MEDICAID SCHOOL-BASED SERVICES PROVIDER OVERVIEW

October, 2014

Two part training – Overview and Application

•Medicaid Origins

1

•SBS Program Basics

2

•Compliance

3

OVERVIEW

Medicaid Origins

• Medicaid, created in 1965 by the federal government, provides payment for medical services for low-income citizens

• People qualify for Medicaid by meeting federal income and asset guidelines and by fitting into specified eligibility categories

School-Based Services (SBS)

• 1988 Law instituted to make Medicaid funds available to schools to relieve fiscal burden - School-Based Services was created.

• Students received medical services in school from qualified health professionals

Types of Services

• Services covered under Michigan State Plan include; specialized transportation, nursing services, occupational therapy, physical therapy, speech language and hearing services, psychology and social work services, orientation & mobility services, personal care services, & targeted case management.

SBS BILLING PROGRAM BASICS

SBS Billing Program Basics

Medicaid SBS Basic Requirements1) ‘Medically necessary’ services must be on the student’s IEP2) Providers must meet Medicaid qualifications – per MDCH

manual3) Service/activity documentation must provide enough detail

for reviewers to recreate the service/activity4) Designated Case Managers only bill if there is also at least

one service5) Signed Parent Permission to Bill Medicaid on File6) Prescription for Services on File7) Provider Signature on File

Medically Necessary

Health-related services required for the student to receive FAPE, as documented in the student’s IEP • Reasonable• Necessary• Specific

•What is the medically related activity?

1

•How does the activity relate to the student’s goals and objectives?

2

•How did the activity affect the student?

3

Service Documentation Must Address 3 Basic Questions:

What is the medically related activity?How does the activity relate to the student’s goal

and objectives?

• Activity/Comments: Discussed student progress with service providers

• Activity/Comments: Reviewed IEP to ensure services are being provided as specified

How did the activity affect the student?

• Outcome: Summarize progress discussion with service providers

• Outcome:Summarize review of IEP

COMPLIANCE AND ETHICS

What is Medicaid Compliance?

For Medicaid providers, compliance means to follow the laws, regulations and rules governing the Medicaid program. Since Medicaid is a joint state and federal program, Medicaid service providers must follow both state and federal laws and regulations.

What You Should Know

• Billing providers must meet Medicaid qualifications• Services must be medically-necessary and

authorized on the student’s IEP/IFSP• Service documentation (Medicaid Progress Note)

must include the relationship of the service provided to the IEP goals

• Face-to-Face services are reimbursable; consult services are critical to student success, but not billable.

Best Practices

• Review billing requirements in the provider-specific Tip Sheet

• Document service immediately after delivering service

Audits and Inspections

• If asked, school districts must supply records to state and federal personnel for audits and reviews, and will usually have 30 calendar days to do so.

• Medicaid encourages that providers maintain their records in an electronic format to ensure that such records are readily accessible.

• If requested, the district must allow state and federal personnel on site for inspections.

‘Audit Day’ Humor

Now remember. When we get in there, let me do all the talking.

Billing Restrictions/Issues

• In Howell, at this time, staff that bill for Medicaid reimbursement are Special Education Teachers, Speech Therapists and Physical Therapists only. Subject to change.

• Do not bill more than once for the same medical service • Insufficient or inadequate service documentation• Billing when student is absent or school is not in session• Billing when qualified staff is absent• Billing by unqualified provider• Parent Consent is not on file• Billed services were not included in IEP• Prescription is not on file

APPLICATION

•Click on the Service Capture link in the home page menu

1

•Click on the Services Calendar icon

2

3

Service Capture

•Navigating the Calendar

1

•Medicaid Eligibility

2

•Customize Columns

3

View and Shortcuts

Navigating the Calendar

• Use arrows to move within the calendar• Change calendar view to day, week or month• Click directly on date you want to make an entry

Customize Columns

Option to Create Caseload Groups

Eligibility changes monthly so a Medicaid eligible group of students would need to be

updated monthly. Because of this, it is recommended that you refer to the Medicaid

eligibility column on your home page.

•Scheduling Future Services – one per month

1

•Editing, Deleting and Voiding Service Records

2

•Monthly Summaries

3

Other Items

One Case Management Encounter per Month

Editing, Deleting & Voiding Service Records

To edit, locate the record on the service capture calendar. Double-click on the record and a new screen will appear. Select edit and make changes. Click save.

Voids can only be done by the Medicaid Coordinator (Janet).Used only when a submitted record has been locked.

Monthly Summaries

Resources

• Michigan Department of Community Health http://www.michigan.gov/mdch

• Office of Inspector General of Department of Health & Human Serviceshttp://www.oig.hhs.gov