School/Preschool Supportive Health Services

1
Preschool/School Supportive Health Services
Program (SSHSP) Medicaid-in-Education Training
on Compliance and Program Update Phase III
1
2
Training Agenda

• Section 1
• NYS Compliance Agreement
• SSHSP Audit Findings
• SSHSP Compliance Training
• Section 2
• NY State Plan Amendment 09-61
• National Provider Identifier (NPI)
• International Classification of Diseases 9th
• Revision (ICD-9) Codes
• Other Program Updates
• Section 3
• Certified Public Expenditures (CPEs)

3
Section 1 Compliance and Audit
3
4
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

4
5
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
• Compliance Programs
• School districts, counties and 4201 schools
• Implement SSHSP
• Monitor Contractors
• Public Consulting Group, Inc (PCG) (DOH
  contractor)
• Assist DOH, SED, and SSHSP providers

6
History

• Federal Audits
• Settlement
• NYS Compliance Agreement
• New York State Plan Amendment (SPA 09-61)

7
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

8
NYS Compliance Agreement
Requirements

• 3 year agreement with federal
  government that began July 19, 2009
• The Compliance Agreement will end upon completion
  of all CMS required activities
• Training pursuant to the Compliance Agreement
  will continue at least through September 2012

9
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)

10
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 the NYSED Med-in-Ed website
• http//www.oms.nysed.gov/medicaid/

11
NYS Compliance Agreement

• Rose Firestein is no longer the NYS SSHSP
  Compliance Officer
• For self-disclosures involving any inappropriate
  Medicaid billings, please contact
• NYS Office of Medicaid Inspector General (OMIG)
• Division of Medicaid Audit Self Disclosure
• 800 North Pearl Street
• Albany, NY 12204-1822
• SelfDisclosures_at_omig.ny.gov (e-mail preferred)
• 518-473-3782
• http//www.omig.ny.gov click on Self
  Disclosure

11
12
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 (school districts or counties) annually
• Up to 250,000 randomly audit 10 providers
  (school districts or counties) annually

12
13
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
• IEP
• Service not included
• Under the Direction of/Under the Supervision
  of

13
14
NYS Compliance Agreement

• Mandatory Training of Relevant Employees
• 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
• 3 years of compliance training
• Phase I and II training completed
• Database of relevant employees

15
NYS Compliance Agreement

• Mandatory Training of Relevant Employees
• 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
  official
• School district/county/4201school special
  education director
• School district/county/4201school Medicaid
  billing clerk
• School district/county/4201school compliance
  officer
• If confirmation of attendance is needed
• E-mail Diana Kaplan at dkaplan_at_mail.nysed.gov
• Online training
• http//www.oms.nysed.gov/medicaid/

15
16
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

17
OMIG Compliance Program

• Aids in preventing, detecting and remedying
  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)

17
18
OMIG Compliance Program

• 5. Disciplinary policies for failing to report,
  permitting
• suspected non-compliance
• 6. System of routine identification of compliance
  risk areas
• internal/external audit
• 7. Procedures to respond to, correct, and report
• compliance issues
• 8. Policy of non-intimidation and non-retaliation
  for making
• a report of suspected non-compliance

18
19
NYS/Federal 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
• Includes ordering practitioners
• Lists should be checked on a monthly basis

19
20
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.

20
21
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/

21
22
OMIG Contact Information

• E-mail for compliance questions
  compliance_at_omig.ny.gov
• Website www.omig.ny.gov
• OMIG ListServ Subscriptionshttp//www.omig.ny.go
  v/data/content/blogsection/17/209/
• Compliance Exclusion Lists
• Carol Booth Sean Parker
• 518-402-1116 518-402-1816

22
23
Question

• The business office has discovered that an
  employee of the school district appears on one of
  the exclusion lists. The business office should
  
• Do nothing
• Contact Sean Parker at OMIG

23
24
Question

• Your supervisor asks you to write a session note
  for a service you did not render. You should
• Write the session note
• Contact your compliance officer
• Contact the NYS compliance officer
• Both b and c are appropriate

24
25
Section 2 SSHSP SPA 09-61 Billing and Claiming
25
26
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

26
27
Medicaid State Plan Amendment (09-61)

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

27
28
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/Attending Practitioner
• Written Orders/Referrals
• Services Included in IEP
• Under the Direction of (UDO) Under the
  Supervision of (USO) Documentation
• Documentation of each Encounter

28
29
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 or reason/need for ordered
  services.

