuals who fail to report suspected problems, participate in non-compliance behavior and/or encourage, direct or facilitate non-compliance behavior may be subject to disciplinary action in accordance with the provisions of New York law and any applicable collective bargaining agreement. EDUCATION AND TRAINING It is the Compliance Officer s responsibility is to ensure that every employee involved with the Medicaid service and billing process is educated about the applicable laws and regulations governing provider billing and documentation. This includes access to training information for non-employees, and formal training for all employees, service providers, administrators, appointees, associates and executive and governing body members of the Board of Education. Moreover, the District s Compliance Program shall be shared with all District employees, be available for inspection and shall be published on the District s website. Training will occur annually during all new employee orientations, the opening dates for the return of all employees to school and during a Board of Education training each year. The Compliance Officer shall also develop, oversee and/or provide in-service training on Medicaid billing and documentation requirements for all staff involved in providing and/or billing for Medicaid services periodically and at other times, including initial employment or assignment. Such training shall be mandatory and the District shall maintain records of all trainings. REPORTING AND INVESTIGATION Reporting Every employee in the District has the responsibility not only to comply with the laws and regulations, but to ensure that others do as well. Employees must report non-compliance to their immediate supervisors, or the District s Compliance Officer. Supervisors are required to report these issues through established channels in Human Resources/Personnel and/or directly to the District s Medicaid Compliance Officer. Calls may be made anonymously, although the District encourages

5 employees to provide their name and telephone number so that reports may be more effectively investigated. Every attempt will be made to preserve the confidentiality of reports of non-compliance. All employees must understand, however, that circumstances may arise in which it is necessary or appropriate to disclose information. In such cases, disclosures will be on a "need to know" basis only. Investigation The Compliance Officer will, personally or through his/her designee, investigate every report of non-compliance as soon as practicable. Investigations may include interviewing employees and/or reviewing documentation. Each employee must cooperate with such investigations. Once the Compliance Officer completes an investigation, he/she will make a report to the Superintendent of Schools. The report will be the basis for the Compliance Officer s Program or recommendation of corrective action and/or discipline. Reports will be retained for a period of six years. Non-Retaliation It is the policy of the district that no person shall retaliate, in any form, against a person who reports in good faith, an act or suspected act of non-compliance (although employees may be disciplined for making intentionally false reports of non-compliance). Any person who is found to have retaliated for such a report shall be subject to discipline. In addition, the Federal False Claims Act and New York State Law provide certain protections to individuals who are discharged, demoted, suspended or threatened, harassed or discriminated against by their employer in retaliation for assisting in the investigation, initiation or prosecution of a False Claims Act violation or which constitutes health care fraud under the New York State Penal Law. Corrective Action/Sanctions In order to make this Compliance Program effective, the Compliance Officer will have authority to impose corrective action. If a service provider or employee is found to be non-compliant in a single instance or relatively insignificant percentage of cases over a short period, the Compliance Officer may require that person to undergo a session of education or training. If a provider or other employee fails to comply with billing or documentation requirements repeatedly, sanctions may be more severe.

6 Plans of correction and discipline may include, but are not limited to: 1. a requirement to undergo training; 2. a period of required supervision or approval of documentation before bills can be issued; 3. expanded auditing, internal or external, for some period of time until compliance improves; 4. self-reporting of violations; and 5. in sufficiently egregious cases, discipline up to and including termination, submission of a Part 83 Report and 3020a proceedings may occur. In addition, the Compliance Officer may recommend some other appropriate course of action to correct non-compliance. AUDITING/REVIEW Monitoring of compliance with billing rules is essential. The Compliance Officer must be able to ensure compliance through an understanding of current regulations and overall levels of compliance throughout the District at any given time. Under this Plan, there will be both internal and external (i.e. by an independent consultant or other professional) auditing of Medicaid billing documentation. Internal Auditing Processes The Junior Accountant, assigned to the Pupil Personnel Department and reporting to the Compliance Officer, will conduct the following monthly review of components of the Medicaid Compliance Program: 1. All providers service delivery schedules and claims for submission are processed through a web based tracking program and may be viewed by the building administrators and Pupil Personnel Department. 2. No claim will be submitted that is not entered into this web based tracking system. 3. A sample of documented services ready for claiming for each provider will be cross-referenced with the providers attendance, student attendance, school

