Transcript How to Implement a Medicaid Reimbursement for your District

How to Implement a Medicaid Reimbursement
Program for Behavioral Health and
Therapeutic Services in your School District
Presented by:
Pacific Health Policy Group
Students with Special Needs
In 2007, 54 Alaskan school districts served over 17,000
students with identified behavioral health and therapeutic
needs
School districts can increase the amount of money
available for these eligible services by submitting Medicaid
claims
Districts will be reimbursed at the current State of Alaska
Medicaid match rate (50.53%)



2
About Medicaid
Medicaid is operated by state governments within a
broad, federally proscribed framework
The federal government covers just over 50% of the cost
of providing covered services to eligible Alaskans
Medicaid is available to Alaskans who are either financially
or categorically eligible
Some services provided to students receiving behavioral
health or therapies are eligible for federal reimbursement
– or the federal match (currently 50.53%)




3
Basic Steps to Bill for Behavioral Health and
Therapeutic Services
Districts enroll as Medicaid providers
Receive parental authorization
Identify eligible students
Bill for rendered services, while continuing to
check recipients eligibility
Maintain documentation in case of audit





4
Criteria for Appropriate Medicaid Billing
Eligible for Medicaid (or Denali KidCare);
Recipient has a properly documented IFSP or IEP;



The type, scope, frequency & duration of the services are
documented
The services are medically necessary and covered under
an existing Medicaid category;
All state and federal regulations are followed;
Services are provided by qualified health care
professionals working under a enrolled district



5
Enrolling as a Provider
For a district to qualify to enroll as a Medicaid Provider,
districts must agree to:




6
Comply with all federal and state requirements for billing,
auditing and reporting
Obtain an NPI number
Reimburse DHSS for any state financial share – the non-federal
portion of the fee schedule
Enrolling as a Provider
Obtain a NPI number
Complete the Alaska Medical Assistance
Program Provider Enrollment Form
Forms and Instructions are included in the
Toolkit



Questions? Contact ACS at (800) 770-5650
Use option 1 or 3 for enrollment assistance

7
8
Clinicians Eligible to Bill Medicaid for
Eligible Services
The Alaska Administrative Code at 7 AAC 4.461
(“Payment for School-based Services”) lays out the
requirements and qualifications of providers:












9
Physician;
Physician’s Assistant;
Advanced Nurse Practitioner;
Physical Therapist;
Occupational Therapist;
Speech-language Pathologist;
Audiologist;
Psychologist or Psychological Associate;
Behavioral Health Professional;
Behavioral Health Associate; or
Another health care provider who is acting within the scope of that
health care provider’s license under AS 08 and is familiar with the child’s
plan, health condition, and treatment history.
Providers NOT Eligible to Bill Medicaid for
Eligible Services

Individuals employed as teachers are not allowed to have
eligible services billed through to Medicaid, even if the
teacher is otherwise qualified to provide the service

Note: Federal regulations do not contain a provision
requiring physician involvement and review of behavioral
health or therapeutic services provided at the school
level
10
Identifying Eligible Students




Districts will need parent authorization of students to
determine if a student is Medicaid eligible
A sample letter can be included with the initial IEP
documentation (moving forward) and would be sent
retroactively to all students that currently have an IEP
Once parent authorization is obtained, the school district
can use an automated system to determine if the student
is Medicaid eligible
Eligibility needs to be checked on a monthly basis
11
Sample Letter
12
Verification Once District is Enrolled

Before providing services, the district must verify:


The age of the recipient
That the recipient is eligible for Alaska Medical Assistance and
school based services




13
Check monthly for Medicaid
Check every six months for Denali KidCare
That the services are school-based and covered by Medical
Assistance
Provider rendering service has the appropriate credentials
Verification Process (continued)

Eligibility can be verified by:




14
Checking the patient’s Medical Assistance identification card or
coupon
Calling the Eligibility Verification System (EVS) at (800) 8843223
Faxing provider inquiry at (907) 644-8126 or (907) 644-8127
When faxing, have available the student’s name, date of birth,
Social Security number or Medicaid ID (available on the
Identification Card or Coupon)
Covered Behavioral Services

Listed in billing manual, included in Toolkit

A shorter list of common covered behavioral services are
also in Toolkit

Age restrictions may apply

Prior Authorization requirements may apply
15
Covered Behavioral Services

Emotional support assistant to help a child process
emotions (CDAKN)


During periods of elevated stress
Behavioral management education that teaches
behavior management, modification, and redirection
techniques to elicit positive behaviors with



16
Families (CDACF),
Groups (CDACE), and
Individuals (CDACD)
Covered Behavioral Services

Crisis response services including:





Crisis intervention (H2011) to prevent harm
Build coping skills
Develop mechanisms for positive self-care
Stabilize a child or family in acute stress
Behavior modification assistance using counseling
techniques to assist in modifying behavior


