Medicaid Eligible Children Served in Oregon Schools

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Techniques and Technology . . .QA
Sandra Peterson, Medicaid Supervisor Multnomah
Education Service District Portland, Oregon Fall
2003
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No Child Left Behind Everyone goes to school
All children, regardless of their disability, are
entitled to an appropriate public education. IDEA
drives the Special Education process
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Medicaid impact in Oregon

• Improved quality of SPED programs by increasing
  credential criteria (especially in speech
  therapy)
• Improved documentation practices of staff
• Provided reimbursement funds that stabilized and
  placed importance on SPED services

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Medicaid SY 2003-2004

• Work backwards from federal and state rules and
  requirements to build in QA.
• Start by analyzing each program requirement
• Develop your QA system over time to ensure full
  compliance with regulations
• Build your procedure manual to document your
  entire process

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Compliance Plan

• Develop realistic compliance standards tailored
  to the specific operations of the educational
  entity (District, Program etc.)
• Analyze unique vulnerabilities of the program
• Establish high-level responsibility (to ensure
  that implementation has been effective)
• Utilize trustworthy individuals (i.e. legal
  counsel, managers, consultants, quality assurance
  professionals etc.)
• Ensure effective education at all levels of the
  organization
• Monitor and audit process and outcomes
• Enforce rules and discipline non-compliant
  individuals
• Be responsive to staff, administration and
  auditors!
• Build in prevention to reduce risk employ
  technology to eliminate or reduce human errors.

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Our Program Partners

• Oregon Office of Medical Assistance Programs
  (OMAP)
• Oregon Department of Education
• Education-Based Medicaid Corporation Consortium
  of districts that participate in the School-Based
  Health Services Program
• Confederation of Oregon School Administrators
• Oregon School Boards Association
• Special Thanks to Salem-Keizer SD for sharing
  their PowerPoint special effects

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Medicaid in Special Ed SY 2003-2004

• build in quality assurance in staff training,
  data collection, claim processing and pre-and
  post-payment reviews

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What to document

• Staff credentials
• Billing process
• Roles and responsibilities
• Awareness and training of all involved
• IEP authorization
• Practitioner recommendation
• Forms and instructions
• Reference tools
• Technology tools
• How staff document services
• Money received
• State match

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Document that staff meet Medicaid credential
requirements

• Collect copies of current licenses/certifications
  of every billable staff
• Licensed psychologist
• ASHA with CCC for speech
• Licensed Occupational Therapist
• Certified Occupational Therapy Assistant
• Note States vary in licensure requirements
• Credentials may not be reciprocal from state to
  state
• Maintain record of current qualifying credential
• Incorporate license number in billing system
• Technology employed Student management system
  or software products like ActiveDox
• Scan document
• Store
• Easy retrieval

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Flowchart billing process from beginning to end.
. .

• FROM Special Ed (SPED) referral TO
• Evaluation and parent permission (SPED)
• Verification of Medicaid Eligibility (CAID)
• Evaluation (s) by medically-qualified staff
  (CAID)
• Establishing SPED eligibility (SPED)
• Verification of medical practitioner
  recommendation (CAID)
• Setting up billing process in management system
  (CAID)
• Student information
• Staff information
• Service authorization (IEP Plan of Treatment)
• Notification to staff to document service (s)
  (CAID)
• Documentation of data collection (or direct entry
  into the electronic management system) (CAID)
• Validation of service against IEP (CAID)
• Claim submission to Medicaid (CAID)
• Posting payment (CAID)
• Reconciling payment or denial statement (CAID)
• See handout

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Medicaid Billing Process
Special Education Referral for Evaluation
Verify Medicaid Eligibility
Conduct Evaluation
Establish Special Education Eligibility
Not Special Education Eligible
IEP
Verify Recommendation
Bill for Evaluation Only
Another Method
Set up Billing
No Treatment Authorization
Notify Staff to Document Service
End of Medicaid Billing Process
Submit Claim
Receive Reimbursement
Post Payment
Reconcile Payment
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Identify roles and responsibilities for. . .

• SPED Directors
• Superintendents
• Business Managers
• SPED Supervisors
• Billing clerical staff
• Medical professional staff
• See handout

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In order to bill Medicaid, recommendation for
treatment must be made by medically-qualified
professionals within the scope of their licensure

• This can be accomplished by including one or more
  of these professionals in the IEP team. BUT the
  recommendation must be documented (in writing)
  and signed by the staff with the appropriate
  credential.

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Use reference tables for. . .

• Credentials of qualifying staff
• Diagnosis codes
• Units of service
• Procedure codes

• Fee schedule
• Reimbursement rates
• Denial codes
• Limitations or restrictions

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Staff readiness is really very simple. . .

• Make sure they know what they can do
• Make sure they know what they cant do
• Make sure they know HOW to do what they can do
• Goal Maximize Revenue Minimize Risk!

• Make sure they know where to get help when they
  arent sure

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Staff training to include. . .

