9/26/2012. Managing Your School Based Medicaid Billing Program. Objectives
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1 Managing Your School Based Medicaid Billing Program NAME Conference, October Elaine Lerner, New Jersey DOE Kathleen Cummins Merry, Wayne RESA, Michigan Stephen Wright, New York State Education Department Bryan Hawkom, Michelle Simmons, Patsy Crawford, PCG Objectives Understand successful approaches to program integrity Learn how new policies are being successfully implemented, including changes with respect to ICD10 and NPI Understand how to successfully use a stakeholder steering committee to improve communication between agencies Compare/contrast four programs, including covered services and approach to cost settlement 2 3 Michigan Background Basic Information: 56 Intermediate School Districts, 570 districts, 250 charters, 1,600,000 Students 100% Program Participation FFS, MAC and Cost settlement Unique Aspects of Program: 1/12 Monthly Interim Payment Methodology based on Previous Year s Cost Reconciliation 4 Cost Pools Summer Quarter Time Study RESA Specifics: Average Staff Pool for = approximately 3000 per quarter Wayne County Public Schools (excluding Detroit) has approximately 24,649 Special Ed students, 38% or 9,396 of which are Medicaid eligible Detroit Public Schools has approximately 15,175 Special Ed students, 71% or 10,828 of which are Medicaid eligible 1
2 Michigan Background RESA Specifics continued: Wayne RESA Reimbursement Outcomes = $5,854, = $8,634,255 (New Program Begins) = $12,988, = $13,020,000 (Final payment not yet received) 4 New Jersey Background Basic Information 300 School districts and Charter Schools currently participate in NJ SEMI Program Mandated Program Participation SEMI(FFS), MAC, Cost Settlement (pending SPA approval) Unique Aspects Statewide billing vendor Combining cost settlement with existing SEMI billing Coordinating with out of district placements Implementation Challenges Certification/licensure requirements Timeline First cost settlement for 2011/12 school year 5 New York Background 6 Basic Information 694 school districts, 57 counties, 2.7 million students Since April 2011, 48% actively participating in program; 154 school districts have not submitted a claim FFS, Cost Settlement (pending SPA approval), MAC on the horizon Unique Aspects NYS Billing Clearinghouse 12 Regional Offices provide Medicaid support State billing software/third Party billing software Implementation Challenges NYS Compliance Agreement Documentation Certified Public Expenditures Timeline First cost settlement for 2011/12 school year 2
3 Program Integrity 7 Training School based training by regional offices Rigorous annual compliance training program Compliance programs/compliance officers Regional Trainings Webinars Policy/operational training for new LEA staff Communication Medicaid Alerts Newsletters School based services website Regional office e mail distribution/listserv Program Integrity Prepayment Reviews Billing Requirements Vendor Processes/Software Pre claiming reviews (required or voluntary) Postpayment Reviews/Audits On site reviews (by state, region) Desk audits Self audits Attendance records, IEPs, licensure, monthly notes 8 Program Integrity LEA Lessons Learned/Audit Findings Using Federal funds Estimating salaries Incorrect IEP service dates & some frequency issues Missing documents (staff departures) 9 3
4 Program Integrity Spotlight: NY Creation of regional compliance committee meetings NYS State Education staff present Sharing of common issues Brainstorming for solutions 10 Stakeholder Communication Steering Committees Regular stakeholder meeting Education/Medicaid; state and LEAs; billers Need to address policy issues and implementation issues May be two different audiences Use of regional/county office structures Regular meeting structures E mail distribution system/listserv Follow up on delinquent LEAs 11 Stakeholder Communication Spotlight: MI Implementers Meeting 12 4
5 Stakeholder Communication Statewide Communication Medicaid Alerts Newsletters School based services website Regional office e mail distribution/listserv Focus on successes Support from state leadership Within LEA Communication Special Education and Finance Interaction Frequent, Focused, Educated 13 New Policies 14 Cost Settlement Requirements Including: Annual cost reporting All billing staff on RMTS rosters Other New Policies: NPI (ordering, attending, billing) Ordering practitioner enrollment CAPTE requirement for physical therapists ICD 10 Group vs. individual services Initial evaluations Speech provider licensure requirements Managing Administrative Requirements 15 Approach to Parental Consent Seeking consent Informational brochures Parental consent training for school staff 3 follow up letters are sent to parents with stamped return envelopes Tracking consent Billing software Pre claim edits check Session Notes Demonstration of Medical Necessity Written Orders 5
6 Managing Administrative Requirements Spotlight: NJ 16 Mandate use of an electronic health service documentation tool Must use to document services for daily claiming and also store key compliance information IEP dates Parental consent dates Physician authorization dates Clinician licensure dates Claims are only submitted when above compliance data is loaded into the system LEAs must keep physical copies RMTS Management Utilizing all support tools provided by RMTS vendor or state agencies Compliance reports Training modes (webinars, manuals, videos) Technical assistance 17 Managing repeat offenders in terms of poor compliance Regional/county offices Escalation and communication through educational associations RMTS Management LEA Focus Ensuring correct staff are on the Staff Pool List Check licensure for all staff on the Direct Service staff pool list to ensure they meet Medicaid requirements Monitor service reporting if staff are not reporting services, should they be on the list?? Train local district office staff on who to place on the staff pool lists Ensuring response rates/compliance levels Daily check of the RMTS website "Compliance Report" Send out e mails to local special ed directors / superintendents when surveys are overdue Train local district staff on compliance face to face setting, and on demand online videos, staff phone calls Using placeholders 18 WAYNE RESA insists and maintains 100% compliance! (MI Statewide? Usually above 93%) 6
7 Closing Thoughts Open communication is important Communicate changes with as much lead time as feasible Program requirements (compliance data, RMTS, etc) can pose a challenge for LEAs Expect some resistance Whenever appropriate, don t impose standards which exceed federal requirements 19 7
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