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Preschool/School Supportive Health Services Program (SSHSP) Medicaid-in-Education Training on Compliance and Program Up

Preschool/School Supportive Health Services Program (SSHSP) Medicaid-in-Education Training on Compliance and Program Update Phase III. 1. Training Agenda. Section 1 NYS Compliance Agreement SSHSP Audit Findings SSHSP Compliance Training Section 2

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Preschool/School Supportive Health Services Program (SSHSP) Medicaid-in-Education Training on Compliance and Program Up

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  1. Preschool/School Supportive Health Services Program (SSHSP) Medicaid-in-Education Training on Compliance and Program Update Phase III 1

  2. Training Agenda • Section 1 • NYS Compliance Agreement • SSHSP Audit Findings • SSHSP Compliance Training • Section 2 • NY State Plan Amendment #09-61 • National Provider Identifier (NPI) • International Classification of Diseases 9th Revision (ICD-9) Codes • Other Program Updates • Section 3 • Certified Public Expenditures (CPEs)

  3. Section 1 Compliance and Audit 3

  4. What is SSHSP? Preschool/School Supportive Health Services Program (collectively “SSHSP”) A New York State program that enables school districts, counties and §4201 schools to access federal monies for medically necessary related services provided to Medicaid-eligible students with disabilities 4

  5. Roles in SSHSP State Education Department (SED) • Implementation • Special Education Policy Department of Health, Office of Health Insurance Programs (OHIP) • Medicaid Policy • Payment Methodology Office of Medicaid Inspector General (OMIG) • Audit • Compliance Programs School districts, counties and §4201 schools • Implement SSHSP • Monitor Contractors Public Consulting Group, Inc (PCG) (DOH contractor) • Assist DOH, SED, and SSHSP providers

  6. History • Federal Audits • Settlement • NYS Compliance Agreement • New York State Plan Amendment (SPA #09-61)

  7. Goals To ensure that policies and practices are modified to achieve compliance with all laws and regulations related to the receipt of federal Medicaid participation in the SSHSP To reinforce and maintain continued compliance through trainings, technical assistance and oversight NYS Compliance Agreement

  8. NYS Compliance Agreement Requirements • 3 year agreement with federal government that began July 19, 2009 • The Compliance Agreement will end upon completion of all CMS required activities • Training pursuant to the Compliance Agreement will continue at least through September 2012

  9. NYS Compliance Agreement • NYS SSHSP Compliance Policy • Confidential Disclosure Policy • NYS Compliance Officer/Compliance Committee • Audit Requirements • Independent Audit • Annual Written Reports • Annual Compliance/Program Update Training • State Plan Amendment (SPA #09-61)

  10. NYS Compliance Agreement NYS adopted two compliance policies: • NYS SSHSP Compliance Policy • New York State’s Commitment to Compliance • Confidential Disclosure Policy • Inappropriate billing • Available at the NYSED Med-in-Ed website • http://www.oms.nysed.gov/medicaid/

  11. NYS Compliance Agreement • Rose Firestein is no longer the NYS SSHSP Compliance Officer • For self-disclosures involving any inappropriate Medicaid billings, please contact: NYS Office of Medicaid Inspector General (OMIG) Division of Medicaid Audit – Self Disclosure 800 North Pearl Street Albany, NY 12204-1822 SelfDisclosures@omig.ny.gov (e-mail preferred) 518-473-3782 http://www.omig.ny.gov – click on “Self Disclosure” 11

  12. “OMIG audit staff shall conduct . . . audits of the SSHSP’s compliance with all applicable federal laws and regulations regarding claims for federal Medicaid participation.” If the providers’ billing to Medicaid is: Over $1,000,000 – all providers will be audited (NYC on an annual basis) $250,000 - $1,000,000 – randomly audit 25 providers (school districts or counties) annually Up to $250,000 – randomly audit 10 providers (school districts or counties) annually NYS Compliance Agreement Audit Requirements 12

  13. Audit Findings for 2009 Date of Payment Lacking or inappropriate documentation Written orders/referrals No written order/referral Billing for services prior to date on written order/referral No date on written order/referral Signature IEP Service not included “Under the Direction of”/”Under the Supervision of” NYS Compliance Agreement Audit Requirements 13

