Arizona Medicaid School Based Claiming Regional Information Session September 2013 www.pcgeducation.com
Agenda Direct Service Claiming Annual Cost Settlement.. 3-45 Random Moment Time Study... 46-50 Direct Service Claiming. 51-56 Quarterly Cost Reporting.. 57-59 Compliance Review 60-65 Resources 66 2
Direct Service Claiming Annual Cost Settlement 3
DSC Annual Cost Settlement Overview As a reminder, the cost settlement process compares Medicaid allowable costs, as determined by the DSC Annual Cost Report, against DSC interim payments received throughout the school year The purpose of cost settlement is to reimburse LEAs for the true cost of providing direct services to Medicaid eligible, special education students For further information, please review the Cost Settlement Calculation Training posted on the dashboard of the Medicaid Cost Reporting and Claiming System (MCRCS) 4
DSC Annual Cost Settlement Cycle Quarterly Staff Pool List LEAs Receive DSC Annual Cost Settlement Payment/ Recoupment Quarterly Random Moment Time Study LEAs Verify DSC Annual Cost Settlement Results DSC Annual Cost Report: Financials Collected via MCRCS AHCCCS Reviews Cost Settlement Results PCG Conducts DSC Annual Cost Report Desk Review and LEAs Edit Costs PCG Calculates the DSC Annual Cost Settlement PCG Calculates the Specialized Trans Trip Ratio Using Interim Payment Data 5
FY12 DSC Annual Cost Settlement Timeline 6
LEA Annual DSC Cost Settlement Next Steps Review of FY12 Annual Cost Report Transportation Costs Release of FY12 DSC Annual Cost Settlement results Verification of FY12 DSC Annual Cost Settlement results Annual Monitoring reviews of FY12 DSC Annual Cost Settlement results Opening of FY 13 DSC Annual Cost Report in MCRCS Payment/Recoupment of FY12 Annual Cost Settlement 7
FY12 Preliminary Cost Settlement Data 117 LEAs participated in FY12 DSC Annual Cost Settlement 78% of LEAs are in a positive settlement For these LEAs, Medicaid allowable costs exceeded DSC interim payments received, and the LEAs will be receiving a settlement check from AHCCCS 22% of LEAs are in a recoupment situation For these LEAs, DSC interim payments exceeded Medicaid allowable costs reported, and the LEAs will be returning the difference back to AHCCCS 8
FY12 Preliminary Cost Settlement Data 44% of LEAs reported costs for providers but did not receive interim payment for at least one (1) service in the corresponding provider category The costs for these providers were not included in the settlement results, and these LEAs lost out on reimbursement due to lack of claiming PCG provides all LEAs an Interim Payment Report that identifies the service types the LEA has claimed to help avoid potential loss of reimbursement 9
FY12 Preliminary Cost Settlement Data 15% of LEAs received interim payments for a service but did not report costs for that particular service type LEAs increase the likelihood of being in a recoupment if claiming for services for which they did not report cost 22% of LEAs had interim payments that exceeded costs reported for a service category This scenario could also lead to a recoupment as LEAs potentially did not report accurate costs for categories in which they claimed LEAs in this scenario should look at reducing the fee schedule used to claim for services 10
Important Variables that LEAs Control Maintaining Staff Pool List (SPL) and ensuring timely and accurate responses to random moments in the Random Moment Time Study (RMTS) system By not including appropriate staff on the SPL, LEAs cannot report these costs on the cost report Accurate reporting of October 1 st student count to report Individualized Education Program (IEP) denominator Failure to report an accurate denominator can lead to an understated IEP ratio, leading to lower Medicaid allowable costs 11
Important Variables that LEAs Control Ongoing direct service claiming and verification that claiming corresponds with costs reported on the Annual Cost Report LEAs must claim for every category in which they report costs, or those costs are not allowable Maintaining documentation to support the specialized transportation trip ratio denominator and claiming for transportation services that meet all requirements which results in an accurate numerator Failure to maintain documentation will lead to a disallowance of costs 12
Important Variables that LEAs Control Working together with all LEA staff involved in the DSC annual cost reporting process, with an emphasis on transportation coordinators Interdepartmental communication is critical to accurate costs being reported Maintaining accurate and compliant documentation for AHCCCS, CMS, and OIG By maintaining accurate and compliant documentation the LEA is prepared for a federal or state audit at any time 13