30
Medicaid State Plan Amendment (09-61)

• Sessions 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 of
  current session)
• The setting in which the service was rendered
  (school, clinic, other)
• Date and time the service was rendered (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

31
Medicaid State Plan Amendment (09-61)

• Clarification of Federal Medicaid Guidelines for
  reimbursement of Initial Evaluations
• Initial evaluations are rendered prior to the
  development of a
• students first Individualized Education
  Program (IEP) including
• physical therapy evaluation
• occupational therapy evaluation
• speech therapy evaluation
• psychological evaluation
• Effective April 1, 2012, initial evaluations
  are Medicaid reimbursable
• only if the evaluation results in an ongoing
  IEP service in that specific
• discipline.
• All other Medicaid requirements must still be
  met
• Additional information can be found in Medicaid
  Alert 12-03

32
(No Transcript)
33
Medicaid Billing Targeted Case Management (TCM)

• Medicaid Alert 11-01 informed SSHSP providers
  that claims for TCM services could resume for
  dates of service 7/1/09 - 6/30/10
• Claims must be submitted by 4/30/2012 for TCM
  services rendered through 6/30/2010

33
34
Medicaid Reimbursement

• Claims will be paid based upon the Claiming and
  Billing calendar posted on www.oms.nysed.gov/Medic
  aid
• SSHSP is a jointly funded program (state and
  federal)
• Billing providers (school districts/counties/4201
  schools) will receive one payment (50 state and
  50 federal share) from the Department of Health
• Billing providers keep 100 of the federal share
  (new money)
• Federal Medicaid share is 50 of a gross approved
  claim as of July 1, 2011

34
35
Medicaid Reimbursement

• Advantages to submitting Medicaid claims timely
• Greater accuracy
• Improved cash flow
• Quicker resolution of denied claims

35
36
National Provider Identifier (NPI)

• Identified health care providers in HIPAA
  standard transactions
• The following NPIs must be included on Medicaid
  claims for dates of service on and after January
  1, 2012
• Billing provider the school district, county or
  4201 school
• Attending provider the clinician who has
  overall responsibility for the students medical
  care
• When the provider works under the direction of
  or under the supervision of a licensed
  clinician, the directing/supervising clinician is
  considered the attending provider
• Special transportation claims do not require an
  attending provider NPI

36
37
National Provider Identifier (NPI)

• If a school district, county or 4201 school is
  billing Medicaid, the following providers
  (employed or contracted by the SSHSP billing
  provider) need an NPI
• licensed speech-language pathologists
• licensed physical therapists
• licensed occupational therapists
• licensed psychologists
• licensed psychiatrists
• licensed clinical social workers
• registered professional nurses
• licensed audiologists and,
• physicians, physician assistants, or nurse
  practitioners that
• render a Medicaid reimbursable evaluation
• Practitioner NPI needs to be reported to every
  school district, county or 4201 school that will
  be billing Medicaid for the services rendered by
  that practitioner

37
38
National Provider Identifier (NPI)

• eMedNY Attending Provider NPI Affiliation
  Process
• Attending providers (employed and contracted)
  must report their NPI to the appropriate billing
  SSHSP provider(s)
• Billing provider must affiliate attending
  provider NPIs with the billing providers
  Medicaid provider number via eMedNY prior to
  submission of claims for dates of service on and
  after January 1, 2012
• See Medicaid Alerts 11-03 and 12-02 for
  additional information