  14. NYS Compliance Agreement • Mandatory Training of Relevant Employees • Relevant employee: any person working for or contracted by a school district, county or §4201 school who, in some way, is involved in the SSHSP • 3 years of compliance training • Phase I and II training completed • Database of relevant employees

  15. Mandatory Training of Relevant Employees Face-to-face training – most are sponsored by your local regional information center (RIC) – all are welcome and encouraged to attend Who MUST attend a face-to-face training session? School district/county/§4201school business official School district/county/§4201school special education director School district/county/§4201school Medicaid billing clerk School district/county/§4201school compliance officer If confirmation of attendance is needed: E-mail Diana Kaplan at dkaplan@mail.nysed.gov Online training http://www.oms.nysed.gov/medicaid/ NYS Compliance Agreement 15

  16. OMIG Compliance Program • Social Services Law §363-d • 18 NYCRR Part 521 • To ensure Medicaid providers establish systemic checks and balances to detect and prevent inaccurate billing and inappropriate practices in the Medicaid program • All persons, providers or affiliates claiming, ordering or receiving payments in excess of $500,000 (gross) from the Medical Assistance Program • Annual recertification

  17. OMIG Compliance Program • Aids in preventing, detecting and remedying inappropriate billing • Protects whistleblowers • Written policies and procedures – compliance expectations • Designated compliance officer • Training and education of employees and persons associated with the provider - administrators and governing body members • Communication line to compliance officer (including anonymous/confidential reporting) 17

  18. OMIG Compliance Program 5. Disciplinary policies for failing to report, permitting suspected non-compliance 6. System of routine identification of compliance risk areas – internal/external audit 7. Procedures to respond to, correct, and report compliance issues 8. Policy of non-intimidation and non-retaliation for making a report of suspected non-compliance 18

  19. NYS/Federal Exclusion Lists Lists of individuals or entities excluded, restricted, terminated or censured from participating in the Medicaid Program Will help providers avoid submitting claims for services provided by excluded individuals/agencies Includes ordering practitioners Lists should be checked on a monthly basis 19

  20. CMS EXCLUSION REGULATION “No payment will be made by Medicare, Medicaid or any of the other federal health care programs for any item or service furnished by an excluded individual or entity, or at the medical direction or on the prescription of a physician or other authorized individual who is excluded when the person furnishing such item or service knew or had reason to know of the exclusion.” NYS/Federal Exclusion Lists 20

  21. NYS Exclusion List http://www.omig.ny.gov/data/content/view/72/52/ Federal Exclusion List http://www.oig.hhs.gov/fraud/exclusions.asp Excluded Parties List System https://www.epls.gov/ NYS/Federal Exclusion Lists 21

  22. OMIG Contact Information E-mail for compliance questions: compliance@omig.ny.gov Website: www.omig.ny.gov OMIG ListServ Subscriptions:http://www.omig.ny.gov/data/content/blogsection/17/209/ ComplianceExclusion Lists Carol Booth Sean Parker 518-402-1116 518-402-1816 22

  23. Question The business office has discovered that an employee of the school district appears on one of the exclusion lists. The business office should • Do nothing • Contact Sean Parker at OMIG 23

  24. Question Your supervisor asks you to write a session note for a service you did not render. You should • Write the session note • Contact your compliance officer • Contact the NYS compliance officer • Both b and c are appropriate 24

  25. Section 2 SSHSP SPA #09-61 Billing and Claiming 25

  26. Medicaid State Plan Amendment (#09-61) • Approved by CMS on April 26, 2010, effective September 1, 2009 • Defines services, providers and their qualifications, and the reimbursement methodology for the SSHSP • Medicaid coverage of IEP related services available until the student’s 21st birthday 26

  27. Medicaid State Plan Amendment (#09-61) 10 Services Covered Under the SSHSP: 1. Speech Therapy 6. Psychological Evaluations 2. Physical Therapy 7. Audiological Evaluations 3. Occupational Therapy 8. Medical Evaluations 4. Skilled Nursing 9. Medical Specialist Evaluations 5. Psychological Counseling 10. Special Transportation 27

