School-Based ACCESS Program
2013 Fall Regional Training
Barry C. Decker, Bureau of Policy, Analysis and
Planning
Pam Tressler, Bureau of Program Integrity www.dpw.state.pa.us >

AGENDA
 Overview
 Participant Roles
 CMS Financial Management Review
 Services
 Requirements
 Documentation
 Verification www.dpw.state.pa.us > 2

AGENDA (cont.)
 Provider Screening
 Audit/Reviews
 Self-audits
 Self-disclosures
 Corrective Action Plans
 Results of CMS Audit
 BPI Findings www.dpw.state.pa.us > 3

AGENDA (cont.)
 Contact Information
 Questions www.dpw.state.pa.us > 4

OVERVIEW
History of SBAP
• Began in 1992
• Involves:
 Centers for Medicare and Medicaid Services (CMS),
 Department of Public Welfare (DPW)
 Pennsylvania Department of Education (PDE)
 LEAs
 Public Consulting Group (PCG) www.dpw.state.pa.us > 5

OVERVIEW (cont.)
School-Based ACCESS Program
(SBAP)
• involves the State Medicaid Agency which through Local Education Agencies
(LEA) are able to receive reimbursement for direct and administrative service costs.
www.dpw.state.pa.us > 6

OVERVIEW (cont.)
Direct Services
• Face-to-face medically necessary services provided by the LEA
• Services must be properly documented in the Individualized Education Program
(IEP)
• Authorized/prescribed by currently licensed practitioner www.dpw.state.pa.us > 7

OVERVIEW (cont.)
Administrative services
• Services provided by the LEAs that are in support of direct services www.dpw.state.pa.us > 8

PARTICIPANT ROLES
Those involved in SBAP:
• Centers for Medicare and Medicaid
Services (CMS)
• Department of Public Welfare (DPW)
 Bureau of Policy, Analysis and Planning
 Bureau of Program Integrity
 Bureau of Financial Reporting www.dpw.state.pa.us > 9

PARTICIPANT ROLES (cont.)
• Pennsylvania Department of Education
(PDE)
 Bureau of Special Education
 Bureau of Early Intervention Services
• LEAs
 School districts, charter schools, intermediate units, approved private schools, vocationaltechnical schools, and pre-school early intervention programs
• Public Consulting Group (PCG) www.dpw.state.pa.us > 10

CMS FMR
Financial Management Review (FMR)
• Began in January 2012
• Met with CMS in May 2012
• Changes effective July 1, 2012
 Daily Progress Note required
 Discontinuance of billing for IEP Meetings as direct service
 Discontinuance of billing for collateral services as part of direct service
 Allow for one way transportation billing www.dpw.state.pa.us > 11

CMS FMR (cont.)
• State Plan Amendment
 Cost-based payment methodology
 Cost reconciliation
 Random Moment Time Study (RMTS)
• State Administrative Claiming Plan
 RMTS
• FMR Draft Report www.dpw.state.pa.us > 12

CMS FMR (cont.)
FMR Findings/Requests:
• State Plan Amendment
• Approved payment methodology
• Discontinue of billing for IEP meetings as direct service
• Discontinuance of billing for collateral services as part of direct service
• Fully document the service
• Identify individual or group in IEP www.dpw.state.pa.us > 13

CMS FMR (cont.)
• Direct services are face-to-face
• Use a procedure code to identify evaluations
• Units of service billed must not be more than the units that are medically necessary and authorized
• Billed units must be documented www.dpw.state.pa.us > 14

SERVICES
SBAP Direct Services
• Services provided by school-based service providers that are provided or purchased by
LEAs enrolled in the Medical Assistance (MA)
Program to MA-eligible beneficiaries 3-21 years of age for whom the service is medically necessary and documented in the IEP.
www.dpw.state.pa.us > 15

SERVICES (cont.)
MA Provider Agreement
• LEAs must comply with all Federal Medicaid and State rules and regulations www.dpw.state.pa.us > 16

SERVICES (cont.)
Assistive Technology Devices (ATD)
 42 CFR 440.70(b)(3)
 Only authorized/prescribed by a physician (MD or
DO)
 LEA obtains from medical supplier
Nursing Services
 42 CFR 440.60(a)
 RN or LPN www.dpw.state.pa.us > 17

SERVICES (cont.)
Nurse Practitioner Services
 42 CFR 440.166
 Certified Registered Nurse Practitioner (CRNP)
 Known as physician service in SBAP
Occupational Therapy Services
 42 CFR 440.110(b)
Orientation, Mobility and Vision Services
 42 CFR 440.130(d) www.dpw.state.pa.us > 18

SERVICES (cont.)
Personal Care Services
 42 CFR 440.167
 Known as PCA service in SBAP
 One-to-one direct service
 Activities of daily living
Physical Therapy Services
 42 CFR 440.110(a) www.dpw.state.pa.us > 19

SERVICES (cont.)
Physician Services
 42 CFR 440.50(a)
Psychological, Counseling and Social Work
Services
 42 CFR 440.50(a) and 42 CFR 440.130(d)
 Known as psychological, social work and psychiatric services in SBAP www.dpw.state.pa.us > 20