Impacts of Each Variable Ability to report costs for direct medical and personal care staff (Annual Payroll) Direct medical percentage Denominator of the IEP ratio (Student Count) Direct service claiming Transportation The following slides will demonstrate effect of these five impacting variables for Sunshine Unified School District 14
Impacting Variable Annual Payroll LEAs cannot report costs on the annual cost report for staff who are not included on the SPL for direct service and personal care Failure to include staff on the SPL will lead to the LEA not being permitted to report costs for these individuals on MCRCS Staff cannot be added retroactively to the SPL 15
Annual Payroll Impact Example Sunshine Unified Scenario 1 (LEA has five district nurses providing services but only included three on the SPL) Last Name First Name Job Category JS OD JM AJ Cost Pool Staff Employment Status District Job Title Salaries Benefits Purchased Professional Services (PPS) Costs Compensation Federal Revenues Gross Compensation Expenditures Net Compensation Expenditures Doe Jane Registered Nurses RN Direct 1 1 1 1 Service Cost Pool Full Time Registered Nurses RN $33,000.00 $7,000.00 $0.00 $0.00 $40,000.00 $40,000.00 Doe John Registered Nurses RN Direct 1 1 1 1 Service Cost Pool Contractor Registered Nurses RN $40,000.00 $9,000.00 $0.00 $0.00 $49,000.00 $49,000.00 Smith Larry Registered Nurses RN Direct 1 1 1 1 Service Cost Pool Full Time Registered Nurses RN $36,000.00 $7,000.00 $0.00 $0.00 $43,000.00 $43,000.00 TOTAL $132,000.00 16
Annual Payroll Impact Example Sunshine Unified Scenario 2 (LEA included all five district nurses on the SPL) Last Name First Name Job Category JS OD JM AJ Cost Pool Staff Employment Status District Job Title Salaries Benefits Purchased Professional Services (PPS) Costs Compensation Federal Revenues Gross Compensation Expenditures Net Compensation Expenditures Doe Jane Registered Nurses RN Direct 1 1 1 1 Service Cost Pool Full Time Registered Nurses RN $33,000.00 $7,000.00 $0.00 $0.00 $40,000.00 $40,000.00 Doe John Registered Nurses RN Direct 1 1 1 1 Service Cost Pool Contractor Registered Nurses RN $40,000.00 $9,000.00 $0.00 $0.00 $49,000.00 $49,000.00 Smith Larry Registered Nurses RN Direct 1 1 1 1 Service Cost Pool Full Time Registered Nurses RN $36,000.00 $7,000.00 $0.00 $0.00 $43,000.00 $43,000.00 Murphy Tom Registered Nurses RN Direct 1 1 1 1 Service Cost Pool Full Time Registered Nurses RN $38,000.00 $6,000.00 $0.00 $0.00 $44,000.00 $44,000.00 Ryan Peg Registered Nurses RN Direct 1 1 1 1 Service Cost Pool Full Time Registered Nurses RN $36,000.00 $7,200.00 $0.00 $0.00 $43,200.00 $43,200.00 TOTAL $219,200.00 17
Impacting Variable - Direct Medical Percentage The direct medical percentage (RMTS results) determines the portion of expenditures that support delivery of direct medical services It is derived from responses of individuals reported on the direct service and personal care SPL Each cost pool (direct service and personal care) has its own unique direct medical percentage applied to costs reported for those staff The goal is to include all direct service providers who deliver claimable services 18
Direct Medical Percentage Impact Example Sunshine Unified Scenario 1 (FY12 statewide direct medical RMTS percentage = 39.82%) Service Type Total Direct Medical and Personal Service Costs Direct Medical Percentage Medicaid Allowable Costs* Audiology Services $31,000 39.82% $3,703 Behavioral Health Services $15,000 39.82% $1,792 Nursing Services $73,000 39.82% $8,721 Occupational Therapy Services $240,000 39.82% $28,670 Personal Care Services $240,000 20.18% $14,530 Physical Therapy Services $29,000 39.82% $3,464 Speech Language and Hearing Services $31,000 39.82% $3,703 Grand Totals $659,000 $64,583 *Calculated with an IEP ratio of 30% applied 19
Direct Medical Percentage Impact Example Sunshine Unified Scenario 2 (FY13 statewide direct medical percentage = 44.73%) Service Type Total Direct Medical and Personal Service Costs Direct Medical Percentage Medicaid Allowable Costs* Audiology Services $31,000 44.73% $4,160 Behavioral Health Services $15,000 44.73% $2,013 Nursing Services $73,000 44.73% $9,796 Occupational Therapy Services $240,000 44.73% $32,206 Personal Care Services $240,000 19.68% $14,170 Physical Therapy Services $29,000 44.73% $3,892 Speech Language and Hearing Services $31,000 44.73% $4,160 Grand Totals $659,000 $70,395 *Calculated with an IEP ratio of 30% applied 20
