Transcript School-based Services - Idaho Training Clearinghouse

Special Study:
School-based Services
Overview
Medicaid Program Integrity
March 5, 2013
Concerns over School-based
Services

2
Medicaid concerns of significantly increasing
Medicaid payments
Concerns over School-based
Services

3
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 schoolbased 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.
Concerns over School-based
Services

4
Office of Inspector General Audit Findings
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
Concerns over School-based
Services

Idaho’s CMS Regional Auditor
–

Medicaid
–
5
identified school-based services as a priority
identified questionable billings of psychosocial
rehabilitation services, physical therapy,
occupational therapy, speech therapy, IBI
consultations
Initiation of Special Study
6

August 2009 – Discussions with Medicaid
regarding special study plan

October 2009 – Met with Medicaid schoolbased services program staff to discuss
concerns and special study plan
Initiation of Special Study

Special study
–
28 school districts selected for review based on:




7
Large annual payments
High average payments per student
High billings of specific services
Previous concerns regarding billings
Communication


January 2010 – discussed plan with Schoolbased Medicaid Committee
March 2010 – gave presentation at statewide
Special Education Director’s Conference
–
–

8
Presented preliminary findings
Provided information on how to survive an audit
June 2011 – gave presentation at Idaho
Association of School Business Officials’
Annual Conference
Communication



9
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
Tips to Help Ensure Good
Outcomes from Audits

Know program and compliance requirements
–
Administrative Rules


–
–
–


10
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
Tips to Help Ensure Good
Outcomes from Audits

Questions to ask before billing Medicaid for
services
–
–
–
–
11
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?
Tips to Help Ensure Good
Outcomes from Audits

Questions to ask before billing Medicaid for
services
–
–
–
–
12
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?
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

13
Make sure multiple services weren’t billed during same
time period
Tips to Help Ensure Good
Outcomes from Audits

Periodic quality assurance review
–
Make sure non-covered services weren’t billed




14
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
Recovery Audit Contractor (RAC)




15
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
Recovery Audit Contractor (RAC)

Contingency Fee Contract
–
Example of Distribution of Recovered Funds:
Identified overpayment - $5,000
Contract Fee - $500
Federal Share - $3,375
School Trust - $1,125
16
Partnering with IDHW
Idaho School-Based Services Audit
March 5, 2013
Agenda
►
►
►
►
►
►
Introductions
Overview of HMS
Recovery Audit Contracts (RACs)
HMS – IDHW Partnership
HMS Audits
What to Expect Going Forward
18
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.
19
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
20
Recovery Audit Contracts (RACs)
The Patient Protection and Affordable Care Act of 2010
required the Recovery Audit Contract (RAC) Program to be
expanded to Medicaid Programs
►
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
21
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)
22
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
23
HMS/MPIU Audit Process
Provider Contact &
Records Request
Trend Analysis
&
Documentation
Review & Post Pay
Provider Education
Data Mining
Transparency
Collaboration
Communication
Recovery
Q&A/
Informal
Resolution
Process
Algorithm
Testing and
Approval by
State
Automated
Review &
Notification of
Findings
Complex
Review
24
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
25
Sample Timeline
►
►
Spring 2013
 HMS begins data mining on 2011 claims data
 Initial provider contacts and records requests sent
 HMS reviews documentation
 Continued data mining
 Initial findings sent to provider for review
 Additional documentation reviewed (if necessary)
 Continued provider contact and outreach
Summer 2013
 Finalize audit findings
 Over/Underpayment file delivered to State
 Provider feedback and education
 Recoupment of overpayments
26
Contacts
Lori Stiles
Supervisor
Medicaid Program Integrity Unit
208.334.0653
[email protected]
Jeremy Evans
Program Manager
Government Services
208.639.8241
[email protected]
27
Questions
28
School-Based Medicaid
District Process
Marlane Garner
Frances Huffman
Special Education Director
Minidoka School District
Special Education Director
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
[email protected]