38
39
International Classification of Diseases, 9th
edition, Clinical Modifications (ICD-9-CM)

• ICD-9-CM is a set of codes used by health care
  providers to indicate diagnosis for all patient
  (student) encounters. The ICD-9-CM is the HIPAA
  transaction code set for diagnosis coding.
• Effective September 1, 2012 electronic Medicaid
  claims must include
• a valid ICD-9 code that represents
• a main condition or symptom that is the reason
  the service is
• being provided
• the diagnosis or the reason/need for a medically
  necessary service included on the written
  order/referral for the SSHSP service can be used
  on claims for the ordered services
• A resulting diagnosis from an evaluation could be
  used on the claim for the evaluation and the
  claims for ongoing services that were recommended
  as a result of the evaluation
• Please see Medicaid Alert 12-04 for additional
  information

40
International Classification of Diseases, 9th
edition, Clinical Modifications (ICD-9-CM)

• Billing providers must report the most specific
  diagnosis code available. Report a
• three-digit code if there are no four-digit codes
  within the category, or
• four-digit code if there are no five-digit codes
  within the category, or
• five-digit code (fifth subclassification codes)
  for those categories where they are available.

40
41
International Classification of Diseases, 9th
edition, Clinical Modifications (ICD-9-CM)

• EXAMPLE
• 314 Hyperkinetic syndrome of childhood
• 314.0 Attention deficit disorder
• 314.00 Without mention of hyperactivity
• 314.01 With hyperactivity
• 314.1 Hyperkinesis with developmental delay
• 314.2 Hyperkinetic conduct disorder
• 314.8 Other specified manifestations of
  hyperkinetic syndrome
• 314.9 Unspecified hyperkinetic syndrome

3-digit code
4-digit code
5-digit code
41
42
International Classification of Diseases, 9th
edition, Clinical Modifications (ICD-9-CM)

• Coding 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)
• The Centers for Medicare and Medicaid Services
  (CMS)

42
43
True/False Question

• The attending provider and the servicing provider
  are always the same individual.
• True
• False

43
44
True/False Question

• Under HIPAA 5010 standards, the most specific
  diagnosis code should be used when available.
• True
• False

44
45
Medicaid SSHSP Update

• Medicaid Alert 12-01
• 2 Across the Board Reduction in Medicaid
  Payments
• Posted on DOH website
• Effective April 2011
• SSHSP is exempt from reduction
• Monies taken from school districts, counties and
• 4201 schools will be reinstated
• Submit questions to (remember to include your
  Medicaid provider name and number)
• 2PercentAcrosstheBoard_at_health.state.ny.us

45
46
Medicaid SSHSP Update

• Electronic Transmitter Identification Number
  (ETIN)
• Unique identifier assigned to billing providers
  to identify their electronic claims
• Certification statements must be renewed annually
• Failure to renew will result in the inability to
  submit claims and receive payments
• Renewal notices are sent to billing providers
  from Computer Science Corporation (CSC)
• Pre-printed forms require signature and must be
  notarized
• Submit copy of renewal form to Regional
  Information Center (RIC)

46
47
Question

• School district A submitted Medicaid claims for
  SSHSP services, but has not been paid for them.
  Reason could be . .
• School districts ETIN hasnt been recertified
• School district doesnt have their relevant
  employees
• trained
• Attending providers NPI not on the claim
• All of the above

47
48
Medicaid Resources

• Medicaid Listserv
• 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 at http//www.oms.nysed.gov/Medicaid

48
49
Medicaid Resources

• NYSED Medicaid-in-Education Website
• 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
• NYSED 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/

49
50
Local Regional Information CenterContacts

• ltRIC please enter your contact information as
  appropriategt

50
51
NYS SSHSP Contacts - SED
Mailbox medined_at_mail.nysed.gov

• Name 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/Nort
  heast
• 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

51
52
NYS SSHSP Contacts - DOH

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

52
53
Medicaid SSHSP Update

• Certified Public Expenditures

53