Arizona Medicaid School Based Claiming Annual Regional Compliance - - PowerPoint PPT Presentation

Arizona Medicaid School Based Claiming

Annual Regional Compliance Training February 2015

www.pcgeducation.com

Agenda

• Introduction
• Compliance Overview
• Medicaid Administrative Claiming (MAC)
• Annual Cost Reporting
• Direct Service Claiming (DSC)
• General Compliance Information

2

Introduction

• Today we will learn how to Build Compliance
• Compliance in the Medicaid School Based Claiming (MSBC) program
• Program component review
• Requirements and documentation
• Compliance review findings and trends
• Tools for Success
• Tools will be shared throughout the presentation to address common findings
• Tools should be added to Local Education Agency’s (LEA’s) Toolbox to improve

program compliance

3

Compliance Overview

• Compliance Overview
• PCG conducts periodic compliance reviews to verify appropriate supporting

documentation is maintained by LEAs

• Comprehensive compliance reviews includes a review of each MSBC program

component

• Direct Service Claiming (DSC)
• Medicaid Administrative Claiming (MAC)
• Annual cost reporting used during cost settlement
• Occurs at least once every three years for all participating LEAs
• LEAs receive a notification 30 days prior to the start of the review
• All reviews and reports are comprehensive with one entrance and exit

meeting where all representatives are present

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Tools for Success

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Conduct random internal periodic reviews Create checklists for departments detailing the required documentation that should be easily accessible Discuss and outline expectations with vendors in terms of the invoice requirements for reimbursement for the MSBC program Cooperate and collaborate with all departments and people within your LEA

Medicaid Administrative Claiming (MAC)

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MAC Compliance Review

• MAC compliance reviews verify 100% of quarterly costs for the last paid

MAC claim

• System-generated and other substantiating reports are requested for the

following:

• Salaries
• Employer-paid benefits
• Purchased Professional Staff (PPS) costs
• Federal revenues
• Cost data from supporting documentation provided by the LEA is entered

into an internal review tool and used to regenerate the applicable quarter’s claim

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MAC Salaries/Benefits Documentation

• All quarterly costs are reported on a cash-basis
• Salaries/benefits by pay dates within the quarter
• PPS costs by date invoice was paid
• Appropriate full/part-time employee documentation
• System-generated reports MUST INCLUDE:
• Fund/function associated with salaries and employer-paid benefits
• Pay dates
• Description of pay
• Employer-paid portion of benefits
• LEA-created documentation (Excel spreadsheet) can only be used to support the

required system-generated reports

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MAC Non-Allowable Funds & Functions

• Functions 2330, 2500, and 2600 are non-allowable
• 2330 - lobbying
• 2500 (including sub-functions 2501-2599) - central services
• 2600 (including sub-functions 2601-2699) – operations and maintenance
• Funds 100-399 are federal funds and must reported appropriately
• With the exception of fund 290 (including sub-funds 291 and 292)
• Report 100% of ALL paid salaries and benefits (including non-allowable and

federally-funded costs as a best practice) in the appropriate column within the Medicaid Cost Reporting and Claiming System (MCRCS)

• Report portions of non-allowable costs and functions, federally-funded

salaries, AND all associated benefits in federal column (labeled ‘Compensation Federal Revenues’ within MCRCS)

• MCRCS subtracts the reported federal portions from the sum of the salaries and

benefits resulting in allowable costs

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MAC Cost Reporting Example

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$6,200.00 $890.00 $0.00 $590.00 $7,090.00 $6,500.00

MAC PPS Documentation

• Appropriate PPS documentation
• Invoices MUST INCLUDE:
• Participant name (first and last) as listed on the staff roster
• Charges allocated to specific participant
• Services provided
• System-generated payment history MUST INCLUDE:
• Fund/function associated with payments
• Date invoice was paid

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MAC PPS Detailed Invoice Example

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MAC Compliance Review Findings: Next Steps

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Variance Identified Underpayment LEA opts to decline additional reimbursement LEA requests to amend costs to receive net reimbursement in future claim Overpayment Variance amount recouped via prior period adjustment on future claim

MAC Common Findings

• Salaries/Benefits
• Misidentification of allowable and non-allowable funds/functions/duties
• Reports generated for pay dates outside the quarter under review
• PPS
• Participants not identified by name on invoice
• Non-itemized invoices
• Costs reported by invoice date or service date rather than date invoice was paid
• Pay history not provided
• Federal Revenues
• Costs not identified as federal revenue
• Incorrect reporting of federal revenue within MCRCS

