CT School-Based Medicaid Billing“Past, Present and the Future”

March 1, 2013

Presented by Pam Katz, CompuClaim Mid-Atlantic Regional Director

Presentation Overview• Opening remarks

• History of Medicaid School Based Child Health Program

• CT SBCH Program

• Maximizing Reimbursement Opportunities

• Medicaid Compliance

• Cost Reports

• Reconciliation and Settlement

• Recent Changes to SBCH program

• Five Keys to Success

History of the Medicaid School Based Child Health

Program

• Medicaid was signed into law on July 30,1965.

• In 1975 IDEA was passed to ensure children with disabilities receive a (FAPE) free appropriate public education in the least restrictive environment.

• Students received medical services in school by qualified health professionals.

• Initially Medicaid did not pay for IEP related services, as they fell

under educational services.

• 1988 Congress recognized the fiscal burden placed on schools

and passed a law to make Medicaid funds available for certain health care services for students with disabilities. This law created what is now known as the School Based

Child Health program (SBCH).

CMS SBCH Guidelines

• CT changed from Bundled rate to Fee for Service in 2010. – How has this affected districts revenue?

• Interim rates - rates began in Oct. 2010 are provisional in nature , pending the completion of cost reconciliation and settlement which the district supplies on a yearly basis.

• Direct Billing for services deemed medically necessary and are included in a student’s IEP

• Some administrative services can be claimed in the cost report with proper documentation. These are not considered claimable as direct billing.

• CT DSS is currently negotiating with CMS on changes that may impact the CT SBCH program. Districts will be informed of all directives from DSS to ensure that all rules and regulations are being followed. CT State Plan and matrix outlines all eligible services and qualified providers.

CT SBCH Program

Maximizing Medicaid Reimbursement Opportunities

• Maximize Claiming Opportunities – District plan to ensure that all services are being claimed through a well designed plan.

• Under billed Services• Out of District Billing• Evaluations

• Nursing Services

Documentation that districts must maintains to ensure

compliance.

• Providers licensure – licenses and certification must be maintained by district

• Signature on file - copy of providers signatures must be documented

• IEP documentation - student is identified to receive “medically necessary services”- this serves as the student’s prescription

• Student Attendance• Provider Attendance• Billing/service records

• Monthly progress – what therapeutic activity was given how the student responded to the service in relationship to the goals in the IEP

• Parental consent – new guidelines from DSS and the Dept. of Education

Medicaid Compliance

Reconciliation and Settlement

• Cost Study – 2011 (desk review – June 2013 settlement due)

• Administrative Costs –Administrative salaries – (must provide support to Medicaid program)

• Include transportation costs reflective of IEP (monitors can only be claimed if one on one is indicated in Student’s IEP)

• Documentation requirements from districts includes:• Data collections, district snap shots, employee

universe and random time studies.

Recent Changes to SBCH• Parental Consent – in order for a district to participate in the SBCH program beginning March 18, 2013 parental consent and parental notification must be obtained for the district to submit claims for Medicaid reimbursement. Guidelines and regulations will be sent to the school district regarding how parental notification and consent will be obtained to meet the new guidelines. The Department of Education will be working with DSS to ensure that districts will be following all necessary guidelines.

• Durable Medical Equipment – For the 2011 and 2012 cost report DME has been removed from calculations. Districts were notified NOT to include this cost from their ED001 reports and not to provide additional documentation at this time.

• Transportation - Districts should be able to document that the actual transportation coincides with a “medically necessary service” provided on the same day of transportation. A.Can drivers and monitors salaries and fringe benefits be included for transportation costs? Districts that have provided this information may be asked to submit documentation for a desk review. Monitors must be indicated as providing one on one services in student’s IEP.

Five Keys to Success

1. On-going oversight to ensure all services are being captured in a timely manner.

2. Establishment of a quality Medicaid billing and oversight program.

3. Holding all staff accountable.

4. Being compliance ready.5. Tracking and integrating changes to

the SBCH program.

SBCH Qualified Providers

These providers must meet the qualifications in accordance with services as defined by CGS (Connecticut General Statutes) and acting within his or her scope of practice under Connecticut State Law. The following providers have been approved in the Connecticut SBCH program to provide “medically necessary services” that are part of a student’s IEP program.

•Audiologist, Audiologist Assistant, Hearing Instrument Specialist, Chiropractor, Naturopath, Physician, Podiatrist, Respiratory Therapist, Optometrist, Nurse Practitioner, Registered Nurse, LPN, Psychiatrist, Psychologist, Social Worker, School Counselor, •Speech Pathologist, Speech Assistant, Physical Therapist, PT Assistant, Occupational Therapist, COTA (Certified Occupational Therapist Assistant)

Assistants must be supervised by a qualified licensed provider who will oversee services being provided that are part of the student’s IEP. All services that are provided must be signed off and documented in student’s file.

SBCH Eligible Services

• The following services have been approved by SBCH and are the current Connecticut State plan based on a matrix from Massachusetts.

Services must be documented in the Student’s current IEP plan and are

provided by licensed providers who meet all state regulations and are acting

within his or her scope of practice under Connecticut State law.

• Audiology• Clinical Diagnostic Laboratory Services• Mental Health Services (Psychological and Counseling Services)• Nursing Services• Occupational Therapy• Physical Therapy• Respiratory Care Services• Speech/Language• Optometric Services• Assessments – the identification and assessment of health related needs

for medical services for the purposes of determining educational recommendations

• CMS – Centers for Medicare and Medicaid• DSS – Department of Social Services• DAS - Department of Administrative Services• SBCH – The Connecticut School Based Child Health program (referred as SBS –

school based health services in other States)

• HP - Hewlett Packard is the fiscal agent for the State- Districts are required to enroll in the SBCH program and apply for

NPI(National Provider Identifier)Number

• OIG - Office of Inspector General – (Audits)• HIPPA - Health Insurance and Portability and Accountability Act (maintains the security

and privacy of health data)• FERPA - Family Educational Rights and Privacy Act – allows a school to disclose information

from a students educational records.• FMAP - Federal Medical Assistance Percentages- In CT – 50% these are the percentage rates to determine the matching funds for each State’s Medicaid programs

Medicaid Nomenclature

Helpful Links• National Alliance for Medicaid in Education (NAME):

http://www.medicaidforeducation.org/

• Center of Medicare / Medicaid Services (CMS): http://www.cms.gov/

• Federal Medical Assistance Percentage (FMAP): http://aspe.hhs.gov/health/fmap.htm

• HIPAA Privacy and Security Rules: http://www.hhs.gov/ocr/privacy/index.html http://www.cms.gov/HIPAAGenInfo/

• HIPAA versus FERPA Privacy Protections and Student Health Records: http://www.cms.hhs.gov/TransactionCodeSetsStands/

• http://www.cms.hhs.gov/SecurityStandard/

• OIG homepage: http://oig.hhs.gov/

Contact InformationPam KatzDirector, Mid Atlantic RegionCompuClaim304 Main Street #415Norwalk, CT 06851pkatz@compuclaim-ri.com203-856-6124

Peter CarsonPresidentCompuClaim221 Third StreetNewport, RI 02840pcarson@compuclaim-ri.com401-849-4702 ext. 120