SERVICES (cont.)
Special Transportation Services
 42 CFR 440.170(a)
Speech, Language and Hearing Services
 42 CFR 440.110(c)
 Known as: audiology services; speech, language and hearing services; and teacher of the hearing impaired services.
www.dpw.state.pa.us > 21

REQUIREMENTS
Medical Authorization
• Practitioner’s orders must be documented on:
 Prescription or SBAP Medical Practitioner Authorization
Form
• Practitioner’s orders must be:
 Concurrent with the IEP and obtained at least annually or whenever there is a change to a student’s MAcovered service www.dpw.state.pa.us > 22

www.dpw.state.pa.us > 23

DOCUMENTATION
LEAs must maintain any and all relevant documents to the services claimed.
• Parental Consent (signed, checked and dated)
• IEP
• MPA/Order/Prescription (signed and dated) www.dpw.state.pa.us > 24

DOCUMENTATION (CONT)
• Daily logs (Easy Trac) o If on behalf of or not electronically documented the original paper document must be retained
• Attendance records o Student o Provider www.dpw.state.pa.us > 25

DOCUMENTATION (CONT)
• Keys for acronyms/abbreviations used
• Provider licenses and/or certifications
• Evaluation reports
• Transportation logs www.dpw.state.pa.us > 26

DOCUMENTATION (CONT)
Records must comply with MA Regulations
(
55 Pa.Code
§ 1101.51
)
Record Retention
• Pennsylvania – records must be maintained for a minimum of 4 years from the date of service (
55 Pa.Code
§ 1101.51(e)
)
• Federal – require documents to be maintained for six years www.dpw.state.pa.us > 27

DOCUMENTATION (CONT)
• Fully disclose the nature and extent of services rendered
• Readily available for review or copying
• Must be legible
• Alterations must be dated and signed
• Plans must be part of the record (IEP, treatment plan, evaluations and reports) www.dpw.state.pa.us > 28

DOCUMENTATION (CONT)
• Must document progress for each session, change in diagnosis, treatment and response to treatment
• Must be dated and signed www.dpw.state.pa.us > 29

DOCUMENTATION (CONT)
Reminder for LEAs using a third party vendor or on behalf of entries
• You must maintain the original documents www.dpw.state.pa.us > 30

VERIFY
LEA’s should verify:
IEP
• Is on file
• Valid for that date of service (DOS)
• Contains the health-related service
• Service is within the duration/frequency www.dpw.state.pa.us > 31

VERIFY (cont)
Parental consent
• On file
• Appropriately marked/checked
• Signed & dated www.dpw.state.pa.us > 32

VERIFY (cont)
Medical Practitioner Authorization
Form(MPA)/Prescription
• On file
• Valid for that DOS
• Contains the health-related service
• Duration
• Frequency
• Signed/Dated www.dpw.state.pa.us > 33

VERIFY (cont)
• Provider meets the appropriate qualifications (valid license, CPR, first aid)
• Provider is not paid with IDEA funds
• Daily log o Completed o Signed/Supervisory signature if necessary www.dpw.state.pa.us > 34

PROVIDER SCREENING
Medical Assistance Bulletin #99-11-05
Provider Screening of Employees and
Contractors for Exclusion from Participation in
Federal Health Care Programs
Effective Date August 15, 2011 www.dpw.state.pa.us > 35

PROVIDER SCREENING (cont)
 You cannot be paid by Medicare, Medicaid, or other Federal healthcare programs for items or services furnished, ordered or prescribed by an excluded individual or entity.
 “Furnished” refers to items or services provided or supplied, directly or indirectly. www.dpw.state.pa.us > 36

PROVIDER SCREENING (cont)
An excluded individual or entity cannot be part of a task that is reimbursed by Federal program dollars, which includes:
 Claims submittal
 Any service, including those not directly related to patient care
 Payment from a Federal program cannot cover salaries, expenses, or fringe benefits www.dpw.state.pa.us > 37

PROVIDER SCREENING (cont)
Exclusion may be imposed on an individual or entity that is not:
 Enrolled in Medicare or Medicaid
 Involved in submitting claims
 Involved in recipient care www.dpw.state.pa.us > 38

PROVIDER SCREENING (cont)
Potential consequences of employing an excluded provider include:
 Repayment of claims
 Penalty of up to $10,000 for each item or service claimed
 Assessment of three times the amount claimed for each item or service
 Exclusion www.dpw.state.pa.us > 39

PROVIDER SCREENING (cont)
Exclusions are documented on the following databases:
 List of Excluded Individuals/Entities (LEIE) at http://www.oig.hhs.gov/fraud/exclusions.asp
 System for Award Management (SAM) at www.sam.gov
 Medicheck List at http://www.dpw.state.pa.us/learnaboutdpw/fraudandabu se/medicheckprecludedproviderslist/index.htm
www.dpw.state.pa.us > 40