17
To individuals (CDACI)
And groups (CDACJ)
Covered Behavioral Services

Functional behavioral assessments (CDBAW) to assess a
child’s behavior

Psycho-educational (H2027) services to help a child
develop or improve specific self-care skills and engage in
age-appropriate social behavior
18
Covered Behavioral Services

Testing (96101) a child’s psychological, cognitive, and
emotional functioning

Interpreting a child’s behavioral assessment results
19
Billing Strategies





Districts need to make sure they have the appropriate
personnel to process the Medicaid claim
Larger districts should hire additional FTEs
For smaller districts, hiring one FTE may not be financially
viable
These districts are encouraged to either hire part-time
support or collaborate with other smaller districts to
“share” resources
Smaller districts can also contract with an outside vendor

20
This would reduce the financial benefit
Example: Kenai School District

Hired a ¼ time clerical member with a medical
background

Kenai has more than 800 students with IEPs who are
Medicaid eligible

Training for administrators was provided by First Health
ACS continues to hold monthly trainings in Anchorage

21
Billing Options for School-based Behavioral
Health Services

Claims may be submitted on paper


CMS 1500
Instructions and Sample Form are available in the Toolkit

Using the appropriate current CPT or ABC codes

Electronically

22
PayerPath (available through ACS)
Timely Billing and Third Party Liabilities

All claims must be filed within 12 months of the date
services were provided to the recipient (Retroactive
claims may be filed if documentation is proper)

Claims may either be submitted on a weekly or monthly
basis

Medicaid is a payor of last resort – it only pays after other
avenues have been exhausted. The State has determined
that no other insurer covers school-based services,
exempting school districts from this requirement
23
Updating Billing Information

Procedure codes can change from year to year, but the
changes are minor

Coverage (reimbursement amount) can change from year
to year

Procedure codes that were covered one year may not be
covered the next year

Be sure to bill with codes that are in effect for the date
the service was provided
24
Remittance Advice


Each week your school district will receive a Remittance
Advice from ACS that details the status of each claim that is in
progress.
The RA will identify claims that are:





Paid
Denied
Suspended
Pages II-9 through II-22 explain each section of the RA in detail
Denied claims will have a denial code so that the school
district can rectify the problem and resubmit the claim

Denial codes can be looked-up online at:
https://alaska.fhsc.com/providers/errorcodes.asp
25
Remittance Advice Sample
26
Adjustments and Voiding Claims


Used to correct or void claims that have already been
paid
Adjustments are done if there was an error in the claim





Recoupments are used to void a previously paid claim



Wrong procedure code
Wrong modifier
Wrong number of units
Wrong date of service
Claim was submitted for a student who is the responsibility of
another district
Claim was submitted without the necessary documentation
Use form AK-05 – Instructions in the Provider Manual
27
Records

A school district documentation must include:







Recipient’s name
Specific services provided
Extent of service provided
Date of service
Name of health care provider who provided service
A Service Documentation Sample is included in the
Toolkit
A billing form is also included to maintain an overview of
the student’s history
28
29
Confidentiality

Two federal statutes: FERPA and HIPAA




Family Educational Rights and Privacy Act (FERPA)
Health Insurance Portability and Accountability Act (HIPAA)
School-based behavioral health and therapeutic services
are covered by FERPA, even the records used to support
Medicaid billing
HIPAA defers to FERPA except as related to the
electronic transmission of Medicaid claims to the fiscal
agent (ACS)
30
Records Needed in Case of an Audit

Districts need to maintain a file for each student that
includes:





31
A parent authorization form;
A copy of the IEP;
Goals and objectives;
Progress notes; and
Service documentation logs
Records Needed in Case of an Audit

A school district must retain the billing, clinical and other
records for a student for which services have been billed
to the Medical Assistance program for at least seven years
for the date the service was provided.

Districts must maintain a IFSP or IEP record with the
following information:




32
The student’s condition
The health care needs for each service
Each individual service provided to the student
Annotated case notes, signed, dated or initialed by the
individual who provided the service, for each service delivered
Records Needed in Case of an Audit

This applies even if the student transfers

Records in electronic format must be readily accessible

The district is responsible for making sure billing services
meet these requirements
33
Records Needed in Case of an Audit

In the event of a Medicaid audit, school districts need to
maintain the following records for seven years:




34
Student attendance records;
Employee leave records;
Employee state credentials, professional licenses or certificates;
and
Contracted individuals’ credentials, licenses or certificates
Common Mistakes








Billing when child is absent or when school is not in
session
Billing when qualified staff are absent and substitute is
delivering services
Billing for unqualified provider
No parent/guardian authorization on file
Inadequate documentation for what is billed
Missing documentation
Services provided and billed were not part of the IEP
Expired IEP
35
Support

PHPG Toolkit


FHSC billing manual
Websites


36
www.hss.state.ak.us/dhcs
http://alaska.fhsc.com
Questions?


E-mail: [email protected]
Contact Jason Milstein


(847) 615-3413
Call the ACS recipient information help line:

37
(800) 780-9972 from 8 am to 5 pm