Arizona Medicaid School Based Claiming Regional Information Sessions September 2009

Arizona Medicaid School Based Claiming

Regional Information Sessions

September 2009

September 2009 Page 2

Agenda

Arizona Project Team

General Updates

Monthly DSC & MAC Trainings

Coordinator Responsibilities

DSC Timely Filing

Health Aides

Speech Language Pathology Assistant (SLPA)

MAC

Audits


Arizona Project Team

Florie Wong, Project Manager

Lisa Pavelek, Deputy Project Manager

Chris Meola, DSC Program Lead

Marilyn Caylor, DSC Coordinator

Jasmina Tarver, Sr. Auditor

LEA Account Managers:

Cindi Carter

Kristy Ferguson

Lisa Gutierrez

Jamey Harrison


General Updates

Coming Soon – Updated Program Handbooks Updated DSC and MAC Handbooks will be available on PCG

website

http://web.pcgus.com/azschools/

Coming Soon! EFT Option for DSC and MAC Checks LEAs can opt to have their DSC and MAC checks deposited directly

to their bank account

LEAs will need to submit an EFT authorization form

Paper checks will still be available



Understanding the process and requirements for both the DSC and MAC program is vital to your success!

Monthly trainings will be provided via Webinars

LEAs can attend each month and are designed to assist LEAs with new coordinators

DSC training topics will include: Services eligible for reimbursement

How to register Providers and LEAs

How to read a remittance advice (RA)



MAC training topics will include: RMTS Online System

Staff Roster Electronic RMTS Forms Benefits of utilizing the Electronic

RMTS System

Compliance

Training schedule will be posted to the project website


Coordinator Responsibilities - DSC Coordinate Qualified Medical/Service Providers

Ensure Medical Providers are correctly licensed/certified

Assist new Providers with obtaining individual NPI & registering with AHCCCS and verify that Providers are linked to LEA and can submit claims

Keep AHCCCS (Provider Registration) updated on provider changes

Establish Internal Policies Create billing forms/service records and clinical notes forms

Establish process for completing and submitting forms (by providers)

Provide Training Provide DSC Program training, information, & requirements to Medical

Providers, health aides, bus drivers, SPED teachers and support staff.

Train Medical Providers on billing forms/service records and clinical notes and how/when to submit them


Coordinator Responsibilities - DSC

Identify Eligible SPED Students Determine if SPED Students have reimbursable Medical Services

prescribed in their IEP, then verify that they are enrolled in AHCCCS

Submit DSC Claims Review remittance advice after claims are processed Establish TPL policy, if needed

Work with Finance Department Ensure payments are processed timely and Certification of Match

Forms are completed and submitted to PCG

Maintain Audit Records, Files, & Documentation for a minimum of 5 years

Participate In/Coordinate Compliance Audits & Reviews Work with Assigned PCG Account Manager


Coordinator Responsibilities - MAC

Identify the staff in your LEA that routinely perform Medicaid Administrative and Outreach Activities.

Prepare and submit Staff Rosters electronically using the RMTS system on a quarterly basis and Position Classification Forms (PCFs) annually.

Distribute training materials to the participants prior to completing the on-line training.

Monitor employees’ participation - LEA Compliance Review the RMTS Compliance Report weekly and conduct follow-

up


Coordinator Responsibilities - MAC

Coordinate with the LEAs finance personnel to ensure that the cost information of the RMTS selected staff is included.

Submit the District Wide Student Rosters on a semi-annual basis to PCG along with the Certification of Student Roster Form in order to determine the Medicaid Eligibility Rate (MER).

Maintain program Audit files for a period of no less than 5 years after the end of a participating quarter.

Work with your assigned PCG LEA Account Manager throughout the quarter for assistance and success in the MAC Program!


DSC – Timely Filing Claiming Time Limits – Initial Claims, Re-Bills, and TPL

Regardless of the LEA’s billing method, all claims must be received in a timely manner at PCG in order to be considered for payment.

