1. School-Based ACCESS Program 2009-2010 Regional Training

2. Building Blocks to A Successful Program 2 Enrollment IEP Reimbursement Provider Qualifications Parent Consent Eligibility Documentation Medical Authorization IEP Enrollment

3. Building Blocks to A Successful Program SBAP Overview PDE DPW o Office of Medical Assistance Programs (OMAP) o Bureau of Program Integrity (BPI) o Office of Finance Leader Services (statewide contractor) In 1992, PDE initiated SBAP. Since that time, Leader Services has served as the program’s statewide vendor. SBAP is a partnership among: 3

4. Building Blocks to A Successful Program SBAP Overview SBAP allows the following school entities to receive federal Medicaid funds for providing IEP health-related services to Medical Assistance (MA) special education students: School districts Intermediate Units MAWAs Charter schools Approved Private Schools 4

5. Building Blocks to A Successful Program SBAP Overview Medicaid: Federal program administered by the Centers for Medicare & Medicaid Services (CMS) that pays certain medical costs for persons with disabilities and/or limited income and resources. Each State’s Medicaid program is administered in accordance with a State plan approved by CMS. The Federal Government and States share the cost of the program. 5

6. Building Blocks to A Successful Program SBAP Overview Pennsylvania Medical Assistance (MA) Program: State Medicaid program for low-income families, elderly persons, and persons with disabilities administered by DPW under a State plan approved by CMS. Enroll: Become eligible to participate in the MA program by completing the application, entering into a provider agreement with DPW 6

7. Building Blocks to A Successful Program SBAP Overview Provider: Individual or facility that signs an agreement with DPW to participate in the MA program. Schools are MA providers (type 35, specialty 350) Provider Agreement: Contract with DPW; provider agrees to comply with all federal and state laws governing participation in the MA program and submit accurate claims. Schools sign provider agreements. 7

8. Building Blocks to A Successful Program SBAP Overview Submit a Claim: Claims for SBAP services are paid for by federal Medicaid money. Leader Services submits claims on behalf of schools but schools are responsible and held accountable for the accuracy of claims. 8

9. Building Blocks to A Successful Program 9 Eligible Services Assistive Devices Audiology IEP Development Nursing (RN & LPN) Occupational Therapy Orientation & Mobility Personal Care Assistant Physical Therapy Physician Psychiatry Psychology Social Work Speech/Language Teacher of Hearing Impaired Special Transportation

10. Building Blocks to A Successful Program 2008-2009 Projected Reimbursement PCA ─ $32,412,671 SLP ─ $23,300,260 OT ─ $12,181,431 Trans.─ $11,260,875 IEP ─ $10,230,088 PT ─ $7,214,976 Psychological ─ $4,117,697 PCA SLP Trans. 10

11. Building Blocks to A Successful Program 2008-2009 Projected Reimbursement RN ─ $4,096,931 THI ─ $2,843,282 Social Work ─ $1,870,888 Other services ─ $1,584,407 LPN ─ $1,227,582 Total = $112,341,088 PCA SLP Trans. Other services include: O&M, Physician, Assistive Devices, Psychiatry, Audiology 11

12. Building Blocks to A Successful Program Prior to MA-Claims Submission Verify: The student is classified as special education under Chapter 14 regulation and is receiving one or more eligible health-related services and that the IEP clearly defines the health- related service including frequency and duration; The student is MA-eligible; Parental consent is on file. 12

13. Building Blocks to A Successful Program Prior to MA-Claims Submission Verify: Medical Authorization or physician’s prescription is on file; Direct service provider meets SBAP licensure/certification requirements for MA participation; Direct service provider’s salary and/or contract is paid with state and/or local funds and is accurately recorded on the cost calculation worksheet; Service is fully documented. 13

14. Building Blocks to A Successful Program 14 Upload to Leader http://www.leaderservices.com/uploads Automatic eligibility check (IEPWriter TM /Children Count ® users only) PROMISe http://promise.dpw.state.pa.us How to Identify Eligible Students F01/01/1997SusanSmith Student Gender Student DOB Student First Name Student Last Name Example format for uploaded data:

15. Building Blocks to A Successful Program 15 IEP Billing Overview IEP Requirements Must include: Formal meeting LEA signature Ongoing SBAP health-related service Reimbursement at a fixed rate (Initial vs. Review) First Right to Bill School Districts Charter Schools MAWAs

16. Building Blocks to A Successful Program 16 IEP Common Mistakes No ongoing SBAP health-related service; No formal meeting; Duplicate billing (waiver); Claiming an Initial meeting in error.