Impacting Variable - IEP Ratio Submission of student roster based on October 1 st student count Please note, LEAs should verify the students identified are in special education AND have an IEP which includes prescribed reimbursable related service Reimbursable services include: Audiology Services Behavioral Health Services Nursing Services Occupational Therapy Services Personal Care Services Physical Therapy Services Speech Language Pathology Services 21
Impacting Variable - IEP Ratio Medicaid eligible students with a reimbursable service in the IEP (Numerator of IEP ratio) Students with an IEP & reimbursable service in the IEP (Denominator of IEP ratio) Students with an IEP Students in an LEA 22
IEP Ratio Impact Example Sunshine Unified Scenario 1 (Inflated denominator of IEP ratio includes all students with an IEP) Service Type Total Direct Medical and Personal Service Costs IEP Ratio Medicaid Allowable Costs* Audiology Services $30,000 5% $600 Behavioral Health Services $15,000 5% $300 Nursing Services $70,000 5% $1,400 Occupational Therapy Services $250,000 5% $5,000 Personal Care Services $240,000 5% $4,800 Physical Therapy Services $30,000 5% $600 Speech Language and Hearing Services $32,000 5% $640 Grand Totals $667,000 $13,340 *Calculated with a RMTS direct medical percentage of 40% applied 23
IEP Ratio Impact Example Sunshine Unified Scenario 2 (Accurate denominator with all students with an IEP prescribed reimbursable related service) Service Type Total Direct Medical and Personal Service Costs IEP Ratio Medicaid Allowable Costs* Audiology Services $30,000 30% $3,600 Behavioral Health Services $15,000 30% $1,800 Nursing Services $70,000 30% $8,400 Occupational Therapy Services $250,000 30% $30,000 Personal Care Services $240,000 30% $28,800 Physical Therapy Services $30,000 30% $3,600 Speech Language and Hearing Services $32,000 30% $3,840 Grand Totals $667,000 $80,040 *Calculated with a RMTS direct medical percentage of 40% applied 24
Impacting Variable - Direct Service Claiming Direct Service Claiming (DSC) is a major component of DSC Annual Cost Reporting Include all direct service providers that you are claiming for on the SPL To have eligible Medicaid allowable costs for a service category, costs must be reported for that category based on individuals reported on the SPL. LEAs must have claimed for that service in order for it to be reimbursable 25
Impacting Variable - Direct Service Claiming Confirm claiming activity by service category corresponds with each cost category of each service type reported on the DSC annual cost report LEAs must claim for and receive DSC interim payments for all service types reported on the DSC annual cost report in order to cost settle for that category LEA should review the Interim Payment Report and review the following: Consistent claiming for services provided by staff included on RMTS staff pool Not claiming for services for job categories if staff are not on the RMTS staff pool for that category 26
Impacting Variable - Direct Service Claiming All DSC claiming activity is closely monitored by PCG and AHCCCS LEAs must submit claims on a consistent and routine basis for all covered services to maintain the integrity of the cost settlement program and meet program compliance Failure to adhere to these guidelines may result in suspension from participation in the Medicaid School Based Claiming (MSBC) program 27
Impacting Variable - Direct Service Claiming DSC interim payments must correspond by service type to the costs reported on the DSC Annual Cost Report DSC Interim Payments Costs Reported on DSC Cost Report 28
Impacting Variable - Direct Service Claiming DSC interim payments must correspond by service type to the costs reported on the DSC Annual Cost Report DSC Interim Payments Speech Therapy Physical Therapy Nursing Services Costs Reported on DSC Annual Cost Report Speech Therapy Physical Therapy Nursing Services 29
Direct Service Claiming Impact Analysis Sunshine Unified Scenario 1 (LEA did not claim for all service categories where costs were reported) Service Type Federal Share Medicaid Costs Costs Allowed for Cost Settlement Interim Payments Federal Share Amount due To/From Provider Audiology Services $3,000 $3,000 $200 $2,800 Behavioral Health Services $1,500 $0 $0 $0 Nursing Services $7,200 $7,200 $3,000 $4,200 Occupational Therapy Services $23,200 $0 $0 $0 Personal Care Services $12,000 $12,000 $17,000 ($5,000) Physical Therapy Services $2,000 $2,000 $4,000 ($2,000) Speech Language and Hearing Services $3,000 $3,000 $4,700 ($1,700) Transportation Services $25,000 $0 $0.00 $0.00 Totals $76,900 $27,200 $28,900 ($1,700) 30
