1. Medicaid Reimbursement Current Hot Issues
Kinney Management Services, LLC. 3 Tallow Wood Drive, Suite G Clifton Park, New York

2. Medicaid Reimbursement Current Hot Issues
Impact of
New Fee for Service Billing
National Health Reform
Parental Consent
Compliance
Excluded/Disqualified/Debarred Providers

3. Also Known As
The Good
The Bad, and
The Ugly

4. The Good New Fee for Service Billing

5. Medicaid Increase in Net Payment
July 1, State can no longer take any share of the federal payment.
Currently the Federal Share is 61.59%. Can change in next federal budget.

6. Medicaid Increase in Net Payment
Old net to district was 25%. $.25 on each dollar. Current net is $.61 on each dollar 40% increase

7. The Good Payment Increase
Speech Therapy
Old Gross Monthly Amount - $432
Value for 10 Months - $4320
Net District Revenue - $1080

8. The Good Increase - Speech Fees
New Average Monthly Amount – Gross $274-$556
Value for 10 Months - $2740-$5560
Net District Revenue - $1687-$3424
Increase from $907-$2344 Annually
18-46% Increase in net revenue.

9. The Good Patient Protection and Affordable Care Act (PPACA).
1997 IDEA - “Many commenters believe that there is always a cost associated with using private insurance, i.e., exhaustion of lifetime caps, decreased benefits, increased co-pays and costs, risk of future uninsurability with another insurance carrier, and possible termination of health insurance. “
As printed in The Federal Register: March 12, 1999 (Volume 64, Number 48) Rules and Regulations

10. The Good Possible Impact PPACA
1997 IDEA - “Under the interpretation in the Notice, public agencies may not access private insurance if parents would incur a financial cost, and use of parent’s insurance proceeds, if parents would incur a financial cost, must be voluntary on the part of the parent.” As printed in The Federal Register: March 12, 1999 (Volume 64, Number 48) Rules and Regulations

11. The Good Possible Impact PPACA
“the public agency may use its Part B funds to pay the cost that the parents otherwise would have to pay to use the parents' benefits or insurance (e.g., the deductible or co-pay amounts).”

12. The Good Possible Impact PPACA
End of Insurance Limits
September 23, 2010
Preexisting Conditions –, prohibited from imposing any preexisting condition exclusions for children who are under age 19.
Lifetime Limits –prohibited from placing lifetime dollar limits on medical claims.
Annual Limits – no unreasonable annual dollar limits on claims. Annual limits will not be permitted at all after January 1, 2014.
Prohibition on Rescissions – Effective September 23, 2010, can not drop coverage due to illness.

13. The Good Possible Impact PPACA
Limits on Cost Sharing
Small group market plans are prohibited from deductibles greater than $2,000 for individuals and $4,000 for families. These maximums may increase only in accordance with increases in average per person health insurance premiums.

14. The Bad .

15. Medicaid Fraud Control Unit Enforcement
The Bad
Federal Medicaid
In Charge
State Health
Issues rules as it gets to it
OIG and US Attorney
Enforcement
State Comptroller
Claim more and more! ???
Whistle Blower
FFCA 15-30%
State Attorney General
Medicaid Fraud Control Unit Enforcement
State Ed
Consent
NYS OMIG
Enforcement

16. Medicaid Covered Services
OLD
New
Speech Therapy
Physical Therapy
Occupational Therapy
Psych Counseling Services
(including school psychologist and other non-licensed health care professionals)
Nursing Services
(if at least 15 minutes)
Medical Evaluation
Specialist Medical Evaluation
Audiological Evaluation
Targeted Case Management
(includes Initial Review, Triennial Review, Annual Review, Amended/Requested Review
Ongoing Service Coordination)
(provided by licensed health care professionals – no educational titles)
(up to 15 minutes)
Special Transportation
Eliminated
State has yet to cover aides even though CMS says it can.

17. Apply to all services since July 1, 2009
The Bad
All Medicaid newly announced requirements apply to any claim not yet submitted.
Apply to all services since July 1, 2009

18. The Bad Why is This Bad?
You are held to requirements that did not exist when the services were provided.
THERE ARE DOCUMENTATION PROBLEMS!

19. The Bad Examples July and August 2009 can not be claimed.
All services must have daily progress note.
MOST SPEECH SERVICES DON’T.
Speech pathologist must be ASHA certified.

