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RMTS and Cost-Based Rate Methodologies
April 23, 2015
Agenda
Welcome Introductions How We Will Handle Questions Reminder Regarding NAME Annual Survey Results
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Rate Methodologies April 23, 2015 Agenda Welcome Introductions - - PowerPoint PPT Presentation
Rate Methodologies April 23, 2015 Agenda Welcome Introductions - - PowerPoint PPT Presentation
RMTS and Cost-Based Rate Methodologies April 23, 2015 Agenda Welcome Introductions How We Will Handle Questions Reminder Regarding NAME Annual Survey Results 2 Session Objective This session will provide NAME members an
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Session Objective
This session will provide NAME members an overview of the most
common cost based rates methodologies currently operating for school-based services programs across the country, with a specific focus on the important role that random moment time study often
- plays. Differences in methodologies and impact on providers,
reimbursement, and procedures will be discussed, as well as RMTS best practices to support optimization of your school-based services program.
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Evolution of School Based Cost Settlement
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School Based Reimbursement - Today
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Goals of Cost Based Reimbursement
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What are the current CMS approved cost settlement methodologies?
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How does RMTS facilitate a Cost Settlement Methodology?
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How are Medicaid costs apportioned?
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Specialized Transportation Costs
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The End Result
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Key Cost Settlement Factors
Costs for All Direct Service Staff on Roster Percent of Time Spent on Direct Service - RMTS % Percent of Time with Medicaid Students - Medicaid IEP % Medicaid Allowable Cost
- FMAP
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How Annual Cost Settlement is Calculated
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Example #1 Example #2 Allowable Annual Expenditures (A) $ 2,000,000 $ 2,000,000 Unrestricted Indirect Cost Rate (B) 10% 15% Total Allowable Costs (C) = A + (A X B) $ 2,200,000 $ 2,300,000 Direct Service RMTS Percentage (D) 40% 30% Medicaid IEP Ratio (E) 45% 40% FMAP (F) 55% 55% Total Allowable Costs (G) = C X D X E X F $ 217,800 $ 151,800 Total Interim Payments Received (Net FMAP) $ 175,000 $ 175,000 Net Due the District / (To Be Recouped) $ 42,800 $ (23,200)
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Existing States with Approved Cost Settlement Methodologies
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How is RMTS used in the cost settlement process?
A key factor in cost settlement is the allocation of the amount of time staff spend
- n Medicaid-covered services
RMTS provides a statistically valid method for determining how staff time is
allocated
Most states have modified their RMTS process so a single time study can be
conducted to capture time spent delivering Medicaid-covered services as well as Medicaid Administrative Claim (MAC) reimbursable activities
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What is RMTS?
RMTS = Random Moment Time Study (or Sample) In this method, random 1 minute increments of time are sampled across an entire
quarter (3 months)
The sample universe (pool of time and staff from which moments are selected) is
based on staff rosters and calendars submitted by participating districts/LEAs/agencies
All work days are typically included in the sample universe Sampling is done “with replacement” Once a moment in time is selected and paired with a participant, both that
moment and participant go back “into the hat” and could be picked again
Staff may receive multiple moments in a quarter or some staff may not
receive any moments
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Variations in RMTS Methodologies
Statistical Validity Thresholds
Most states are now required to meet a 95% confidence level with an error rate of +/-2% - 2,401 valid moments per cost pool required
The 2003 CMS Guide and some states still operate under a 95% confidence level with an error rate of +/- 5% - 385 valid moments per cost pool required
Number of Cost Pools
A cost pool is a grouping of staff for sampling purposes
Most states use 2 Cost Pools
Direct Service Providers – Staff eligible to bill for Medicaid-covered direct services Administrative Providers – Staff who are not eligible to bill for direct services, but who participate in
allowable activities under the MAC Program
Other variations
3 Cost Pools – Example: Admin Pool + 2 Distinct Pools of Direct Service Providers 4 Cost Pools - Example: Admin Pool + Direct Service Pool + Personal Care Pool + TCM Pool Others
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Variations in RMTS Methodologies
Moment Notification Timelines
The majority of approved programs allow staff to be notified up to 5 calendar days
prior to the sampled moment
States now seeking approval of programs have been required to eliminate any prior
moment notification; participant receives notification of moment exactly at the time the moment occurs
Moment Response Time Requirements
Much variation state to state in definition of “timely moment completion”
Moments are “due” a certain number of days after the moment occurs Moments submitted after deadline are invalid
States now seeking approval of programs have been required to only allow the
participant 2 business (school) days after the moment to complete the documentation
- f the moment