Direct Service Claiming Impact Analysis Sunshine Unified Scenario 2 (LEA claimed for all service categories where costs were reported) Service Type Federal Share Medicaid Costs Costs Allowed for Cost Settlement Interim Payments Federal Share Amount due To/From Provider Audiology Services $3,000 $3,000 $200 $2,800 Behavioral Health Services $1,500 $1,500 $400 $1,100 Nursing Services $7,000 $7,000 $3,700 $3,300 Occupational Therapy Services $23,200 $23,200 $10,100 $13,100 Personal Care Services $12,000 $12,000 $10,900 $1,100 Physical Therapy Services $2,900 $2,900 $200 $2,700 Speech Language and Hearing Services $3,100 $3,100 $2,000 $1,100 Transportation Services $25,300 $25,300 $15,000 $10,300 Totals $78,000 $78,000 $42,000 $35,500 31
Impacting Variable - Transportation Transportation Categories: Reporting costs as General versus Specialized The Specialized Transportation category is used exclusively to report transportation costs for vehicles that are modified and carry only special education students with specialized transportation in their IEP 32
Impacting Variable - Transportation Shared Transportation The General Transportation category is used to report costs for vehicles that serve multiple functions (vehicles used for transporting only general education students should not be reported) The adapted vehicles must have AT LEAST one claimable route that is ridden exclusively by special education students who have specialized transportation prescribed in their IEP. If a vehicle or cost category does not satisfy this requirement, transportation costs should not be reported 33
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Impacting Variable - Transportation How is the LEA maintaining documentation to account for the denominator of the one-way trip ratio? Method 1- Counting the number of actual one-way trips taken using documentation from bus logs and attendance records. 35
Impacting Variable - Transportation Method 2- Determining the number of one-way trips using the following calculation: Number of students with specialized transportation in their IEP Number of school days The maximum number of trips allowed per day (2) Total number of one way trips 36
Impacting Variable - Transportation Is the LEA properly claiming all one way trips taken by Medicaid eligible students with specialized transportation in their IEP? As a reminder, the numerator is derived from transportation paid claims If the LEA does not receive an interim payment for Medicaid trips taken, these trips will not appear in the numerator This will directly lead to a lower trip ratio, and reduced Medicaid allowable costs for transportation services 37
Impacting Variable - Transportation Common transportation errors found during the desk review process: Did not receive interim payments for all one way trips, leading to a lower numerator, and a lower trip ratio Counted round trips and not one way trips for the denominator Counted the routes the bus has rather than the individual trips per student for the denominator Identified only Medicaid eligible students and not all special education students with specialized transportation in their IEP in the denominator (as Medicaid ratio is taken into account in the numerator) 38
Transportation Impact Example Sunshine Unified Scenario 1 (Lack of claiming = lower trip ratio) Service Type Specialized Medicaid Net Direct Costs One Way Transportation Allowable plus Indirect Costs Trip Ratio Vehicle Ratio Costs Transportation Services (general trans) $100,000 20.00% 4.50% $900 Transportation Services (specialized trans) $1,500,000-4.50% $67,500 Grand Totals $1,600,000 $68,400 39
Transportation Impact Example Sunshine Unified Scenario 2 (LEA accurately claimed and received payment for transportation services) Service Type Net Direct Costs plus Indirect Costs Specialized Transportation Vehicle Ratio One Way Trip Ratio Medicaid Allowable Costs Transportation Services (general trans) $100,000 20.00% 25% $5,000 Transportation Services (specialized trans) $1,500,000-25% $375,000 Grand Totals $1,600,000 $380,000 40
Documentation Requirements Timeframes and Maintenance of Records A state or federal audit can occur at any time! It is critical to gather, maintain, and have readily available accurate documentation to support: Costs reported Services claimed Maintain records for a minimum of five (5) years from the date of payment Records under review by a state or federal agency must be maintained until review has been finalized even if the time period of records exceed five (5) years 41
