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

2 Training Agenda Section 1  Background Information  NYS Compliance Agreement  SSHSP Compliance Training  SSHSP Audit Findings Section 2  NY State Plan Amendment - #09-61  Billing And Claiming Resumption  National Provider Identifier (NPI)  International Classification of Diseases 9 th revision (ICD-9) Codes  Available Resources

Section 1 Compliance and Audit 3

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 School districts, §4201 schools, and counties  Implement SSHSP  Monitor Contractors

6 History  Federal Audits  Settlement  NYS Compliance Agreement  New York State Plan Amendment (SPA #09-61)  First year of compliance training completed

7 Compliance  NYS Compliance Agreement/Implementation Plan  OMIG Compliance Program

8 NYS Compliance Agreement 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

9 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) NYS Compliance Agreement

10 NYS adopted two compliance policies:  NYS SSHSP Compliance Policy NYS SSHSP Compliance Policy  New York State’s Commitment to Compliance  Confidential Disclosure Policy Confidential Disclosure Policy  Inappropriate billing  Available at: NYS Compliance Agreement

11 Confidential Disclosure Contact When you believe policies or billing procedures are inappropriate Rose Firestein NYS SSHSP Compliance Officer New York State Department of Health Office of General Counsel 90 Church Street, 4th Floor New York, New York Telephone: Facsimile: NYS Compliance Agreement

“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 (districts or counties) annually  Up to $250,000 – randomly audit 10 providers (districts or counties) annually NYS Compliance Agreement Audit Requirements 12

Audit Period: 2009 Date of Payment  Audits for all Medicaid providers paid over $1,000,000 (43, includes NYC)  Audits for 25 Medicaid providers paid $250,000 - $1,000,000 – randomly selected  Audits for 10 Medicaid providers paid less than $250,000 – randomly selected NYS Compliance Agreement Audit Requirements 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 stamp  IEP  Service not included  No parental notification of CSE meetings  Missing or unsigned progress notes  Under the Direction of/Under the Supervision of NYS Compliance Agreement Audit Requirements 14

15 Mandatory Training of Relevant Employees  June 2, 2010 Memo June 2, 2010 Memo  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  Annual compliance training  Database of relevant employees NYS Compliance Agreement

 Two ways to fulfill the mandatory training requirement  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 officials  School district/county/§4201school special education director  School district/county/§4201school Medicaid billing clerks  School district/county/§4201school compliance officers  Confirmation of attendance  Contact Diana Kaplan at  Online training NYS Compliance Agreement 16

 Statistics  Phase I training: 40,000+ relevant employees trained  18,000+ trained in-person  22,000+ trained online  Training timeline  Phase I: June February 2011  Phase II: May December 2011  Phase III: January 2012 – September 2012 (Anticipated dates) NYS Compliance Agreement 17

 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 18 OMIG Compliance Program

Prevents, detects and remedies inappropriate billing Protects whistleblowers 1.Written policies and procedures – compliance expectations 2.Designated compliance officer 3.Training and education of employees and persons associated with the provider - administrators and governing body members 4.Communication line to compliance officer (including anonymous/confidential reporting) continued… OMIG Compliance Program 19

OMIG Compliance Program Prevents, detects and remedies inappropriate billing Protects whistleblowers 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 20

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  Lists should be checked on a monthly basis 21

NYS/Federal Exclusion Lists 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.” 22

NYS/Federal Exclusion Lists NYS Exclusion List Federal Exclusion List Excluded Parties List System 23

OMIG Contact Information OMIG website: for compliance questions: ComplianceExclusion Lists Carol BoothSean Parker

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

 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 21 st birthday Medicaid State Plan Amendment (#09-61) 26

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 Medicaid State Plan Amendment (#09-61) 27

Medicaid Qualified Service Providers Services must be provided by a Medicaid qualified service provider acting within his/her scope of practice under NYS Law (See Provider Qualifications and Documentation Requirements)Provider Qualifications and Documentation Requirements Documentation of practitioners’ qualifications kept on file (license, registration, and/or certification as applicable) Medicaid State Plan Amendment (#09-61) 28

SSHSP 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 Practitioner  Written Orders/Referrals  Services Included in IEP  Under the Direction of (UDO)/Under the Supervision of (USO) Documentation  Documentation of each Encounter (Session Notes) 29

30 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 and/or reason/need for ordered services. Medicaid State Plan Amendment (#09-61)

