LEA Medi-Cal Billing. ~Catching the In-House Wave~ Presenters:

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1 LEA Medi-Cal Billing ~Catching the In-House Wave~ Presenters: Margie Bobe, Los Angeles Unified School District & Cathy Bennett, Sacramento City Unified School District

2 ~Catching the In-House Wave~ Billing Services Providers Audits Are you an LEA? Does your LEA provide direct School Based Services to their students? Have you ever wondered how an in-house LEA billing process operates? Join Margie and Cathy while they share their experience of having successful in-house LEA direct School Based Services billing programs.

3 At the Completion of this Breakout the Participants will be able to: Recognize the benefits of an in-house School Based Services billing program. Identify the key factors to having a successful in-house School Based Services billing program. Services Utilize the Self Audit Check List to insure program success. Providers Audits Billing

4 LEA Medi-Cal Billing Option Program - Program Requirements LEA s Must Meet The Following Requirements: Provider Participation Agreement Service provider qualifications Submit Annual Report to DHCS Establish Collaborative for reinvestment Targeted Case Management Labor Survey Annual Cost and Reimbursement Comparison Schedule (CRCS Report) LEA specified procedure codes and rates

5 LEA Medi-Cal Billing Option Program -Services The California Department of Health Care Services will reimburse LEA s for the following direct IEP/IFSP and Non-IEP services: Assessments Counseling Speech Audiology Occupational Therapy Physical Therapy Specialized Nursing Targeted Case Management Transportation

6 LEA Medi-Cal Billing Option Program - Service Requirements IEP/IFSP Services Documented in Students IEP/IFSP Non-IEP Services Must meet Free Care Requirements Transportation & Mileage Billable only when a Medi-Cal covered service is provided

7 LEA Medi-Cal Billing Option Program - Service Requirements The following must be provided by the specified licensed provider: Referrals IEP Assessments Speech and Audiology Treatments Protocols Speech and Audiology Treatments Recommendations Counseling Treatments

8 LEA Medi-Cal Billing Option Program - Service Requirements Continued - The following must be provided by the specified licensed provider: Prescriptions Occupational and Physical Therapy Treatments Supervision Licensed Vocational Nurse Trained Health Care Aides Non-credentialed licensed nurse Credentialed only Speech Therapists providing Speech Treatments

9 LEA Medi-Cal Billing Option Program - DHCS Audits and Investigations Types of Audits Random Prepayment random audit of claims submitted for payment Medi-Cal Payment Error Study (MPES) Post payment error study to detect, identify and prevent fraud and abuse in the Medi-Cal Program

10 Sacramento City Unified School District General Education Enrollment 48,000+ Students Special Education Student Enrollment 6000 Students Sacramento City LEA Medi-Cal Billable Services IEP Assessments IEP Audiology Treatments IEP Counseling Treatments IEP Speech Therapy IEP Occupational Therapy IEP Nursing Special Procedures IEP Transportation

11 Sacramento City Unified School District In The Beginning. In 1999 SCUSD was using a outside vendor Attempted to gather paperwork Very little revenue No direction or program compliance Then Management said... Hmm Perhaps there s a better way.. In 2000 SCUSD hired staff to start up the In-house billing program Acquired a claim adjudication software license

12 Sacramento City Unified School District Overview of In-House Billing Department Staffing: 1 Supervisor, 1 Technician Activities include: Review internal processes Meet with staff, develop relationships Streamline paper process Train, train and more training services providers and technician Monitor and track incoming services Compare and share outcomes Co-chair SCUSD LEA Collaborative Self audit guide

13 Sacramento City Unified School District - Key to Success The Key to Success Developed Relationships Special Education SELPA Services Providers Department of Health Care Services Local Consortium Other LEA s Program Compliance Keep up on internal processes Keep up on state and federal regulations

14 Los Angeles Unified School District -Data General Education Population 700,000 Special Education Population 80,000 LEA Medi-Cal Billable Services IEP Assessments IEP Audiology Treatments IEP Counseling Treatments IEP Speech Therapy IEP Physical Therapy IEP Occupational Therapy IEP Nursing Special Procedures IEP Transportation

15 Los Angeles Unified School District -Billing In-House billing as of 2003 Purchased software license of electronic IEP, service tracking and billing system Transition from vendor to in-house paper logs February to April 2003 Reduced program costs Vendor contract Printing of paper logs Multiple staff to liaison with vendor and distribution of logs Transition from paper to electronic system 2004 to 2008 Transition to electronic environment by provider group Largest group, 600 nurses, totally electronic FY08-09

16 Los Angeles Unified School District -LEA Billing Process Service documentation and billing requirements Providers document Special Education services in system Billing requirements are incorporated into electronic system, i.e. recommendations are part of provider documentation for service records Student Medi-Cal eligibility is uploaded into system

17 Continued Los Angeles Unified School District -LEA Billing Process Service documentation and billing requirements Billing system is configured with billing codes and rules to evaluate data for billing requirements and generate an electronic billing file Student Medi-Cal eligibility Provider qualifications Billable services and amount of time provided to meet claim criteria Billing requirements for services Timelines for submission of claims LEAs have 12 months from date of service to submit claims

18 Los Angeles Unified School District -LEA Billing Staff Billing staff of 5; Supervisor and Clerical Data entry of paper logs Previewed for quality assurance of documentation and billing requirements Review electronic documentation of providers Suppress claims that do not meet documentation requirements Verify provider qualifications Verify license and credential data and update system when applicable; expiration dates

19 Los Angeles Unified School District -LEA Billing Staff Continued Billing staff of 5; Supervisor and Clerical Claim submission and claim payment files are electronically transferred to and from Medi-Cal As data entry workload was reduced, staff absorbed billing for other non-lea health services provided by District staff Child Health Disability Prevention (CHDP) Mental Health

20 Los Angeles Unified School District Key to Success District Medi-Cal Reimbursement Coordinator responsible for LEA Program Program Policies Coordination with provider groups Service Documentation Referrals, Recommendations, Prescriptions Collaborative Committee Monthly Service Tracking System meetings with service providers System upgrades and enhancements

21 Los Angeles Unified School District Key to Success Continued District Medi-Cal Reimbursement Coordinator responsible for LEA Program Internal Quality Assurance Review Committee Quarterly meetings with representatives from each provider group to reinforce standards of practice for documentation to align with billing requirements. Medi-Cal Reimbursement unit also performs audits of documentation and shares findings with provider groups in addition to encouraging them to perform self audits.

22 ~Catching the In-House Wave~ So what are the benefits? The Three C s

23 ~Catching the In-House Wave~ The Three C s Control Direct interaction with service providers Implement program policies and procedures Total oversight of the billing process Compliance Monitor and maintain program integrity with state and federal regulations Develop relationships with service providers to gain better outcomes Cost Effective Reduce expenditures, allowing increased revenue for reinvestment into school health programs Vested interest to optimize program Lower audit liability risk

24 Something to think about What is My LEA s Special Ed Enrollment? What is My LEA s Medi-Cal Eligibility %? Are my LEA service providers qualified? Does my LEA meet the program requirements? Would your Management and Special Education Administration provide support?

25 Program Resources

26 Later Dude ~ Any Questions??

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