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MAC Compliance Trends

• 30 LEAs reviewed in 2014
• 10 LEAs underreported costs
• Average underpayment was $80.00
• 16 LEAs over reported costs
• Average overpayment was $183.00
• 4 LEAs had no variance
• Average overall variance was $71.00 overpayment (recoupment)

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MAC Compliance Trends

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10 20 30 40 50 60 70 80 90 100 Salaries Benefits PPS Federal Funds

Percentage of Total Variances Reporting Component

Most Common MAC Review Variance Areas

Over Under

Tool for Success

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Maintain documentation used to enter cost data Know your payroll software, available reports, and resources Report quarterly costs on cash-basis Accurately identify and report allowable and non-allowable costs, in addition to federal funds Work with contractors to receive invoices with required program components Prepare and submit documentation early

LEAs that have ‘built’ success

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• Congratulations to the following LEAs who achieved an overall final

score of 100% on the MAC portion of their OD13 comprehensive compliance review: Apache Junction Unified School District Flowing Wells Unified School District Willcox Unified School District Winslow Unified School District

Annual Cost Reporting

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Annual

• Annual costs

reported for DS, Personal Care, and transportation staff

• Accrual method
• Pre-payment

review

• Used to

calculate cost settlement

MAC

• Quarterly costs

reported for DS and Admin staff

• Cash-based

method

• Post-payment

review

• Results in

quarterly claim reimbursement

• Allowable

Salaries, Benefits, and PPS are the same

• Report within

MCRCS

• Only staff

included on RMTS roster may have associated costs reported

Annual Cost Reporting

• The annual component of the review verifies the certified DSC annual costs

within the Medicaid Cost Reporting and Claiming System (MCRCS) against LEA supplied supporting documentation including:

• Salary and benefit information for direct medical service providers and

transportation staff

• IEP Ratio information
• Transportation data
• Documentation is reviewed and entered into the annual compliance review

tool and compared to costs reported in MCRCS for that period

• If the supporting documentation reviewed does not match what was reported that

information must be corrected within MCRCS in a timely fashion to ensure a pre payment correction

• All annual costs must be reported on an accrual accounting methodology

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Transportation Other Cost Data

• All transportation other costs are reviewed by PCG to ensure accuracy in

transportation reporting

• PCG continues to ensure that LEAs understand the difference in reporting

“specialized transportation” versus “general transportation”

• As a reminder, “general transportation” does not mean exclusively

general/regular education costs, these costs must pertain to a vehicle that is physically adapted and has at least one claimable route ridden exclusively by special education students who have specialized transportation in their IEP

• “Specialized transportation” criteria must pertain exclusively, 100% of the time to

a vehicle that is physically adapted and is always ridden entirely by special education students with specialized transportation in their IEPs

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Transportation Other Cost Data

• Transportation Other Costs categories reviewed:
• Lease/Rental
• Insurance
• Maintenance and Repairs
• Fuel and Oil
• Purchased Professional Services
• The invoices, contracts, and all other appropriate supporting documentation

for these costs must be appropriately identified as “specialized” or “general” and figures have to align with what was reported in MCRCS

• Creativity in reporting transportation costs is a major audit risk, only report

allowable costs

• When in doubt, ask PCG

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Transportation Other Cost Data

• If PCG identifies non-allowable costs in transportation ‘other costs’ data

documentation, they must be removed. Some examples include:

• Purchased professional services contracts covering the wrong time period OR

are for general/regular education transportation costs only

• Prorated fuel and oil bills (or other cost category)
• If you cannot discretely break down specialized transportation costs, lump

sums must be reported as “general” if they pertain to a vehicle that is physically adapted and has at least one claimable route ridden exclusively by special education students who have specialized transportation in their IEP

• Non-allowable costs (commonly found in Maintenance and Repairs)
• Costs must pertain to the operation of the vehicle (making the vehicle go)
• These costs must be discretely identified by documentation to ascertain

what exactly the cost category was

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Transportation Other Cost Data

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• Costs reported as transportation other costs must pertain to operation of the

vehicle (making the vehicle go!)

• Are these costs allowable?
• Invoice for copy paper for the transportation office?
• Physicals for your bus drivers?
• Oil filters for you physically modified vehicles?
• Uniforms for your drivers?
• Transportation Software Systems?
• A set of new tires for your specialized bus?