17. Building Blocks to A Successful Program PCA Services Must be: Provided by an aide certified in First Aid and CPR; Defined in IEP; Authorized by an MD, DO, or CRNP 1:1 with a student; Documented. 17

18. Building Blocks to A Successful Program PCA Common Mistakes Services not defined in IEP; No Typical Daily Schedule or schedule does not meet requirements; Insufficient daily notes; No supervisory signature; Billing for individual when attending to more than one student; Billing for more time than actually with student. 18

19. Building Blocks to A Successful Program Special Transportation Must be: Defined as a related service in the IEP daily; Claimed in conjunction with an ongoing health-related service; Claimed only for students who regularly receive special transportation; Documented on a Transportation trip log and reconciled against Leader’s transportation claims report. 19

20. Building Blocks to A Successful Program Transportation Costs Must be reported annually; Report Special Transportation costs only; Include all specialized vehicles; Report total number of students who need specialized vehicles regardless of special education, regular education, or MA status. 20

21. Building Blocks to A Successful Program 21 Transportation Common Mistakes Not specified as daily to/from school; Not listed in IEP; No ongoing health-related service in IEP; No daily bus attendance; Not specifying LEA providing health-related service(s); Not listing start/end dates if applicable; Not notifying Leader of changes; Not validating Transportation Claims report and returning with Confirmation Form.

22. Building Blocks to A Successful Program Record Keeping Requirements Record Keeping Requirements: 55 Pa. Code §1101. 51(e), (e)(1)(i-x): Records must comply with § 1101.51(e), including but not limited to:  Must be maintained for 4 years;  Must fully disclose the nature and extent of the services rendered;  Must be readily available for review or copying by state/federal officials (readily available means records must be available at the provider’s place of business or, upon written request, forwarded without charge to DPW). 22

23. Building Blocks to A Successful Program Record Keeping Requirements Records must comply with § 1101.51(e)(1)(i-x) including but not limited to: Must be legible (anyone can read them without difficulty); Alterations of the record must be signed and dated; Treatments and the treatment plans must be in the record; (example, IEP); Must document the progress at each visit, change in diagnosis, change in treatment and response to treatment; Must contain results/interpretations/reports of tests and consultations (example: psychological testing, other reports); Must contain documentation of the medical necessity of a rendered, ordered, or prescribed service. 23

24. Building Blocks to A Successful Program 24 Federal Audits Federal audits are currently underway in Pennsylvania. Two such audits are: the Medicaid Payment Error Rate Measurement (PERM), and the Medicaid Integrity Contractor (MIC)

25. Building Blocks to A Successful Program 25 State Reviews Currently BPI is conducting reviews of the SBAP program. Leader is concluding technical assistance reviews of the program.

26. Building Blocks to A Successful Program 26 State Reviews There are many regulations, rules, and requirements from various agencies. Everyone must understand and correctly implement all of them. Oversight agencies conduct compliance reviews for their specific regulatory standards; Medicaid regulations differ from education regulations.

27. Building Blocks to A Successful Program 27 State Reviews Compliance with one set of regulations does not necessarily constitute compliance with another. The following are applicable to SBAP: MA Regulations: Applies to all enrolled providers; Based on state and federal law; SBAP providers are responsible for compliance with 55 Pa. Code §1101; Available in the SBAP manual and through DPW on line at http://tinyurl.com/chapter1101

28. Building Blocks to A Successful Program Identify and Prevent Frequently Noted Violations The following examples (provided by BPI) are recent examples of frequently noted violations identified through BPI reviews. Although it is a composite, these findings have been identified in all reviews 28

29. Building Blocks to A Successful Program Identify and Prevent Frequently Noted Violations Violation 1: Services not rendered Examples: Claims for students who are absent Claims for dates when school is not in session Claims that included more units of service than provided Claims for special transportation when it was not provided on the dates billed 29

30. Building Blocks to A Successful Program Identify and Prevent Frequently Noted Violations Violation 1: Services not rendered Proactive Compliance Hints: Check absentee/attendance logs before submitting a claim Verify date entry for accuracy Confirm that the amount and duration of services are identified in IEP Reconcile transportation reports from Leader with services billed 30

31. Building Blocks to A Successful Program Violation 2: More expensive service billed than rendered Example: Claims for individual services that were documented as group Identify and Prevent Frequently Noted Violations 31

32. Building Blocks to A Successful Program Identify and Prevent Frequently Noted Violations 32 Violation 2: More expensive service billed than rendered Proactive Compliance Hints: Require submission of documentation with billing forms before claim submission; Compare documentation with billing forms; Confirm that service to be billed is the services that is documented as rendered.

