School-Based ACCESS Program 2009-2010 Regional Training.

School-Based ACCESS Program2009-2010

Regional Training

Building Blocks toA Successful Program

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Enrollment IEP

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Provi

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Qualifi

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Eligib

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Med

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IEP

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SBAP Overview

• PDE• DPW

o Office of Medical Assistance Programs (OMAP)

o Bureau of Program Integrity (BPI)o Office of Finance

• Leader Services (statewide contractor)

In 1992, PDE initiated SBAP. Since that time, Leader Services has served as the program’s statewide vendor. SBAP is a partnership among:

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SBAP Overview

SBAP allows the following school entities to receive federal Medicaid funds for providing IEP health-related services to Medical Assistance (MA) special education students:

• School districts• Intermediate Units• MAWAs

• Charter schools• Approved Private

Schools

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SBAP Overview

Medicaid: Federal program administered by the Centers for Medicare & Medicaid Services (CMS) that pays certain medical costs for persons with disabilities and/or limited income and resources. Each State’s Medicaid program is administered in accordance with a State plan approved by CMS. The Federal Government and States share the cost of the program.

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SBAP Overview

Pennsylvania Medical Assistance (MA) Program:

State Medicaid program for low-income families, elderly persons, and persons with disabilities administered by DPW under a State plan approved by CMS.

Enroll: Become eligible to participate in the MA program by completing the application, entering into a provider agreement with DPW

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SBAP Overview

Provider: Individual or facility that signs an agreement with DPW to participate in the MA program. Schools are MA providers (type 35, specialty 350)

Provider Agreement: Contract with DPW; provider agrees to comply with all federal and state laws governing participation in the MA program and submit accurate claims. Schools sign provider agreements.

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SBAP Overview

Submit a Claim: Claims for SBAP services are paid for by federal Medicaid money. Leader Services submits claims on behalf of schools but schools are responsible and held accountable for the accuracy of claims.

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Eligible Services

• Assistive Devices• Audiology• IEP Development• Nursing (RN & LPN)• Occupational Therapy• Orientation & Mobility• Personal Care Assistant• Physical Therapy

• Physician• Psychiatry• Psychology• Social Work• Speech/Language• Teacher of Hearing

Impaired• Special

Transportation


2008-2009 Projected Reimbursement

PCA ─ $32,412,671

SLP ─ $23,300,260

OT ─ $12,181,431

Trans.─ $11,260,875

IEP ─ $10,230,088

PT ─ $7,214,976

Psychological ─ $4,117,697

PCA

SLPTrans.

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2008-2009 Projected ReimbursementRN ─ $4,096,931

THI ─ $2,843,282

Social Work ─ $1,870,888

Other services ─ $1,584,407

LPN ─ $1,227,582

Total = $112,341,088

PCA

SLPTrans.

Other services include:O&M, Physician, Assistive Devices, Psychiatry, Audiology 11


Prior to MA-Claims Submission

Verify:• The student is classified as special education

under Chapter 14 regulation and is receiving one or more eligible health-related services and that the IEP clearly defines the health-related service including frequency and duration;

• The student is MA-eligible;• Parental consent is on file.

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Prior to MA-Claims SubmissionVerify:• Medical Authorization or physician’s

prescription is on file;• Direct service provider meets SBAP

licensure/certification requirements for MA participation;

• Direct service provider’s salary and/or contract is paid with state and/or local funds and is accurately recorded on the cost calculation worksheet;

• Service is fully documented.13


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• Upload to Leader http://www.leaderservices.com/uploads

• Automatic eligibility check(IEPWriterTM/Children Count® users only)

• PROMISehttp://promise.dpw.state.pa.us

How to Identify Eligible Students

F01/01/1997SusanSmith

Student Gender

Student DOB

Student First Name

Student Last Name

Example format for uploaded data:


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IEP Billing Overview

IEP Requirements

Must include:• Formal meeting• LEA signature• Ongoing SBAP

health-related service

• Reimbursement at a fixed rate

(Initial vs. Review)

First Right to Bill• School Districts• Charter Schools• MAWAs


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IEP Common Mistakes

• No ongoing SBAP health-related service;• No formal meeting;• Duplicate billing (waiver);• Claiming an Initial meeting in error.


PCA Services

Must be:• Provided by an aide certified in First Aid and

CPR;• Defined in IEP;• Authorized by an MD, DO, or CRNP• 1:1 with a student;• Documented.

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PCA Common Mistakes

• Services not defined in IEP;• No Typical Daily Schedule or schedule does

not meet requirements;• Insufficient daily notes;• No supervisory signature;• Billing for individual when attending to more

than one student;• Billing for more time than actually with

student.

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Special Transportation

Must be:• Defined as a related service in the IEP

daily;• Claimed in conjunction with an ongoing

health-related service;• Claimed only for students who regularly

receive special transportation;• Documented on a Transportation trip log

and reconciled against Leader’s transportation claims report. 19


Transportation Costs

• Must be reported annually;• Report Special Transportation costs only;• Include all specialized vehicles;• Report total number of students who

need specialized vehicles regardless of special education, regular education, or MA status.

