School/Preschool Supportive Health Services

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Preschool/School Supportive Health Services
Program (SSHSP) Medicaid-in-Education
Training on Compliance and Program UpdatePhase
II
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Training Agenda

• Section 1
• Background Information
• NYS Compliance Agreement
• SSHSP Compliance Training
• SSHSP Audit Findings
• Section 2
• NY State Plan Amendment - 09-61
• Billing And Claiming Resumption
• National Provider Identifier (NPI)
• International Classification of Diseases 9th
  revision (ICD-9) Codes
• Available Resources

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Section 1 Compliance and Audit
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What is SSHSP?

• Preschool/School Supportive Health Services
  Program (Collectively SSHSP)
• A New York State program that enables
• school districts, counties and 4201 schools
• to access federal monies for medically
• necessary related services provided to
• Medicaid-eligible students with disabilities

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Roles in SSHSP

• State Education Department (SED)
• Implementation
• Special Education Policy
• Department of Health Office of Health Insurance
  Programs (OHIP)
• Medicaid Policy
• Payment Methodology
• Office of Medicaid Inspector General (OMIG)
• Audit
• School districts, 4201 schools, and counties
• Implement SSHSP
• Monitor Contractors

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History

• Federal Audits
• Settlement
• NYS Compliance Agreement
• New York State Plan Amendment (SPA 09-61)
• First year of compliance training completed

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Compliance

• NYS Compliance Agreement/Implementation Plan
• OMIG Compliance Program

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NYS Compliance Agreement

• Goals
• To ensure that policies and practices are
  modified to achieve compliance with all laws and
  regulations related to the receipt of federal
  Medicaid participation in the SSHSP
• To reinforce and maintain continued compliance
  through trainings, technical assistance, and
  oversight

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NYS Compliance Agreement

• NYS SSHSP Compliance Policy
• Confidential Disclosure Policy
• NYS Compliance Officer/Compliance Committee
• Audit Requirements
• Independent Audit
• Annual Written Reports
• Annual Compliance/Program Update Training
• State Plan Amendment (SPA 09-61)

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NYS Compliance Agreement

• NYS adopted two compliance policies
• NYS SSHSP Compliance Policy
• New York States Commitment to Compliance
• Confidential Disclosure Policy
• Inappropriate billing
• Available at http//www.oms.nysed.gov/medicaid/

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NYS Compliance Agreement

• Confidential Disclosure Contact
• When you believe policies or billing procedures
  are inappropriate
• Rose FiresteinNYS SSHSP Compliance OfficerNew
  York State Department of HealthOffice of General
  Counsel90 Church Street, 4th FloorNew York, New
  York 10007Telephone [phone]Facsimile
  212-417-4392E-mail ref01_at_health.state.ny.us

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NYS Compliance Agreement Audit Requirements

• OMIG audit staff shall conduct . . . audits of
  the SSHSPs compliance with all applicable
  federal laws and regulations regarding claims for
  federal Medicaid participation.
• If the providers billing to Medicaid is
• Over 1,000,000 all providers will be audited
  (NYC on an annual basis)
• 250,000 - 1,000,000 randomly audit 25
  providers (districts or counties) annually
• Up to 250,000 randomly audit 10 providers
  (districts or counties) annually

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NYS Compliance Agreement Audit Requirements

• Audit Period 2009 Date of Payment
• Audits for all Medicaid providers paid over
  1,000,000 (43, includes NYC)
• Audits for 25 Medicaid providers paid 250,000 -
  1,000,000 randomly selected
• Audits for 10 Medicaid providers paid less than
  250,000 randomly selected

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NYS Compliance Agreement Audit Requirements

• Audit Findings for 2009 Date of Payment
• Lacking or inappropriate documentation
• Written orders/referrals
• No written order/referral
• Billing for services prior to date on written
  order/referral
• No date on written order/referral
• Signature stamp
• IEP
• Service not included
• No parental notification of CSE meetings
• Missing or unsigned progress notes
• Under the Direction of/Under the Supervision of