33. Building Blocks to A Successful Program Violation 3: Unqualified staff Examples: Claims for PCA services when staff did not possess required CPR and/or first aid certification for dates billed Claims for direct services provided by staff whose licenses were invalid or did not meet SBAP requirements Claims for social work services documented as provided by non-licensed individuals Identify and Prevent Frequently Noted Violations 33

34. Building Blocks to A Successful Program Identify and Prevent Frequently Noted Violations Violation 3: Unqualified staff Proactive Compliance Hints: Develop a process to ensure that all staff have certifications/licenses that are current and cover the service dates; Require proof of certifications/licenses Check the status of certifications and licenses periodically Validate licensure at http://www.licensepa.state.pa.us/ 34

35. Building Blocks to A Successful Program Identify and Prevent Frequently Noted Violations Violation 4: Unsupervised Services Examples: Claims for services documented as provided by personnel requiring supervision; the documentation/ professional services log did not include the required supervisory signature; PCA services billed; no supervisory signature on documentation. 35

36. Building Blocks to A Successful Program Identify and Prevent Frequently Noted Violations Violation 4: Unsupervised Services Proactive Compliance Hints: Confirm that there is a supervisory signature on all documentation as required before submission of a claim 36

37. Building Blocks to A Successful Program Violation 5: Services not identified in the IEP Examples: Transportation services not identified/recommended in the IEP; PCA services not identified/recommended in the IEP. Identify and Prevent Frequently Noted Violations 37

38. Building Blocks to A Successful Program Violation 5: Services not identified in the IEP Proactive Compliance Hints: Health-related services billed to Medicaid must be specifically identified in the IEP; Before submitting a claim, confirm that the service is identified in the IEP as a health related service. Identify and Prevent Frequently Noted Violations 38

39. Building Blocks to A Successful Program Violation 6: Dates of service not covered by IEP Examples: Previous IEP covers 9/1/06 – 6/15/07; New IEP dated 9/9/07; claims submitted before dates 9/2/07 – 9/8/07 Identify and Prevent Frequently Noted Violations 39

40. Building Blocks to A Successful Program Violation 6: Dates of service not covered by IEP Proactive Compliance Hints: The IEP must cover all the dates billed; Before submitting a claim, confirm that the dates are covered by an IEP; If there is a lapse between the IEP period covered, claims should not be submitted for the lapsed dates. Identify and Prevent Frequently Noted Violations 40

41. Building Blocks to A Successful Program Identify and Prevent Frequently Noted Violations Violation 7: Service not identified on practitioner’s authorization or prescription Examples: Transportation services not identified on practitioner’s authorization or prescription; PCA services not identified on practitioner’s authorization or prescription. 41

42. Building Blocks to A Successful Program Identify and Prevent Frequently Noted Violations Violation 7: Service not identified on practitioner’s authorization or prescription Proactive Compliance Hints: Health-related services billed to Medicaid must be prescribed by a practitioner within their scope of practice, either by prescription or the SBAP Medical Practitioner Authorization form Before submitting a claim, confirm that the service is identified on the practitioner’s authorization or a prescription and that it covers the dates to be billed 42

43. Building Blocks to A Successful Program Identify and Prevent Frequently Noted Violations Violation 7: Service not identified on practitioner’s authorization or prescription Proactive Compliance Hints: If the student’s health related service has changed, do not bill for newly added services until those changes/services are authorized 43

44. Building Blocks to A Successful Program Violation 8: Service frequency exceeds IEP recommendations and/or practitioner’s authorization Example: IEP and practitioner’s authorization identify individual speech therapy for 30 minutes/week; 60 minutes/week is billed Identify and Prevent Frequently Noted Violations 44

45. Building Blocks to A Successful Program Identify and Prevent Frequently Noted Violations Violation 8: Service frequency exceeds IEP recommendations and/or practitioner’s authorization Proactive hints: Before submitting a claim, confirm that the frequency to be billed is the same as identified in the IEP and practitioner’s authorization or prescription; If the student’s needs change, do not submit a claim for a greater frequency of service until an updated IEP and practitioner’s authorization or prescription reflecting the change is obtained. 45

46. Building Blocks to A Successful Program Identify and Prevent Frequently Noted Violations Violation 9: No documentation for the services and date billed Examples: No service log, or daily progress note, or monthly summary in the record for the services and dates billed No transportation logs in the record for the services and dates billed 46