• Review the process
• Rules
• Limitations
• Tools
• Contacts
• Practice hands-on when using automated tools

• Definitions
• Billing rules
• Forms to use
• Where to get
• How to complete
• Privacy rules
• Confidentiality
• FERPA v. HIPAA
• Documentation requirements
• Tools operational contacts targeted reference
  tools
• Assure that school billing to Medicaid cannot
  impact student/parent financially-short-term or
  long term
• Identify unique requirements that pertain to them
• Avoid confusion focus on N2K
• Allow time to respond to questions
• Goal Maximize Revenue
• Minimize Risk!

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Document staff participation

• Identify roles and responsibilities
• Track professional credentials
• Organize information by employer/billing entity
• Make certain job descriptions include Medicaid
  role/participation
• Train staff at least annually
• Ensure new staff are trained and mentored
• Ensure staff document services
• Document training

Record keeping methods
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A word about Staff training. . .

• Organize training by medical discipline.
  Examples
• Do not mix nurses with speech pathologists
• May train Occupational and Physical Therapy staff
  (Motor Team) together
• Note Include billing staff in medical
  professional training
• Document staff participation (Who)
• Sign-up sheets
• Web registration and verification
• Document training content (When and what)
• Agenda w/date/time and audience target
• Document training type face-to-face web read
  n review etc.
• Training materials PowerPoint/Speaker materials
• Handouts
• Quiz or statement of learning
• Record summary training information
• See handout

Program Glue
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The IEP is like the plan of treatment
The Plan of Treatment is like the prescription
that goes with the authority to bill for
therapy/treatment services. Billable service
activity must be related to the health-related
goals and objectives on the IEP Service
documentation must connect the dots between the
service and the IEP. e.g. what is written on the
service log demonstrates how the activity helps
the child meet goals and objectives. When the
service is medical in nature, Medicaid
reimbursement is possible.
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Encourage use of action verbs in documentation
Action verbs may be used to describe a starting
point or an outcome.

• administered
• applied
• demonstrated
• developed
• exercised
• Fabricated splint
• identified
• initiated

• Introduced near/far concepts
• Modified plan
• Practiced /s/ sound
• produced
• prompted
• repeated
• reported

Action verbs show mental, emotional, physical,
technological, social or personal process
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Enhance QA with Technology that documents process
and records

• Medisync Billing Software
• Electronic Eligibility Verification System
• ActiveDox image accessing
• Training web registration and verification system
• Community Data Link Accountability Software

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Technology is a tool it cannot replace the
professional

• Professionals must make decisions based on
  program (SPED) knowledge
• Professionals must use medical skills to ensure
  students can perform and participate in the
  educational environment
• Professionals must use ethical standards
• Professionals must conduct medical analysis
• Professionals must train, monitor and supervise
  assistants with lesser training and credential
• Professionals must practice their skilled trade
  in a unique environment (school)
• Professionals must apply knowledge, skills and
  ability to problem solve health situations that
  may have little scientific or historical reference

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Technology is a tool how can it help?

• Saves time for professional
• Contains historical reference information (i.e.
  IEP, previous services, caseload information,
  look-up tables of diagnosis and procedure codes,
  code descriptions etc.)
• Includes preloaded student information.
• Allows direct data entry of service activity
  documentation.
• Includes auto-format tools
• Increases accuracy
• Edit features ensure accurate dates, times,
  units, calculations, codes, services cross-match
  (transportation with direct treatment) etc.
• Automatically calculates math
• Reduces risk of lost records
• Enhances privacy of student health information
• Ensures service validation against IEP
• Reduces risk of lost records, enhances privacy of
  student health information.

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Quality Assurance Pre-payment review

• Conducted by billing staff for paper system
• One form one service provider
• Completeness of student information
• Completeness of service information
• Compare service against IEP authorization
• Compare signature and initials of service
  provider against file
• Ensure medical credentials are listed
• Timeliness of billing entry
• Verifies or calculates math (add units, calculate
  fees)
• Checklist of 21 manual edits

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Quality Assurance Pre-payment review

• Imbedded in Technology--billing system
• Secure access with multiple lock-outs to protect
  privacy
• Role-based access N2K
• Student information edits (auto-populate)
• Service information edits
• Validates IEP authorization against service
  provided
• E-signatures and initials of service built
  in/secure
• Auto-populates standard info i.e. medical
  credentials
• Verifies completeness of DOS
• Verifies and/or calculates math (add units,
  calculate fees)
• Auto-formats dates, required information,
  diagnosis codes, procedure codes, UOS, Medicaid
  ID
• Presets required data elements to eliminate
  routine errors
• Compares direct treatment with transportation
  service

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Quality Assurance . . . Post payment review

• Each month District pulls 1 sampling of all
  service logs paid by Medicaid the previous month
  in order to review records for
• completeness
• accuracy and
• adequateness of documentation.
• Compares sample against peer review document
  checklist (takes a minimum of 1 hour per file)
• District notify supervisors of the result of this
  QA review
• District may meet with supervisors and staff
  about findings for purposes of mutual problem
  solving
• Communication to professional staff summarizes
  findings and make recommendations to improve
  billing effort.
• Future workshops include information about what
  we learn in this process
• Goal Maximize Revenue Minimize Risk!

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Questions?Special Education and Medicaid are
challenging to integrate. Its a jungle out
there.