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>www.dpw.state.pa.us >
School-Based ACCESS Program
2013 Fall Regional Training
Barry C. Decker, Bureau of Policy, Analysis and Planning
Pam Tressler, Bureau of Program Integrity
>www.dpw.state.pa.us >
AGENDA
Overview Participant Roles CMS Financial Management Review Services Requirements Documentation Verification
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AGENDA (cont.)
Provider Screening Audit/Reviews Self-audits Self-disclosures Corrective Action Plans Results of CMS Audit BPI Findings
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History of SBAP• Began in 1992• Involves:
Centers for Medicare and Medicaid Services (CMS), Department of Public Welfare (DPW) Pennsylvania Department of Education (PDE) LEAs Public Consulting Group (PCG)
OVERVIEW
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School-Based ACCESS Program (SBAP)
• involves the State Medicaid Agency which through Local Education Agencies (LEA) are able to receive reimbursement for direct and administrative service costs.
OVERVIEW (cont.)
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Direct Services• Face-to-face medically necessary
services provided by the LEA • Services must be properly documented
in the Individualized Education Program (IEP)
• Authorized/prescribed by currently licensed practitioner
OVERVIEW (cont.)
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Administrative services• Services provided by the LEAs that are
in support of direct services
OVERVIEW (cont.)
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Those involved in SBAP:•Centers for Medicare and Medicaid Services (CMS)•Department of Public Welfare (DPW)
Bureau of Policy, Analysis and Planning Bureau of Program Integrity Bureau of Financial Reporting
PARTICIPANT ROLES
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• Pennsylvania Department of Education (PDE) Bureau of Special Education Bureau of Early Intervention Services
• LEAs School districts, charter schools, intermediate
units, approved private schools, vocational-technical schools, and pre-school early intervention programs
• Public Consulting Group (PCG)
PARTICIPANT ROLES (cont.)
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Financial Management Review (FMR)• Began in January 2012• Met with CMS in May 2012• Changes effective July 1, 2012
Daily Progress Note required Discontinuance of billing for IEP Meetings as
direct service Discontinuance of billing for collateral
services as part of direct service Allow for one way transportation billing
CMS FMR
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• State Plan Amendment Cost-based payment methodology
Cost reconciliation Random Moment Time Study (RMTS)
• State Administrative Claiming Plan RMTS
• FMR Draft Report
CMS FMR (cont.)
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FMR Findings/Requests:• State Plan Amendment• Approved payment methodology• Discontinue of billing for IEP meetings as direct
service• Discontinuance of billing for collateral services
as part of direct service• Fully document the service• Identify individual or group in IEP
CMS FMR (cont.)
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>www.dpw.state.pa.us >
CMS FMR (cont.)
• Direct services are face-to-face • Use a procedure code to identify evaluations• Units of service billed must not be more than the
units that are medically necessary and authorized• Billed units must be documented
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SERVICES
SBAP Direct Services•Services provided by school-based service providers that are provided or purchased by LEAs enrolled in the Medical Assistance (MA) Program to MA-eligible beneficiaries 3-21 years of age for whom the service is medically necessary and documented in the IEP.
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SERVICES (cont.)
MA Provider Agreement• LEAs must comply with all Federal Medicaid
and State rules and regulations
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SERVICES (cont.)
Assistive Technology Devices (ATD) 42 CFR 440.70(b)(3) Only authorized/prescribed by a physician (MD or
DO) LEA obtains from medical supplier
Nursing Services 42 CFR 440.60(a)
RN or LPN
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SERVICES (cont.)
Nurse Practitioner Services 42 CFR 440.166 Certified Registered Nurse Practitioner (CRNP) Known as physician service in SBAP
Occupational Therapy Services 42 CFR 440.110(b)
Orientation, Mobility and Vision Services 42 CFR 440.130(d)
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SERVICES (cont.)
Personal Care Services 42 CFR 440.167 Known as PCA service in SBAP One-to-one direct service Activities of daily living
Physical Therapy Services 42 CFR 440.110(a)
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SERVICES (cont.)
Physician Services 42 CFR 440.50(a)
Psychological, Counseling and Social Work Services
42 CFR 440.50(a) and 42 CFR 440.130(d)
Known as psychological, social work and psychiatric services in SBAP
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SERVICES (cont.)