47. Building Blocks to A Successful Program Identify and Prevent Frequently Noted Violations Violation 9: No documentation for the services and date billed Proactive hints: Require submission of documentation for review before services are billed Compare documentation before submitting a claim 47

48. Building Blocks to A Successful Program Identify and Prevent Frequently Noted Violations Violation 10: Monthly summary fails to fully describe treatment rendered and response to treatment Examples: PCA services billed 5 days a week for 5 consecutive months. The monthly documentation for each month billed states: Student has shown some improvement in staying on task for the month. 48

49. Building Blocks to A Successful Program Identify and Prevent Frequently Noted Violations Violation 10: Monthly summary fails to fully describe treatment rendered and response to treatment Examples (continued) : Occupational Therapy services are billed 2 times a week for the month of January. Monthly documentation states: Student had demonstrated slight improvement with his coordination skills. 49

50. Building Blocks to A Successful Program Identify and Prevent Frequently Noted Violations Violation 10: Monthly summary fails to fully describe treatment rendered and response to treatment Proactive hints: Documentation must give a full picture of the services provided A person who does not know the student should be able to read the notes and understand what treatment was provided, what goals were addressed, what activities occurred, and what progress was made 50

51. Building Blocks to A Successful Program Identify and Prevent Frequently Noted Violations Violation 10: Monthly summary fails to fully describe treatment rendered and response to treatment Proactive hints: At a minimum, daily and/or monthly notes must document: Treatment services performed Activities performed during each treatment episode Description of student’s participation and interactions during treatment 51

52. Building Blocks to A Successful Program Violation 11: Failure to maintain records that were readily available Example: Provider is unable to provide copies of records to BPI upon request. Identify and Prevent Frequently Noted Violations 52

53. Building Blocks to A Successful Program Violation 11: Failure to maintain records that were readily available Proactive hints: Providers must retain records for 4 years and make them readily available for review by State and Federal officials or their authorized agents; Readily available means that records are made available at the provider’s place of business or, upon written request, are forwarded in the specified time. Identify and Prevent Frequently Noted Violations 53

54. Building Blocks to A Successful Program 54 Administrative cooperation and participation An outline of internal procedures Internal monitoring procedures Sufficient allocation of time and staff Annual staff trainings (minimum) Maintain centralized location for SBAP records Understand MA regulations (see DPW handout pg. 4-5) Perform routine self-audits; disclose errors Keys to a Successful Program

55. Building Blocks to A Successful Program 55 Self-Audits/Monitoring Activities Through self-monitoring activities, schools can identify inappropriate billing Self-audit activities include: Periodic self-auditing of service delivery and billing Comparison of what was billed with MA recipient (student) records Review of regulations and requirements to ensure that services were rendered and billed correctly

56. Building Blocks to A Successful Program 56 Self-Audits/Monitoring Activities Some benefits of self audit activities are: Identification of overpayments and underpayments; Identification of individuals that might be implementing services inappropriately; Identification of individuals that might be submitting time inappropriately; Schools, not DPW, conduct the review; DPW will not seek double damages for self- reported inappropriate payments.

57. Building Blocks to A Successful Program 57 Self-Audits/Monitoring Activities A few examples of self-audits are: A school discovers that: Services were billed that were not in the IEP and/or not prescribed; Undocumented services were billed; Services were billed by an employee who did not meet SBAP provider qualifications.

58. Building Blocks to A Successful Program 58 Monthly Management Reports Comprehensive reports provided to LEAs by Leader Available online within WebSDS and WebPSL

59. Building Blocks to A Successful Program 59 Withdrawing Funds Funds are deposited into a PDE-restricted account, which earns no interest; Review your account balance prior to requesting a funds withdrawal; Funds must be used to enhance or supplement special education services, or cover costs incurred to administer SBAP.

60. Building Blocks to A Successful Program 60 Withdrawing Funds ACCESS funds requests must be submitted on PDE 352 or PDE 352M (EI) form; The LEA six-digit LEC number must appear on the form; The Comptroller’s office will not process requests under $1,000; Submit the ACCESS Funds Request Form to PDE along with a short narrative describing how the SBAP funds will be used and how they will enhance special education.

61. Building Blocks to A Successful Program 61 Requests to Withdraw Funds PA Department of Education 333 Market Street, 7th Floor Harrisburg, PA 17126-0333 ATTN: Elizabeth Zeisloft