Trip Ratio

• Trip ratio denominator is reported using either total actual count of

specialized trips provided, or by conservative reporting of total number of special education students by two trios a day and then the total number of school days

• This ratio drives costs down to the Medicaid eligible portion of your

specialized transportation costs

• Supporting documentation provided by LEAs and reviewed by PCG for the

transportation trip ratio denominator includes:

• IEPs ensuring that students had specialized transportation properly prescribed in

their IEP

• Bus logs indicating that the student was actually on the bus for the days in which

trips were reported

• PCG also reviews the desk review “statement of understanding” to ensure

the LEA has a proper system in place and understands how to report the denominator of the trip ratio

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IEP Ratio

• The IEP Ratio is the driving factor in apportioning Medicaid allowable direct

medical service costs by allocating costs to the Medicaid eligible special education population who have a reimbursable related service within their IEP

• PCG reviews a sample of IEPs to ensure that students captured in the IEP

Ratio, based off of the student roster, do indeed have a valid prescribed reimbursable medical service on October 1, of the reviewed year

• Common issues identified as part of the compliance review which led to

students being removed from either the denominator and/or numerator of the ratio (based off eligibility)

• IEP did not cover the proper date
• A qualified medical professional did not sign and date the IEP
• Reimbursable service was not prescribed

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Vehicle Ratio & Transportation Depreciation

• If a LEA has reported transportation costs as “generalized” PCG uses

information reported in the “transportation depreciation” section along with documentation to verify the vehicle ratio has been reported correctly

• PCG also reviews desk review responses pertaining to the vehicle ratio to ensure

the LEA understands the requirements

• Common examples of documentation reviewed includes:
• Vehicle Asset Ledgers
• ADE Vehicle Report
• Only vehicles that are physically adapted and have at least one claimable

route ridden exclusively by special education students who have specialized transportation in their IEP should be depreciated

• The denominator of the vehicle ratio is all vehicles used to transport

students (not including maintenance or general district vehicles)

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Annual Cost Reporting Next Steps

• Completing the annual compliance review component
• Annual Compliance Reviews are pre-payment reviews and all findings must be

corrected within MCRCS once the review finalizes

• PCG will open up the LEAs Annual DSC Cost Report
• LEA must make corrections and re-certify within 20 working days
• This is a crucial step in the process to ensure proper payment
• LEAs who identify systemic issues as a result of a finding from the annual

compliance review should take that opportunity to revisit future cost reports to ensure programmatic compliance moving forward

• Overall, LEAs continue to exhibit a more robust understanding of annual

requirements, kudos for your efforts!

• The more you know and the better you document, the more compliant you

are!

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Annual Compliance Trends

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5 10 15 20 25 30 Cost Data

• Trans. Other

Costs Trip Ratio IEP Ratio Vehicle Ratio

Total Number of LEAs Reporting Component

Most Common Annual Review Adjustment Areas

Adjustment Needed

76.67% 44.00% 24.00% 20.00% 46.67%

Tool for Success

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Ensure Student Roster is submitted correctly to PCG and IEPs are valid for direct medical services and/or transportation (if prescribed) All costs reported must tie back to documentation, make certain that all annual certified costs match the source Transportation costs must be allowable and relate to the

• peration of vehicles (making the vehicle go) Questionable

costs must be removed! Meet with your transportation department on all requirements to verify costs and ratios are reported correctly Document everything. If you didn’t document it, it didn’t happen!

LEAs that have ‘built’ success

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• Congratulations to the following LEAs who achieved an overall final score of

100% on the Annual portion of their comprehensive compliance review:

Palominas Elementary School District success

Direct Service Claiming (DSC)

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Direct Service Claiming (DSC)

• PCG reviews the supporting documentation that is maintained by the LEA to

substantiate interim direct service payments for approved claims

• PCG pulls a sample of paid claims for a selected period of time
• PCG verifies supporting documentation for paid claims
• Scores are given for each standard, service area, and final overall score
• Related Service Claims
• Health Aide and Nursing Claims
• Transportation Claims
• Evaluation Claims
• Claims that are identified as non compliant will result in a recoupment
• Overall final score lower than 89.99% will result in strategic intervention

training

• Standards with a score lower than 89.99% will require a corrective action plan

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Program Requirements

• Individualized Education Program (IEP)
• Student must have a valid IEP
• Reflects the student on the claim (name and unique identifier)
• Duration of the IEP covers date of service
• The service must be prescribed by THE Qualified Medical Provider (QMP)
• Signed AND dated by the QMP
• LEA maintains certification / licensure for QMP
• The IEP must contain outcome oriented goals for the service type under review
• Units billed for the service cannot exceed prescription
• The IEP must contain scope, frequency, and duration for the service under