31 Session notesSession 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)  The setting in which the service was rendered (school, clinic, other)  Date and time the service was rendered (length of session – 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 Medicaid State Plan Amendment (#09-61)

32 Individualized Education Program (IEP) vs. Medical Necessity  SSHSP  Program services are designed to enable a child with a disability to benefit from special education  IEP  Determines what services needed to receive Free Appropriate Public education (FAPE)  Does not determine medical necessity  Written order or referral  Determines medical necessity (Medicaid requirement)

33 Evaluations and Re-evaluations  Required evaluation/re-evaluation documentation  Written order/referral  Evaluation report  Evaluation must be reflected in the IEP  Evaluations/re-evaluations are only Medicaid reimbursable for students with IEPs Medicaid State Plan Amendment (#09-61)

 Medicaid Alert Medicaid Alert  School districts with supporting documentation may bill through 6/30/2010 (including 7/1/09- 8/31/09) for:  Initial Evaluation Review 5491  Amended/Requested IEP Review 5494  Annual IEP Review 5492  Triennial/Re-evaluation IEP Review 5493  Ongoing Service coordination 5495 Medicaid Billing: Targeted Case Management 34

35  Medicaid Alert Medicaid Alert  SSHSP billing began April 2011 for appropriately documented services provided 9/1/09 and after  Encounter-based billing methodology  Current Procedural Terminology (CPT) codes Current Procedural Terminology (CPT) codes Medicaid Billing

Medicaid Reimbursement  Claims will be paid based upon the Claiming and Billing calendar, posted on  School Districts/Counties/4201 Schools will be reimbursed 100% of the federal share  Billing providers will receive one payment (state and federal share) from the Department of Health  Federal Medicaid share is 50% of a gross approved claim as of July 1,

National Provider Identifier (NPI)  Federal requirement per the Health Insurance Portability and Accountability Act (HIPAA)  NPI is used by HIPAA-covered entities  Identifies health care providers in HIPAA standard transactions  10-digit intelligence-free numeric identifier(does not carry information about health care providers)  To apply for an NPI or if you have questions: 37

NPI Requirements for SSHSP  Billing provider (currently required on SSHSP Medicaid claim)  Effective January 1, 2012 Servicing provider NPI must be on SSHSP Medicaid claims  Special transportation claims will not use a servicing provider NPI  If services are provided “under the direction of” or “under the supervision of”, the supervising practitioner’s NPI must be reported on the claim  Ordering provider (not required on SSHSP Medicaid claim) 38

39 International Classification of Diseases, 9th edition, Clinical Modifications (ICD-9-CM) ICD-9-CM is a set of codes used by physicians, hospitals, and allied health workers to indicate diagnosis for all patient encounters. The ICD- 9-CM is the HIPAA transaction code set for diagnosis coding.  Effective 2012 claims must include an appropriate ICD-9 code  Benefits:  Expanded details on claims,  Improved data,  Improved accuracy of claims,  HIPAA compliant, and  Establishes reason/need for procedure provided (records a symptom, diagnosis or complaint on the claim)  ICD codes are used in combination with CPT codes to show correlation between the health condition and the services provided.

SSHSP Implementation of ICD-9 Coding  Diagnosis (reason/need)  Usually supplied by ordering/referring practitioner on written order/referral  May or may not be in the form of ICD-9 code  Claim must have the actual numeric ICD-9 code  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) International Classification of Diseases, 9th edition, Clinical Modifications (ICD-9-CM) 40

Medicaid Listserv  Developed to provide relevant employees of school districts, counties and §4201 schools immediate access to Medicaid updates/changes  To subscribe, please send an message to  The body of the message must read: SUBSCRIBE MEDINED firstname lastname  Complete instructions for subscribing/unsubscribing on 41

? Frequently Asked Questions 42

Additional Resources  SED Medicaid-in-Education Medicaid-in-Education Handbook (coming soon) Medicaid-in-Education Questions & Answers Medicaid Alerts Claiming and Billing Calendar Training Calendar  NYS Office of Professions  NYS Department of Health  National Alliance for Medicaid in Education (NAME) 43

Local Regional Information Center Contacts 44

NYS SSHSP Contacts - SED Telephone Region Steven Wright Kelly Gicobbi Jeff Foley Paula Cooper Northeast Sheila Costa Western/Southern Kelly Mason Monroe/Central/Finger Mailbox: 45

NYS SSHSP Contacts - SED

Connie Donohue Cristin Carter Melissa Kinnicutt NYS SSHSP Contacts - DOH 47