REMINDERS FOR SKILLED PROFESSIONAL MEDICAL PERSONNEL

REMINDERS FOR SKILLED PROFESSIONAL MEDICAL PERSONNEL Yu may use the cdes reserved fr Skilled Prfessinal Medical Persnnel (SPMP) if yu meet the fllwing qualificatins: A. Yu are in a psitin that requires skilled medical prfessinal educatin and training, based n yur jb descriptin. B. Yu have cmpleted prgram f tw years r lnger leading t an academic degree r licensure r certificatin in a medically related field (M.D., P.A., R.N., LVN with a twyear prgram, master s level scial wrker) r a degree in a medical field frm an accredited university r cllege prgram. C. Yu wrk fr a public agency. Cde 4: SPMP Outreach t Medically-at-Risk Individuals and the SPMP Medicaid Care Crdinatin activities included in Cdes 9A 9I are enhanced cdes reserved by use by SPMP. These SPMP cdes shuld be used nly when yu are using yur prfessinal medical knwledge and skills t perfrm the activity. In ther wrds, des the activity rutinely require a specific level f medical expertise and training t perfrm? If it des nt, then the nn-spmp versin f the activity cde shuld be used. The use f SPMP cdes has recently cme under mre scrutiny by the federal gvernment in sme settings. Therefre, it is imprtant t distinguish between activities (r the prtin f an activity) that require medical expertise and training and thse that d nt. A rule f thumb: Use the SPMP cde when, in yur prfessinal judgment, yu used yur medical knwledge and skill t perfrm the activity. If the same activity culd be perfrmed fr the same purpse r with the same result by staff withut yur same medical knwledge and skill, then d nt use the SPMP cde. The fllwing examples may prvide further guidance in using the SPMP cdes. SPMP Skilled Prfessinal Medical Cnsultatin and Assistance: A registered nurse cnsults with a grup f child care prviders abut caring fr children with seizure disrders and the apprpriate respnses t medical emergencies they may experience. Nn-SPMP Referral, Linkage, Crdinatin & Mnitring f Medical Services: A registered nurse assists a parent t schedule an appintment fr her child with a pediatric neurlgist. SPMP Interagency Crdinatin f Medicaid Services: A licensed audilgist attends an interagency task frce meeting t wrk n develping new clinical prtcls fr infant hearing screens and fllw-up at lcal hspitals. Nn-SPMP Cmmunity Resurce Develpment, Systems Planning and Interagency Crdinatin f Medicaid Services: A licensed audilgist attends a mnthly meeting f an Aging Services task frce; data n the elderly s access t speech, language and hearing aid services is reviewed. SPMP Outreach t Medically-at-Risk Individuals: A licensed clinical scial wrker uses her clinical assessment skills t identify at-risk teen mthers wh might benefit frm behaviral health services cvered by Medicaid. Nn-SPMP Medicaid Outreach: A nutritinist prvides infrmatin t a single mther n the availability f Early Peridic Screening, Diagnsis and Treatment (EPSDT) services fr her children, and hw t enrll in Medicaid. January 2005

Skilled Prfessinal Medical Persnnel Intrductin: Lcal Health Jurisdictins may emplyee staff wh meet the federal qualificatins t be designated as Skilled Prfessinal Medical Persnnel (SPMP). With such designatin, the LHJ claiming unit has the ptential t be reimbursed at the enhanced rate f 75% FFP fr the cst f time reprted t the activities cdes subsumed under Cde 9:SPMP Medical Care Crdinatin. Dcumenting that SPMP meet all the federal requirements that are a cnditin f enhanced reimbursement is critical. The federal laws and regulatins that gvern SPMP status are described belw, as well as the requirements fr qualifying as an SPMP. Statutry Basis fr SPMP Sectin 1903(a)(2) f the Scial Security Act prvides fr increased FFP fr medical staff, as fllws: an amunt equal t 75 per centum f s much f the sums expended during such quarter (as fund necessary by the Secretary fr the prper and efficient administratin f the State plan) as are attributable t cmpensatin r training f skilled prfessinal medical persnnel, and staff directly supprting such persnnel f the State agency r any ther public agency The intent f sectin 1903(a) (2) is t encurage States t emply medical staff with prfessinal medical expertise t develp and administer Medicaid prgrams that are medically sund as well as administratively efficient. Prfessinal medical knwledge is necessary t shape the medical aspects f the prgram. Skilled prfessinal Medicaid persnnel are distinguished frm skilled prfessinal medical persnnel. Regulatry Basis fr SPMP Final revised SPMP regulatins were issued n Nv. 12, 1985, superseding any previus regulatins and plicy guidelines by the Health Care Financing Administratin (nw CMS) r its predecessr agency. 42 Cde f Federal Regulatins (CFR) 432.2 defines directly supprting staff, skilled prfessinal medical persnnel and staff f ther public agencies. Sectin 432.45 specifies that the enhanced FFP is nt available fr state persnnel wh cnduct survey activities and certify facilities fr Medicaid participatin. Sectin 432.50, in part, specifies that 75% FFP is available fr staffing and training csts f SPMP and directly supprting staff f the Medicaid agency f ther public agencies and that the allcatin f their csts must be based n either the actual percentages f time spent carrying ut duties in the specified areas r anther methdlgy apprved by HCFA. Sectin 432.50(d)(1)(i-v) delineates ther limitatins n FFP, including a definitin f prfessinal educatin and training. And lastly, 42 CFR 433.15 states that 75% FFP is available fr cmpensatin and training f SPMP and staff directly supprting them if all criteria in 432.50 (c) and (d) are met. (Please refer t the Appendix fr the text f these regulatins.) 1

