medicaid man welcomes you… medicaid fee for service program 2009-10

Medicaid Manwelcomes you…

Medicaid Fee for Service

Program2009-10

Medicaid Support

Regina Smith, Program Supervisor(O) 313.873.4085

Tanisha Vogl, Financial Specialist(O) 313.873.4283

We’re here to help you!

Fee-For-Service Recovery Effort

Seeks reimbursement for medically-related services provided to Medicaid eligible students pursuant to their IEP or IFSP.

Eligibility• Students must be:

• Special Ed

• Services must pertain to a “medical” service on the student’s IEP.

Tip Sheets

• List all services that are billable for your practitioner type. Shaded areas indicate data that is not valid for the particular procedure code.

• Include Medicaid practitioner qualifications, valid procedure codes, notes.

• Make sure you have the qualifications listed before billing.

Consultative Services• Consults are no longer billable unless:

– You are the student’s Designated Case manager

– Your profession has a procedure code that includes consultations

– If you are on the IEP for Direct or Direct/Consult you may bill for your Direct Services up to the maximum amount of time indicated

METs and IEPs

• MET Assessments (and the corresponding reports

and meeting) are reimbursable only if your Tip Sheet

includes a code ending in “HT”.

• The IEP meeting is reimbursable if your Tip Sheet

includes a code ending in “TM”.

METs and IEPs• Do not record assessments, report-writing,

observations or preliminary meetings separately

• If a meeting spans multiple days or is reconvened, record just once on the final meeting date

• If an additional IEP meeting is scheduled during the year to modify the plan of care, record as a new/ separate IEP

Unbillable-Record Keeping Only Services

• Use the Unbillable service option on your procedure code drop-down list if you want to track:– Missed sessions, consultations, services for

LD/CI only students, etc. that are not “billable”

These “services” will not generate claims, but should be made “ready to bill” to keep them off the “open services” report.

LD or CI OnlyIs the student Learning Disabled or Cognitively impaired ONLY? (No speech, social work, OT, PT, psychology, nursing, O&M, etc. on the IEP) Ancillary staff may still record MET and

IEP/IFSP Assessments

The only reimbursable direct service is Crisis Intervention

OT/PT ClarificationOn January 15, 2004 the MDCH clarified that:“97110 is the only code for individual OT or PT services and is to be used for all regular OT and PT. 97112 is used for ATD services provided as part of a specific therapy.”Since then, additional codes have been added to provide staff with more specific options for reporting billable services.

OT/PT Clarification

• When in doubt: Use 97110 for Individual therapy

• However, if one of the additional, more specific, codes accurately describes what you are doing, use them instead of the generic 97110 code

• Always use 97150 for group therapy services. No other code applies to a group.

IEP GoalsDon’t let the wording of IEP goals stop you from billing:

– Your service is “Medical”, even if the wording of IEP goals is educational

– You may use educational activities as part of your therapy to address a medical issue

For example: You may use “handwriting” as a means of developing a student’s visual motor or gross motor skills.

For Example

• Avoid: Slight progress toward handwriting goal

• Instead: Worked on visual motor and gross motor skills in order to improve Billy’s grasp and the legibility of his handwriting. Billy is progressing slowly.

Service Notes

• A DAILY progress note is required for direct services.

• Must describe the service provided and the student’s response to the service.

Summary Notes

• Using your Daily progress notes, describe the student’s overall progress toward IEP/IFSP goals, Changes in Medical or Mental Status, and/or Changes in their Treatment Plan.

• If the only service being recorded is the IEP, indicate if it’s an initial or re-eval and the outcome

Designated Case Management• Only ONE Designated Case Manager per student

• Recorded ONCE per month

• Service Date is the last school day of the month

• Use Procedure Code T2023

• Record the letter, A-K, that describes a single service during the month

• Provide service details in the Summary Note

MET and IEPCase Managers Only

Case managers must use the Unbillable code for initial

MET’s and IEP’s . (Not to be confused that you can

bill for the “HT” and “TM” for your participation in

the MET or IEP meetings.

DCM SummariesUse the 3 W’s!

WHO?

• Were you interacting with:– Parent(s) or Guardian– Speech Path, Social Worker, OT, PT, etc.– Outside Agency

If only with the student – it’s a direct service – DO NOT BILL as Case Management.

WHAT?

• Be specific:

Bad = Parent Meeting

Good = Met with parents and social worker to discuss progress on behavioral goals

DCM SummariesUse the 3 W’s!

WHEN?

• Don’t forget to record actual Service Dates in your summary!!!

