SchoolBased ACCESS Program

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School-Based ACCESS Program

• 2009-2010
• Regional Training

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Reimbursement
Documentation
Medical Authorization
Provider Qualifications
Enrollment
IEP
Enrollment
Parent Consent
Eligibility
IEP
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SBAP Overview
In 1992, PDE initiated SBAP. Since that time,
Leader Services has served as the programs
statewide vendor. SBAP is a partnership among

• PDE
• DPW
• Office of Medical Assistance Programs (OMAP)
• Bureau of Program Integrity (BPI)
• Office of Finance
• Leader Services (statewide contractor)

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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

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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 States Medicaid program is administered in
  accordance with a State plan approved by CMS. The
  Federal Government and States share the cost of
  the program.

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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

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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.

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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.

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Eligible Services

• Physician
• Psychiatry
• Psychology
• Social Work
• Speech/Language
• Teacher of Hearing Impaired
• Special Transportation

• Assistive Devices
• Audiology
• IEP Development
• Nursing (RN LPN)
• Occupational Therapy
• Orientation Mobility
• Personal Care Assistant
• Physical Therapy

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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.
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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 includeOM, Physician, Assistive
Devices, Psychiatry, Audiology
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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.

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Prior to MA-Claims Submission

• Verify
• Medical Authorization or physicians prescription
  is on file
• Direct service provider meets SBAP
  licensure/certification requirements for MA
  participation
• Direct service providers 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.

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How to Identify Eligible Students

• Upload to Leader http//www.leaderservices.co
  m/uploads
• Automatic eligibility check (IEPWriterTM/Children
  Count users only)
• PROMISe
• http//promise.dpw.state.pa.us

Example format for uploaded data
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IEP Billing Overview

• IEP Requirements
• Must include
• Formal meeting
• LEA signature
• Ongoing SBAP health-related service

• (Initial vs. Review)
• First Right to Bill
• School Districts
• Charter Schools
• MAWAs

• Reimbursement at a fixed rate

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IEP Common Mistakes

• No ongoing SBAP health-related service
• No formal meeting
• Duplicate billing (waiver)
• Claiming an Initial meeting in error.

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PCA Services

• Must be
• Provided by an aide certified in First Aid and
  CPR
• Defined in IEP
• Authorized by an MD, DO, or CRNP
• 11 with a student
• Documented.

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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.

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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 Leaders transportation claims
  report.

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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.

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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.

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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 providers
  place of business or, upon written request,
  forwarded without charge to DPW).

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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.

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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)

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State Reviews

• Currently BPI is conducting reviews of the SBAP
  program.
• Leader is concluding technical assistance reviews
  of the program.

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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.
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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

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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

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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

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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

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Identify and Prevent Frequently Noted Violations

• Violation 2 More expensive service billed than
  rendered
• Example
• Claims for individual services that were
  documented as group

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Identify and Prevent Frequently Noted Violations

• 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.

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Identify and Prevent Frequently Noted Violations

• 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

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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/

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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.

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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

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Identify and Prevent Frequently Noted Violations

• 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.

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Identify and Prevent Frequently Noted Violations

• 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.

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Identify and Prevent Frequently Noted Violations

• 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

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Identify and Prevent Frequently Noted Violations

• 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.

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Identify and Prevent FrequentlyNoted Violations

• Violation 7 Service not identified on
  practitioners authorization or prescription
• Examples
• Transportation services not identified on
  practitioners authorization or prescription
• PCA services not identified on practitioners
  authorization or prescription.

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Identify and Prevent FrequentlyNoted Violations

• Violation 7 Service not identified on
  practitioners 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 practitioners
  authorization or a prescription and that it
  covers the dates to be billed

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Identify and Prevent FrequentlyNoted Violations

• Violation 7 Service not identified on
  practitioners authorization or prescription
• Proactive Compliance Hints
• If the students health related service has
  changed, do not bill for newly added services
  until those changes/services are authorized

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Identify and Prevent Frequently Noted Violations

• Violation 8 Service frequency exceeds IEP
  recommendations and/or practitioners
  authorization
• Example
• IEP and practitioners authorization identify
  individual speech therapy for 30 minutes/week 60
  minutes/week is billed

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Identify and Prevent Frequently Noted Violations

• Violation 8 Service frequency exceeds IEP
  recommendations and/or practitioners
  authorization
• Proactive hints
• Before submitting a claim, confirm that the
  frequency to be billed is the same as identified
  in the IEP and practitioners authorization or
  prescription
• If the students needs change, do not submit a
  claim for a greater frequency of service until an
  updated IEP and practitioners authorization or
  prescription reflecting the change is obtained.

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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

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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

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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.

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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.

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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

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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 students participation and
  interactions during treatment

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Identify and Prevent Frequently Noted Violations

• Violation 11 Failure to maintain records that
  were readily available
• Example
• Provider is unable to provide copies of records
  to BPI upon request.

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Identify and Prevent Frequently Noted Violations

• 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 providers place of business or,
  upon written request, are forwarded in the
  specified time.

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Keys to a Successful Program

• 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

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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

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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.

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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.

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Monthly Management Reports

• Comprehensive reports provided to LEAs by Leader
• Available online within WebSDS and WebPSL

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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.

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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 Comptrollers 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.

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Requests to Withdraw Funds

• PA Department of Education
• 333 Market Street, 7th Floor
• Harrisburg, PA 17126-0333
• ATTN Elizabeth Zeisloft