Transcript Medicaid Changes

Medicaid Changes
Discussion Points
• What?
• Why?
• The Federal False
Claims Act
• NYS False Claims
Act
• Speech Therapy
• Counseling
• Transportation
• Financial Impact
What?
• Medicaid stopped payments for
speech, counseling, and
transportation.
• All pending claims will be
denied.
• No future payments will be
made until State can be sure all
services meet new standard.
• Applies to all unpaid speech,
counseling, and transportation
service.
Why?
US Attorney
“Stop or else”
Federal False Claims Act
• ‘‘knowing’’ and ‘‘knowingly’’
acts in deliberate ignorance of
the truth or falsity of the
information;
• acts in reckless disregard of the
truth or falsity of the
information.
• No proof of specific intent to
defraud.
Federal False Claims Act
1986 Amendments to false
claims act means any person or
entity in the process can be
liable even if they didn't know
the claim was false.
Federal False Claims Act
It is immaterial that [United
Labs] did not deal directly with
the Government. That they were
one step removed from direct
contact with the [Government]
does not vitiate or diminish their
liability.
Federal False Claims Act
Summary
Any school, provider or
contractor is liable if it submits
or causes to be submitted a false
or fraudulent claim or a false
statement in support of a claim.
Federal False Claims Act
• The fact that your staff or
contractor did not know enough
to claim correctly is not
material.
• Not knowing is not a defense.
NYS State False Claims
Act
• "Local government" ….
school district, board of
cooperative educational
services, …….
NYS State False Claims
Act
• False claim" means any
claim which is, either in
whole or part, false or
fraudulent
• Includes any claim paid out
of state aid, local taxes, etc.
NYS State False Claims
Act
• acts in reckless disregard of
the truth or falsity of such
claim or information. Proof
of specific intent to
defraud is not required,
provided, however that acts
occurring by mistake or as a
result of mere negligence are
not covered by this article
NYS State False Claims
Act
• The attorney general shall
have the authority to
investigate violations
• Any person may bring a qui
tam civil action for a
violation
• Provide protection for
employee who brings an
action.
NYS State False Claims
Act
• NEW YORK STATE PAYS
U.S. $26.97 MILLION TO
SETTLE DISPUTE
• Denoncourt will receive 15
percent of the United States'
recovery, or $4.05 million.
• http://www.usdoj.gov/opa/pr/Pr
e_96/December94/725.txt.html
False Claims Acts
Summary
• Do not continue to bill the old
way.
• All documentation must be in
hand before a bill is submitted.
• Show actual nature, duration
and scope of each service.
• Provider qualifications must be
confirmed.
• Provider Certification
Speech Therapy
• Services Provided by a
“Speech Teacher” must be
clinically supervised by a
licensed and currently registered
speech pathologist.
• ASHA Certification OUT!
Speech Supervision
Federal standard being applied
is their standard for Audiology.
– Clinical Supervision.
– LSP is responsible. Its their
license.
– Periodic meetings with child and
teacher.
– Agreement must show they are
the clinical supervisor.
Speech - Summary
• LSP are OK, if currently
registered.
• ASHA out.
• Unless supervision was in place
you cannot bill for any service
before the supervision starts.
• Starts with first documented
meeting with child.
Counseling
Person providing counseling
must be licensed and currently
registered to practice privately.
Not Covered Counseling
• School Counselors, School
Psychologists, School Social
Workers are not eligible.
• Anyone who only holds a
certificate from the
Office of Teaching Initiatives
Covered Counseling
Licensed from the
Office of the Professions
• Mental Health Practitioners
– Creative Arts Therapists
– Marriage and Family Therapists
– Mental Health Counselors
– Psychoanalysts
Covered Counseling
• Social Work
– Licensed Clinical Social Worker
– Licensed Master Social Worker
• Psychologist
Covered Counseling
Supervision - Unknown
Transportation
• Must have logs for all trips
regardless of date.
• Logs must contain on and off
information both ways.
• Reduction in speech and
counseling billing will impact
transportation payments.
Financial Impact
• All billing will be delayed at
least for the next 60-90 days.
• Anticipate delay in payments
for balance of school year.
• If supervision was not in place,
it can’t be.
Financial Impact
• Must void all claims discovered
as not meeting requirements.
• E.G. LSP is not currently
registered.
Regulatory and
Congressional Actions
• Protecting Children's Health
in Schools Act of 2007
(Introduced in House)
HR 1017 IH
• Protecting Children's Health
in Schools Act of 2007
(Introduced in Senate)
S 578 IS
Regulatory and
Congressional Actions
• Proposed Regulation
– Medicaid Program; Cost Limit
for Providers Operated by Units
of Government and Provisions To
Ensure the Integrity of FederalState Financial Partnership
Source -Federal Register: January
18, 2007 (Volume 72, Number
11)]
"Under the Direction of"
Audiology services provided under §440.110(c)(1) require that the "services be provided
by or under the direction of an audiologist for which a patient is referred by a physician
or other licensed practitioner of the healing arts within the scope of his or her practice
under State law."
We interpret the authority to provide services "under the direction of" an audiologist to
mean that a federally qualified audiologist who is directing audiology services must
supervise each beneficiary's care. To meet this requirement, the qualified audiologist
must see the beneficiary at the beginning of and periodically during treatment, be familiar
with the treatment plan as recommended by the referring physician or other licensed
practitioner of the healing arts practicing under State law, have continued involvement in
the care provided, and review the need for continued services throughout treatment. The
supervising audiologist must assume professional responsibility for the services provided
under his or her direction and monitor the need for continued services. The concept of
professional responsibility implicitly supports face-to-face contact by the qualified
audiologist at least at the beginning of treatment and periodically thereafter. Thus,
audiologists must spend as much time as necessary directly supervising services to ensure
beneficiaries are receiving services in a safe and efficient manner in accordance with
accepted standards of practice. To ensure the availability of adequate supervisory
direction, supervising audiologists must ensure that individuals working under their
direction have contact information to permit them direct contact with the supervising
audiologist as necessary during the course of treatment.
In many cases, qualified audiologists are employed by entities such as a Medicaid
agency, clinic, or school. In such instances, the terms of the audiologist's employment
must ensure that the audiologist is adequately supervising any individual providing
audiology services. In addition to the supervisory requirements described above,
employment terms should provide for supervisory ratios that are reasonable and ethical
and in keeping with professional practice acts in order to permit the supervising
audiologist to adequately fulfill his or her supervisory obligations and ensure quality care.
In all cases, documentation must be kept supporting the qualified audiologist's
supervision of services and ongoing involvement in the treatment services. Because
Medicaid law requires that documentation be kept supporting the provision and proper
claiming of services, appropriate documentation of services provided by supervising
audiologists, as well as services performed by individuals working under the direction of
a qualified audiologist, are necessary. Absent appropriate service documentation,
Medicaid payment for services may be denied providers.
Where appropriate, audiology services must adhere to all State requirements and State
practice acts governing the provision of services under the direction of a qualified
audiologist. As with all Medicaid benefits that permit services furnished under direction,
both Federal and State requirements must be met at the time services are furnished for the
Medicaid program to appropriately provide Federal financial participation for services
furnished on behalf of Medicaid eligible individuals.