1 Preschool/School Supportive Health Services Program (SSHSP) Medicaid-in-Education Training on...

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Preschool/School Supportive Health Services Program

(SSHSP) Medicaid-in-Education

Training on Compliance and Program Update

Phase II

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Training AgendaSection 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

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 enablesschool districts, counties and §4201 schools to access federal monies for medicallynecessary related services provided toMedicaid-eligible students with disabilities

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Roles in SSHSPState 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 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)

NYS Compliance Agreement

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NYS adopted two compliance policies:

NYS SSHSP Compliance Policy New York State’s Commitment to Compliance

Confidential Disclosure Policy Inappropriate billing

Available at: http://www.oms.nysed.gov/medicaid/

NYS Compliance Agreement

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• Confidential Disclosure Contact

• When you believe policies or billing procedures are inappropriate

Rose FiresteinRose FiresteinNYS SSHSP Compliance OfficerNYS SSHSP Compliance Officer

New York State Department of HealthNew York State Department of HealthOffice of General CounselOffice of General Counsel

90 Church Street, 4th Floor90 Church Street, 4th FloorNew York, New York 10007New York, New York 10007Telephone: 212-417-4393Telephone: 212-417-4393Facsimile: 212-417-4392Facsimile: 212-417-4392

E-mail: E-mail: ref01@health.state.ny.us

NYS Compliance Agreement

“OMIG audit staff shall conduct . . . audits of the SSHSP’s 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

NYS Compliance Agreement Audit Requirements

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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

NYS Compliance Agreement Audit Requirements

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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

NYS Compliance Agreement Audit Requirements

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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

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@mail.nysed.gov

Online traininghttp://www.oms.nysed.gov/medicaid/

NYS Compliance Agreement

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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)

NYS Compliance Agreement

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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 18

OMIG Compliance Program

Prevents, detects and remedies inappropriate billing Protects whistleblowers

1.Written policies and procedures – compliance expectations

2.Designated compliance officer

3.Training and education of employees and persons associated with the provider - administrators and governing body members

4.Communication line to compliance officer (including anonymous/confidential reporting)

continued…

OMIG Compliance Program

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OMIG Compliance Program

Prevents, detects and remedies inappropriate billing Protects whistleblowers

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

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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 Listhttp://www.omig.ny.gov/data/content/view/72/52/

Federal Exclusion Listhttp://www.oig.hhs.gov/fraud/exclusions.asp

Excluded Parties List Systemhttps://www.epls.gov/

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OMIG Contact Information

OMIG website: www.omig.ny.gov

E-mail for compliance questions: compliance@omig.ny.gov

Compliance Exclusion Lists

Carol Booth Sean Parker518-402-1116 518-402-1816

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Section 2

SSHSP SPA #09-61Billing and Claiming

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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 student’s 21st birthday

Medicaid State Plan Amendment (#09-61)

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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

Medicaid State Plan Amendment (#09-61)

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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)

Medicaid State Plan Amendment (#09-61)

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SSHSP Documentation Requirements Summary

IDEA Requirements Referral to CSE/CPSE

Individualized Education Program (IEP)

Parental Consent

Quarterly Progress Notes

Medicaid RequirementsProvider Agreement and Statement of Reassignment

Verification of Current Certification, Licensure, or Registration, as Appropriate, of Servicing Practitioner

Written Orders/ReferralsServices Included in IEPUnder the Direction of (UDO)/Under the Supervision of (USO) Documentation

Documentation of each Encounter (Session Notes) 29

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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 provider’s 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 practitioner’s National Provider Identifier (NPI) or license

number; and, Patient diagnosis and/or reason/need for ordered services.

Medicaid State Plan Amendment (#09-61)

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Session notes must include: Student’s 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 student’s 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

Medicaid State Plan Amendment (#09-61)

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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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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

Medicaid State Plan Amendment (#09-61)

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

Medicaid Billing: Targeted Case Management

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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

Medicaid Billing

Medicaid Reimbursement

Claims will be paid based upon the Claiming and Billing calendar, posted on www.oms.nysed.gov/Medicaid

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?forward=static.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 practitioner’s 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.

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)

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

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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@LISTSERV.NYSED.GOV

The body of the message must read:

SUBSCRIBE MEDINED firstname lastname

Complete instructions for subscribing/unsubscribing on http://www.oms.nysed.gov/Medicaid

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Frequently Asked Questions42

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.ny.us/health_care/medicaid

National Alliance for Medicaid in Education (NAME) http://www.medicaidforeducation.org/

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Local Regional Information CenterContacts

<RIC – please enter your contact information as appropriate>

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NYS SSHSP Contacts - SED

Telephone E-mail Region

Steven Wright 518-486-4887 swright2@mail.nysed.gov NYC

Kelly Gicobbi 518-486-7828 kgicobbi@mail.nysed.gov Broome/Mohawk

Jeff Foley 518-402-5121 jfoley@mail.nysed.gov Nassau/Suffolk/Northeast

Paula Cooper 518-402-5218 pcooper@mail.nysed.gov Mid-Hudson/Westchester/ Northeast

Sheila Costa 518-474-4178 scosta@mail.nysed.gov Western/Southern Tier

Kelly Mason 518-486-2287 kmason2@mail.nysed.gov Monroe/Central/Finger Lakes

Mailbox: medined@mail.nysed.gov

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NYS SSHSP Contacts - SED

Connie Donohue518-473-2160cld03@health.state.ny.us

Cristin Carter 518-473-2160cmc10@health.state.ny.us

Melissa Kinnicutt518-473-2160mak16@health.state.ny.us

NYS SSHSP Contacts - DOH

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