Criteria fr Determining SPMP There are seven specific criteria that must be satisfied. They are: (1) The expenditures that qualify fr enhanced FFP are salary r ther cmpensatin, fringe benefits, travel, per diem and training f SPMP and their directly supprting staff when they are perfrming activities that are directly related t the administratin f the Medicaid prgram. Operating expenses (e.g., rent and supplies) and indirect csts charged directly r allcated t these persnnel qualify fr 50% FFP. (2) SPMP have prfessinal educatin and training in the field f medical care r apprpriate medical practice. This is defined as cmpletin f a tw-year r lnger prgram leading t an academic degree r certificate in a medically related prfessin, demnstrated by pssessin f a medical license, certificate r ther dcument issued by a recgnized Natinal r State medical licensure r certifying rganizatin r a degree in a medical field issued by a cllege r university certified by a prfessinal medical rganizatin. The medical license r certificate must dcument the minimal tw-year prfessinal educatin and training requirement. In ther wrds, an individual with a certificate r license (such as a licensed practical nurse) des nt autmatically qualify as an SPMP if s/he has nt cmpleted the requisite tw-year degree prgram in the field f medical care. The a recent financial review guide issued by CMS mentins using the American Universities and Clleges reference guide, cmpiled by the American Cuncil n Educatin, t check n degree fields cnsidered medical in nature (thse listed under Health Prfessins ) and whether a cllege r university is certified by a prfessinal medical rganizatin. Several Departmental Appeals Bard decisins have discussed SPMP status by prfessinal degree and license as part f their rulings in a particular case. These discussins are summarized belw: Psychlgy. The Review Guide ntes that the Departmental Appeals Bard (DAB), in Decisin N. 1033, determined that a Ph.D. in psychlgy tgether with a State license t practice as a psychlgist meets the educatinal limitatin fr SPMP status. Medical Scial Wrk. Accrding t the Review Guide, the issuance f DAB decisins n medical scial wrk prmpted the federal agency t rethink plicy regarding prfessinal educatin requirements. The threshld fr fr scial wrkers t qualify as SPMP is if their educatin (including training received as part f academic wrk) specifically included the health care and/r medical applicatins f the scial wrk field. Wrk experience r n-the-jb training culd nt be substituted fr meeting the educatinal requirements. State agencies must shw that scial wrkers educatin and training in scial wrk specifically includes health care and/r medical applicatins. The Review Guide ntes that States shuld use graduate level cncentratins, r specializatins r tracks, as defined by varius MSW prgrams, t identify thse scial wrkers that wuld be eligible fr the enhanced rate. 2