  28. Documentation Requirements Summary IDEA Requirements Referral to CSE/CPSE Individualized Education Program (IEP) Parental Consent Quarterly Progress Notes • Medicaid Requirements • Provider Agreement and Statement of Reassignment • Verification of Current Certification, • Licensure, or Registration, as Appropriate, of Servicing/Attending Practitioner • Written Orders/Referrals • Services Included in IEP • “Under the Direction of” (UDO) “Under the Supervision of” (USO) Documentation • Documentation of each Encounter 28

  29. Medicaid State Plan Amendment (#09-61) Written Orders and Referrals must include: • The name of the child for whom the order is written; • The complete date the order was written and signed; • The service that is being ordered; • Ordering provider’s contact information (office stamp or preprinted address and telephone number); • Signature of a NYS licensed and registered physician, physician assistant, or licensed nurse practitioner acting within his or her scope of practice (for psychological counseling services this also includes an appropriate school official and for speech therapy services, a speech-language pathologist); • The time period for which services are being ordered; • The ordering practitioner’s National Provider Identifier (NPI) or license number; and, • Patient diagnosis or reason/need for ordered services.

  30. Medicaid State Plan Amendment (#09-61) • Sessions notes must include: • Student’s name • Specific type of service provided • Whether the service was provided individually or in a group (specify the actual group size of current session) • The setting in which the service was rendered (school, clinic, other) • Date and time the service was rendered (record session start time and end time) • Brief description of the student’s progress made by receiving the service during the session • Name, title, signature and credentials of the person furnishing the service and signature/credentials of supervising/directing clinician as appropriate

  31. Clarification of Federal Medicaid Guidelines for reimbursement of InitialEvaluations Initial evaluations are rendered prior to the development of a student’s first Individualized Education Program (IEP) including: physical therapy evaluation occupational therapy evaluation speech therapy evaluation psychological evaluation Effective April 1, 2012, initial evaluations are Medicaid reimbursable only if the evaluation results in an ongoing IEP service in that specific discipline. All other Medicaid requirements must still be met` Additional information can be found in Medicaid Alert #12-03 Medicaid State Plan Amendment (#09-61)

  32. Medicaid Billing: Targeted Case Management (TCM) • Medicaid Alert #11-01informed SSHSP providers that claims for TCM services could resume for dates of service 7/1/09 - 6/30/10 • Claims must be submitted by 4/30/2012 for TCM services rendered through 6/30/2010 33

  33. Medicaid Reimbursement Claims will be paid based upon the Claiming and Billing calendar posted on www.oms.nysed.gov/Medicaid SSHSP is a jointly funded program (state and federal) Billing providers (school districts/counties/§4201 schools) will receive one payment (50% state and 50% federal share) from the Department of Health Billing providers keep 100% of the federal share (new money) Federal Medicaid share is 50% of a gross approved claim as of July 1, 2011 34

  34. Medicaid Reimbursement • Advantages to submitting Medicaid claims timely: • Greater accuracy • Improved cash flow • Quicker resolution of denied claims 35

  35. National Provider Identifier (NPI) • Identified health care providers in HIPAA standard transactions • The following NPIs must be included on Medicaid claims for dates of service on and after January 1, 2012: • Billing provider – the school district, county or §4201 school • Attending provider – the clinician who has overall responsibility for the student’s medical care • When the provider works “under the direction of” or “under the supervision of” a licensed clinician, the directing/supervising clinician is considered the attending provider • Special transportation claims do not require an attending provider NPI 36

  36. National Provider Identifier (NPI) • If a school district, county or §4201 school is billing Medicaid, the following providers (employed or contracted by the SSHSP billing provider) need an NPI: • licensed speech-language pathologists; • licensed physical therapists; • licensed occupational therapists; • licensed psychologists; • licensed psychiatrists; • licensed clinical social workers; • registered professional nurses; • licensed audiologists; and, • physicians, physician assistants, or nurse practitioners that • render a Medicaid reimbursable evaluation • Practitioner NPI needs to be reported to every school district, county or §4201 school that will be billingMedicaid for the services rendered by that practitioner 37

  37. National Provider Identifier (NPI) • eMedNY Attending Provider NPI Affiliation Process: • Attending providers (employed and contracted)must report their NPI to the appropriate billing SSHSP provider(s) • Billing provider must affiliate attending provider NPIs with the billing provider’s Medicaid provider number via eMedNY prior to submission of claims for dates of service on and after January 1, 2012 • See Medicaid Alerts #11-03 and #12-02 for additional information 38