If the LEA is a self biller, or uses a biller who bills electronically, “received” indicates the date the file is confirmed by PCG for a direct-post submitter.

An initial claim must be received by PCG no later than 6 months from the date of service.

Claims received beyond the 6-month time frame will be denied.

A denied claim can be resubmitted (Re-Billed) for up to 12 months from the date of service.

TPL claims for students must be submitted with supporting documentation to PCG within 6 months of the date of service.


DSC- Health Aides If a student is prescribed more than 2 hours (8 units) of Health

Aide services in their IEP, then the LEA must submit a request to PCG for approval prior to billing more than 8 units. Health Aide services must be identified in the IEP. Scope, frequency, and duration must be clearly addressed and written in

the IEP as prescribed by a qualified provider through the appropriate IEP documentation and supporting medical records.

Request should specify amount of time or additional units being sought for approval.

Only time/units associated with allowable activities of daily living (ADLs) will be approved.

PCG will deny requests for additional units that are provided in a range. e.g. 4 – 6 hours per day.

Regardless of the number of units billed, LEAs must have proper documentation in place to support claim.


DSC- Health Aides

Health Aide Results Total IEP’s Reviewed – 117

Total IEP’s Approved – 52

Total IEP’s Denied – 62

Denial Reasons 31 - no supporting documentation on IEP, (Scope, Frequency & Duration)

12 - documentation less than 2 hours of Health Aides services

12 - requested services for reinforcement of therapy goals

3 - educational services

2 - no supporting documentation to justify 2 hours of HA services

The following slide will show various reasons for the denials.


DSC- Health Aides

Preventing Billing Errors: Only time spent actually providing a covered medical service may

be billed. A health Aide may not log, record or bill more hours than the time worked in a day, regardless of the number of children in the classroom.

Verify that the service log matches the items in the related services section of the IEP.

Verify that the service is within the “Scope of Practice” of the Health Aide. For example, a health aide providing catheter care or tube feedings is not working within their “Scope of Practice” when billing for Medicaid services.

If you are unclear if a service may be billed by a Health Aide, please contact your PCG Account Manager.

Please see the PCG website for guidance for Health Aide Documentation,

(http://web.pcgus.com/azschools/downloads.html)


DSC- Health Aides Example of Health Aide Language on a IEP

An Aide will meet Johnny’s personal care needs by assisting Johnny daily for one hour to help with ADLs including mobility, transfers, and positioning throughout the duration of the IEP.

Example of HA Language on a IEP Exceeding 8 units (120 min)/Day An Aide will assist Sally with Eating/Feeding for one hour daily.

An Aide will assist Sally with grooming for 15 minutes daily.

An Aide will assist Sally with dressing for 15 minutes daily.

An Aide will assist Sally with toileting for one hour daily.

An Aide will assist Sally with transfers, positioning, and mobility for one hour daily.

Note: Each ADL is clearly separated by ADL and time.

Note: Separate ADLs as services rendered by HA: Eating/feeding, Dressing, Toileting, Transfers, Positioning, Mobility, Grooming, Use of Assistive Devices.

September 2009 Page 16Speech Language Pathology Assistant (SLPA) Update AHCCCS is reviewing current policies regarding future

SLPA services & claiming SLPAs must have proper credentials to be reimbursed (See AZ

DOHS website for information on licensing requirements)

SLPA will be required to keep proper documentation according to license requirements

LEA Reminders LEAs cannot claim for SLPAs that do not have proper licensing

AND supervision

SLPAs cannot write progress notes (must be done by supervising SLP)


MAC - Background

CMS has recently increased scrutiny of the MAC program nationally.

CMS had identified areas of concern and has required States to update their MAC Claiming Methodologies.

Per CMS request, Arizona submitted a proposed Claiming Methodology in June of 2009 that reflected modifications requested by CMS.

AHCCCS and PCG has communicated these changes through memos and the newsletter.