CMS als recmmends that States demnstrate an educatin equivalency fr every scial wrker being claimed as SPMP where the schls they attended d nt ffer medical r health cncentratins, r where they are ffered but the scial wrker did nt cmpete ne. CMS laid ut guidelines fr its auditrs t use when reviewing MSWs being claimed as SPMP. State agencies must shw that each scial wrker has an MSW degree, and as part f the curse wrk fr the master s degree, a specializatin (track r cncentratin) in clinical practice, health care practice, ther medical applicatin, r its equivalent. The CMS Financial Review Guide specifies the equivalency standards, as fllws:. a) Cmpletin f a graduate degree at a schl that ffered health care r medical specializatins but the scial wrker frmally cncentrated in anther area. The scial wrker wuld qualify if he/she cmpleted as many health curses as wuld be required fr a cncentratin in health care. b) If the applicable graduate prgram ffers cncentratins, but nne distinctly in health care r medical applicatins, the transcript must shw at least as many credits received in health care as wuld be required fr any f the cncentratins ffered. Fr example, if a minimum f fur curses is required fr any cncentratin, the transcript must shw cmpletin f at least fur curses in health r medical applicatins. c) If the applicable MSW prgram did nt ffer cncentratins at all, the transcript must shw mre credits received in health care r medical applicatins than in any ther specialized area f study. N amunt f n-the-jb experience in a Medicaid agency r any ther jb r emplyment situatin can be substituted fr prfessinal educatin and training. In these earlier DAB decisins, it was clear that states needed t distinguish between medical scial wrkers and individuals with an MSW degree withut a medical r health fcus. The DAB, in its findings, cnsidered the educatin/training f individual scial wrkers. It stressed that having medical cursewrk r curses with medical applicatin f scial wrk, including field wrk in a health r medical setting, was the standard, and that n-the-jb training r wrk experience did nt apply. The DAB, hwever, refrained frm establishing the actual curses r numbers f curses that qualified, but rather cnsidered these n an individual basis. A later DAB decisin in West Virginia (Decisin N.1434) in 1993 mentined the CMS standard f a medical r health care cncentratin. Hwever, it did nt specifically apply this standard when reviewing individual scial wrkers in this appeal; the DAB again lked at curses and field placements with a medical/health care cntent. 3

The Review Guide s use f the medical r health care cncentratin as the criterin, r alternative educatin equivalency requirements, narrws the definitin f SPMP status fr scial wrkers. The cncentratin and equivalent educatin standards were applied in a 2004 Office f the Inspectr General (OIG) audit f SPMP payments received by the West Virginia Bureau fr Medical Services. The OIG recmmended a refund f claims fr scial wrkers that did nt have a master s degree in scial wrk r had a master s degree but the State did nt have dcumentatin that the graduate curse wrk included the required specializatin [in clinical practice, health care practice, ther medical applicatin, r its equivalent]. (3) SPMP must be in psitins that have duties and respnsibilities that require thse prfessinal medical knwledge and skills. The functin perfrmed by the SPMP must require that level f medical expertise t be perfrmed effectively. The primary evidence f this wuld be psitin descriptins, jb annuncements r jb classificatins. The Review Guide states that the reviewer may als want t establish whether the psitin is listed in a handbk r dictinary f ccupatinal titles as an apprpriate medical classificatin (such as the Occupatinal Outlk Handbk, Bureau f Labr Statistics, U. S. Department f Labr r the Standard Occupatinal r the standard Occupatinal Classificatin Manual, Natinal Technical Infrmatin Service, U. S. Department f Cmmerce). Examples f functins that wuld meet the functinal criteria include, but are nt limited t, the fllwing: Acting as a liaisn n the medical aspects f the prgram with prviders f services and ther agencies that prvide medical care. Furnishing expert medical pinins fr the adjudicatin f administrative appeals. Reviewing cmplex physician billings. Prviding technical assistance and drug abuse screening n pharmacy billings. Participating in medical review r independent prfessinal review team activities. Assessing the necessity fr and adequacy f medical care and services prvided, as in utilizatin review. Assessing, thrugh case management activities, the necessity fr and adequacy f medical care and services required by individual recipients. (Excluded is case management prvided under an apprved HCBS waiver.) The Review Guide als listed functins which d nt require prfessinal medical expertise and therefre d nt qualify fr 75% FFP. CMS ntes in the Guide that this list is nt all inclusive. Accunting and auditing Budgeting Prgram management fr categries f services nt requiring medical expertise: emergency transprtatin, nn emergency transprtatin, and hme and cmmunitybased waiver services. Prgram analysis where the emphasis is cst r utilizatin f services in lieu f the medical aspects f the prgram. 4

