Preschool/School Supportive Health Services Program (SSHSP) Medicaid-in-Education Training on Compliance Agreement, Written Compliance Policies and Program Update

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Preschool/School Supportive Health Services
Program (SSHSP) Medicaid-in-Education
Training on Compliance Agreement, Written
Compliance Policies and Program Update
1
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NYS 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

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Agenda

• How did we get here?
• NYS Compliance Agreement
• OMIG Compliance Program
• Medicaid State Plan Amendment
• Implementation of New SSHSP Requirements
• Contact Information

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How Did We Get Here?

• Federal Audits
• Settlement
• Compliance Agreement

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Compliance

• NYS Compliance Agreement
• Implementation Plan
• OMIG Compliance Program

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Compliance Agreement

• NYS SSHSP Compliance Policy
• Confidential Disclosure Policy
• Compliance Officer/Compliance Committee
• Audit Requirements
• Independent Audits
• Annual Written Reports
• Training
• State Plan Amendment

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Compliance Agreement

• Goals
• Remedy the consequences of past practices and
  policies
• Ensure that policies and practices are modified
  to achieve compliance

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Compliance Agreement

• Adoption of two specific policies
• NYS Policy Regarding Its Commitment to Ensure
  Compliance
• Confidential Disclosure Policy (inappropriate
  billing)

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Compliance Agreement

• Confidential Disclosure Policy
• The NYS Supportive Health Services Program
  Compliance Agreement, entered into on July 20,
  2009, by the NYS Department of Health (DOH), the
  NYS Education Department (SED) and the NYS Office
  of the Medicaid Inspector General (OMIG) requires
  that the State and local school districts shall
  establish a confidential disclosure mechanism
  enabling employees to disclose anonymously any
  practices or billing procedures, deemed by the
  employee to be inappropriate, to the State's
  Compliance Officer.

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Compliance Agreement
Confidential Disclosure Contact Rose
FiresteinCompliance OfficerNew York State
Department of HealthOffice of General Counsel90
Church Street, 4th FloorNew York, New York
10007Telephone [phone]Facsimile
212/417-4392ref01_at_health.state.ny.us
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OMIG Compliance Program

• Effective October 1, 2009 all districts and
  counties billing Medicaid in excess of 500,000
  (gross) require a written Compliance Program
• Presentation by Robert Hussar, OMIG, is available
  both as a PowerPoint document and in the web cast
  format on SEDs website
• OMIG www.omig.state.ny.us see Compliance tab

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OMIG Compliance Program

• Prevents, detects and remedies inappropriate
  billing protects whistleblowers eight
  elements
• Written policies and procedures, including how to
  report
• Designated compliance officer (best practice)
• Training for employees, administrators and board
  members
• Reporting line to compliance officer (including
  anonymous/confidential)
• Discipline failing to report, permitting
  suspected non-compliance
• Routine identification of risk areas
  internal/external audit
• Procedures to respond to, correct, and report
  compliance issues
• Policy barring intimidation, retaliation or
  compliance activities

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OMIG Compliance Program

• OMIG
• Over 1,000,000 all 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

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Compliance Agreement

• OMIG Audits
• Independent Audit
• Annual Written Reports

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Compliance Agreement

• Training
• Relevant employee database http//www.forms2.ny
  sed.gov/oms/medicaid/shsp.cfm
• Annual compliance training to relevant employees
• Training certification for attendees

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Medicaid State Plan Amendment (09-61)

• New York State Plan Amendment (SPA 09-61)
• Covered services
• Documentation requirements
• Clarify Medicaid billing and program policy
• Planning ahead

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Medicaid State Plan Amendment (09-61)

• Changes
• Clarification on qualified providers
• Payment methodology

• Unchanged areas
• Medical necessity
• Service included in Individual Education Program
  (IEP)
• Provided by qualified professionals
• Documentation complete

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Medicaid State Plan Amendment (96-41)

• Changes Removal of Targeted Case Management
• Separate SPA (96-41)
• SSHSP Targeted Case Management SPA rescinded as
  of July 1, 2010

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Medicaid State Plan Amendment (09-61)

• 10 Services Covered Under the SSHSP
• Speech Therapy 6. Psychological Evaluations
• Physical Therapy 7. Audiological Evaluations
• Occupational Therapy 8. Medical
  Evaluations
• Skilled Nursing 9. Medical Specialist
  Evaluations
• Psychological Counseling 10. Special
  Transportation

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Medicaid State Plan Amendment (09-61)

• Early and Periodic Screening, Diagnostic, and
• Treatment (EPSDT) section of the State Medicaid
  
• Plan
• Medicaid coverage of IEP related services
• available only until the students 21st birthday

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Medicaid State Plan Amendment (09-61)

• Clarifications Related to Service Provision
• See handout 1 for specific provider
  qualifications
• Documentation of qualification kept on file
  (license, certification, or registration)
• NYS licensed/registered provider, acting within
  his/her scope of practice under NYS Law