20. The Bad What ASHA CCC Mean
Maintaining Your ASHA Certification
The Certification Maintenance Standards require that all certificate holders-CCC-A and CCC-SLP-must accumulate 30 Certificate Maintenance Hours (CMHs) of professional development during each 3-year certification maintenance interval in order to maintain their ASHA Certificates of Clinical Competence (CCC).
Requirements for Maintaining Your CCCs
Submit your compliance form to verify your 30 professional development hours
Abide by the ASHA Code of Ethics
Maintain affiliation by paying annual dues of annual certification fee - $225

21. The Bad Examples - Code Changes
Old Code for Physical Therapy
SSHSP Monthly Fee Code 5328
Two or more services per month
Monthly Fee $430

22. The Bad Examples - Code Changes
New codes Physical therapy
23 Codes - Current Procedural Terminology (CPT®)
(Over 100 for all services)
CPT codes are developed, maintained and copyrighted by the American Medical Association.

23. The Bad Examples - Code Changes
Some New PT Codes
Physical Therapy 97014
APPLICATION OF A MODALITY TO ONE OR MORE AREAS; ELECTRICAL STIMULATION (UNATTENDED) See Footnote 2 1 per session $10.70
2. With one exception providers should not report more than one physical medicine and rehabilitation therapy service for the same fifteen minute time period. (The only exception involves a
“supervised modality” defined by CPT codes which may be reported for the same fifteen minute time period as other therapy services.) .

24. The Bad Examples - Code Changes
Some New PT Codes
Physical Therapy 97112
THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINUTES; NEUROMUSCULAR REEDUCATION OF MOVEMENT, BALANCE, COORDINATION, KINESTHETIC SENSE, POSTURE, AND/OR PROPRIOCEPTION FOR SITTING AND/OR STANDING ACTIVITIES
Special rule -Intended to identify therapeutic exercise designed to re-train a body part to perform some task that the body part was previously able to do. This will usually be in the form of some commonly performed task for that body part. Some common examples include Proprioceptive Neuromuscular Facilitation (PNF), Feldenkreis, Bobath, BAP's Boards, and dessensitization techniques. 15 minutes $23.29 .

25. The Bad Some Other Changes
Detail - Order quantity over IEP quantity
Medicaid can only be billed for those services included in the written order.
The frequency of services may be included on the written order at the discretion of the ordering provider. .

26. The Bad Some Other Changes
Counseling is limited to State Medicaid recognized Licensed Practitioners.
No School Psychologist
No Guidance Counselors

27. The Bad Some Other Changes
Claiming for meetings and ongoing service coordination is no longer allowed
State agreed with CMS that school can not provide a targeted case management (TCM) services that meet Medicaid requirements. .

28. The Bad Some Other Changes
“Response: Based on discussion with the State Education Department, it has been determined that the proposed “care coordination” activities are not comprehensive enough to meet federal requirements for Medicaid targeted case management. Subsequently, the enclosed revised SPA pages no longer include “care coordination as a covered service.”
Letter to CMS from NYS Health Department dated March 19,

29. Up To Here it was only bad, now its getting darn ugly!
The Ugly
Up To Here it was only bad, now its getting darn ugly!

30. The Ugly
All New Requirements may apply to all payments made since January 1, They certainly apply to all services since January 1, 2009.

31. The Ugly
“Pre-July 1, 2009 claims must be supported by a minimum of two session notes. In addition, provider qualifications/credentials, agreement and statement of reassignment must be in place, and there must be documentation of the Medicaid eligible student's information including referral to the CSE/CPSE; IEP; consent for release of information; referrals or orders for services as required; and special transportation needs if applicable.”
from State Health dated Mon 6/14/2010 5:58 PM

32. The Ugly
Pre July 1, 2009
Must have a Medicaid eligible services for every day transportation is claimed.
To be eligible a services must have a session note.
Therefore, there must be at least one session note for everyday transportation is claimed.

33. The Ugly From the same email:
“If the ordering or referring professional never met with the child before issuing the "order" can the services still be claimed? As noted before many such orders or referrals were made based on a review of the recommendations of the servicing provide like the PT or OT. (Doesn't apply to speech.)
It is not acceptable under the Medicaid program for the ordering or referring professional never to have met with the child as it is incompatible with the obligations of the ordering practitioner to assure that the ordered care, services, or supplies will meet the recipient's needs and restore him or her to the best possible functional level.”