Documentation Requirements Follow Up Desk Reviews Response Format Timely Responses Secure Emails/ File Transfer Protocol (FTP) site Submission of IEP Ratio information, or confidential student information 42
Interdepartmental Communication 43
Friendly Reminders Smart claiming reevaluate your claiming practices Claim for all eligible services Understand impact of not claiming for eligible services and impact on transportation Providers rendering eligible services must be included on the SPL Reduce program risks and not raising red flags with AHCCCS or CMS Manage a compliant program and meet all program requirements 44
Friendly Reminders Utilize training resources and manage LEA contacts in MCRCS FY13 annual report opens 10/1/13 Due 12/2/13 IEP ratio denominator is based on upcoming October 1, 2013 student count for FY14 45
Random Moment Time Study (RMTS) 46
RMTS Comparison FY12 and FY13 Direct Medical Services Percentages FY12 FY13 OD11 JM12 AJ12 Annual % OD12 JM13 *AJ13 *Annual % Direct Service Providers 40.09% 41.41% 37.93% 39.82% 46.59% 47.36% 42.23% 44.73% Personal Care Providers 18.53% 20.21% 22.04% 20.18% 19.77% 19.30% 18.90% 19.68% *Preliminary results 47
RMTS Comparison FY12 and FY13 MAC Percentages FY13 showed consistency in MAC percentages across quarters FY12 FY13 OD11 JM12 AJ12 JS12* OD12 JM13 Direct Service Providers 7.32% 10.37% 11.19% 9.63% 12.61% 11.26% Administrative Service Providers Only 3.66% 4.22% 2.78% 3.56% 3.61% 3.37% *Average of the previous 3 quarters 48
RMTS Changes Effective OD13 the number of quarterly sampled moments for the personal care providers cost pool is reduced from 4,000 to 3,500 moments Sample is reduced due to continual improvement in return rate compliance percentage and statistical validity achieved during each quarter of FY12 and FY13 The sample size will be increased if there is a negative return rate trend in the future 49
RMTS Changes RMTS compliance policy effective OD13 Step 1: 1 st quarter Step 2: Two consecutive quarters Step 3: Three consecutive quarters Receipt of warning letter outlining the consequences for noncompliance LEA required to submit a Corrective Action Plan (CAP) Receipt of second warning letter outlining consequences of continued non-compliance LEA will document why strategies in the CAP were not effective, make revisions, and work towards compliance LEA may be removed from participating in the MSBC program for failure to comply with the program requirements as defined in the Participation Agreement 50
Direct Service Claiming (DSC) 51
DSC Interim Payment Report Distributed to LEAs on the 15 th following the close of the quarter Displays by provider type the total interim payments received for the fiscal year and staff included on the RMTS staff pool list LEAs will know how much they have received in interim payments for a specific fiscal year throughout the year Use report to compare against the certified public expenditures (CPE) amount from the annual cost report for the same fiscal year to know where you are at with cost settlement Use report to compare against previous year s interim payment reports for like quarters as a guide on claiming activity by provider types 52
DSC Denied Claims Report Denied Claims Report is distributed to LEAs on the 15 th following the close of the quarter The report summarizes LEA denied claims from all remits received over a quarter. The report includes the denial code, denial descriptions, number of claims denied, and denial percentage LEAs should use this report to understand their claiming LEAs should look for unnecessary denials and analyze where there is a breakdown in process; at the LEA level or with a vendor For example, claims that are denying for timely filing 53
DSC Claiming Thresholds Claiming for eligible services is still a critical component of participation in the MSBC program Each LEA s claiming is reviewed and compared against previous fiscal year s claiming LEAs may be required to provide documentation to explain variances between current and previous years Threshold Report The report displays paid claim counts for the fiscal year compared to claim counts from the two previous fiscal years The purpose of the report is for LEAs to know how their current claiming practices compare to their claiming history 54
DSC Health Aide Prepayment Review Most LEAs have streamlined their Health Aide prepayment review (HA review) submission process Statewide approval rate on HA reviews is currently 81% If your LEA is below the statewide approval rate, you need to assess why Common reasons for rejected HA reviews: Missing signature and date of the qualified medical provider on an IEP that has had an amendment or addendum which affects scope, frequency, and/or duration of the reimbursable ADL service(s) Non reimbursable ADLs such as G-tube feeding or reinforcement of therapy goals included with Medicaid reimbursable ADLs 55
