1. >www.dpw.state.pa.us > School-Based ACCESS Program 2013 Fall Regional Training Barry C. Decker, Bureau of Policy, Analysis and Planning Pam Tressler, Bureau of Program Integrity

2. >www.dpw.state.pa.us > AGENDA  Overview  Participant Roles  CMS Financial Management Review  Services  Requirements  Documentation  Verification 2

3. >www.dpw.state.pa.us > AGENDA (cont.)  Provider Screening  Audit/Reviews  Self-audits  Self-disclosures  Corrective Action Plans  Results of CMS Audit  BPI Findings 3

4. >www.dpw.state.pa.us > AGENDA (cont.)  Contact Information  Questions 4

5. >www.dpw.state.pa.us > History of SBAP Began in 1992 Involves:  Centers for Medicare and Medicaid Services (CMS),  Department of Public Welfare (DPW)  Pennsylvania Department of Education (PDE)  LEAs  Public Consulting Group (PCG) OVERVIEW 5

6. >www.dpw.state.pa.us > School-Based ACCESS Program (SBAP) involves the State Medicaid Agency which through Local Education Agencies (LEA) are able to receive reimbursement for direct and administrative service costs. OVERVIEW (cont.) 6

7. >www.dpw.state.pa.us > Direct Services Face-to-face medically necessary services provided by the LEA Services must be properly documented in the Individualized Education Program (IEP) Authorized/prescribed by currently licensed practitioner OVERVIEW (cont.) 7

8. >www.dpw.state.pa.us > Administrative services Services provided by the LEAs that are in support of direct services OVERVIEW (cont.) 8

9. >www.dpw.state.pa.us > Those involved in SBAP: Centers for Medicare and Medicaid Services (CMS) Department of Public Welfare (DPW)  Bureau of Policy, Analysis and Planning  Bureau of Program Integrity  Bureau of Financial Reporting PARTICIPANT ROLES 9

10. >www.dpw.state.pa.us > Pennsylvania Department of Education (PDE)  Bureau of Special Education  Bureau of Early Intervention Services LEAs  School districts, charter schools, intermediate units, approved private schools, vocational- technical schools, and pre-school early intervention programs Public Consulting Group (PCG) PARTICIPANT ROLES (cont.) 10

11. >www.dpw.state.pa.us > Financial Management Review (FMR) Began in January 2012 Met with CMS in May 2012 Changes effective July 1, 2012  Daily Progress Note required  Discontinuance of billing for IEP Meetings as direct service  Discontinuance of billing for collateral services as part of direct service  Allow for one way transportation billing CMS FMR 11

12. >www.dpw.state.pa.us > State Plan Amendment  Cost-based payment methodology  Cost reconciliation  Random Moment Time Study (RMTS) State Administrative Claiming Plan  RMTS FMR Draft Report CMS FMR (cont.) 12

13. >www.dpw.state.pa.us > FMR Findings/Requests: State Plan Amendment Approved payment methodology Discontinue of billing for IEP meetings as direct service Discontinuance of billing for collateral services as part of direct service Fully document the service Identify individual or group in IEP CMS FMR (cont.) 13

14. >www.dpw.state.pa.us > CMS FMR (cont.) Direct services are face-to-face Use a procedure code to identify evaluations Units of service billed must not be more than the units that are medically necessary and authorized Billed units must be documented 14

15. >www.dpw.state.pa.us > SERVICES SBAP Direct Services Services provided by school-based service providers that are provided or purchased by LEAs enrolled in the Medical Assistance (MA) Program to MA-eligible beneficiaries 3-21 years of age for whom the service is medically necessary and documented in the IEP. 15

16. >www.dpw.state.pa.us > SERVICES (cont.) MA Provider Agreement LEAs must comply with all Federal Medicaid and State rules and regulations 16

17. >www.dpw.state.pa.us > SERVICES (cont.) Assistive Technology Devices (ATD)  42 CFR 440.70(b)(3)  Only authorized/prescribed by a physician (MD or DO)  LEA obtains from medical supplier Nursing Services  42 CFR 440.60(a)  RN or LPN 17

18. >www.dpw.state.pa.us > SERVICES (cont.) Nurse Practitioner Services  42 CFR 440.166  Certified Registered Nurse Practitioner (CRNP)  Known as physician service in SBAP Occupational Therapy Services  42 CFR 440.110(b) Orientation, Mobility and Vision Services  42 CFR 440.130(d) 18

19. >www.dpw.state.pa.us > SERVICES (cont.) Personal Care Services  42 CFR 440.167  Known as PCA service in SBAP  One-to-one direct service  Activities of daily living Physical Therapy Services  42 CFR 440.110(a) 19

20. >www.dpw.state.pa.us > SERVICES (cont.) Physician Services  42 CFR 440.50(a) Psychological, Counseling and Social Work Services  42 CFR 440.50(a) and 42 CFR 440.130(d)  Known as psychological, social work and psychiatric services in SBAP 20

