Special Study: School-based Services Overview Medicaid Program Integrity March 5, 2013.
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Special Study: School-based Services Overview Medicaid Program Integrity March 5, 2013
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Transcript of Special Study: School-based Services Overview Medicaid Program Integrity March 5, 2013.
Special Study:School-based Services
Overview
Medicaid Program Integrity
March 5, 2013
Concerns over School-based Services
Medicaid concerns of significantly increasing Medicaid payments
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Concerns over School-based Services
US Department of Health and Human Services’ concern of school-based services billings
– On March 9, 2011, Inspector General testified before a US Senate subcommittee that series of audits over past decade identified improper federal Medicaid payments for school-based health services.
– FFY 2013 Work Plan - will review Medicaid payments for school-based services in selected states to determine whether costs claimed for services are reasonable and properly allocated.
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Concerns over School-based Services
State Year Overpayment
Colorado 2012 $871,000
New Hampshire 2012 $2,695,809
Arizona 2010 $21,288,312
Maryland 2007 $32,760,910
New Jersey 2006 $51,262,909
Vermont 2005 $1,463,395
Texas 2005 $8,749,158
Rhode Island 2004 $1,201,193
Oklahoma 2002 $1,902,390
Office of Inspector General Audit Findings
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Concerns over School-based Services
Idaho’s CMS Regional Auditor– identified school-based services as a priority
Medicaid – identified questionable billings of psychosocial rehabilitation services, physical therapy, occupational therapy, speech therapy, IBI consultations
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Initiation of Special Study
August 2009 – Discussions with Medicaid regarding special study plan
October 2009 – Met with Medicaid school-based services program staff to discuss concerns and special study plan
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Initiation of Special Study
Special study– 28 school districts selected for review based on:
Large annual payments High average payments per student High billings of specific services Previous concerns regarding billings
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Communication
January 2010 – discussed plan with School-based Medicaid Committee
March 2010 – gave presentation at statewide Special Education Director’s Conference– Presented preliminary findings– Provided information on how to survive an audit
June 2011 – gave presentation at Idaho Association of School Business Officials’ Annual Conference
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Communication
Published 2 articles in monthly Medicaid newsletters about school-based services
Held periodic meetings with State Department of Education personnel, and Medicaid staff to discuss findings/concerns
Communicated overall review findings and status of study quarterly to School-based Medicaid Committee
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Tips to Help Ensure Good Outcomes from Audits
Know program and compliance requirements– Administrative Rules
IDAPA 16.03.09 IDAPA 16.05.07
– Provider Handbooks– Medicaid Provider Agreement– Medicaid Bulletins/Information Releases
Document at the time of service Reconcile payments on a regular basis
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Tips to Help Ensure Good Outcomes from Audits
Questions to ask before billing Medicaid for services– Is there a recommendation/referral in place prior to
providing service?– Are services listed on the IEP?– Do services exceed the limits listed on the IEP?– Does person providing the service have the required
criminal history and background check clearance?
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Tips to Help Ensure Good Outcomes from Audits
Questions to ask before billing Medicaid for services– Is person providing the service on a state or federal
exclusion list?– Does person providing the service have required
credentials and/or licensure to provide service?– Does documentation support the service billed?– Are date spanned services for consecutive dates of
service?