DCM SummariesUse the 3 W’s!

Good Case Management Summaries

10/20/08 Met with RN to discuss change in medications

11/3/08 Contacted parents to discuss …therapy, counseling, meds, speech goals, BIP…

11/14/08 Conference with parents/service providers regarding…medical issues/ goals (describe)

Not so Good DCM Summaries

10/5/08 Attendance Issues, Behavior Issues, Parent Meeting

Report Cards

No Services this month

Math, Reading, Language, Work Skills

NON-BILLABLE Case Management Services

• Direct services such as teaching, therapy and evaluations

• Services that are not a part of the IEP

• Services that are not medically related (such as vocational, work skills services)

• Medical services not covered in the IEP

Supervisor Signature• A co-signature by an appropriately-licensed

supervising staff member is required for:

SLP or TSLI without a CCC• Have your supervisor review your services

before entering their name in this field.

Personal CareBillable when performed by an Aide for students whose disability prevents them from doing tasks on their own.

– Eating/Feeding/Meal Preparation, Toileting/ Maintaining Continence, Grooming, Dressing, Personal Hygiene/Bathing, Behavior Re-Direction, Mobility/Positioning, Ambulation, Transferring, Skin Care, Respiratory Assistance, Assistance with self-administered meds, etc.

Personal Care Policy

• Must be documented in the student’s IEP

• Must be authorized by a licensed practitioner operating within their scope of practice. – Registered Nurse – Social Worker– OT/PT– Speech Pathologist

Personal Care Policy• Authorizing staff must have face-to-face

contact with the student at beginning of treatment and periodically thereafter

• Must be medically necessary– “Needed to attain or retain the capability for

normal activity, independence, or self care”

• Each child’s record must contain a completed, signed and dated monthly activity checklist (to be kept for 7 years)

The False Claims ActPreventing Fraud, Waste, Abuse

Detroit Public Schools is committed to ensuring that its coding, billing and reimbursement procedures comply with all federal and state laws. However, we cannot ensure that the services reported were provided as stated, that they were medically necessary or were not false or misleading.

If you have knowledge or information that School-Based Services being reported to Detroit Public Schools Risk Management Office for the purposes of Medicaid billing are false or fraudulent, such as the falsification of records or submitting services for billing that were not performed, please report the situation to your supervisor or to the Attorney General’s Health Care Fraud Division at: 800-242-2873.

The False Claims ActPreventing Fraud, Waste, Abuse

cont.

Whistleblower Provision

Federal and state law prohibit any retaliation or retribution against any person who reports suspected fraudulent billing to law enforcement officials or who file “whistleblower” lawsuits on behalf of the government.

Random Moment Time Study (RMTS)

Your name has been put in a “pool” with all of the other Direct Service Staff in the state.

What is the RMTS?

Out of this pool comes the Random Moment Time Study. This is the tool that Michigan uses to determine the amount of time school staff spend on activities that are in support of the Medicaid program

When is the RMTS?

Every quarter, names will be drawn and you could be chosen at any point to participate in one or more of these random moment time study surveys.

There is no limit to how many times your name can be drawn in a quarter.

How Does It Work?

If you are selected to participate, you will receive notification in the mail that you need to complete a RMTS survey on-line. This should take no more than 10 minutes of your time. It is mandatory to complete your moment within 24 hours of the date/time of selected moment.

What Do I Have To Do?

In the Random Moment Time Study, a “moment” is one minute of time. Completion of the time study moment will require you to answer four questions regarding the activity you were performing during that one moment of work time.

4 Questions

• What were you doing?

• Who were you doing it with?

• Why were you doing it?

• Is the service documented in the IEP?

(Not exactly worded like this, but you get the idea)

Please Be Descriptive• Not descriptive:

Getting ready for my day

Catching up on Paperwork

Teaching

• Better:– With a student working on… speech goals, behavior issues,

gross/fine motor skills, administering meds…

– Reviewing student behavior plan/IEP goals with staff

– Updating goals and objectives for next IEP/At the IEP

– Discussing progress toward ___ goals with parent

No “Bad” Answers•It’s OK to say:

–I was on my lunch break–I was on a personal phone call–I was driving from 1 school to another to provide speech services to...

Only Public Consulting Group (PCG) sees your answers… DPS cannot.

RMTS Follow-Up• If you are not descriptive enough and clarity is

needed, you will receive a follow-up call from Public Consulting Group.

• Please return follow-up phone calls promptly.

What If I Have Questions?

Contact the DPS Medicaid Office.

Questions and Answers