MAC- Significant Impact to LEAs

Increased RMTS Sample Size

Going Electronic – No More Paper

Return Rate Compliance

September 2009 Page 19MAC- Increased RMTS Sample Size continued… CMS requires an increased sample size to better capture

the percentage of time spent doing outreach and administration activities.

Effective with the 4th quarter of 2009 (October – December) the number of moments will increase from 1,200 to 6,000

Two cost pools each containing 3,000 sampled moments – 6,000 sampled moments per quarter statewide.

Why two sample pools? To ensure the participant’s costs are either associated with Direct

Medical Services and the related Administrative /Outreach Activities or the Administrative /Outreach Activities.

September 2009 Page 20MAC- Increased RMTS Sample Size continued… The staff roster is separated into two different cost pools

based on the participant’s job title. 1 - Direct Service Cost Pool

2 - Administrative Personnel Cost Pool


MAC- Electronic – No Paper Beginning with the October – December 2009 quarter

there will no longer be an option to receive paper RMTS forms. All moments must be completed electronically.

LEAs may elect to still have participants receive notification of their selected moments on paper.

NOTE: As a special note to the LEA MAC Coordinators, paper notification cannot be provided to the participant more than five days prior to the moment. Therefore, LEAs choosing to continue with paper notification for some or all of their participants will need to have a process in place to track and distribute moments within the appropriate timeframes for each participant.


MAC- Electronic – No Paper continued… If a LEA elects to have participants receive a paper

notification of a participant(s) selected moment(s), a written request from the MAC Coordinator sent via e-mail to your PCG Account Manager will be required. In addition:

LEAs will need to create internal procedures for handling paper notifications.

Paper notifications cannot be provided to the participant more than 5 days prior to the moment.

L EA will need to create a tracking file.

Documents when the paper notifications were provided to each participant/moment.

Internal procedures and tracking files will be subject to audit and therefore must adhere to the record retention guidelines for the Program.


MAC- Electronic – No Paper continued… Benefits of utilizing the Electronic RMTS System.

Built in compliance for electronic moment notifications, participant training and information required to complete moment.

Participant specific log-in is unique and records ‘signature and date’ when a moment is completed.

System generated reports are available to assist the MAC Coordinator in managing the MAC Program.

Individual Master Sample File – list of current LEA moments

Compliance Report – status of past and current LEA moments

Reduces clerical activities for the MAC Coordinator.

No longer need training sign-in sheets, scheduling training sessions, and making/mailing copies of paper forms.


MAC- Electronic – RMTS Forms All sampled moments must be completed on-line by the

participant within 5 days from the moment in time.

Forms not completed within 5 days are considered non-responsive and can affect reimbursement for all LEAs as well as the LEA’s ability to participate in the future.

No paper forms will be provided. For replacements contact your assigned Account Manager prior to the sampled moment.

PCG will continue to provide a Moment List (Control List) prior to the start of the quarter. The MAC Coordinator cannot provide the moment notification to the participant more than 5 days in advance.


MAC- Electronic – Staff Rosters

Q4-09 staff rosters will be updated in the RMTS System. A certification process is required to submit the staff roster.

1 - Direct Service Cost Pool 2 - Administrative Personnel Cost Pool

The process for submitting annual Position Classification Forms will remain the same.


MAC- Electronic – Staff Rosters

Use of Vacant Positions

Vacant Positions will no longer be allowed on the Staff Roster effective Q4-09.

Based on PCG monitoring sampled Vacant Positions, it was found that the majority of Vacant Positions were never filled and/or carried over to subsequent Staff Rosters.

Due to the increase of the RMTS sample size, the number of Vacant Positions being sampled will increase. This could have a detrimental impact on the RMTS results percentage, which can result in a an invalid sample.

September 2009 Page 27MAC- Electronic – Participant Training Changes Participant training will no longer be conducted annually by the

MAC coordinator

Participant training will be completed by the participant electronically when they log on to complete the RMTS form in the RMTS system.

MAC Coordinators will no longer have to maintain training sign-in sheets.

Instead MAC Coordinators will be responsible for distributing to participants training material from PCG that explains how to access and use the RMTS system.


