School-Based Health Services October 2015 LIMITED OFFICIAL USE ONLY - - PowerPoint PPT Presentation

School-Based Health Services

October 2015

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Agenda

• OIG/OAS – Who We Are
• Medicaid Program Overview
• OAS SBHS Work
• Case Studies
• Future Work
• Questions

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OIG/OAS Who We Are

• HHS OIG works to fight waste, fraud, and

abuse in Medicare, Medicaid, and other HHS programs.

• OAS conducts independent audits of HHS

programs, grantees, and contractors.

• OAS also assists investigations conducted

by OIG/OI and the DOJ.

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OIG/OAS Who We Are

• Overview

– Number of employees and reports – Medicaid Work Plan Items – Focus of our audit work

• States
• Providers
• CMS

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Medicaid Program Overview

• Pursuant to Title XIX of the Social Security

Act, the Medicaid program provides medical assistance to certain low-income individuals and individuals with disabilities.

• The Federal and State Governments jointly

fund and administer the Medicaid program.

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Medicaid Program Background

2014 Expenditure Estimates

• Federal and State expenditures of $499
• billion. Federal government funding

60 percent

• Expenditures are projected to increase

at an average annual rate of 6.2 percent and to reach $835 billion by 2023.

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Medicaid Program Background

2014 Enrollment Estimates

• Average Medicaid enrollment of 65

million people

• Average enrollment is projected to

increase at an average annual rate of 3.0 percent over the next 10 years and to reach 79 million in 2023.

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OAS School-Based Work

• General Overview

– Since FY 2002 OAS has issued 35 audit reports concerning school-based health services, related transportation services, and Random Moment Time Studies (RMTS). – $1,077,111,432 in Questioned Costs – $1,142,810 in Funds Put to Better Use – Covering 14 States

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Findings

• School-Based Health Service Reviews

– Billing errors (including duplication and incorrect coding) – Expenses claimed for activities fully funded or reimbursed by sources other than Medicaid – Claims made for students absent or discharged from school – Claims made for out-of-state students – Federal provider requirements not met – Services rendered by unlicensed providers

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Findings (con’t)

– Inappropriate administrative costs – Improper payment rate used – Services not rendered – No or inadequate documentation – No or untimely child’s plan/family plan – Prescription/referral requirements not met – Recoupment and return of reimbursement for duplicate claims not made in a timely manner – Services claimed for student in an institution for mental diseases

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Findings (con’t)

– Claimed services not reimbursable by Medicaid – Services not specified in child’s plan/family plan – State did not remit checks for increased reimbursement rate back to school districts – Student eligibility requirements not met – Transportation requirements not met – Unallowable operating costs

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Findings (con’t)

• Transportation Service Reviews

– Received reimbursement for transportation services when, according to State regulations, they were prohibited from doing so at the time – No or inadequate documentation – Services not rendered – Transportation expenses claimed when no associated health service was rendered – Transportation services not included in child’s plan – Services overbilled

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Findings (con’t)

• Random Moment Time Study Reviews

– Inaccurate time studies and/or cost reports used – Interim payments were not reconciled with actual costs – Administrative costs overstated – No documentation to support RMTS methodology

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Causes

• Inadequate or incorrect guidance from State agencies
• Inadequate policies and procedures
• Insufficient monitoring from State agencies
• School-based health providers did not comply with

Federal requirements such as maintaining documentation

• Third party contractors improperly calculated

payment rates, duplicated certain costs, and billed for services on days when students were not in school.

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Case Studies

• Arizona Improperly Claimed Federal

Reimbursement for Medicaid School-Based Administrative Costs (A-09-11-2020)

• Kansas Improperly Received Medicaid

Reimbursement for School-Based Health Services (A-07-13-4207)

• New Hampshire Did Not Always Correctly

Claim Medicaid Payments for School-Based Transportation Services (A-01-11-00008)

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Case Study: A-09-11-2020

Arizona Improperly Claimed Federal Reimbursement for Medicaid School-Based Administrative Costs

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Case Study: A-09-11-2020

Objective To determine whether (1) the State agency maintained required documentation to support the RMTS methodology used to allocate school-based administrative costs to the Medicaid program and (2) the RMTS methodology was consistent with Federal requirements.