21. >www.dpw.state.pa.us > SERVICES (cont.) Special Transportation Services  42 CFR 440.170(a) Speech, Language and Hearing Services  42 CFR 440.110(c)  Known as: audiology services; speech, language and hearing services; and teacher of the hearing impaired services. 21

22. >www.dpw.state.pa.us > REQUIREMENTS Medical Authorization Practitioner’s orders must be documented on:  Prescription or SBAP Medical Practitioner Authorization Form Practitioner’s orders must be:  Concurrent with the IEP and obtained at least annually or whenever there is a change to a student’s MA- covered service 22

23. >www.dpw.state.pa.us > 23

24. >www.dpw.state.pa.us > DOCUMENTATION LEAs must maintain any and all relevant documents to the services claimed. Parental Consent (signed, checked and dated) IEP MPA/Order/Prescription (signed and dated) 24

25. >www.dpw.state.pa.us > DOCUMENTATION (CONT) Daily logs (Easy Trac) o If on behalf of or not electronically documented the original paper document must be retained Attendance records o Student o Provider 25

26. >www.dpw.state.pa.us > DOCUMENTATION (CONT) Keys for acronyms/abbreviations used Provider licenses and/or certifications Evaluation reports Transportation logs 26

27. >www.dpw.state.pa.us > DOCUMENTATION (CONT) Records must comply with MA Regulations ( 55 Pa.Code § 1101.51 ) Record Retention Pennsylvania – records must be maintained for a minimum of 4 years from the date of service ( 55 Pa.Code §1101.51(e) ) Federal – require documents to be maintained for six years 27

28. >www.dpw.state.pa.us > DOCUMENTATION (CONT) Fully disclose the nature and extent of services rendered Readily available for review or copying Must be legible Alterations must be dated and signed Plans must be part of the record (IEP, treatment plan, evaluations and reports) 28

29. >www.dpw.state.pa.us > DOCUMENTATION (CONT) Must document progress for each session, change in diagnosis, treatment and response to treatment Must be dated and signed 29

30. >www.dpw.state.pa.us > DOCUMENTATION (CONT) Reminder for LEAs using a third party vendor or on behalf of entries You must maintain the original documents 30

31. >www.dpw.state.pa.us > VERIFY LEA’s should verify: IEP Is on file Valid for that date of service (DOS) Contains the health-related service Service is within the duration/frequency 31

32. >www.dpw.state.pa.us > VERIFY (cont) Parental consent On file Appropriately marked/checked Signed & dated 32

33. >www.dpw.state.pa.us > VERIFY (cont) Medical Practitioner Authorization Form(MPA)/Prescription On file Valid for that DOS Contains the health-related service Duration Frequency Signed/Dated 33

34. >www.dpw.state.pa.us > VERIFY (cont) Provider meets the appropriate qualifications (valid license, CPR, first aid) Provider is not paid with IDEA funds Daily log o Completed o Signed/Supervisory signature if necessary 34

35. >www.dpw.state.pa.us > PROVIDER SCREENING Medical Assistance Bulletin #99-11-05 Provider Screening of Employees and Contractors for Exclusion from Participation in Federal Health Care Programs Effective Date August 15, 2011 35

36. >www.dpw.state.pa.us > PROVIDER SCREENING (cont) You cannot be paid by Medicare, Medicaid, or other Federal healthcare programs for items or services furnished, ordered or prescribed by an excluded individual or entity. “Furnished” refers to items or services provided or supplied, directly or indirectly. 36

37. >www.dpw.state.pa.us > PROVIDER SCREENING (cont) An excluded individual or entity cannot be part of a task that is reimbursed by Federal program dollars, which includes: Claims submittal Any service, including those not directly related to patient care Payment from a Federal program cannot cover salaries, expenses, or fringe benefits 37

38. >www.dpw.state.pa.us > PROVIDER SCREENING (cont) Exclusion may be imposed on an individual or entity that is not: Enrolled in Medicare or Medicaid Involved in submitting claims Involved in recipient care 38

39. >www.dpw.state.pa.us > PROVIDER SCREENING (cont) Potential consequences of employing an excluded provider include: Repayment of claims Penalty of up to $10,000 for each item or service claimed Assessment of three times the amount claimed for each item or service Exclusion 39

40. >www.dpw.state.pa.us > PROVIDER SCREENING (cont) Exclusions are documented on the following databases: List of Excluded Individuals/Entities (LEIE) at http://www.oig.hhs.gov/fraud/exclusions.asp http://www.oig.hhs.gov/fraud/exclusions.asp System for Award Management (SAM) at www.sam.gov www.sam.gov Medicheck List at http://www.dpw.state.pa.us/learnaboutdpw/fraudandabu se/medicheckprecludedproviderslist/index.htm http://www.dpw.state.pa.us/learnaboutdpw/fraudandabu se/medicheckprecludedproviderslist/index.htm 40

