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

Preschool/School Supportive Health Services Program (SSHSP) Medicaid-in-Education Training on Compliance and Program Update Phase II . 1. Training Agenda. Section 1 Background Information NYS Compliance Agreement SSHSP Compliance Training SSHSP Audit Findings Section 2

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

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

  2. Training Agenda • Section 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

  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 School districts, §4201 schools, and counties • Implement SSHSP • Monitor Contractors

  6. History • Federal Audits • Settlement • NYS Compliance Agreement • New York State Plan Amendment (SPA #09-61) • First year of compliance training completed

  7. Compliance • NYS Compliance Agreement/Implementation Plan • OMIG Compliance Program

  8. 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

  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 State’s Commitment to Compliance • Confidential Disclosure Policy • Inappropriate billing • Available at: http://www.oms.nysed.gov/medicaid/

  11. NYS Compliance Agreement • Confidential Disclosure Contact • When you believe policies or billing procedures are inappropriate Rose FiresteinNYS SSHSP Compliance OfficerNew York State Department of HealthOffice of General Counsel90 Church Street, 4th FloorNew York, New York 10007Telephone: 212-417-4393Facsimile: 212-417-4392E-mail: ref01@health.state.ny.us

  12. NYS Compliance Agreement Audit Requirements “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 12

  13. NYS Compliance Agreement Audit Requirements 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 13

  14. 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 stamp • IEP • Service not included • No parental notification of CSE meetings • Missing or unsigned progress notes • Under the Direction of/Under the Supervision of 14

  15. NYS Compliance Agreement • 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

  16. 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 training http://www.oms.nysed.gov/medicaid/ 16

  17. NYS Compliance Agreement • 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) 17

  18. 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

  19. OMIG Compliance Program Prevents, detects and remedies 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) continued… 19

  20. OMIG Compliance Program Prevents, detects and remedies inappropriate billing Protects whistleblowers • Disciplinary policies for failing to report, permitting suspected non-compliance • System of routine identification of compliance risk areas – internal/external audit • Procedures to respond to, correct, and report compliance issues • Policy of non-intimidation and non-retaliation for making a report of suspected non-compliance 20

  21. 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 21

  22. 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.” 22

  23. 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/ 23

  24. OMIG Contact Information OMIG website: www.omig.ny.gov E-mail for compliance questions: compliance@omig.ny.gov ComplianceExclusion Lists Carol Booth Sean Parker 518-402-1116 518-402-1816 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 student’s 21st birthday 26

  27. Medicaid State Plan Amendment (#09-61) 10 Services Covered Under the SSHSP: Speech Therapy 6. Psychological Evaluations Physical Therapy 7. Audiological Evaluations Occupational Therapy 8. Medical Evaluations Skilled Nursing 9. Medical Specialist Evaluations Psychological Counseling 10. Special Transportation 27

  28. Medicaid State Plan Amendment (#09-61) • 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) 28

  29. SSHSP 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 Practitioner • Written Orders/Referrals • Services Included in IEP • Under the Direction of (UDO)/Under the Supervision of (USO) Documentation • Documentation of each Encounter (Session Notes) 29

  30. 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 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.

  31. Medicaid State Plan Amendment (#09-61) • 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

  32. 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)

  33. Medicaid State Plan Amendment (#09-61) 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

  34. Medicaid Billing: Targeted Case Management • 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 34

  35. Medicaid Billing • 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

  36. 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 36

  37. 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 37

  38. 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) 38

  39. 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 2012claims 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 incombinationwith CPT codes to show correlation between the health condition and the services provided.

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

  41. 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 41

  42. Frequently Asked Questions ? 42

  43. 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 Healthhttp://www.health.state.ny.us/health_care/medicaid • National Alliance for Medicaid in Education (NAME) http://www.medicaidforeducation.org/ 43

  44. Local Regional Information CenterContacts <RIC – please enter your contact information as appropriate> 44

  45. NYS SSHSP Contacts - SED Mailbox: medined@mail.nysed.gov TelephoneE-mailRegion 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 45

  46. NYS SSHSP Contacts - SED

  47. NYS SSHSP Contacts - DOH Connie Donohue 518-473-2160 cld03@health.state.ny.us Cristin Carter 518-473-2160 cmc10@health.state.ny.us Melissa Kinnicutt 518-473-2160 mak16@health.state.ny.us 47

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