Transcript SBAP Informational DPW Handout

School-Based ACCESS Program
2013 Fall Regional Training
Barry C. Decker, Bureau of Policy, Analysis and
Planning
Pam Tressler, Bureau of Program Integrity
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AGENDA
 Overview
 Participant Roles
 CMS Financial Management Review
 Services
 Requirements
 Documentation
 Verification
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AGENDA (cont.)
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Provider Screening
Audit/Reviews
Self-audits
Self-disclosures
Corrective Action Plans
Results of CMS Audit
BPI Findings
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AGENDA (cont.)
 Contact Information
 Questions
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OVERVIEW
History of SBAP
• Began in 1992
• Involves:
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Centers for Medicare and Medicaid Services (CMS),
Department of Public Welfare (DPW)
Pennsylvania Department of Education (PDE)
LEAs
Public Consulting Group (PCG)
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OVERVIEW (cont.)
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.
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OVERVIEW (cont.)
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
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OVERVIEW (cont.)
Administrative services
• Services provided by the LEAs that are
in support of direct services
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PARTICIPANT ROLES
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
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PARTICIPANT ROLES (cont.)
• Pennsylvania Department of Education
(PDE)
 Bureau of Special Education
 Bureau of Early Intervention Services
• LEAs
 School districts, charter schools, intermediate
units, approved private schools, vocationaltechnical schools, and pre-school early
intervention programs
• Public Consulting Group (PCG)
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CMS FMR
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
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CMS FMR (cont.)
• State Plan Amendment
 Cost-based payment methodology
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Cost reconciliation
Random Moment Time Study (RMTS)
• State Administrative Claiming Plan
 RMTS
• FMR Draft Report
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CMS FMR (cont.)
FMR Findings/Requests:
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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
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CMS FMR (cont.)
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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
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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
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Practitioner’s orders must be documented on:
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Prescription or SBAP Medical Practitioner Authorization
Form
Practitioner’s orders must be:
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Concurrent with the IEP and obtained at least annually
or whenever there is a change to a student’s MAcovered 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 records
o Student
o Provider
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DOCUMENTATION (CONT)
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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 party
vendor 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/Dated
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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 Completed
o 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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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/fraudandabu
se/medicheckprecludedproviderslist/index.htm
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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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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/frau
dandabuse/maprovidercompliancehotlinerespo
nseform/index.htm
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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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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/Me
dicalAssistance/DoingBusiness/FraudAbu
se/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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SELF AUDITS (cont)
Benefits
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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 Integrity
P.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
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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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BPI FINDINGS
Findings:
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Licensing Problems
Signatures
PCS
Documentation
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CONTACT INFORMATION
Barry Decker, BPAP
717-772-6341
[email protected]
Pam Tressler, BPI
717-705-6873
[email protected]
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QUESTIONS
Questions?
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