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Case Study: A-09-11-2020

Methodology

• Reviewed applicable Federal laws, regulations, and

guidance and the State plan;

• Reviewed the contract between the State agency and

Maximus for the MAC program;

• Reviewed the State guides developed in calendar years

2004 (amended in October 2008), 2009, and 2010;

• Interviewed CMS officials to obtain an understanding of

the RMTS methodology and documentation requirements in the CMS guide;

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Case Study: A-09-11-2020

• Interviewed officials from the State agency, Maximus, and

selected local education agencies to obtain an understanding of the MAC program and the State agency’s RMTS methodology for allocating school-based administrative costs to Medicaid;

• Obtained from the State agency computer-generated data

files related to Medicaid school-based administrative costs claimed for the audit period;

• Verified the mathematical accuracy of the State agency’s

calculations of Medicaid school-based administrative costs reported on the invoices and summary sheets for the MAC program;

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Case Study: A-09-11-2020

• Determined whether the State agency’s RMTS results were

statistically valid by obtaining a professional opinion from

• ur statistical consultant, who evaluated

– our description of the findings as presented in the section entitled “Sampling Methodology Not Fully Consistent With Federal Requirements,” – the result of our analysis showing the sample size and the number of discarded sample items for each quarter (when available), and – CMS’s responses to our questions related to the discarded sample items;

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Case Study: A-09-11-2020

• Reviewed the quarterly data files and observation forms to deter

mine the number of sample items that Maximus selected but discarded when calculating a statewide Medicaid percentage and to identify activity codes for the discarded sample items;

• Recalculated the statewide Medicaid percentages on the basis of
• ur review of the quarterly data files and observation forms;
• Used the State agency’s formulas for calculating Medicaid

school-based administrative costs and determined the effect on the Federal reimbursement by comparing the original claiming invoices with the revised invoices; and

• Shared the results of our review with CMS and State agency
• fficials.

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Case Study: A-09-11-2020

Findings

• For 2 of the 19 quarters, the State agency did

not maintain required documentation to support (1) the universes of total available moments in time and RMTS participants and/or (2) the sample of random moments for selected participants.

– Because the State agency did not maintain this documentation, the $5,421,711 in Federal reimbursement that it received for these quarters was unallowable.

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Case Study: A-09-11-2020

• For the remaining 17 quarters, the State agency’s RMTS

methodology was not fully consistent with Federal requirements:

– The State agency inappropriately discarded sample items when calculating the statewide Medicaid percentages. We determined $6,295,139 of Federal reimbursement was unallowable on the basis of the revised statewide Medicaid percentages we calculated. – The RMTS methodology did not meet acceptable statistical sampling standards because the universes from which the sample items were selected were incomplete or incorrect. Because we were unable to determine which portion of the State agency’s claim for Federal reimbursement would have been allowable if complete or correct universes had been used to calculate the statewide Medicaid percentages, we set aside the remaining $18,828,972 for CMS resolution.

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Case Study: A-09-11-2020

Findings - Causes

• The State agency did not have adequate controls to

ensure that it maintained all required documentation to support the RMTS methodology and that the RMTS methodology was consistent with Federal requirements.

• The 2004 State guide did not adhere to the CMS guide

and stated that the State agency could discard sample items, such as nonresponses and observation forms with missing or inaccurate information, from the sample when calculating the statewide Medicaid percentage.

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Case Study: A-09-11-2020

Recommendations We recommend that the State agency:

• refund to the Federal Government $11,716,850 for unallowable school-

based administrative costs,

• work with CMS to determine the allowability of $18,828,972 that we set

aside and refund to the Federal Government any amount determined to be unallowable,

• strengthen controls to ensure that all required documentation to

support the RMTS methodology is maintained and the RMTS methodology is consistent with Federal requirements, and

• review periods after our audit period and make appropriate financial

adjustments for any unallowable school-based administrative costs claimed.