Special Transportation Services 42 CFR 440.170(a)
Speech, Language and Hearing Services 42 CFR 440.110(c)
Known as: audiology services; speech, language and hearing services; and teacher of the hearing impaired services.
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REQUIREMENTS
Medical Authorization• Practitioner’s orders must be documented on:
Prescription or SBAP Medical Practitioner Authorization Form
• Practitioner’s orders must be: Concurrent with the IEP and obtained at least annually
or whenever there is a change to a student’s MA-covered service
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DOCUMENTATION
LEAs must maintain any and all relevant documents to the services claimed.
• Parental Consent (signed, checked and dated)
• IEP
• MPA/Order/Prescription (signed and dated)
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DOCUMENTATION (CONT)
• Daily logs (Easy Trac)o If on behalf of or not electronically
documented the original paper document must be retained
• Attendance recordso Studento Provider
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DOCUMENTATION (CONT)
• Keys for acronyms/abbreviations used
• Provider licenses and/or certifications
• Evaluation reports
• Transportation logs
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DOCUMENTATION (CONT)
Records must comply with MA Regulations (55 Pa.Code § 1101.51)
Record Retention
• Pennsylvania – records must be maintained for a minimum of 4 years from the date of service (55 Pa.Code §1101.51(e))
• Federal – require documents to be maintained for six years
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DOCUMENTATION (CONT)
• Fully disclose the nature and extent of services rendered
• Readily available for review or copying
• Must be legible
• Alterations must be dated and signed
• Plans must be part of the record (IEP, treatment plan, evaluations and reports)
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DOCUMENTATION (CONT)
• Must document progress for each session, change in diagnosis, treatment and response to treatment
• Must be dated and signed
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DOCUMENTATION (CONT)
Reminder for LEAs using a third partyvendor or on behalf of entries
• You must maintain the original documents
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VERIFY
LEA’s should verify:
IEP
• Is on file
• Valid for that date of service (DOS)
• Contains the health-related service
• Service is within the duration/frequency
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VERIFY (cont)
Parental consent
•On file
•Appropriately marked/checked
•Signed & dated
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VERIFY (cont)
Medical Practitioner Authorization Form(MPA)/Prescription
•On file
•Valid for that DOS
•Contains the health-related service
•Duration
•Frequency
•Signed/Dated33
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VERIFY (cont)
• Provider meets the appropriate qualifications (valid license, CPR, first aid)
• Provider is not paid with IDEA funds
• Daily log o Completedo Signed/Supervisory signature if necessary
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PROVIDER SCREENING
Medical Assistance Bulletin #99-11-05
Provider Screening of Employees and Contractors for Exclusion from Participation in Federal Health Care Programs
Effective Date August 15, 2011
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PROVIDER SCREENING (cont)
You cannot be paid by Medicare, Medicaid, or other Federal healthcare programs for items or services furnished, ordered or prescribed by an excluded individual or entity.
“Furnished” refers to items or services provided or supplied, directly or indirectly.
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PROVIDER SCREENING (cont)
An excluded individual or entity cannot be part of a task that is reimbursed by Federal program dollars, which includes:
Claims submittal
Any service, including those not directly related to patient care
Payment from a Federal program cannot cover salaries, expenses, or fringe benefits
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>www.dpw.state.pa.us >
PROVIDER SCREENING (cont)
Exclusion may be imposed on an individual or entity that is not:
Enrolled in Medicare or Medicaid
Involved in submitting claims
Involved in recipient care
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PROVIDER SCREENING (cont)
Potential consequences of employing an excluded provider include:
Repayment of claims
Penalty of up to $10,000 for each item or service claimed
Assessment of three times the amount claimed for each item or service
Exclusion
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PROVIDER SCREENING (cont)
Exclusions are documented on the following databases:
List of Excluded Individuals/Entities (LEIE) at http://www.oig.hhs.gov/fraud/exclusions.asp
System for Award Management (SAM) at www.sam.gov
Medicheck List at http://www.dpw.state.pa.us/learnaboutdpw/fraudandabuse/medicheckprecludedproviderslist/index.htm
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>www.dpw.state.pa.us >
PROVIDER SCREENING (cont)
Protect yourself and your company
Develop policies and procedures for screening all employees and contractors
Develop and maintain auditable documentation of screening efforts
Periodically conduct self-audits to determine compliance with this requirement
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PROVIDER SCREENING (cont)
Check Federal and State Databases:
Before hiring or contracting with an individual or entity
Monthly thereafter
This maybe a good time to verify licenses with the Department of State
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>www.dpw.state.pa.us >
PROVIDER SCREENING (cont)
If you discover an excluded individual?