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Medicaid State Plan Amendment (09-61)

• Clarifications Related to Service Provision
• Psychological evaluations provided by
• NYS licensed and registered Psychiatrist or
• NYS licensed and registered Psychologist
• Psychological counseling provided by
• A NYS licensed and registered Psychiatrist
• A NYS licensed and registered Psychologist
• A Licensed Clinical Social Worker (LCSW)
• A Licensed Master Social Worker Under the
  supervision of NYS licensed and registered
  psychiatrist, NYS licensed and registered
  psychologist, LCSW

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Medicaid State Plan Amendment (09-61)
Clarifications Related to Service Provision

• Under the direction of (UDO)
• Sees the student at beginning and periodically
• Is familiar with the treatment plan and has
  continued involvement and directly supervises
  services
• Assumes professional responsibility
• Keeps documentation supporting the supervision of
  services

• Under the Supervision of
• Apprises the supervisor of the diagnosis and
  treatment
• Cases are discussed and supervisor provides
  oversight and guidance
• Supervisor provides at least one hour per week or
  two hours every other week of in-person clinical
  supervision

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Under the Direction of (UDO) Under the
Supervision of

• See handout 2
• UDO Applies to
• Teacher of the Speech and Hearing Handicapped
  (TSHH)
• Physical Therapy Assistant (PTA)
• Occupational Therapy Assistant (OTA)
• Under the Supervision of applies only to Licensed
  Master Social Worker

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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)

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Medicaid State Plan Amendment (09-61) Written
Orders/Referrals

• 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
• Providers contact information (office stamp or
  preprinted address and telephone number)
• Signature of a NYS licensed and registered
  physician, a physician assistant, or a 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)

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Medicaid State Plan Amendment (09-61)
Written Orders/Referrals

• Written Orders and Referrals must include
  (continued)
• The time period for which services are being
  ordered
• The ordering practitioners National Provider
  Identifier (NPI) or license number and,
• Patient diagnosis and/or reason/need for ordered
  services.
• For purposes of the SSHSP, where written
  referrals are permitted
• (e.g., speech therapy services, psychological
  counseling services),
• the written referral must include the information
  listed above

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Medicaid State Plan Amendment (09-61) Session
Notes (handout 3)

• Session notes must include
• Students 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 students 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 clinician as
  appropriate

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Medicaid State Plan Amendment (09-61)
Session Notes

• Other Documentation Requirements may exist under
  other programs for example
• IDEA-required quarterly progress notes
• IDEA-required parental consent

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Medicaid State Plan Amendment (09-61)

• Evaluations
• See flow chart handout 4
• Student suspected of having a disability
• Referred to CSE/CPSE
• Evaluation process initiated (written
  order/referral on file)
• Student not found to have a disability
• No IEP is developed and evaluation can not be
• reimbursed by Medicaid
• Student found to have a disability
• Evaluation must be listed on IEP in order to be
• reimbursed by Medicaid

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WHEN ARE EVALUATIONS MEDICAID REIMBURSABLE?
Student referred to CSE/CPSE due to a suspected
disability
Student is classified with a disability. CSE/CPSE
meets to develop IEP
Prior to the evaluation, was a written
order/referral obtained from a qualified provider?
Y
Was a disability identified?
Evaluation(s) reflected in IEP services to be
delivered included in IEP and written
order/referral(s) for evaluations and services
must be included in students record
Y
N
N
Without documented written order/referral from a
qualified provider the evaluation is not Medicaid
reimbursable.
If student is Medicaid eligible and all
documentation for evaluations and ongoing
services are included in students record,
Medicaid may be billed.
If student is not classified with a disability,
the evaluation is not Medicaid reimbursable.
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Medicaid State Plan Amendment (09-61)

• Evaluations
• Must be reflected in the IEP
• Assist with determination of medical necessity
  (critical for billing Medicaid)
• Service provided by appropriate qualified
  provider

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Medicaid State Plan Amendment (09-61)

• Changes Payment Methodology
• Encounter-based claiming methodology
• Each service encounter must be documented for
  reimbursement (Session Notes)
• Current Procedural Terminology (CPT) Codes
• Fees for services were benchmarked at 75 of the
  2010 Medicare fee schedule for the Mid Hudson
  Region
• Transportation continues to be billed using a
  cost-based methodology (one-way rates)

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Medicaid State Plan Amendment (09-61)

• Current Procedural Terminology (CPT)
• Describes the type of service being supplied
• See handout 5
• Timed and untimed
• Individual and group

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Special Transportation

• Rate-based reimbursement (see handout 6)
• Specify the nature of the students special
  transportation needs in IEP
• Other Medicaid-reimbursable services listed in
  the IEP
• One-way rates established
• To or from a Medicaid covered service
• Session notes for the Medicaid reimbursable
  service other than transportation
• Please note Regular transportation provided to
  preschool students is no longer
• Medicaid reimbursable. Special transportation as
  described above is available for
• both school aged and preschool students.