review

• IEP must be legible and free of alterations / errors

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Program Requirements

• Summary reports
• Covers the date of service on the claim
• Reflects the student on the claim (name and unique identifier)
• Signed AND dated by the QMP
• Clinical notes
• Describes service provided on date of claim
• Reflects the student on the claim (name and unique identifier)
• Signed AND dated by the rendering provider and their supervisor when required
• Additional documentation
• Claimed service must be consistent with provided service
• Attendance records must show that the student attended school on date of

service

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Program Requirements

• Electronically signed documentation must meet requirements including:
• Unique log-in credentials
• Signature and time and date stamp associated with each entry
• ‘Locking’ mechanism in place to pend entry until approved by supervisor when

necessary

• Ability to keep history of all entries and revisions

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Requirements Specific to Nursing Services

• Nursing services DO NOT require goals within the IEP
• Nursing services DO NOT require summary reports
• Previously mentioned documentation is still required including:
• Valid IEP with QMP signature and date
• Licensure of QMP
• Clinical notes
• Attendance records
• Complete scope, frequency, and duration including a

time increment

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Requirements Specific to Health Aide Services

• Health aide services can be prescribed by ANY qualified medical provider
• Signed AND dated by any qualified medical provider
• LEA maintains certification / licensure for qualified medical providers
• Health aide services DO NOT require goals within the IEP
• Health aide services DO NOT require summary reports
• Service logs will be reviewed in lieu of clinical notes but should still contain:
• Brief description of service provided
• Service date
• Student name AND unique identifier
• Signature and date of service provider

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Requirements Specific to Transportation Services

• School-based transportation services are reimbursable when provided to

eligible students who receive another billable DSC service at school that same day

• IEP Contains:
• At least one DSC covered service AND contains the signature and date of at

least one qualified medical provider

• Transportation statement of need including documentation that the student

Requires transportation due to need for an adapted vehicle or for behavioral issues

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Requirements Specific to Transportation Services

• Trip Log
• Student’s name
• Date of transport
• Mileage transported
• Driver’s initials verifying that they provided transportation
• Additional Documentation
• Attendance logs for date of claim
• Drivers license for the bus driver
• Note – In accordance with Arizona Department of Transportation

requirements, a CDL is not required if the vehicle used for transporting fifteen or fewer persons including the driver

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Requirements Specific to Evaluation Services

• Evaluation services are only reimbursable when:
• Leads to one or more DSC covered service
• The resulting service is included in an IEP as a result of the evaluation
• Evaluation report
• Shows that the evaluation was performed by an appropriately qualified medical

provider

• Reflects the student on the claim
• Additional documentation
• LEA maintains licensure for the qualified medical provider
• Claimed service must be consistent with provided service
• Attendance records must show that the student attended school on date of

service

42

DSC Compliance Trends

• 2014 Final Overall DSC Compliance Score Average = 98.56%
• 6 LEAs had a final overall score of 100%
• 28 LEAs had final overall scores above 95%
• Only 1 LEA had a final over score below 90%
• 1.54% increase in final overall score from quarter to quarter

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DSC Compliance Trends

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5 10 15 20 25 30 1C 2 7C 8C

Total Number of LEAs Standard

Most Common Non-Compliant Related Service Standards

Compliant Non-Compliant

6.67% 93.33% 3.33% 96.67% 96.67% 3.33% 96.67% 3.33%

Related Service Common Findings

• 1C- IEPs missing signature and date by an appropriate QMP
• Check to make sure the appropriate QMP has signed and dated the IEP for the

service being prescribed

• An SLP must sign for speech services, an OT for occupational therapy services,

etc.

