Special Study: School-based Services

1. Special Study:School-based Services Overview Medicaid Program Integrity March 5, 2013

2. Concerns over School-based Services • Medicaid concerns of significantly increasing Medicaid payments

3. Concerns over School-based Services • US Department of Health and Human Services’ concern of school-based services billings • On March 9, 2011, Inspector General testified before a US Senate subcommittee that series of audits over past decade identified improper federal Medicaid payments for school-based health services. • FFY 2013 Work Plan - will review Medicaid payments for school-based services in selected states to determine whether costs claimed for services are reasonable and properly allocated.

4. Concerns over School-based Services • Office of Inspector General Audit Findings

5. Concerns over School-based Services • Idaho’s CMS Regional Auditor • identified school-based services as a priority • Medicaid • identified questionable billings of psychosocial rehabilitation services, physical therapy, occupational therapy, speech therapy, IBI consultations

6. Initiation of Special Study • August 2009 – Discussions with Medicaid regarding special study plan • October 2009 – Met with Medicaid school-based services program staff to discuss concerns and special study plan

7. Initiation of Special Study • Special study • 28 school districts selected for review based on: • Large annual payments • High average payments per student • High billings of specific services • Previous concerns regarding billings

8. Communication • January 2010 – discussed plan with School-based Medicaid Committee • March 2010 – gave presentation at statewide Special Education Director’s Conference • Presented preliminary findings • Provided information on how to survive an audit • June 2011 – gave presentation at Idaho Association of School Business Officials’ Annual Conference

9. Communication • Published 2 articles in monthly Medicaid newsletters about school-based services • Held periodic meetings with State Department of Education personnel, and Medicaid staff to discuss findings/concerns • Communicated overall review findings and status of study quarterly to School-based Medicaid Committee

10. Tips to Help Ensure Good Outcomes from Audits • Know program and compliance requirements • Administrative Rules • IDAPA 16.03.09 • IDAPA 16.05.07 • Provider Handbooks • Medicaid Provider Agreement • Medicaid Bulletins/Information Releases • Document at the time of service • Reconcile payments on a regular basis

11. Tips to Help Ensure Good Outcomes from Audits • Questions to ask before billing Medicaid for services • Is there a recommendation/referral in place prior to providing service? • Are services listed on the IEP? • Do services exceed the limits listed on the IEP? • Does person providing the service have the required criminal history and background check clearance?

12. Tips to Help Ensure Good Outcomes from Audits • Questions to ask before billing Medicaid for services • Is person providing the service on a state or federal exclusion list? • Does person providing the service have required credentials and/or licensure to provide service? • Does documentation support the service billed? • Are date spanned services for consecutive dates of service?

13. Tips to Help Ensure Good Outcomes from Audits • Conduct periodic quality assurance reviews • Select a sample of billings • Compare billings to documentation • Units billed match what’s documented • Time specific codes match time documented • Services match what is billed • Documentation is not cloned • Make sure multiple services weren’t billed during same time period

14. Tips to Help Ensure Good Outcomes from Audits • Periodic quality assurance review • Make sure non-covered services weren’t billed • Make sure group treatment/therapy was not billed as individual • Make sure IDAPA and handbook documentation requirements were met • Verify that students were qualified to receive billed services • Check billings against school calendars and attendance records

15. Recovery Audit Contractor (RAC) • Affordable Care Act required the Recovery Audit Contract (RAC) Program to be expanded to Medicaid programs • A competitive bid process led to HMS being selected as Idaho Medicaid’s designated RAC vendor • Implementation began in Fall of 2012 • Contract is administered through Medicaid Program Integrity Unit

16. Recovery Audit Contractor (RAC) • Contingency Fee Contract • Example of Distribution of Recovered Funds: Identified overpayment - $5,000 Contract Fee - $500 Federal Share - $3,375 School Trust - $1,125

17. Partnering with IDHW Idaho School-Based Services Audit March 5, 2013

18. Agenda • Introductions • Overview of HMS • Recovery Audit Contracts (RACs) • HMS – IDHW Partnership • HMS Audits • What to Expect Going Forward

19. Our Mission HMS helps protect the integrity of government-sponsored health and human services programs. We are experts in cost management, focused on delivering comprehensive solutions that allow healthcare dollars to reach more people, save taxpayer money, and make the system work better for everyone.

20. HMS Overview • Established in 1974 • Serving Medicaid since 1985 • Publicly traded since 1992 (NASDAQ: HMSY) • 36 offices nationwide, 2,300+ employees • Current RAC vendor in 31 states • Local office in Boise, ID

21. Recovery Audit Contracts (RACs) The Patient Protection and Affordable Care Act of 2010 required the Recovery Audit Contract (RAC) Program to be expanded to Medicaid Programs • CMS Requirements for Medicaid RACs • Identify over and underpayments (states must incentivize both) • Coordinate audit efforts with other auditing entities • Must not review claims older than 3 years • Must not audit claims already audited by another entity • Must work with State to develop education and outreach program for providers and other internal stakeholders

22. HMS Partnership with IDHW • A competitive bid process led to HMS being selected to serve as Idaho Medicaid’s designated RAC vendor • Implementation began in Fall of 2012 • Contract is administered through Medicaid Program Integrity Unit (MPIU)

23. HMS Audits Beginning in 2013, HMS will assume operations of the School-Based Services audits, reviewing payments made for services performed 7/1/11 – 1/31/12. This transition will include: • Phased implementation • Coordination with MPIU efforts • Expanded focus • Targeted data mining • Provider support resources • Audit transparency

24. HMS/MPIU Audit Process Transparency Collaboration Communication Q&A/ Informal Resolution Process

25. What to Expect Going Forward • Replication of 2009 State audit methods • Additional data mining • HMS/State communication with providers • Increased automation • Additional provider education • State audits based on: • Complaints • Referrals • Billing aberrancies

26. Sample Timeline • Spring 2013 • HMS begins data mining on 2011 claims data • Initial provider contacts and records requests sent • HMS reviews documentation • Continued data mining • Initial findings sent to provider for review • Additional documentation reviewed (if necessary) • Continued provider contact and outreach • Summer 2013 • Finalize audit findings • Over/Underpayment file delivered to State • Provider feedback and education • Recoupment of overpayments

27. Contacts Lori Stiles Supervisor Medicaid Program Integrity Unit 208.334.0653 stilesl@dhw.idaho.gov Jeremy Evans Program Manager Government Services 208.639.8241 jeremy.evans@hms.com

28. Questions

29. School-Based Medicaid District Process Marlane Garner Frances Huffman Special Education Director Special Education Director Minidoka School District Coeur D’Alene School District

30. Verification of Eligibility

31. Verification of Staff Qualifications

32. Physician’s Referral Eligibility and IEP

33. Verification of Billable Units

34. Data sheets

35. No Duplication of Billing

36. Questions

37. What is Next • 3 Webinars • Personal Care Services • Behavioral Intervention/Consultation • Related Services – TBA in March • Statewide Regional Trainings • April/May

38. Contact Information: Shannon Dunstan Early Childhood & Interagency Coordinator Idaho State Department of Education Division of Student Achievement and School Improvement Division of Special Education (208) 332-6908 sdunstan@sde.idaho.gov