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Medicaid State Plan Amendment (09-61)

• Requirements for submitting claims (see handout
  7)
• For services delivered before 7/01/09
• Use existing monthly rate codes for 16 SSHSP
  services
• Requires supporting documentation
• For services 7/1/09 8/31/09
• No reimbursement available
• For services delivered 9/1/09 and thereafter
• Use encounter based billing for 10 SSHSP services
  
• Requires supporting documentation
• Servicing provider must identify services
  provided for each encounter by CPT code

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Documentation Required to Support Medicaid
Reimbursement

• IEP
• Written orders
• Written referrals
• Documenting service delivery
• Session notes
• UDO/Supervision if applicable
• Provider credentials kept on file

• Special Transportation
• Medical/Behavioral need (included in IEP)
• Documented receipt of Medicaid covered service
• Transportation logs

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Retention of Documentation

• 18 NYCRR 517.3 Audit and record retention
• Retain for a period of six years from the date
  services
• were paid
• All documents relating in any manner to Medicaid
  reimbursement for services
• All documents relating in any manner to
  referrals, prescriptions or orders for these
  services
• For disposal of documents, follow your
• employers policy and/or records retention and
• disposition schedule.

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Planning Ahead

• National Provider Identifier (NPI)
• The national standard for identifying health care
  providers
• Federal requirement per Health Insurance
  Portability and Accountability Act (HIPAA)
  regulations
• Target date - Jan 1, 2012
• National Plan Provider Enumeration System
  (NPPES) website for more information and to apply
  for an NPI - https//nppes.cms.hhs.gov/NPPES/Stat
  icForward.do?forwardstatic.instructions
• Diagnosis codes

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Planning Ahead

• ICD-9 Codes International Classification of
  Diseases, 9th Revision
• ICD-9-CM International Classification of
  Diseases 9th Revision Clinical Modification
  used to code and classify data from clinical
  records
• An example
• 2010 ICD-9-CM Diagnosis Code 389.00
• Conductive hearing loss unspecified 389.0
• 389.00 is a billable ICD-9-CM medical code that
  can be used to specify a diagnosis on a
  reimbursement claim.
• Diagnosis Definition(s) - involves lesions of the
  external and middle ear resulting in
  malconduction of airborne sound.

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Additional Resources

• Medicaid-in-Education homepage
• http//www.oms.nysed.gov/medicaid/
• Medicaid-in-Education Questions Answers
• http//www.oms.nysed.gov/medicaid/q_and_a/
• Office of Professions homepage
• http//www.op.nysed.gov
• National Alliance for Medicaid in Education
• http//medicaidforeducation.org/
• LEAnet
• http//www.theleanet.com/

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Contacts Medicaid in Education
medined_at_mail.nysed.gov
SED
DOH

• Harold Matott 518-486-1979
• hmatott_at_mail.nysed.gov
• Steven Wright 518-486-4887
• swright2_at_mail.nysed.gov
• Kelly Gicobbi 518-486-7828
• kgicobbi_at_mail.nysed.gov
• Jeff Foley 518-402-5121
• jfoley_at_mail.nysed.gov
• Paula Cooper 518-402-5218
• pcooper_at_mail.nysed.gov
• Sheila Costa 518-474-4178
• scosta_at_mail.nysed.gov
• Kelly Mason 518-486-2287
• kmason2_at_mail.nysed.gov

• Connie Donohue 518-473-2160
• cld03_at_health.state.ny.us
• Cristin Carter 518-473-2160
• cmc10_at_health.state.ny.us
• Melissa Kinnicutt 518-473-2160
• mak16_at_health.state.ny.us

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CPT Examples
Medicaid State Plan Amendment (09-61)
Code Description Session length/units
96110 DEVELOPMENTAL TESTING LIMITED (EG, DEVELOPMENTAL SCREENING TEST II, EARLY LANGUAGE MILESTONE SCREEN), WITH INTERPRETATION AND REPORT One per session
96111 DEVELOPMENTAL TESTING EXTENDED (INCLUDES ASSESSMENT OF MOTOR, LANGUAGE, SOCIAL, ADAPTIVE AND/OR COGNITIVE FUNCTIONING BY STANDARDIZED DEVELOPMENTAL INSTRUMENTS) WITH INTERPRETATION AND REPORT One per session
97140 MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 MINUTES 15 minutes
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CPT Examples
Medicaid State Plan Amendment (09-61)
Code Description Session length/units
90804 INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE, IN AN OFFICE OR OUTPATIENT FACILITY, APPROXIMATELY 20 TO 30 MINUTES FACE-TO-FACE WITH THE PATIENT 20-30 minutes
90853 GROUP PSYCHOTHERAPY (OTHER THAN OF A MULTIPLE-FAMILY GROUP) One per session