• Any QMP can sign for health aides and transportation services on an IEP
• COTA’s, PTAs and SLPAs are not qualified medical providers who can prescribe

services

• 2- Maintaining licensure/certification by the LEA
• LEA must retain a copy of the licensure for both the rendering provider and the

prescribing provider

• Verify licensure covers the signature date and service date

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Related Service Common Findings

• 7C- Summary reports
• Must cover the date of service
• Must be signed and dated by the Qualified Medical Provider
• Technical changes made without QMP signature and date
• 8C- Clinical notes
• Must cover the date of service
• Must identify the service provided
• Must be signed and dated by the Qualified Medical Provider and rendering

provider

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DSC Compliance Trends

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5 10 15 20 25 1C 2 4 5 8C

Total Number of LEAs Standard

Most Common Non-Compliant Health Aide / Nursing Standards

Compliant Non-Compliant 7.69% 92.31% 7.69% 92.31% 3.85% 96.15% 11.54% 96.15% 3.85% 88.46%

Health Aide / Nursing Common Findings

• 1C- IEPs missing signature and date by an appropriate QMP
• A nurse MUST prescribe nursing services
• 2- Maintaining licensure/certification by the LEA
• LEA must retain a copy of the licensure for both the rendering provider and the

prescribing provider

• Verify licensure covers the signature date and service date
• 4- Units of paid services exceeded the amount of services prescribed
• Ensure prescription have a clear frequency ex. 30 minutes daily, up to 15

minutes

• 5- IEP did not contain scope, frequency, and duration of service
• Nursing services must be appropriately prescribed to include a complete

accurate scope, frequency, and duration

• 8C- Service logs must contain all required elements and must be signed

and date by the appropriate qualified medical provider

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DSC Compliance Trends

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5 10 15 20 2TR 3TR 8TR

Total Number of LEAs Standard

Most Common Non-Compliant Transportation Standards

Compliant Non-Compliant

8.70% 91.30% 91.30% 4.35% 95.65% 8.70%

Transportation Common Findings

• 2TR- Valid IEP that contains at least one DSC covered service and

signature and date of QMP

• 3TR- Transportation statement of need not present in the IEP
• IEP must indicate that the student requires transportation in an adapted vehicle

due to physical or behavioral issues

• 8TR- Licensure is maintained for driver’s license
• Licensure must be retained by the LEA for both the driver and the prescribing

QMP

• Internet verification of licensure is not valid documentation

50

DSC Compliance Trends

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5 10 15 20 25 1ES 2ES 3ES 5ES

Total Number of LEAs Standard

Most Common Non-Compliant Evaluation Service Standards

Compliant Non-Compliant

78.26% 21.74% 4.35% 95.65% 4.35% 95.65% 13.04% 86.96%

Evaluation Common Findings

• 1ES- Evaluation lead to a DSC covered service in the IEP
• IEP contains a corresponding DSC service that resulted from the evaluation
• Do not claim for evaluations that do not result in a DSC covered service
• 2ES- Evaluation performed by an appropriate QMP
• Licensure to cover QMP for evaluation date
• Evaluation was rendered by a QMP who signed and dated the report
• 3ES- Evaluations reflect the student on the claim
• Evaluation reports must include a unique student identifier
• 5ES- Services claims were consistent with provided service
• Procedure code on claim must be substantiated by the documentation

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Allow yourself enough time to gather all required documentation – verify completeness and organize well! Ensure that a QMP has prescribed an appropriate service with a fully executed handwritten signature and date on all documents Retain approved copies of licensure for prescribing, rendering

• r transportation providers

Evaluations can only be billed if they result in the prescription

• f or continuation of a DSC covered service

Provided documents should cover billed date of service Must indicate statement of need as to why transportation is medically necessary

Tool for Success

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LEAs that have Built Success

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• Congratulations to the following LEAs who achieved an overall final

score of 100% on the DSC portion of their comprehensive compliance review: Clarkdale-Jerome Elementary School District Cottonwood-Oak Creek Elementary School District Prescott Unified School District Saddle Mountain Unified School District Stanfield Elementary School District Winslow Unified School District

General Compliance Information

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Compliance Review - Documentation

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• Submission of Documentation
• All documentation that contains student information MUST be sent securely
• Emails should not contain identifying student information
• All correspondence will be deleted immediately if it contains student

information and is not submitted securely

• Acceptable methods to submit sensitive documentation include:
• File Transfer Protocol (FTP) site
• Send email to azaudit@pcgus.com once documentation is uploaded
• Secure Fax Line at (602)324-5091
• Faxes should include a cover letter with information including recipient
• Mail or ship to PCG
• Expansion of review or discontinuation of participation
• If LEA is unable to supply documentation to support reported costs or

claimed services it is implied that they are not able to

• Previous and future costs / claims are non-allowable

Questions

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Help Desk – 1-877-877-8011 DSC - azdirect@pcgus.com RMTS - azrmts@pcgus.com Cost Reporting - azcostreport@pcgus.com