34. The Ugly Content of Session note
Student’s name
Specific type of service provided
Whether the service was provided individually or in a group (should record actual group size)
The setting in which the service was rendered (school, clinic, other)
Date and time the service was rendered (length of session)
NOT THE SCHEDULED DURATION
Brief description of the student’s progress made by receiving the service during the session
Name, title, signature and credentials of the servicing provider and signature/credentials of supervising clinician as appropriate

35. The Bad Compliance Plan Components
Written policies and procedures that describe compliance expectations;
Designation of an employee vested with the responsibility for the day- to-day operation of the compliance program (compliance officer);
Training and education for affected employees and persons associated with the provider;
Establishment of communication lines to the compliance officer for anonymous/confidential disclosure;
Disciplinary policies to encourage good faith participation in the compliance program by all affected individuals;
Creation of a system for routine identification of compliance risk areas specific to the provider type;
Creation of systems for responding to compliance issues as they are raised; and,
A policy barring intimidation or retaliation for participating in the compliance program

36. The Ugly
Compliance Plans Require
Creation of a system for routine identification of compliance risk areas specific to the provider type;
Creation of systems for responding to compliance issues as they are raised

37. The Ugly Identified compliance risk areas.
You now have
Identified compliance risk areas.
Districts must respond by determining if there are issues.
Must properly deal with all identified.

38. The Ugly
If overpayments are identified They must be immediately returned
Under Section 6402 of PPACA, must “report and return” the overpayment to the state, and to provide an explanation “in writing of the reasons for the overpayment, within 60 days of identification of the overpayment.”

39. The Ugly
If overpayments are identified they must be immediately returned
Failure to do so may expose the “person” to liability under the False Claims Act, including whistleblower actions, treble damages and penalties.

40. The Sun Will Come Out Tomorrow!
What Should You do?
Review and revise your plan for continuing health care billing.
Report on all services, not just on known Medicaid eligible's.
Have a compliance plan.
Designate a compliance officer

41. The Sun Will Come Out Tomorrow!
What Should You do?
Involve the board and the top executives.
Actually follow the plan.
Be sure your billing staff understands what is required.
Be sure any contractors involved in billing understand the requirements.
If needed get outside help.

42. Consent How to fix it.
The Idea and FERPA regs both say the Medicaid application can be informed consent if it meets the IDEA requirements.
NY Medicaid application meet these requirements and is normally signed at least every 12 months.

43. Consent How to fix it.
If parental consent is given directly to another agency, such as the State Medicaid agency, the LEA does not have to independently obtain a separate parental consent, as long as the parental consent provided to the other agency meets the requirements of 34 CFR §§300.9 and (d).
JUL letter to us from US DOE.

44. Consent How to fix it. IEP’s are done at least once a year.
Medicaid application are done at least once a year.
The issue is one of coordination and requires the state or your county to assist you.

45. Excluded/Disqualified/Debarred Providers
What are they?
Parties that you may not deal with if you are receiving government money.

46. Excluded/Disqualified/Debarred Providers
What are they?
Disqualified – New York State
participation in the Medicaid program has been restricted, terminated or excluded under the provisions of 18 NYCRR § (b) - (h), 18 NYCRR §515.3, or 18 NYCRR §515.7.

47. Excluded/Disqualified/Debarred Providers
Excluded _ HHS OIG
Bases for exclusion include convictions for program-related fraud and patient abuse, licensing board actions and default on Health Education Assistance Loans.

48. Excluded/Disqualified/Debarred Providers
Debarred _ OMB and GSA
Executive Order President Reagan
government-wide effect. No agency shall allow a party to participate in any procurement or nonprocurement activity if any agency has debarred, suspended, or otherwise excluded (to the extent specified in the exclusion agreement) that party from participation in a procurement or nonprocurement activity.

49. Excluded/Disqualified/Debarred Providers
Exlcuded –What HHS OIG says it means
No program payment for ANY items or services
In ANY capacity
In ANY setting (except emergency items/services)
For ANY administrative or management services
For ANY salary or fringe benefits
DIRECTLY to anyone
INDIRECTLY on any cost reports or reimbursement mechanisms

50. Excluded/Disqualified/Debarred Providers
What are you required to do?
CMS (federal Medicaid), OMIG and HHS OIG
You should check monthly all employees and contractors.

51. Excluded/Disqualified/Debarred Providers
Specially Designated Nationals List
The Office of Foreign Assets Control ("OFAC") of the US Department of the Treasury administers and enforces economic and trade sanctions based on US foreign policy and national security goals against targeted foreign countries and regimes, terrorists, international narcotics traffickers, those engaged in activities related to the proliferation of weapons of mass destruction, and other threats to the national security, foreign policy or economy of the United States.

52. Excluded/Disqualified/Debarred Providers
NYS disqualified may also be OIG excluded
OIG excluded will be ON GSA debarred.
GSA debarred is not always OIG excluded
Other States may or may not be on OIG or GSA list, not on NY OMIG list.

53. QUESTIONS