MAC- Return Rate Compliance

With the enhanced sampling methodology, compliance is critical for all participating LEAs! LEAs must be proactive with program participation.

LEAs should strive for 100% compliance and complete all moments selected for participants in their district or charter. CMS requires a minimum 85% compliance rate.

Time study results are applied to all LEAs in a State-Wide methodology. A reduction in the percentage of time spent on reimbursable activities, will adversely affect the reimbursement of all participating LEAs.

Every Moment Counts!

September 2009 Page 29MAC- Return Rate Compliance continued... MAC Coordinators must monitor employee participation in

completing electronic RMTS forms.

All MAC Coordinators have access to the RMTS Compliance Report.

In an effort to assist LEAs with monitoring compliance, PCG will be sending a weekly Statewide RMTS Compliance Report.

Due to more stringent oversight of the program, LEAs should expect that penalties will result for failure to comply. PCG is currently reaching out to LEAs who do not meet the 85% compliance rate.

Every Moment Counts!


MAC- Coordinator Validation Process

The Validation process completed by MAC Coordinators will be eliminated effective with the 4th quarter of 2009 (October – December).

MAC Coordinators will no longer have to contact the participant to validate the RMTS form.

The MAC Coordinator will no longer have to complete the Validation Report.


Audits

Program AuditsEnhancing the process to improve

results!


Compliance Review Audits

PCG will resume the Compliance Review Audits in keeping with our contract with AHCCCS starting Q4-09 (October – December).

Compliance Review Audits and Re-Audits were rescheduled until sufficient claims were paid under the PCG submitter ID at AHCCCS.


Compliance Review Audits

LEAs chosen for an audit will be notified approximately thirty days before the audit date to allow for preparation of required documentation.

The audit time frame will be 2008/2009 school year for DSC claims.

The audit time frame for MAC will be the last paid claim under PCG.

PCG will not be utilizing contractors or subcontractors.


Audit Process LEA Notification

LEAs are contacted regarding the date of their on-site review

Engagement letter

Compliance Review Tool

Student Files

Entrance Meeting - The audit team explains the review process and answers any questions

File Review - All files will be reviewed according to the Compliance Review Tools

Exit Meeting

Scheduled at the conclusion of the On-site Compliance Review

Exit Report- provides the LEA with areas of compliance and noncompliance


Audit Process

Components of the CAP

Area of Non-Compliance (PCG)

Strategy for Correction (Provided by the LEA)

Person (s) Responsible & Timeline (Provided by the LEA)

Verification Data (Provided by the LEA)

Annual Progress Report (PCG)


Potential Participation Impact

All participating LEA’s are scheduled for a Compliance Review Audit every (3) years The LEA must achieve a 90% compliance rating in ALL the

components that are reviewed to be considered compliant.

Components under the 90% compliance rate will require a CAP approved by PCG and the LEA will be re-audited within 3-6 months for the components that failed the initial audit.

If the results of the focused Re-Audit are not above 90% compliance, the LEA is scheduled for a Full 1 Year Compliance Review Audit.

If any components of the 1 Year Review Audit are below 90%, the LEA is subject to sanctions including temporary or permanent suspension of claiming.


Potential Participation Impact

Compliance Rates Review of prior audits indicates LEAs are failing to come into

compliance and follow the approved CAP after an audit

Impact for LEA’s AHCCCS is developing sanctions for continued non-compliance

with program requirements

If any components of the 1 Year Review Audit are below 90%, the LEA is subject to sanctions which may include temporary or permanent suspension of claiming and participation in the MAC program


Audits Continued

Reminder Participating LEAs must comply with record keeping requirements

and must maintain documentation for a period of five (5) years from the date a claim has been paid.

The LEA may be required to maintain documentation longer if information is related to a time period undergoing a State or Federal Audit.

Just because we do not audit a document, you still need to know the rules and be compliant with the requirements of the DSC and MAC Claiming Program!


Questions

September 2009 Page 40Thank you for joining us have a wonderful day!