School Based Claiming Program Regional Information Session Spring - - PowerPoint PPT Presentation

Arizona Medicaid School Based Claiming Program

Regional Information Session

Spring 2015

Agenda

• For each program component, we will

discuss:

• Trend Analysis
• Back to Basics (B2B)

 RMTS  Quarterly Cost Reporting  Annual Cost Settlement  Direct Service Claiming

Know-Want-Learn Worksheet

• First Column: List what you already know about the MSBC program (Know)
• Second Column: List what you want to know about the MSBC program and/or what

you hope to learn during today’s RIS information session (Want)

What I Know What I Want to Know What I Learned

RIS Survey

• In February 2015, PCG requested feedback from LEA coordinators asking

how well they understand the components of Medicaid School Based Claiming (MSBC) program and where more information is needed

• Survey sent to 106 LEAs with 19 questions rating level of understanding on a

5 point scale (1 = lowest and 5 = highest) for MSBC program components

• RIS survey provided in-depth data on:
• Overall average understanding of the MSBC program
• Level of understanding of each MSBC program component
• Level of understanding of specific program functions

RIS Survey Results

• Overall average of the survey results displayed an intermediate understanding

(3.18) of all MSBC program components

• Area(s) of least level of understanding: Quarterly & Annual Cost Reporting
• Area(s) of highest level of understanding: RMTS & Compliance

RIS Survey Results

RIS Survey Questions

Areas of strongest understanding:

 Requirements to participate in the Random Moment Time Study (RMTS)  Which staff should be included on the RMTS Staff Pool List  Submitting DSC claims only for providers listed on the Staff Pool List  Using the RMTS web-based system  Securely sending student information

Areas of least understanding:

 Accurate billing for transportation services  Using the Medicaid Cost Reporting and Claiming System (MCRCS)  How to report costs for direct replacements  Calculation and application of ratios to annual and transportation costs  Determining allowable annual transportation other costs

Random Moment Time Study

RMTS Results – Direct Medical %

RMTS Results – Direct Medical %

• CONCERN: Personal care provider direct service percentage has been

consistently declining

• What does this mean for your LEA?
• Possible variables impacting the decline – Group discussion
• What variables do you think have contributed to the decline?
• Within your LEA
• Within the state
• What are ways to address this so the decline doesn’t continue?
• How is personal care return rate compliance within your LEA?
• Ways to improve return rate

RMTS Results – MAC %

RMTS – Compliance

RMTS – Success Story Strategies

Lake Havasu Unified School District

• RMTS training occurs one week before the first week of school for all

participants, focusing on the RMTS program, importance, and how to complete a moment

• Training is available throughout the year for new providers, as well as any

teachers who would like to understand the program in order to assist their personal care aides

• Follow-up emails are sent to any participants with incomplete moments, with

advisor or principal cc’d

• Coordinator has “Open door” policy throughout the year, extending time to

meet with providers if guidance is needed with RMTS submission

RMTS – Success Story Strategies

Alhambra Elementary School District

• Late notifications are sent to the participant, and copying the Director of

Student Services

• Assistance is offered for moment completion and a confirmation email is

required once the moment has been completed

• If a 3 day late notification is received, the participant receives an email and

phone call from the coordinator

• Prior to winter and spring breaks, all participants are contacted on the day of

their moment to ensure it is completed that day

B2B: RMTS – Cost Pools

• The RMTS staff pool list consists of three cost pools that must be updated

each quarter:

• Cost Pool 1- Direct Service Providers:
• Includes all direct service providers who render health care services as

prescribed in an IEP

• Actively billing
• Registered with AHCCCS
• Have a unique email address and access to a computer with Internet

B2B: RMTS – Cost Pools

• Cost Pool 1- Direct Service Providers

Job Code Job Category Job Code Job Category 01 Audiologists 11 Physical Therapy Assistants 02 Certified Occupational Therapy Assistants 12 Psychiatrists 04 Speech-Language Pathologists 13 Psychologists 06 Licensed Marriage and Family Therapists 14 Registered Nurses and Licensed Practical Nurses 08 Licensed Professional Counselors LPC 15 Social Workers 09 Occupational Therapists 28 Speech-Language Pathology Assistants 10 Physical Therapists

B2B: RMTS – Cost Pools

• Cost Pool 2- Administrative Service Providers Only
• Includes LEA staff who routinely perform administrative and outreach activities to

students and/or their families that support health related / Medicaid services

• Providers that DO NOT provide direct health care services nor bill for Medicaid

reimbursement (e.g. certain psychologists, nurses)

