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How to Implement a Medicaid Reimbursement Program for Behavioral Health and Therapeutic Services in your School District Presented by: Pacific Health Policy.

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Presentation on theme: "How to Implement a Medicaid Reimbursement Program for Behavioral Health and Therapeutic Services in your School District Presented by: Pacific Health Policy."— Presentation transcript:

1 How to Implement a Medicaid Reimbursement Program for Behavioral Health and Therapeutic Services in your School District Presented by: Pacific Health Policy Group

2 Students with Special Needs  In 2007, 54 Alaskan school districts served over 17,000 students with identified behavioral health and therapeutic needs  School districts can increase the amount of money available for these eligible services by submitting Medicaid claims  Districts will be reimbursed at the current State of Alaska Medicaid match rate (50.53%) 2

3 About Medicaid  Medicaid is operated by state governments within a broad, federally proscribed framework  The federal government covers just over 50% of the cost of providing covered services to eligible Alaskans  Medicaid is available to Alaskans who are either financially or categorically eligible  Some services provided to students receiving behavioral health or therapies are eligible for federal reimbursement – or the federal match (currently 50.53%) 3

4 Basic Steps to Bill for Behavioral Health and Therapeutic Services  Districts enroll as Medicaid providers  Receive parental authorization  Identify eligible students  Bill for rendered services, while continuing to check recipients eligibility  Maintain documentation in case of audit 4

5 Criteria for Appropriate Medicaid Billing  Eligible for Medicaid (or Denali KidCare);  Recipient has a properly documented IFSP or IEP;  The type, scope, frequency & duration of the services are documented  The services are medically necessary and covered under an existing Medicaid category;  All state and federal regulations are followed;  Services are provided by qualified health care professionals working under a enrolled district 5

6 Enrolling as a Provider  For a district to qualify to enroll as a Medicaid Provider, districts must agree to:  Comply with all federal and state requirements for billing, auditing and reporting  Obtain an NPI number  Reimburse DHSS for any state financial share – the non-federal portion of the fee schedule 6

7 Enrolling as a Provider  Obtain a NPI number  Complete the Alaska Medical Assistance Program Provider Enrollment Form  Forms and Instructions are included in the Toolkit  Questions? Contact ACS at (800) 770-5650 Use option 1 or 3 for enrollment assistance 7

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9 Clinicians Eligible to Bill Medicaid for Eligible Services  The Alaska Administrative Code at 7 AAC 4.461 (“Payment for School-based Services”) lays out the requirements and qualifications of providers:  Physician;  Physician’s Assistant;  Advanced Nurse Practitioner;  Physical Therapist;  Occupational Therapist;  Speech-language Pathologist;  Audiologist;  Psychologist or Psychological Associate;  Behavioral Health Professional;  Behavioral Health Associate; or  Another health care provider who is acting within the scope of that health care provider’s license under AS 08 and is familiar with the child’s plan, health condition, and treatment history. 9

10 Providers NOT Eligible to Bill Medicaid for Eligible Services  Individuals employed as teachers are not allowed to have eligible services billed through to Medicaid, even if the teacher is otherwise qualified to provide the service  Note: Federal regulations do not contain a provision requiring physician involvement and review of behavioral health or therapeutic services provided at the school level 10

11 Identifying Eligible Students  Districts will need parent authorization of students to determine if a student is Medicaid eligible  A sample letter can be included with the initial IEP documentation (moving forward) and would be sent retroactively to all students that currently have an IEP  Once parent authorization is obtained, the school district can use an automated system to determine if the student is Medicaid eligible  Eligibility needs to be checked on a monthly basis 11

12 Sample Letter 12

13 Verification Once District is Enrolled  Before providing services, the district must verify:  The age of the recipient  That the recipient is eligible for Alaska Medical Assistance and school based services  Check monthly for Medicaid  Check every six months for Denali KidCare  That the services are school-based and covered by Medical Assistance  Provider rendering service has the appropriate credentials 13

14 Verification Process (continued)  Eligibility can be verified by:  Checking the patient’s Medical Assistance identification card or coupon  Calling the Eligibility Verification System (EVS) at (800) 884- 3223  Faxing provider inquiry at (907) 644-8126 or (907) 644-8127  When faxing, have available the student’s name, date of birth, Social Security number or Medicaid ID (available on the Identification Card or Coupon) 14

15 Covered Behavioral Services  Listed in billing manual, included in Toolkit  A shorter list of common covered behavioral services are also in Toolkit  Age restrictions may apply  Prior Authorization requirements may apply 15

16 Covered Behavioral Services  Emotional support assistant to help a child process emotions (CDAKN)  During periods of elevated stress  Behavioral management education that teaches behavior management, modification, and redirection techniques to elicit positive behaviors with  Families (CDACF),  Groups (CDACE), and  Individuals (CDACD) 16

17 Covered Behavioral Services  Crisis response services including:  Crisis intervention (H2011) to prevent harm  Build coping skills  Develop mechanisms for positive self-care  Stabilize a child or family in acute stress  Behavior modification assistance using counseling techniques to assist in modifying behavior  To individuals (CDACI)  And groups (CDACJ) 17