DSC Health Aide Prepayment Review NEW Health Aide Authorization Portal Web-based portal for HA reviews will be implemented starting October 2013 All HA reviews will be completed online by the LEA Student IEPs will be securely uploaded and attached to the electronic HA review form LEAs will be able to view real-time reports showing the status of their submitted HA reviews 56
Quarterly Cost Reporting 57
Quarterly Cost Reporting Effective January March 2013 (JM13) LEAs are no longer required to report quarterly costs for personal care staff in the cost reporting system Costs are not included in the quarterly MAC claim Costs for personal care staff that were included in the personal care staff pool list should be included in the annual cost report 58
Quarterly Cost Reporting Personal care staff will continue to appear in the cost reporting system Users attempting to entering quarterly costs for personal care staff will be prompted with an error either via data upload or by editing data for a single personal care participant The No Payroll Report edit will no longer apply to the personal care staff pool Users will be able to certify quarterly financials without reporting any payroll information for the personal care staff pool 59
Compliance 60
Compliance Reviews Common Findings Related Services Summary reports were not signed and dated by the qualified medical provider Summary reports must be signed and dated by the qualified medical provider Clinical notes were not signed and dated by the qualified medical provider Clinical notes must be entered by the rendering provider and contain a supervisory signature when required 61
Compliance Reviews DSC Common Findings Health aide / Nursing Services Billed units exceeded prescribed units IEP did not contain a valid scope, frequency, and duration for the service type under review A valid prescription must be present for health aide / nursing services that includes the scope of services to be rendered, a complete frequency that includes a time increment for time-based billed services per unit, and a complete and accurate duration 62
Compliance Reviews DSC Common Findings Transportation Services There is not documentation in the IEP that either the student required transportation in an adapted vehicle, OR the student could have been transported in a non-adapted vehicle but due to behavioral issues, must be transported separately A statement of need that spells out why transportation is medically necessary is required Evaluation Services Evaluations did not lead to one or more DSC covered service(s) included in the student s IEP as a result of the evaluation All evaluations must lead to one or more DSC covered services appropriately prescribed in the child s subsequent IEP in order to be reimbursable 63
Compliance Reviews DSC Common Findings Electronic Signature Approval Ensure you are approved for ALL software programs that you utilize within your LEA Confirm that an electronic signature questionnaire has been approved for each software program utilized within your LEA and for each new version Just because the software program itself is approved for electronic signature DOES NOT mean that your LEA is approved to use the program Be aware of what software programs you use for each application to satisfy MSBC requirements For example: IEP software may be utilized for summary report updates whereas billing software may be utilized for clinical notes / service logs 64
Compliance Reviews Quarterly Cost Reporting Federally funded portions of salaries or benefits not reported correctly Salaries AND benefits must be reported in the total columns as well as the federal compensation revenues column within the MCRCS system Invoices for Purchased Professional Service (PPS) providers lack participant name as listed on the roster Costs on the invoice associated with the provider who rendered the service must be clear and must match name as listed on the staff pool roster 65
Resources PCG program website: https://web.pcgus.com/azschools/ Program Handbook Trainings: recorded trainings available PCG Post Newsletters Compliance Review Tools Medicaid Cost Reporting and Claiming System (MCRCS): https://costreporting.pcgus.com/az Cost Reporting Guide Deadlines AHCCCS website: www.azahcccs.gov AMPM Provider Registration information and forms 66
Help Desk 1-877-877-8011 DSC - azdirect@pcgus.com RMTS - azrmts@pcgus.com Cost Reporting - azcostreport@pcgus.com