• LEA specific job titles that do not have a clear Job Category and Code should be

included under the Program and Staffing Specialist or Student Services Personnel job categories

• Must have a unique email address and access to a computer with Internet

B2B: RMTS – Cost Pools

• Cost Pool 2- Administrative Service Providers Only

Job Code Job Category Job Code Job Category 16 Administrators for Exceptional Student Education* 24 Program and Staffing Specialist* 17 Audiology Assistants 25 Special Education Teachers* 18 Augmentative Specialists 27 Student Services Personnel* 19 Bilingual Specialists 29 Non-Billing DSC Providers 20 Dietitians 30 Guidance Counselors* 21 Interpreter 32 School Based Psychologists 22 Liaisons for Exceptional Student Education* *Position Classification Form (PCF) Required

B2B: RMTS – PCF

• Position Classification Forms (PCFs) are required for certain job titles listed

under RMTS job categories within the Administrative Service Providers Only cost pool that have some ambiguity of job duties

• PCFS are required for the following job codes:
• Administrators for Exceptional Student Education- Job Code 16
• Liaisons for Exceptional Student Education- Job Code 22
• Program and Staffing Specialists- Job Code 24
• Special Education Teachers- Job Code 25
• Student Services Personnel- Job Code 27
• Guidance Counselors- Job Code 30

B2B: RMTS – PCF

• The PCF provides supporting documentation as to why job titles/job duties

not clearly identifiable through the title are listed on the staff pool list

• Needs to be submitted once during the duration of the LEA’s participation in

the program

• A new PCF is required when a new job title has been added to the staff pool

list or if there has been a change in the responsibilities of the job title

• PCF must match exactly the job title on the RMTS staff pool list
• PCFs are available on PCG website and RMTS dashboard

B2B: RMTS – Cost Pools

• Cost Pool 3- Personal Care Providers
• Health Aide staff registered with AHCCCS and billing Medicaid for Activities of

Daily Living (ADL) services prescribed in the IEP

• Do not include instructional aides that provide educational services only
• Must have a unique email address and access to a computer with Internet

Job Code Job Category 31 School Health Aides

B2B: RMTS – Compliance

• Managing RMTS participant changes and LEA compliance
• It is important to communicate changes (leave of absence, direct replacements,

term dates) to PCG for participants with sampled moments so the moments can be justified

• PCG enters the term date and leave information for the moment. PCG does

not update the staff pool list. LEA coordinators are responsible for inactivating participants and adding (new) direct replacements to the SPL for the upcoming quarter in the RMTS system

• “Justified” moments will not be counted against compliance when a

participant:

• Terms before the moment
• Changes to a position that does not participate in the time study
• Is on leave and not returning within the 5 days to complete the

moment timely

B2B: RMTS – Compliance

• Notify PCG when participants with sampled moments falls into one of the

scenarios below :

• Participant has termed: prior to the moment, send an email to

azrmts@pcgus.com with the participant’s name, sampled moment, and the date the participant left the LEA

• Participant is on a leave of absence: prior to the moment, send an email

azrmts@pcgus.com with the participant’s name, sampled moment, start and end date of the leave, and whether the leave is paid or unpaid

• This is for extended leave where the leave covers the moment assigned and

the 5 working days after the moment

B2B: RMTS – Compliance

• Participant has termed and a direct replacement has been hired:
• Email azrmts@pcgus.com with the termed participant’s first and last name,

sampled moment and the direct replacement’s first and last name and email address

• Participants cannot have a replacement if they are on extended leave- it

must be a direct replacement

• Direct replacement cannot be a participant who is already listed on the staff

pool list, a substitute, or an employee covering the position

• Direct replacements must meet the requirements to be included in the time

study and the cost pool for which they are being placed

B2B: RMTS – Compliance

Compliance policy for LEAs not reaching quarterly minimum return rate of 85%

Student Roster

Student Roster

• The student roster is one of the program components that has a significant

impact on LEA reimbursement

• This data determines how much the LEA spends providing Medicaid allowable

services and activities to their specific Medicaid population

• Many LEAs struggle with completing the student roster template accurately

and timely based on the guidelines provided in the annual data request

• Common Issues:
• Data is not consistent with the template requirements
• Only includes the special education population
• Missing student’s date of birth and gender
• Conflicting information to questions ‘student in special education’ – NO, ‘related

service on the IEP’ – YES

Student Roster – Impact #1

• The student roster is used to calculate the Medicaid Eligibility Rate

(MER)