Immediately self report any discovered exclusion to the Bureau of Program Integrity
This can be done via e-mail through the MA Provider Compliance form at the following link: http://www.dpw.state.pa.us/learnaboutdpw/fraudandabuse/maprovidercompliancehotlineresponseform/index.htm
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>www.dpw.state.pa.us >
AUDITS/REVIEWS
Who can conduct audits/reviews?•Centers for Medicare & Medicaid Services
(CMS)•Office of Inspector General (OIG)•Payment Error Rate Measurement (PERM)•Medicaid Integrity Contract (MIC)•Bureau of Program Integrity (BPI)•PCG
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>www.dpw.state.pa.us >
SELF AUDITS
Self-Auditing activities include: • Periodic self auditing of service delivery and
billing• Reconciliation of MA claims with the amount
received• Review of regulation/requirements to ensure that
services were rendered and billed correctly
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SELF AUDITS (cont)
Pennsylvania’s voluntary MA Provider Self Audit Protocol provides a mechanism for disclosure and repayment of improper MA payments and provides guidance on the preferred methodology.
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SELF AUDITS (cont)
Self Audit Protocol can be assessed at:
www.dpw.state.pa.us/PartnersProviders/MedicalAssistance/DoingBusiness/FraudAbuse/003670226.htm
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SELF AUDITS (cont)
Help you to:•Identify incomplete/inaccurate documentation•Promote a commitment to comply with rule/regulations•Prevent/detect criminal conduct and violations•Avoid penalties
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>www.dpw.state.pa.us >
SELF AUDITS (cont)
Benefits•Identify overpayments•Identify underpayment•Identify services you could be billing for•Identify individuals that might not be submitting time appropriately•DPW isn’t standing over you shoulder conducting the review
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SELF DISCLOSURES
LEAs are encouraged to self disclose billing errors and violations identified
Providers have a legal and ethical commitment to return inappropriate Medicaid payments.
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SELF DISCLOSURES (cont)
Send Self Audits/Self Disclosures to BPI at:
Department of Public Welfare, Office of Administration, Bureau of Program IntegrityP.O. Box 2675, Harrisburg, PA 17105-2675
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CORRECTIVE ACTION PLANS
A CAP is:• A written step-by-step plan of action
developed to achieve targeted outcomes for resolution of identified problems
• Requested by BPI as a component of its review when violations are identified
• BPI will either accept a provider’s CAP or request revisions
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CORRECTIVE ACTION PLANS
The ultimate goal is to incorporate a CAP into an LEA’s everyday operations in an effort to:
• Comply with state and federal regulations;• Ensure quality, accessible, timely services;• Achieve measurable improvement in the
highest priority areas;
• Eliminate repeated deficient practices
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CORRECTIVE ACTION PLANS
CAPs must include at a minimum:• Specific policies and procedures
developed to address the issue• Specific measures taken or to be taken to
ensure compliance• Timeline for the measures• Date(s) of implementation• Responsible person/persons• Follow-ups to ensure compliance
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RESULTS OF CMS AUDIT
Missing documentation
• IEP• Daily progress note• Parental Consent• Medical Practitioners Authorization • Attendance Record• Transportation Logs
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RESULTS OF CMS AUDIT (cont)
Incomplete Documentation/Didn’t Meet Requirements
• Daily log must include the providers name and be signed
• Units billed not equal to units documented• More units billed than medically necessary• IEP did not specify group vs individual• Service not listed on IEP
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RESULTS OF CMS AUDIT (cont)
• MPA signed post date of service• Provider not licensed on date of service• One way transport paid for round trip
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CONTACT INFORMATION
Barry Decker, BPAP
717-772-6341
Pam Tressler, BPI
717-705-6873
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