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Tips to Help Ensure Good Outcomes from Audits
Conduct periodic quality assurance reviews– Select a sample of billings
Compare billings to documentation– Units billed match what’s documented– Time specific codes match time documented– Services match what is billed– Documentation is not cloned
Make sure multiple services weren’t billed during same time period
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Tips to Help Ensure Good Outcomes from Audits
Periodic quality assurance review – Make sure non-covered services weren’t billed
Make sure group treatment/therapy was not billed as individual
Make sure IDAPA and handbook documentation requirements were met
Verify that students were qualified to receive billed services Check billings against school calendars and attendance
records
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Recovery Audit Contractor (RAC)
Affordable Care Act required the Recovery Audit Contract (RAC) Program to be expanded to Medicaid programs
A competitive bid process led to HMS being selected as Idaho Medicaid’s designated RAC vendor
Implementation began in Fall of 2012 Contract is administered through Medicaid
Program Integrity Unit
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Recovery Audit Contractor (RAC)
Contingency Fee Contract
– Example of Distribution of Recovered Funds:
Identified overpayment - $5,000Contract Fee - $500
Federal Share - $3,375School Trust - $1,125
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Partnering with IDHWIdaho School-Based Services Audit
March 5, 2013
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Agenda
► Introductions► Overview of HMS► Recovery Audit Contracts (RACs)► HMS – IDHW Partnership► HMS Audits► What to Expect Going Forward
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Our Mission
HMS helps protect the integrity of government-sponsored health and human services programs.
We are experts in cost management, focused on delivering comprehensive solutions that allow healthcare dollars to reach more people, save taxpayer money, and make the system work better for everyone.
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HMS Overview
► Established in 1974► Serving Medicaid since 1985► Publicly traded since 1992 (NASDAQ: HMSY)► 36 offices nationwide, 2,300+ employees► Current RAC vendor in 31 states► Local office in Boise, ID
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Recovery Audit Contracts (RACs)
► CMS Requirements for Medicaid RACs Identify over and underpayments (states must incentivize both) Coordinate audit efforts with other auditing entities Must not review claims older than 3 years Must not audit claims already audited by another entity Must work with State to develop education and outreach
program for providers and other internal stakeholders
The Patient Protection and Affordable Care Act of 2010 required the Recovery Audit Contract (RAC) Program to be expanded to Medicaid Programs
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HMS Partnership with IDHW
► A competitive bid process led to HMS being selected to serve as Idaho Medicaid’s designated RAC vendor
► Implementation began in Fall of 2012
► Contract is administered through Medicaid Program Integrity Unit (MPIU)
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HMS Audits
Beginning in 2013, HMS will assume operations of the School-Based Services audits, reviewing payments made for services performed 7/1/11 – 1/31/12. This transition will include:
►Phased implementation►Coordination with MPIU efforts►Expanded focus►Targeted data mining►Provider support resources►Audit transparency
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HMS/MPIU Audit Process
TransparencyCollaboration
Communication
Q&A/Informal
Resolution Process
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What to Expect Going Forward
► Replication of 2009 State audit methods
► Additional data mining► HMS/State communication with
providers► Increased automation► Additional provider education► State audits based on:
Complaints Referrals Billing aberrancies
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Sample Timeline
► Spring 2013HMS begins data mining on 2011 claims dataInitial provider contacts and records requests sentHMS reviews documentationContinued data miningInitial findings sent to provider for reviewAdditional documentation reviewed (if necessary)Continued provider contact and outreach
► Summer 2013Finalize audit findingsOver/Underpayment file delivered to StateProvider feedback and educationRecoupment of overpayments
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Contacts
Lori Stiles
Supervisor
Medicaid Program Integrity Unit
208.334.0653
Jeremy Evans
Program Manager
Government Services
208.639.8241
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Questions
School-Based Medicaid District Process
Marlane Garner Frances HuffmanSpecial Education Director Special Education DirectorMinidoka School District Coeur D’Alene School District
Verification of Eligibility
Verification of Staff Qualifications
Physician’s Referral
Eligibility and IEP
Verification of Billable Units
Data sheets
No Duplication of Billing
Questions
What is Next• 3 Webinars
– Personal Care Services – Behavioral Intervention/Consultation– Related Services – TBA in March
• Statewide Regional Trainings– April/May
Contact Information:
Shannon Dunstan
Early Childhood & Interagency Coordinator
Idaho State Department of Education
Division of Student Achievement and School Improvement
Division of Special Education(208) 332-6908