41. >www.dpw.state.pa.us > PROVIDER SCREENING (cont) Protect yourself and your company Develop policies and procedures for screening all employees and contractors Develop and maintain auditable documentation of screening efforts Periodically conduct self-audits to determine compliance with this requirement 41

42. >www.dpw.state.pa.us > PROVIDER SCREENING (cont) Check Federal and State Databases:  Before hiring or contracting with an individual or entity  Monthly thereafter  This maybe a good time to verify licenses with the Department of State 42

43. >www.dpw.state.pa.us > PROVIDER SCREENING (cont) If you discover an excluded individual? Immediately self report any discovered exclusion to the Bureau of Program Integrity This can be done via e-mail through the MA Provider Compliance form at the following link: http://www.dpw.state.pa.us/learnaboutdpw/frau dandabuse/maprovidercompliancehotlinerespo nseform/index.htm http://www.dpw.state.pa.us/learnaboutdpw/frau dandabuse/maprovidercompliancehotlinerespo nseform/index.htm 43

44. >www.dpw.state.pa.us > AUDITS/REVIEWS Who can conduct audits/reviews? Centers for Medicare & Medicaid Services (CMS) Office of Inspector General (OIG) Payment Error Rate Measurement (PERM) Medicaid Integrity Contract (MIC) Bureau of Program Integrity (BPI) PCG 44

45. >www.dpw.state.pa.us > SELF AUDITS Self-Auditing activities include: Periodic self auditing of service delivery and billing Reconciliation of MA claims with the amount received Review of regulation/requirements to ensure that services were rendered and billed correctly 45

46. >www.dpw.state.pa.us > SELF AUDITS (cont) Pennsylvania’s voluntary MA Provider Self Audit Protocol provides a mechanism for disclosure and repayment of improper MA payments and provides guidance on the preferred methodology. 46

47. >www.dpw.state.pa.us > SELF AUDITS (cont) Self Audit Protocol can be assessed at: www.dpw.state.pa.us/PartnersProviders/Me dicalAssistance/DoingBusiness/FraudAbu se/003670226.htm 47

48. >www.dpw.state.pa.us > SELF AUDITS (cont) Help you to: Identify incomplete/inaccurate documentation Promote a commitment to comply with rule/regulations Prevent/detect criminal conduct and violations Avoid penalties 48

49. >www.dpw.state.pa.us > SELF AUDITS (cont) Benefits Identify overpayments Identify underpayment Identify services you could be billing for Identify individuals that might not be submitting time appropriately DPW isn’t standing over you shoulder conducting the review 49

50. >www.dpw.state.pa.us > SELF DISCLOSURES LEAs are encouraged to self disclose billing errors and violations identified Providers have a legal and ethical commitment to return inappropriate Medicaid payments. 50

51. >www.dpw.state.pa.us > SELF DISCLOSURES (cont) Send Self Audits/Self Disclosures to BPI at: Department of Public Welfare, Office of Administration, Bureau of Program Integrity P.O. Box 2675, Harrisburg, PA 17105-2675 51

52. >www.dpw.state.pa.us > CORRECTIVE ACTION PLANS A CAP is: A written step-by-step plan of action developed to achieve targeted outcomes for resolution of identified problems Requested by BPI as a component of its review when violations are identified BPI will either accept a provider’s CAP or request revisions 52

53. >www.dpw.state.pa.us > CORRECTIVE ACTION PLANS The ultimate goal is to incorporate a CAP into an LEA’s everyday operations in an effort to: Comply with state and federal regulations; Ensure quality, accessible, timely services; Achieve measurable improvement in the highest priority areas; Eliminate repeated deficient practices 53

54. >www.dpw.state.pa.us > CORRECTIVE ACTION PLANS CAPs must include at a minimum: Specific policies and procedures developed to address the issue Specific measures taken or to be taken to ensure compliance Timeline for the measures Date(s) of implementation Responsible person/persons Follow-ups to ensure compliance 54

55. >www.dpw.state.pa.us > RESULTS OF CMS AUDIT Missing documentation IEP Daily progress note Parental Consent Medical Practitioners Authorization Attendance Record Transportation Logs 55

56. >www.dpw.state.pa.us > RESULTS OF CMS AUDIT (cont) Incomplete Documentation/Didn’t Meet Requirements Daily log must include the providers name and be signed Units billed not equal to units documented More units billed than medically necessary IEP did not specify group vs individual Service not listed on IEP 56

57. >www.dpw.state.pa.us > RESULTS OF CMS AUDIT (cont) MPA signed post date of service Provider not licensed on date of service One way transport paid for round trip 57

58. >www.dpw.state.pa.us > BPI FINDINGS Findings: Licensing Problems Signatures PCS Documentation 58

59. >www.dpw.state.pa.us > CONTACT INFORMATION Barry Decker, BPAP 717-772-6341 bdecker@pa.gov Pam Tressler, BPI 717-705-6873 ptressler@pa.gov 59

60. >www.dpw.state.pa.us > QUESTIONS Questions? 60