PROVIDER SCREENING (cont)
Protect yourself and your company
 Develop policies and procedures for screening all employees and contractors
 Develop and maintain auditable documentation of screening efforts
 Periodically conduct self-audits to determine compliance with this requirement www.dpw.state.pa.us > 41

PROVIDER SCREENING (cont)
 Check Federal and State Databases:
 Before hiring or contracting with an individual or entity
 Monthly thereafter
 This maybe a good time to verify licenses with the Department of State www.dpw.state.pa.us > 42

PROVIDER SCREENING (cont)
If you discover an excluded individual?
Immediately self report any discovered exclusion to the Bureau of Program Integrity
 This can be done via e-mail through the MA
Provider Compliance form at the following link: http://www.dpw.state.pa.us/learnaboutdpw/frau dandabuse/maprovidercompliancehotlinerespo nseform/index.htm
www.dpw.state.pa.us > 43

AUDITS/REVIEWS
Who can conduct audits/reviews?
• Centers for Medicare & Medicaid Services
(CMS)
• Office of Inspector General (OIG)
• Payment Error Rate Measurement (PERM)
• Medicaid Integrity Contract (MIC)
• Bureau of Program Integrity (BPI)
• PCG www.dpw.state.pa.us > 44

SELF AUDITS
Self-Auditing activities include:
• Periodic self auditing of service delivery and billing
• Reconciliation of MA claims with the amount received
• Review of regulation/requirements to ensure that services were rendered and billed correctly www.dpw.state.pa.us > 45

SELF AUDITS (cont)
Pennsylvania’s voluntary MA Provider Self
Audit Protocol provides a mechanism for disclosure and repayment of improper MA payments and provides guidance on the preferred methodology.
www.dpw.state.pa.us > 46

SELF AUDITS (cont)
Self Audit Protocol can be assessed at: www.dpw.state.pa.us/PartnersProviders/Me dicalAssistance/DoingBusiness/FraudAbu se/003670226.htm
www.dpw.state.pa.us > 47

SELF AUDITS (cont)
Help you to:
• Identify incomplete/inaccurate documentation
• Promote a commitment to comply with rule/regulations
• Prevent/detect criminal conduct and violations
• Avoid penalties www.dpw.state.pa.us > 48

SELF AUDITS (cont)
Benefits
• Identify overpayments
• Identify underpayment
• Identify services you could be billing for
• Identify individuals that might not be submitting time appropriately
• DPW isn’t standing over you shoulder conducting the review www.dpw.state.pa.us > 49

SELF DISCLOSURES
LEAs are encouraged to self disclose billing errors and violations identified
Providers have a legal and ethical commitment to return inappropriate
Medicaid payments.
www.dpw.state.pa.us > 50

SELF DISCLOSURES (cont)
Send Self Audits/Self Disclosures to BPI at:
Department of Public Welfare, Office of
Administration, Bureau of Program Integrity
P.O. Box 2675, Harrisburg, PA 17105-2675 www.dpw.state.pa.us > 51

CORRECTIVE ACTION PLANS
A CAP is:
• A written step-by-step plan of action developed to achieve targeted outcomes for resolution of identified problems
• Requested by BPI as a component of its review when violations are identified
• BPI will either accept a provider’s CAP or request revisions www.dpw.state.pa.us > 52

CORRECTIVE ACTION PLANS
The ultimate goal is to incorporate a CAP into an LEA’s everyday operations in an effort to:
• Comply with state and federal regulations;
• Ensure quality, accessible, timely services;
• Achieve measurable improvement in the highest priority areas;
• Eliminate repeated deficient practices www.dpw.state.pa.us > 53

CORRECTIVE ACTION PLANS
CAPs must include at a minimum:
• Specific policies and procedures developed to address the issue
• Specific measures taken or to be taken to ensure compliance
• Timeline for the measures
• Date(s) of implementation
• Responsible person/persons
• Follow-ups to ensure compliance www.dpw.state.pa.us > 54

RESULTS OF CMS AUDIT
Missing documentation
• IEP
• Daily progress note
• Parental Consent
• Medical Practitioners Authorization
• Attendance Record
• Transportation Logs www.dpw.state.pa.us > 55

RESULTS OF CMS AUDIT (cont)
Incomplete Documentation/Didn’t Meet
Requirements
• Daily log must include the providers name and be signed
• Units billed not equal to units documented
• More units billed than medically necessary
• IEP did not specify group vs individual
• Service not listed on IEP www.dpw.state.pa.us > 56

RESULTS OF CMS AUDIT (cont)
• MPA signed post date of service
• Provider not licensed on date of service
• One way transport paid for round trip www.dpw.state.pa.us > 57

BPI FINDINGS
Findings:
• Licensing Problems
• Signatures
• PCS
• Documentation www.dpw.state.pa.us > 58

CONTACT INFORMATION
Barry Decker, BPAP
717-772-6341 bdecker@pa.gov
Pam Tressler, BPI
717-705-6873 ptressler@pa.gov
www.dpw.state.pa.us > 59

QUESTIONS
Questions?
www.dpw.state.pa.us > 60