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NYS Compliance Agreement

• Mandatory Training of Relevant Employees
• June 2, 2010 Memo
• Relevant employee any person working for or
  contracted by a school district, county or 4201
  school who, in some way, is involved in the SSHSP
• Annual compliance training
• Database of relevant employees

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NYS Compliance Agreement

• Two ways to fulfill the mandatory training
  requirement
• Face-to-face training most are sponsored by
  your local regional information center (RIC)
  all are welcome and encouraged to attend
• Who MUST attend a face-to-face training session?
• School district/county/4201school business
  officials
• School district/county/4201school special
  education director
• School district/county/4201school Medicaid
  billing clerks
• School district/county/4201school compliance
  officers
• Confirmation of attendance
• Contact Diana Kaplan at dkaplan_at_mail.nysed.gov
• Online training
• http//www.oms.nysed.gov/medicaid/

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NYS Compliance Agreement

• Statistics
• Phase I training 40,000 relevant employees
  trained
• 18,000 trained in-person
• 22,000 trained online
• Training timeline
• Phase I June 2010 - February 2011
• Phase II May 2011 - December 2011
• Phase III January 2012 September 2012
  (Anticipated dates)

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OMIG Compliance Program

• Social Services Law 363-d
• 18 NYCRR Part 521
• To ensure Medicaid providers establish systemic
  checks and balances to detect and prevent
  inaccurate billing and inappropriate practices in
  the Medicaid program
• All persons, providers or affiliates claiming,
  ordering or receiving payments in excess of
  500,000 (gross) from the Medical Assistance
  Program
• Annual recertification

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OMIG Compliance Program

• Prevents, detects and remedies inappropriate
  billing
• Protects whistleblowers
• Written policies and procedures compliance
  expectations
• Designated compliance officer
• Training and education of employees and persons
  associated with the provider - administrators and
  governing body members
• Communication line to compliance officer
  (including anonymous/confidential reporting)
• continued

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OMIG Compliance Program

• Prevents, detects and remedies inappropriate
  billing
• Protects whistleblowers
• Disciplinary policies for failing to report,
  permitting suspected non-compliance
• System of routine identification of compliance
  risk areas internal/external audit
• Procedures to respond to, correct, and report
  compliance issues
• Policy of non-intimidation and non-retaliation
  for making a report of suspected non-compliance

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Exclusion Lists

• Lists of individuals or entities excluded,
  restricted,
• terminated or censured from participating in the
  Medicaid
• Program
• Will help providers avoid submitting claims for
• services provided by excluded
  individuals/agencies
• Lists should be checked on a monthly basis

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NYS/Federal Exclusion Lists

• CMS EXCLUSION REGULATION
• No payment will be made by Medicare,
  Medicaid or any of the other federal health care
  programs for any item or service furnished by an
  excluded individual or entity, or at the medical
  direction or on the prescription of a physician
  or other authorized individual who is excluded
  when the person furnishing such item or service
  knew or had reason to know of the exclusion.

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NYS/Federal Exclusion Lists

• NYS Exclusion List
• http//www.omig.ny.gov/data/content/view/72/52/
• Federal Exclusion List
• http//www.oig.hhs.gov/fraud/exclusions.asp
• Excluded Parties List System
• https//www.epls.gov/

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OMIG Contact Information

• OMIG website www.omig.ny.gov
• E-mail for compliance questions
  compliance_at_omig.ny.gov
• Compliance Exclusion Lists
• Carol Booth Sean Parker
• 518-402-1116 518-402-1816

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Section 2 SSHSP SPA 09-61 Billing and Claiming
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Medicaid State Plan Amendment (09-61)

• Approved by CMS on April 26, 2010,
• effective September 1, 2009
• Defines services, providers and their
• qualifications, and the reimbursement
• methodology for the SSHSP
• Medicaid coverage of IEP related services
• available until the students 21st birthday

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Medicaid State Plan Amendment (09-61)

• 10 Services Covered Under the SSHSP
• Speech Therapy 6. Psychological Evaluations
• Physical Therapy 7. Audiological Evaluations
• Occupational Therapy 8. Medical Evaluations
• Skilled Nursing 9. Medical Specialist
  Evaluations
• Psychological Counseling 10. Special
  Transportation