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Variations in RMTS Methodologies
Moment Completion Process
Most states have participants complete moments on-line
Easily confirms date and time of moment submission Allows for enforcement of completion requirements Allows for electronic signature compliance
Some states allow some staff to complete moments on paper
Requires quality assurance review of returned moments Timelines for completion usually shortened to allow for receipt of documentation Additional document retention and verification requirements
Centralized Coding
Many states have moved to a Centralized Coding methodology in which the sampled
participant answers a series of questions, but DOES NOT select an activity code describing their time
Centralized staff review the narrative response and assign to the moment an activity code
which results in more consistent coding
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Drivers of RMTS
Staff Pool List
Staff can only be claimed for reimbursement if they were listed on the quarterly
participant roster*
Important to include all staff billing for direct medical services Including staff who do not regularly perform these billable activities could lower the
reimbursement percentage/allowable cost base
* Some programs allow for the claiming of direct replacements for staff who have left the
district
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Scenario #1 Scenario #2 Amount of Allowable Costs (A) $1,000,000 $750,000 Direct Service RMTS Percentage % (B) 30% 45% Medicaid IEP Ratio ( C ) 40% 40% FMAP (D) 55% 55% Net Claim Amount (A X B X C X D) $66,000 $74,250
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Drivers of RMTS
Impact of Federal Funds
Staff who are 100% federally funded should not be included on the staff pool list
Federal reimbursement not available on cost base of federal funding Related note: Staff who are 100% federally funded should not bill for direct medical services No allowable costs would be eligible to be included in the cost settlement calculation;
reimbursement would have been received for those services; district would be in a deficit situation at that start of the cost settlement process
In order to avoid risk, some districts adjust distribution of federal funds across various staff groups as allowed within the rules of funding sources
Contractors and Billing
Some districts include contracted staff on their staff pool list as they also bill for their direct services
Contracted staff on the staff pool list may get selected for a moment and would be required to complete that moment or it could affect compliance
Some districts have been hesitant to include contracted staff because of RMTS compliance issues
Some states allow for an alternative methodology for including contracted staff
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Drivers of RMTS and Methodology (cont’d)
Private Facilities
Some districts include private facility staff on their staff pool list since they also bill for their direct services
Private facility staff on the staff pool list may get selected for a moment and would be required
to complete that moment or it could affect compliance
Some districts have been hesitant to include private facility staff because of RMTS compliance issues
They often change and the district is not notified of staff changes Less ability to compel to complete a moment because they work directly for the private facility and not
the district
Some states allow an alternative method for including Private Facility Staff
Tracking of Replacements
CMS has increased compliance requirements around RMTS
Districts need to track replacements of staff that change during a quarter to ensure that sampled moments get completed in the required time frames
Decreased response times increase this urgency for staff responsible for tracking and notifying replacements and routing an sampled moments
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Best Practices / Lessons Learned
STAFF POOL LIST:
Make sure the appropriate staff are listed on the staff pool list Utilize detailed work schedules for staff on roster to better ensure moments selected
represent work time
Closely manage staff roster and communicate direct replacements
RMTS:
Continuously training all RMTS participants regarding level of detail needed on
responses
Train program stakeholders regularly in terms of program intent and requirements Include escalation (to supervisor) on notification of non-compliant staff Give LEA coordinators real-time, direct access to detailed RMTS compliance data
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Best Practices / Lessons Learned
GENERAL:
Communication and collaboration amongst all stakeholders: program policy group and implementer group – providers, DOE, Medicaid, audit, billers
Understand that the program will continue to evolve and be prepared by knowing your data / impact analysis
Maintain clear and concise audit trail/data
Manage federal funds where appropriate away from reimbursement-eligible staff
Strengthen interdepartmental communication – Finance, Special Education, Building Leadership, Human Resources
Regular dialogue with providers regarding compliance review results within the state, trends, and understanding of intricacies of the overall program
Review OIG audit results on a regular basis for an indication of CMS areas of concern
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Questions?
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For More Information, Contact:
Your NAME Region 3 Representatives Jeremy Ford, CA (LEA) Melinda Hollinshead, AZ (Medicaid) Shannon Huska, CO (At-Large) Stacie Martin, KS (Education) Email: Region3@medicaidforeducation.org Region 3: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Kansas, Montana, Nebraska, Nevada, New Mexico, North Dakota, Oregon, South Dakota, Utah, Washington and Wyoming
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