• MER is a variable that is used in the calculation of the Quarterly

MAC claim

Student Roster - Impact #2

• The student roster is used to calculate the Individualized

Education Program Ratio (IEP Ratio)

• The IEP ratio is a variable that is used in the calculation of the

DSC Annual Cost Settlement

Student Roster

• Overview and requirements
• Who is included?
• Indicate whether or not the student is in special education on October 1st
• Indicate whether or not the student has an IEP prescribed reimbursable related

service on October 1st

• Speech, Physical Therapy, Occupational Therapy, Audiology Services, Nursing

Services, Behavioral Health Services, and Personal Care Services

• Indicate whether or not the student requires specialized transportation as

prescribed in an IEP on October 1st

• Group Exercise
• Assemble Student Roster
• Identify Yes or No for Special Education and IEP Service columns

Quarterly Cost Reporting / MAC

MAC – Reimbursement

MAC – Success Stories

• 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

B2B: MAC Overview

• Medicaid Administrative Claiming (MAC) offers quarterly reimbursement for

the costs associated with administrative and outreach activities performed by staff listed on the Staff Pool List (SPL)

• Only Direct Service Providers and Administrative Service Providers participate in

the MAC program.

• Each quarterly submission requires LEAs to report payroll costs using a

cash-based accounting method for staff listed (or a direct replacement for someone listed) on the SPL for the applicable period within the web-based Medicaid Cost Reporting and Claiming System (MCRCS)

B2B: 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 in 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

B2B: MAC – Cost Reporting Example

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

B2B: MAC – Purchased Professional Staff (PPS) Documentation

• Invoices MUST INCLUDE:
• Participant name (first and last) as listed on the staff roster
• Charges allocated to specific participant
• Services provided
• If PPS costs cannot be substantiated with detailed invoices, they cannot be

reported

• Work with your vendors to obtain the detail necessary to accurately report costs
• You are entitled to this information as their customer
• Financial impacts
• $12.7 million reported in contractor costs statewide in OD14
• Per review of statewide JS14 and OD14 edit explanations, 13% of line items had

no costs reported due to lack of detailed invoices

B2B: MAC – PPS Detailed Invoice Example

B2B: MAC – Reporting Costs for Direct Replacements

• If an employee has terminated their employment during the reporting period

and a new employee has directly replaced the terminated employee in the same position, costs paid for that position during the reporting period can be reported for both employees

• Costs paid for the terminated employee from the reporting period start date

to the date of termination are added to the costs paid for the direct replacement (or new employee) from the hire date to the reporting period end date

• Total costs paid for that position (terminated employee’s costs + direct

replacement’s costs) would be reported under the terminated employee’s line within the cost report

B2B: MAC – Reporting Costs for Direct Replacements

• Please note in the “Notes” column the date of termination of the terminated

employee, and the direct replacement’s name and date of hire

• The direct replacement must be directly replacing a terminated employee in

the same position within the reporting period

• NOTE: Substitute employee costs paid while an employee is on extended

leave cannot be reported

B2B: MAC – Reporting Costs for Direct Replacements Example

• Susan Sanchez is a SLP who terminated 10-24-14
• Total salaries from 10-1-14 to 10-24-14 are $1500.00
• Total benefits from 10-1-14 to 10-24-14 are $500.00
• Roger Marks is a SLP who replaced Susan Sanchez, and was hired 11-1-14
• Total salaries from 11-1-14 to 12-31-14 are $4500.00
• Total benefits from 11-1-14 to 12-31-14 are $1500.00

Venn Diagram Exercise – MAC, Annual, or Both?

J) Cash-based methodology I) Administrative Cost Pool D) Quarterly claim reimbursement E) Allowable salaries, benefits, & PPS costs A) Impacted by RMTS % F) Student Roster B) Accrual-based methodology C) Direct Service Cost Pool H) Used to calculate cost settlement G) Personal Care Cost Pool K) IEP Ratio L) MER %

Annual

• Accrual-based

methodology

• Used to calculate

cost settlement

• Personal Care

Cost Pool

• IEP Ratio

MAC

• Cash-based

methodology

• Quarterly claim

reimbursement

• Administrative

Cost Pool

• MER %

Both

• Allowable

Salaries, Benefits, and PPS costs

• Impacted by

RMTS %

• Direct Service

Cost Pool

• Student Roster

MAC vs. Annual

Direct Service Claiming (DSC) Annual Cost Settlement

DSC Annual Cost Settlement

• Where are we with DSC Annual Cost Settlement?