7 calendar, IEP documented service frequencies and durations and signed parental consents on a monthly basis. 4. This monthly sample audit will serve to identify errors, and employees who require additional training. 5. A file of credentialed employees will be maintained for all employees in the district or in private settings providing services for students who are the responsibility of the Poughkeepsie City School District. No claim will be submitted for a service rendered should the provider be found to be ineligible for licensing. 6. The junior Accountant will check the New York State Professional Licensing Website to insure that providers remain credentialed on a monthly basis. 7. Under the Direction and Under the Supervision of Support will be provided to all related service providers requiring this level of oversight. 8. Appropriately credentialed related services providers assigned with providing Under the Direction of or Under the Supervision of oversight will be Board of Education appointed and receive an annual stipend if the District employs them. Consultant providers will not be eligible for this stipend. 9. Under the Direction Of and Under the Supervision Of providers will sign off that they are providing the required oversight. This signed form will be maintained in the Pupil Personnel Department as will a schedule of oversight for each provider. 10. All of the information generated in report formats associated with the sample audit process will be maintained in the Pupil Personnel Department. 11. Once notified that the state is sending payment to the District the Junior Accountant will notify the District Treasurer of the amount. 12. The District Treasurer will notify the Junior Accountant once payment is received and note any discrepancies to be corrected. 13. If the District receives an overpayment for Medicaid, the District will record this as a liability to the State. Subsequently, the District will cut a check to return the amount of overpayment.

8 External Audit Process The District engages in an annual Independent External Audit Process. The Independent External Auditor is selected through a five year Request For Proposal (RFP) process in accordance with the Hevise Five Point Plan. The Compliance Officer may engage an external auditing firm as deemed necessary to assess the District s overall compliance at any time. All employees must cooperate fully with this effort by making themselves and/or any pertinent documents available. All external auditors will report to the Assistant Superintendent for Business who will in turn communicate with the Compliance Officer concerning the results of any audit process that reviews the submission and receipt of reimbursement in association with Medicaid reimbursement. The Compliance Officer will report, in turn, to the Superintendent of Schools and the Board of Education. 1. The District will engage the services of a third party consultant to submit all Medicaid claims through the MedWeb Website for payment. 2. The consultant will develop a Database of Eligible Students through the CNYRIC data center that will be periodically updated. 3. The consultant will submit claims for all Eligible Students after cross referencing corresponding and student specific: a. written referrals; b. parental consent; c. conformity to the IEP prescribed duration and frequency; d. session notes contain CPT Codes and ICD-9 Codes e. Under the Direction Of initial observation sign off; f. assurance that no claim is paid for a service provided by an employee paid through a federal fund; g. assurance that all providers are not on the Federal Medicaid Exclusion list. 4. Once a claim is submitted any errors will be corrected and resubmitted in the next claim 5. The CNYRIC NonBilll Report is reviewed monthly and rejections corrected. 6. The CNYRIC monthly ClmRjct and RemitData reports are uploaded into the District Database. 7. Students will be deleted from the Eligible Student Database who have exited the district, are declassified or whose Medicaid eligibility has expired.

9 ONGOING ASSESSMENTS The Compliance Officer will make an annual assessment of the success of this Compliance Program. That assessment will be based on the examination of results of internal audits and investigations, reports of any outside audits that may have been conducted, and or his/her own personal experience with the functioning of the Program over the previous year. A summary of this assessment shall be provided to the Superintendent of Schools and the Board of Education. LP 3/2013

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