Cst reimbursement including all analytical wrk, related t the prgram cst f cvered services, cst reprt settlement, and establishment f rates. Prgram integrity including any investigatin and fllw-up activities nt directly invlving the determinatin f the medical necessity f specific services. Third party liability activities/verpayment cllectin activities. Administrative practices and prcedures including the develpment f State plans, administrative rates, cst allcatin and prvider agreements. All claims prcessing activities except IS THIS DONE? EPSDT, including all utreach activities such as ntifying clients f required screens frm a peridicity schedule, scheduling appintments, infrming clients and arranging transprtatin. Eligibility determinatin Legal services including administrative appeals. Cntract management. FFP wuld be available at 50% fr an therwise qualified SPMP perfrming a functin which is unrelated t the specialized field f medical care and requires n skilled medical training. Time spent by a qualified SPMP n supervisry related administrative functins such as persnnel, staff meetings, cunseling, etc., wuld be allwable at 50% FFP. When a team perfrms an SPMP functin (e.g., medical review team), each individual team member must qualify as an SPMP t claim his/her time at the enhanced rate. (4) A state-dcumented emplyer-emplyee relatinship must exist between the Medicaid agency (r any ther public agency) and the SPMP and directly supprting staff.. The federal interpretatin here is that the persnnel are under the State s merit persnnel system in all aspects as dcumented by the State s persnnel and payrll system and recrds. Fr the mst part, 75% FFP is nt allwed fr cntractrs with private rganizatins r independent cntractrs. In situatins where the Medicaid agency (r any ther public agency) cntracts directly fr persnal services as a cmmn methd f securing services f an SPMP, it must demnstrate that a dcumented emplyer-emplyee relatinship exists directly between them and the Medicaid agency (r any ther public agency). The Review Guide tells its reviewers t examine the substantive relatinship between the parties n a caseby-case basis. The standard laid ut in the Guide fllws: Generally, if the substantive relatinship specified in the cntract indicates that the Medicaid agency r any ther public agency has cntrl ver when, where, and hw the cntractr wrks, we wuld allw this level f cntrl t indicate that a dcumented emplyer-emplyee relatinship exists, even thugh that persn may n be under the State s merit persnnel system as dcumented in the persnnel and payrll recrd systems f the State. It des nt include emplyees f a State s fiscal agent r ther cntractr, wh may cntract with r emply SPMPs directly. These cntracts wuld be reimbursed at nly 50% FFP. (5) Directly supprting staff are secretarial, stengraphic, and cpying persnnel and file and recrds clerks wh prvide clerical services that are directly necessary fr the cmpletin f the prfessinal medical respnsibilities and functins f the skilled prfessinal medical staff. The skilled prfessinal medical staff must directly supervise the supprting staff and the perfrmance f the supprting staff s wrk. 5

The Review Guide ntes that supprt staff is defined in the cngressinal reprts as clerical staff, wh are interpreted t be thse mentined in the previus paragraph. The Guide ntes that ther sub prfessinal staff, such as administrative and management assistants, statistical r accunting clerks, ffice managers, technicians, cannt be claimed at the enhanced rate, if they prvide supprt t SPMPs. There must be dcumentatin r ther evidence that the direct supprt (defined as clerical services, such as typing, filing, cpying, preparing crrespndence, preparing recrds and ther general ffice wrk) is directly related and necessary t the cmpletin f the prfessinal medical functins f the SPMP. The SPMP must be immediately respnsible fr the wrk perfrmed by the clerical staff and must directly supervise (immediate first-level supervisin) the supprting staff and the perfrmance f that staff s wrk. The best evidence f this, accrding t the Review Guide, wuld be that the SPMP is respnsible fr the supprting staff s perfrmance appraisal. Enhanced (75%) FFP is allwed nly fr that prtin f the clerical time related t the perfrmance f the SPMP s skilled medical functins. (6) The rate f 75% FFP is available fr SPMP and directly supprting staff f ther public agencies if all f the applicable criteria in items 1-5 are met and the public agency has a written agreement with the Medicaid agency t verify that thse requirements are met. Where SPMP and directly supprting staff emplyed by pubic agencies ther than the Medicaid agency assist in the administratin f the Medicaid prgram, they can get 75% FFP fr the csts f salary r ther cmpensatin, benefits, travel, per diem and training as lng as there is a written interagency agreement specifying that the staff and their functins meet the applicable criteria. The agreement shuld als spell ut the directly related duties that the ther public agency will perfrm thse necessary t the peratin f the Medicaid prgram. An entity is cnsidered public if it is part f State and lcal gvernment and subject t supervisin and cntrl f a gvernmental unit; the receipt f Federal funding des nt in itself bestw public status t a private agency. (7) FFP must be prrated fr split functins fr SPMP and directly supprting staff. Only the prtin f an individual s wrking time that is spent in perfrming SPMP duties can be reimbursed at 75% FFP. Where the SPMP and directly supprting staff spend less than 100% f their time in SPMP functins, their csts must be allcated amng all functins, based n actual time spent in each functin r anther apprved methdlgy. Accrding t the Review Guide, CMS accepts current timesheets kept by the SPMP persnnel r sme frm f sampling methdlgy. Prratin is needed when an SPMP is als a supervisr perfrming general administrative functins that must be claimed at 50% FFP. 6