Jan ‘15 Feb ‘15 March ‘15 Apr ’15 May ‘15 June ‘15 July ‘15 Aug ‘15 Sep ‘15 Oct ‘15 Nov ‘15 Dec ‘15

DSC Annual Cost Settlement

• FY14 Desk Review Lessons Learned
• LEAs still need further clarification on transportation reporting and requirements
• What is allowable versus what is not?
• What makes the bus go?
• Stay tuned for transportation activity!
• “Specialized” vs. “General” Costs
• Annual Payroll continues to cause confusion
• Only report salary and benefits for quarters individuals are on the staff pool

list

• The “right” people are not always filling out the cost reports
• Or they are not trained to do so and have a lack of understanding for

program policy

• LEAs are not always reporting based on approved methods
• We still see “back of the envelope” calculations and non-approved methods
• f reporting costs

DSC Annual Cost Settlement

• LEAs who are successful in the annual DSC Annual Cost Settlement

process:

• Have a plan for success
• Engage the right individuals
• Make sure documentation is prepared and ready
• Are prepared for compliance reviews, desk reviews, and any other questions

PCG asks

• Are organized with an audit folder - If PCG asks, the LEA can answer

questions with confidence

• Practice Interdepartmental Communication
• Everyone knows who is responsible for what
• Transition plans exist for staff turnover or job shifts
• Understand reporting requirements and methodologies
• As does their transportation department
• Respond in a timely manner to PCG requests

B2B: DSC Annual Cost Reporting

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

in MCRCS against LEA supplied supporting documentation including:

• Salary and benefit information for direct medical service providers and

transportation staff

• IEP Ratio information
• Transportation data
• All annual costs must be reported on an accrual accounting methodology
• PCG conducted 30 Annual Compliance Reviews on FY13 data
• Congratulations to the following LEA who achieved an overall final score of 100%
• n the Annual portion of their comprehensive compliance review:
• Palominas Elementary School District

B2B: DSC Annual Cost Reporting

B2B: DSC Annual Cost Reporting

• As a reminder, the purpose of DSC Annual Cost Reporting is to reimburse

LEAs for the true cost of providing direct medical services and specialized transportation services to Medicaid eligible students

• The total reimbursement equates to what you have received in DSC interim

claiming throughout the year, in addition to your cost settlement amount

• LEAs will be entering their fourth year of DSC Annual Cost Reporting in

October, as they will be submitting costs for FY15 (July 1, 2014 – June 30, 2015)

• The two biggest areas for improvement are:
• Annual Payroll
• Transportation Other Costs

B2B: DSC Annual Cost Reporting

• Annual Payroll
• Who is entering your LEA’s Annual Payroll costs?
• Do they understand that costs should pertain only to the quarters for which the

individual was on the staff pool list?

• Costs will always be reported on an accrual basis for the annual report and
• nly for the quarters on which the providers are listed on the SPL
• If a provider is only listed on the SPL for two of the four quarters, only the

salary and benefit information relating to those two quarters should be reported

• This type of erroneous reporting continues to be an audit finding in both desk

reviews and compliance reviews

• The person responsible for entering payroll should verify which quarters the

individual was on the staff pool list, and report the amounts for that time period

B2B: DSC Annual Cost Reporting

• Reporting annual payroll costs
• Costs should only be reported for the quarters identified with a “1”
• Columns with a “0” indicate the staff member was not included on that quarter’s

Staff Pool List

B2B: DSC Annual Cost Reporting

Group Exercise: What Makes the Bus Go?

B2B: DSC Annual Cost Reporting

Group Exercise: What Makes the Bus Go?

B2B: DSC Annual Cost Reporting

B2B: DSC Annual Cost Reporting

B2B: DSC Annual Cost Reporting

B2B: DSC Annual Cost Reporting

B2B: DSC Annual Cost Reporting

B2B: DSC Annual Cost Reporting

B2B: DSC Annual Cost Reporting

B2B: DSC Annual Cost Reporting

B2B: DSC Annual Cost Reporting

B2B: DSC Annual Cost Reporting

• Prior to reporting allowable, Transportation other costs, the

following questions should be reviewed:

• Are the costs relatable to making a bus go for the purpose of

transporting a special education student to school to receive a direct medical service?

• Or- are these costs pertaining to general/regular education

transportation (driver uniforms, etc.)?