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Case Study: A-07-13-4207

Kansas Improperly Received Medicaid Reimbursement for School-Based Health Services

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Case Study: A-07-13-4207

Objective To determine whether the direct medical service costs that the State agency claimed for SBHS were reasonable, adequately supported, and otherwise allowable in accordance with applicable Federal and State requirements.

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Case Study: A-07-13-4207

Methodology

• Reviewed applicable Federal and State requirements;•
• Reviewed the State agency’s policies and procedures concerning

SBHS, which included the State agency’s monitoring and oversight procedures;

• Interviewed State agency employees to understand how they

administered the SBHS program statewide;

• Interviewed Contractor employees to understand how they

administered the SBHS program and how the statewide RMTS percentages were calculated;

• Reconciled the State agency’s CMS-64 reports to supporting

documentation to determine whether interim costs claimed were adequately supported;

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Case Study: A-07-13-4207

• Reconciled the actual costs reported on the annual cost reports

for the Wichita and Kansas City, Kansas, public school districts to accounting records;

• Interviewed Wichita and Kansas City, Kansas, public school

district employees to understand how they administered the SBHS program;

• Judgmentally selected 30 healthcare providers each, that were

performing direct medical services for the Wichita and Kansas City, Kansas, public school districts, and ensured that the providers were qualified to provide these services as defined by the State plan;

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Case Study: A-07-13-4207

• Judgmentally selected 30 direct medical service claims each for

the Wichita and Kansas City, Kansas, public school districts to determine whether they were properly billed;

• Reviewed all 2,894 survey responses that were (1) completed by

employees of participating school districts in Kansas and (2) coded by the Contractor as IEP-covered direct medical services, to determine whether the responses were coded appropriately;

• Reviewed a sample of 337 random moments that the Contractor

coded as allowable SBHS activities used in the RMTS (we did this to estimate the number of unsupported responses provided by participants completing the RMTS surveys);

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Case Study: A-07-13-4207

• Recalculated the Wichita and Kansas City, Kansas, public school

districts’ annual costs, using the corrected expenditures and the corrected statewide RMTS percentages, to determine the amounts that should have been claimed;

• Recalculated the other participating Kansas school districts’

annual costs, using the audited statewide RMTS percentages, to determine the amounts that should have been claimed;

• Used the State agency’s formulas for calculating actual annual

costs and determined the financial effect of all errors identified by comparing the original annual costs to the recalculated annual costs using audited costs and RMTS responses;

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Case Study: A-07-13-4207

• Shared the results of this review, including the details of
• ur recommended adjustments, with Wichita public

school district officials on July 31, 2013, and with Kansas City, Kansas, public school district officials on August 6, 2013; and

• Shared the results of this review, including the details of
• ur recommended adjustments, with State agency officials
• n August 6, 2013.

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Case Study: A-07-13-4207

Sample Results

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Case Study: A-07-13-4207

Sample Results

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Case Study: A-07-13-4207

Sample Results

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Case Study: A-07-13-4207

Findings

• The State agency accounted for only $17,067,870 ($11,891,835 Federal

share) of the $24,792,498 ($17,270,734 Federal share) in interim payments during final cost settlement. Because the State agency excluded $7,724,627 ($5,378,899 Federal share) in interim payments at cost settlement, the Medicaid direct medical service costs were

• verstated and therefore not reasonable. As a result of this error, the

State agency received $5,378,899 in unallowable Federal reimbursement.

• The State agency claimed unallowable costs based on RMTS errors.

Specifically, the Contractor selected invalid participants, selected random moments on invalid dates, and coded some activities

• inaccurately. As a result of these errors, the State agency received

$4,715,310 in unallowable Federal reimbursement.

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Case Study: A-07-13-4207

• The State agency claimed Medicaid direct medical service

costs that were not supported by its internal cost reporting

• system. As a result, the State agency received $643,094 in

unallowable Federal reimbursement.

• The State agency claimed unallowable costs because the

Kansas City, Kansas, public school district overstated employee benefit and supply costs by $94,835. As a result, the State agency received $11,403 in unallowable Federal reimbursement.

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Case Study: A-07-13-4207

Findings – Causes The State agency did not have adequate policies and procedures to monitor the SBHS program and to ensure that it claimed all costs in accordance with applicable Federal and State requirements.