18 Covered Behavioral Services  Functional behavioral assessments (CDBAW) to assess a child’s behavior  Psycho-educational (H2027) services to help a child develop or improve specific self-care skills and engage in age-appropriate social behavior 18

19 Covered Behavioral Services  Testing (96101) a child’s psychological, cognitive, and emotional functioning  Interpreting a child’s behavioral assessment results 19

20 Billing Strategies  Districts need to make sure they have the appropriate personnel to process the Medicaid claim  Larger districts should hire additional FTEs  For smaller districts, hiring one FTE may not be financially viable  These districts are encouraged to either hire part-time support or collaborate with other smaller districts to “share” resources  Smaller districts can also contract with an outside vendor  This would reduce the financial benefit 20

21 Example: Kenai School District  Hired a ¼ time clerical member with a medical background  Kenai has more than 800 students with IEPs who are Medicaid eligible  Training for administrators was provided by First Health  ACS continues to hold monthly trainings in Anchorage 21

22 Billing Options for School-based Behavioral Health Services  Claims may be submitted on paper  CMS 1500  Instructions and Sample Form are available in the Toolkit  Using the appropriate current CPT or ABC codes  Electronically  PayerPath (available through ACS) 22

23 Timely Billing and Third Party Liabilities  All claims must be filed within 12 months of the date services were provided to the recipient (Retroactive claims may be filed if documentation is proper)  Claims may either be submitted on a weekly or monthly basis  Medicaid is a payor of last resort – it only pays after other avenues have been exhausted. The State has determined that no other insurer covers school-based services, exempting school districts from this requirement 23

24 Updating Billing Information  Procedure codes can change from year to year, but the changes are minor  Coverage (reimbursement amount) can change from year to year  Procedure codes that were covered one year may not be covered the next year  Be sure to bill with codes that are in effect for the date the service was provided 24

25 Remittance Advice  Each week your school district will receive a Remittance Advice from ACS that details the status of each claim that is in progress.  The RA will identify claims that are:  Paid  Denied  Suspended  Pages II-9 through II-22 explain each section of the RA in detail  Denied claims will have a denial code so that the school district can rectify the problem and resubmit the claim  Denial codes can be looked-up online at: 25

26 Remittance Advice Sample 26

27 Adjustments and Voiding Claims  Used to correct or void claims that have already been paid  Adjustments are done if there was an error in the claim  Wrong procedure code  Wrong modifier  Wrong number of units  Wrong date of service  Recoupments are used to void a previously paid claim  Claim was submitted for a student who is the responsibility of another district  Claim was submitted without the necessary documentation  Use form AK-05 – Instructions in the Provider Manual 27

28 Records  A school district documentation must include:  Recipient’s name  Specific services provided  Extent of service provided  Date of service  Name of health care provider who provided service  A Service Documentation Sample is included in the Toolkit  A billing form is also included to maintain an overview of the student’s history 28

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30 Confidentiality  Two federal statutes: FERPA and HIPAA  Family Educational Rights and Privacy Act (FERPA)  Health Insurance Portability and Accountability Act (HIPAA)  School-based behavioral health and therapeutic services are covered by FERPA, even the records used to support Medicaid billing  HIPAA defers to FERPA except as related to the electronic transmission of Medicaid claims to the fiscal agent (ACS) 30

31 Records Needed in Case of an Audit  Districts need to maintain a file for each student that includes:  A parent authorization form;  A copy of the IEP;  Goals and objectives;  Progress notes; and  Service documentation logs 31

32 Records Needed in Case of an Audit  A school district must retain the billing, clinical and other records for a student for which services have been billed to the Medical Assistance program for at least seven years for the date the service was provided.  Districts must maintain a IFSP or IEP record with the following information:  The student’s condition  The health care needs for each service  Each individual service provided to the student  Annotated case notes, signed, dated or initialed by the individual who provided the service, for each service delivered 32

33 Records Needed in Case of an Audit  This applies even if the student transfers  Records in electronic format must be readily accessible  The district is responsible for making sure billing services meet these requirements 33

34 Records Needed in Case of an Audit  In the event of a Medicaid audit, school districts need to maintain the following records for seven years:  Student attendance records;  Employee leave records;  Employee state credentials, professional licenses or certificates; and  Contracted individuals’ credentials, licenses or certificates 34

35 Common Mistakes  Billing when child is absent or when school is not in session  Billing when qualified staff are absent and substitute is delivering services  Billing for unqualified provider  No parent/guardian authorization on file  Inadequate documentation for what is billed  Missing documentation  Services provided and billed were not part of the IEP  Expired IEP 35

36 Support  PHPG Toolkit  FHSC billing manual  Websites   36

37 Questions?  E-mail:  Contact Jason Milstein  (847) 615-3413  Call the ACS recipient information help line:  (800) 780-9972 from 8 am to 5 pm 37

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