B2B: DSC Annual Cost Reporting

• “Specialized” vs. “General” Transportation Clarification
• When you report any transportation costs you are required to identify those costs

as “specialized” or “general”

• Before you report any specialized transportation costs…

Direct Service Claiming (DSC)

DSC - Provider Registration

• The AHCCCS Provider Registration process is required for those who

provide medical care services

• When notified by AHCCCS that it is time for a provider to re-enroll, the

reenrollment packet must be completed and returned to registration by their deadline

• Failure to complete the necessary forms may result in termination of the AHCCCS

Provider ID and an inability to bill for services

• Transportation providers are not required to have their own AHCCCS ID
• For your reference, the following forms can be found at the link below:
• http://www.azahcccs.gov/commercial/ProviderRegistration/packet.aspx
• Registration Packets
• Re-enrollment Packet
• Where to Send Completed Forms
• Who to Contact with Questions

DSC - Health Aide Reviews

• Common denial reasons:
• All questions on Health Aide Prepayment Review Form (HA Form) are not

complete or reflective of attached IEP

• Conflicting information between the HA Form and the IEP documentation
• AHCCCS ID is not accurate
• Missing signature and date of prescribing qualified provider on the IEP and/or the

IEP amendment / addendum

• Non reimbursable ADLs included with Medicaid reimbursable ADL minutes
• As a reminder, non reimbursable ADLs include:
• G-tube feeding
• Behavior management
• Supervision
• Reinforcement of therapy goals
• Minutes in documentation given as a range exceeding 60 minutes
• Prescribed frequency for reimbursable ADLs is not consistent throughout IEP

B2B: Health Aide Prepayment Review

• Health Aide services must be prescribed by a Qualified Medical Provider for

Activities of Daily Living (ADLs)

• Scope, frequency and duration must be clearly documented in IEP
• Health Aide prepayment review form(s) with documentation must be

submitted for authorization Qualified Medical Providers:  Audiologist  Licensed Clinical Social Worker  Licensed Marriage and Family Therapist  Licensed Professional Counselor  Occupational Therapist  Physical Therapist  Psychiatrist  Psychologist  Licensed Practical Nurse  Registered Nurse  Speech-Language Pathologist

B2B: Activities of Daily Living Examples

Activity Examples Eating/Feeding Cleaning hands and face, cutting up or preparing food, carrying breakfast or lunch tray, setting up food or opening packages, assist with hand to mouth or bottle feeding Dressing Putting on, taking off or tying shoe laces, putting on jacket/coat Grooming Brushing teeth, hand or face washing Mobility Assistance to and from the bus, in-between classes, pushing wheelchair for non- ambulatory students, stand by assistance while student is ambulating Positioning Frequent body changes (sitting up or laying prone, etc.), realignment of body for proper posture, relieving pressure off points of the body Toileting Washing hands, changing diaper, stand by assistance Transfers Moving student to various equipment, physical movement from one place or piece of equipment to another Assistive Devices Using a hoyer lift, stander, walker or medically necessary prescribed equipment, assisting with hearing aids or glasses, assisting to set up or use augmentative or electronic device

B2B: DSC Health Aide Status

• LEAs receive a Health Aide Inventory report weekly which identifies the

status of authorization requests

• Approved – Indicates that the HA request has been reviewed and approved for a

specified number of units and date range

• Denied – Indicates that the documentation provided by the LEA along with the HA

forms has been reviewed and denied

• System Hold – Indicates that at the time of authorization creation the system

identified an issue with the student’s eligibility

• Verify the student is age appropriate for the program within the date span of

authorization (3 to 21 years old)

• Verify student eligibility with AHCCCS within the date span of authorization
• This status does not prevent a LEA from billing, does not pend claims and no

additional documentation needs to be provided Note: An authorization is never a guarantee of payment and the LEA can only bill for days that the student was in attendance, eligible and approved for services

Training Resources

• 2015 Annual Regional Compliance Training:

http://web.pcgus.com/azschools/resources/trainings/index.html

05/14/2015 05/21/2015 06/11/2015 06/24/2015

Health Aide Refresher Training MSBC 101 DSC Compliance Requirements MAC Compliance Review

Know-Want-Learn Worksheet

• Third Column: List what you learned as a result of today’s RIS information

session in the third column (Learn)

• Is there anything you wanted to know (second column) that was not covered

in today’s session? What I Know What I Want to Know What I Learned

Questions

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