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Case Study: A-07-13-4207

Recommendations We recommend that the State agency:

• Refund $10,748,706 to the Federal Government for

unallowable SBHS costs and

• Strengthen policies and procedures to monitor the

SBHS program and ensure that (1) SBHS costs are accurate and supported and (2) in claims all SBHS costs in accordance with applicable Federal and State requirements.

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Case Study: A-01-11-0008

New Hampshire Did Not Always Correctly Claim Medicaid Payments for School-Based Transportation Services

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Case Study: A-01-11-0008

Objective To determine whether the State agency claimed Federal Medicaid reimbursement for school-based transportation services in accordance with Federal and State

• requirements. Our audit period were the

calendar years 2006 through 2009.

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Case Study: A-01-11-0008

Methodology

• Reviewed applicable Federal and State laws, regulations,

and guidance;

• Interviewed officials from CMS, the State agency, and the

SAUs;

• Obtained a computer-generated file from the MMIS

containing all Medicaid school-based health claims submitted by the State agency with claim paid dates from January 2006 – December 2009;

• Evaluated the file to identify 636,838 items for Medicaid

school-based transportation services $28,611,539 ($15,214,592 Federal share);

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Case Study: A-01-11-0008

• Identified a sampling frame of 227,553 items for Medicaid

school-based transportation services having a high risk for

• verpayment totaling $15,766,315 ($8,375,998 Federal

share);

• Selected a stratified random sample of 115 of the 227,553

items;

• Analyzed service logs, IEPs, and other documentation for

each of the 115 items to determine whether each was allowable and accurate in accordance with Federal and State requirements; and

• Estimated the total overpayments and the Federal share of

these overpayments based on our sample results.

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Case Study: A-01-11-0008

Sampling Results

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Case Study: A-01-11-0008

Sampling Results

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Case Study: A-01-11-0008

Sampling Results

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Case Study: A-01-11-0008

Findings

• Of the 115 sample items, 37 items met Federal

and State requirements.

• The remaining 78 items had 1 or more school-

based transportation services that were not reimbursable, totaling $272,327 ($136,397 Federal share).

• Based on our results, we estimated that the

State agency improperly claimed $5,086,636 ($2,695,809 Federal share) for Medicaid payments made to SAUs.

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Case Study: A-01-11-0008

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Case Study: A-01-11-0008

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Specifically, we found items with the following deficiencies:

• For 63 items, the State agency claimed Federal reimbursement for

transportation services for which the documentation did not support that the students had received another medical service on the same day.

• For 11 items, the State agency claimed Federal reimbursement for

transportation services provided by SAUs that were overbilled.

• For 7 items, the State agency claimed Federal reimbursement for

transportation services that did not meet Federal documentation requirements.

• For 6 items, the State agency claimed Federal reimbursement for

school-based transportation services that were not provided.

Case Study: A-01-11-0008

Findings - Causes

• The State agency issued guidance to the SAUs based on its

misunderstanding of Federal requirements. Specifically, State agency

• fficials informed us that they believed the CMS letter clarified that

transportation in a specialized vehicle to and from school is a stand- alone covered service and that another medical service is not required

• n the same day. As a result of this misunderstanding, the State agency

issued policy memorandums to SAUs dated June 24, 1999, and August 15, 2000, stating that all specialized transportation is reimbursable by Medicaid, regardless of whether a student received another Medicaid- covered service on the same day.

• The State agency did not adequately monitor claims submitted by

SAUs for allowability.

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Case Study: A-01-11-0008

Recommendations We recommend that the State agency:

• Refund $2,695,809 to the Federal Government,
• Work with CMS to review Medicaid payments made

to SAUs after our audit period and refund and

• verpayments,
• Strengthen its oversight of New Hampshire

Medicaid to Schools program to ensure that claims for school-based transportation services comply with Federal and State requirements; and

• Issue new guidance on school-based transportation

that is consistent with Federal requirements.

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Future Work

• We have ongoing audits in several States
• Potential for:

– additional RMTS work in future years. – roll-up report to CMS summarizing our individual state work.

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• Questions?

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