  38. International Classification of Diseases, 9th edition, Clinical Modifications (ICD-9-CM) • ICD-9-CM is a set of codes used by health care providers to indicate diagnosis for all patient (student)encounters. The ICD-9-CM is the HIPAA transaction code set for diagnosis coding. • Effective September 1,2012electronicMedicaid claims must include a valid ICD-9 code that represents • a main condition or symptom that is the reason the service is being provided • the diagnosis or the reason/need for a medically necessary service included on the written order/referral for the SSHSP service can be used on claims for the ordered services • A resulting diagnosis from an evaluation could be used on the claim for the evaluation and the claims for ongoing services that were recommended as a result of the evaluation • Please see Medicaid Alert #12-04 for additional information

  39. International Classification of Diseases, 9th edition, Clinical Modifications (ICD-9-CM) Billing providers must report the most specific diagnosis code available. Report a: • three-digit code if there are no four-digit codes within the category, or • four-digit code if there are no five-digit codes within the category, or • five-digit code (fifth subclassification codes) for those categories where they are available. 40

  40. EXAMPLE: 314 Hyperkinetic syndrome of childhood 314.0 Attention deficit disorder 314.00 Without mention of hyperactivity 314.01 With hyperactivity 314.1 Hyperkinesis with developmental delay 314.2 Hyperkinetic conduct disorder 314.8 Other specified manifestations of hyperkinetic syndrome 314.9 Unspecified hyperkinetic syndrome International Classification of Diseases, 9th edition, Clinical Modifications (ICD-9-CM) 3-digit code 4-digit code 5-digit code 41

  41. Coding resources for professionals: American Physical Therapy Association (APTA) American Occupational Therapy Association (AOTA) American Speech-Language-Hearing Association (ASHA) American Psychological Association (APA) American Medical Association (AMA) The Centers for Medicare and Medicaid Services (CMS) International Classification of Diseases, 9th edition, Clinical Modifications (ICD-9-CM) 42

  42. True/False Question The attending provider and the servicing provider are always the same individual. • True • False 43

  43. True/False Question Under HIPAA 5010 standards, the most specific diagnosis code should be used when available. • True • False 44

  44. Medicaid SSHSP Update Medicaid Alert #12-01 2% Across the Board Reduction in Medicaid Payments Posted on DOH website Effective April 2011 SSHSP is exempt from reduction Monies taken from school districts, counties and §4201 schools will be reinstated Submit questions to (remember to include your Medicaid provider name and number): 2PercentAcrosstheBoard@health.state.ny.us 45

  45. Electronic Transmitter Identification Number (ETIN) Unique identifier assigned to billing providers to identify their electronic claims Certification statements must be renewed annually Failure to renew will result in the inability to submit claims and receive payments Renewal notices are sent to billing providers from Computer Science Corporation (CSC) Pre-printed forms require signature and must be notarized Submit copy of renewal form to Regional Information Center (RIC) Medicaid SSHSP Update 46

  46. Question School district A submitted Medicaid claims for SSHSP services, but has not been paid for them. Reason could be . . • School district’s ETIN hasn’t been recertified • School district doesn’t have their relevant employees trained • Attending provider’s NPI not on the claim • All of the above 47

  47. Medicaid Resources Medicaid Listserv To subscribe, please send an e-mail message to LISTSERV@LISTSERV.NYSED.GOV The body of the message must read: SUBSCRIBE MEDINED firstname lastname Complete instructions for subscribing/unsubscribing at http://www.oms.nysed.gov/Medicaid 48

  48. Medicaid Resources • NYSED Medicaid-in-Education Website http://www.oms.nysed.gov/medicaid/ • Medicaid-in-Education Handbook (coming soon) • Medicaid-in-Education Questions & Answers • Medicaid Alerts • Claiming and Billing Calendar • Training Calendar • NYSED Office of Professions http://www.op.nysed.gov • NYS Department of Healthhttp://www.health.state.ny.us/health_care/medicaid • National Alliance for Medicaid in Education (NAME) http://www.medicaidforeducation.org/ 49

  49. Local Regional Information CenterContacts <RIC – please enter your contact information as appropriate> 50

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