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Medicaid State Plan Amendment (09-61)

• Medicaid Qualified Service Providers
• Services must be provided by a Medicaid qualified
  service provider acting within his/her scope of
  practice under NYS Law
• (See Provider Qualifications and Documentation
  Requirements)
• Documentation of practitioners qualifications
  kept on file (license, registration, and/or
  certification as applicable)

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SSHSP Documentation Requirements Summary

• IDEA Requirements
• Referral to CSE/CPSE
• Individualized Education Program (IEP)
• Parental Consent
• Quarterly Progress Notes

• Medicaid Requirements
• Provider Agreement and Statement of Reassignment
• Verification of Current Certification, Licensure,
  or Registration, as Appropriate, of Servicing
  Practitioner
• Written Orders/Referrals
• Services Included in IEP
• Under the Direction of (UDO)/Under the
  Supervision of (USO) Documentation
• Documentation of each Encounter (Session Notes)

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Medicaid State Plan Amendment (09-61)

• Written Orders and Referrals must include
• The name of the child for whom the order is
  written
• The complete date the order was written and
  signed
• The service that is being ordered
• Ordering providers contact information (office
  stamp or preprinted address and telephone
  number)
• Signature of a NYS licensed and registered
  physician, physician assistant, or licensed nurse
  practitioner acting within his or her scope of
  practice (for psychological counseling services
  this also includes an appropriate school official
  and for speech therapy services, a
  speech-language pathologist)
• The time period for which services are being
  ordered
• The ordering practitioners National Provider
  Identifier (NPI) or license number and,
• Patient diagnosis and/or reason/need for ordered
  services.

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Medicaid State Plan Amendment (09-61)

• Session notes must include
• Students name
• Specific type of service provided
• Whether the service was provided individually or
  in a group (specify the actual group size)
• The setting in which the service was rendered
  (school, clinic, other)
• Date and time the service was rendered (length of
  session record session start time and end
  time)
• Brief description of the students progress made
  by receiving the service during the session
• Name, title, signature and credentials of the
  person furnishing the service and
  signature/credentials of supervising/directing
  clinician as appropriate

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Individualized Education Program (IEP) vs.
Medical Necessity

• SSHSP
• Program services are designed to enable a child
  with a disability to benefit from special
  education
• IEP
• Determines what services needed to receive Free
  Appropriate Public education (FAPE)
• Does not determine medical necessity
• Written order or referral
• Determines medical necessity (Medicaid
  requirement)

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Medicaid State Plan Amendment (09-61)

• Evaluations and Re-evaluations
• Required evaluation/re-evaluation documentation
• Written order/referral
• Evaluation report
• Evaluation must be reflected in the IEP
• Evaluations/re-evaluations are only Medicaid
  reimbursable for students with IEPs

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Medicaid Billing Targeted Case Management

• Medicaid Alert 11-01
• School districts with supporting documentation
  may bill through 6/30/2010 (including
  7/1/09-8/31/09) for
• Initial Evaluation Review 5491
• Amended/Requested IEP Review 5494
• Annual IEP Review 5492
• Triennial/Re-evaluation IEP Review 5493
• Ongoing Service coordination 5495

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Medicaid Billing

• Medicaid Alert 11-02
• SSHSP billing began April 2011 for appropriately
  documented services provided 9/1/09 and after
• Encounter-based billing methodology
• Current Procedural Terminology (CPT) codes

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Medicaid Reimbursement

• Claims will be paid based upon the Claiming and
  Billing calendar, posted on www.oms.nysed.gov/Medi
  caid
• School Districts/Counties/4201 Schools will be
  reimbursed 100 of the federal share
• Billing providers will receive one payment (state
  and federal share) from the Department of Health
• Federal Medicaid share is 50 of a gross approved
  claim as of July 1, 2011

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National Provider Identifier (NPI)

• Federal requirement per the Health Insurance
  Portability and Accountability
  Act (HIPAA)
• NPI is used by HIPAA-covered entities
• Identifies health care providers in HIPAA
  standard transactions
• 10-digit intelligence-free numeric
  identifier(does not carry information about
  health care providers)
• To apply for an NPI or if you have questions
• https//nppes.cms.hhs.gov/NPPES/StaticForward.do?f
  orwardstatic.instructions

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NPI Requirements for SSHSP

• Billing provider (currently required on SSHSP
  Medicaid claim)
• Effective January 1, 2012 Servicing provider NPI
  must be on SSHSP Medicaid claims
• Special transportation claims will not use a
  servicing provider NPI
• If services are provided under the direction of
  or under the supervision of, the supervising
  practitioners NPI must be reported on the claim
• Ordering provider (not required on SSHSP Medicaid
  claim)

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International Classification of Diseases,
9th edition, Clinical Modifications (ICD-9-CM)

• ICD-9-CM is a set of codes used by physicians,
  hospitals, and allied health workers to indicate
  diagnosis for all patient encounters. The
  ICD-9-CM is the HIPAA transaction code set for
  diagnosis coding.
• Effective 2012 claims must include an
  appropriate ICD-9 code
• Benefits
• Expanded details on claims,
• Improved data,
• Improved accuracy of claims,
• HIPAA compliant, and
• Establishes reason/need for procedure provided
  (records a symptom, diagnosis or complaint on the
  claim)
• ICD codes are used in combination with CPT codes
  to show correlation between the health condition
  and the services provided.

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International Classification of Diseases,
9th edition, Clinical Modifications (ICD-9-CM)

• SSHSP Implementation of ICD-9 Coding
• Diagnosis (reason/need)
• Usually supplied by ordering/referring
  practitioner on written order/referral
• May or may not be in the form of ICD-9 code
• Claim must have the actual numeric ICD-9 code
• Resources for professionals
• American Physical Therapy Association (APTA)
• American Occupational Therapy Association (AOTA)
• American Speech-Language-Hearing Association
  (ASHA)
• American Psychological Association (APA)
• American Medical Association (AMA)

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Medicaid Listserv

• Developed to provide relevant employees of school
  districts, counties and 4201 schools immediate
  access to Medicaid updates/changes
• To subscribe, please send an e-mail message to
  LISTSERV_at_LISTSERV.NYSED.GOV
• The body of the message must read
• SUBSCRIBE MEDINED firstname lastname
• Complete instructions for subscribing/unsubscribin
  g on http//www.oms.nysed.gov/Medicaid

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Frequently Asked Questions

• ?

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Additional Resources

• SED Medicaid-in-Education
• http//www.oms.nysed.gov/medicaid/
• Medicaid-in-Education Handbook (coming soon)
• Medicaid-in-Education Questions Answers
• Medicaid Alerts
• Claiming and Billing Calendar
• Training Calendar
• NYS Office of Professions
• http//www.op.nysed.gov
• NYS Department of Health http//www.health.state.n
  y.us/health_care/medicaid
• National Alliance for Medicaid in Education
  (NAME)
• http//www.medicaidforeducation.org/

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Local Regional Information CenterContacts

• ltRIC please enter your contact information as
  appropriategt

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NYS SSHSP Contacts - SED
Mailbox medined_at_mail.nysed.gov

• Telephone E-mail
  Region
• Steven Wright 518-486-4887
  swright2_at_mail.nysed.gov NYC
• Kelly Gicobbi 518-486-7828
  kgicobbi_at_mail.nysed.gov Broome/Mohawk
• Jeff Foley 518-402-5121
  jfoley_at_mail.nysed.gov
  Nassau/Suffolk/Northeast
• Paula Cooper 518-402-5218
  pcooper_at_mail.nysed.gov Mid-Hudson/Westchester
  /
• Northeast
• Sheila Costa 518-474-4178
  scosta_at_mail.nysed.gov Western/Southern
  Tier
• Kelly Mason 518-486-2287
  kmason2_at_mail.nysed.gov Monroe/Central/Finger
  Lakes

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NYS SSHSP Contacts - SED

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NYS SSHSP Contacts - DOH

• Connie Donohue 518-473-2160
• cld03_at_health.state.ny.us
• Cristin Carter 518-473-2160
• cmc10_at_health.state.ny.us
• Melissa Kinnicutt 518-473-2160
• mak16_at_health.state.ny.us

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