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Transportation Common Mistakes

• Not specified as daily to/from school;• Not listed in IEP;• No ongoing health-related service in IEP;• No daily bus attendance;• Not specifying LEA providing health-related

service(s);• Not listing start/end dates if applicable;• Not notifying Leader of changes;• Not validating Transportation Claims report

and returning with Confirmation Form.


Record Keeping RequirementsRecord Keeping Requirements: 55 Pa. Code §1101. 51(e),

(e)(1)(i-x): • Records must comply with § 1101.51(e), including but

not limited to: Must be maintained for 4 years; Must fully disclose the nature and extent of the

services rendered; Must be readily available for review or copying by

state/federal officials (readily available means records must be available at the provider’s place of business or, upon written request, forwarded without charge to DPW). 22


Record Keeping Requirements• Records must comply with § 1101.51(e)(1)(i-x)

including but not limited to: • Must be legible (anyone can read them without

difficulty);• Alterations of the record must be signed and dated; • Treatments and the treatment plans must be in the

record; (example, IEP);• Must document the progress at each visit, change in

diagnosis, change in treatment and response to treatment;

• Must contain results/interpretations/reports of tests and consultations (example: psychological testing, other reports);

• Must contain documentation of the medical necessity of a rendered, ordered, or prescribed service.

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Federal Audits

Federal audits are currently underway in Pennsylvania.

Two such audits are:

•the Medicaid Payment Error Rate Measurement (PERM), and

•the Medicaid Integrity Contractor (MIC)


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State Reviews

• Currently BPI is conducting reviews of the SBAP program.

• Leader is concluding technical assistance reviews of the program.


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State Reviews

There are many regulations, rules, and requirements from various agencies. Everyone must understand and correctly implement all of them. Oversight agencies conduct compliance reviews for their specific regulatory standards; Medicaid regulations differ from education regulations.


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State ReviewsCompliance with one set of regulations does not necessarily constitute compliance with another.

The following are applicable to SBAP:

MA Regulations:

• Applies to all enrolled providers;• Based on state and federal law;• SBAP providers are responsible for compliance

with 55 Pa. Code §1101;• Available in the SBAP manual and through DPW

on line at http://tinyurl.com/chapter1101


Identify and Prevent Frequently Noted Violations

The following examples (provided by BPI) are recent examples of frequently noted violations identified through BPI reviews. Although it is a composite, these findings have been identified in all reviews

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Violation 1: Services not rendered

Examples:• Claims for students who are absent• Claims for dates when school is not in

session• Claims that included more units of service

than provided• Claims for special transportation when it was

not provided on the dates billed 29



Violation 1: Services not renderedProactive Compliance Hints:

• Check absentee/attendance logs before submitting a claim

• Verify date entry for accuracy• Confirm that the amount and duration of

services are identified in IEP• Reconcile transportation reports from

Leader with services billed30


Violation 2: More expensive service billed than rendered

Example:• Claims for individual services that were

documented as group


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Violation 2: More expensive service billed than renderedProactive Compliance Hints:

• Require submission of documentation with billing forms before claim submission;

• Compare documentation with billing forms;• Confirm that service to be billed is the

services that is documented as rendered.


Violation 3: Unqualified staff

Examples:• Claims for PCA services when staff did not

possess required CPR and/or first aid certification for dates billed

• Claims for direct services provided by staff whose licenses were invalid or did not meet SBAP requirements

• Claims for social work services documented as provided by non-licensed individuals


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Violation 3: Unqualified staffProactive Compliance Hints:

• Develop a process to ensure that all staff have certifications/licenses that are current and cover the service dates;

• Require proof of certifications/licenses• Check the status of certifications and

licenses periodically• Validate licensure at

http://www.licensepa.state.pa.us/34



Violation 4: Unsupervised Services

Examples:• Claims for services documented as

provided by personnel requiring supervision; the documentation/ professional services log did not include the required supervisory signature;

• PCA services billed; no supervisory signature on documentation.

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Violation 4: Unsupervised Services

Proactive Compliance Hints:• Confirm that there is a supervisory signature

on all documentation as required before submission of a claim

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Violation 5: Services not identified in the IEP

Examples:• Transportation services not

identified/recommended in the IEP;• PCA services not identified/recommended in

the IEP.


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Violation 5: Services not identified in the IEPProactive Compliance Hints:

• Health-related services billed to Medicaid must be specifically identified in the IEP;

• Before submitting a claim, confirm that the service is identified in the IEP as a health related service.


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Violation 6: Dates of service not covered by IEP

Examples:• Previous IEP covers 9/1/06 – 6/15/07;

New IEP dated 9/9/07; claims submitted before dates 9/2/07 – 9/8/07


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Violation 6: Dates of service not covered by IEP

Proactive Compliance Hints:• The IEP must cover all the dates billed;• Before submitting a claim, confirm that the

dates are covered by an IEP;• If there is a lapse between the IEP period

covered, claims should not be submitted for the lapsed dates.


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Identify and Prevent FrequentlyNoted Violations

Violation 7: Service not identified on practitioner’s authorization or prescription

Examples:• Transportation services not identified on

practitioner’s authorization or prescription;• PCA services not identified on practitioner’s

authorization or prescription.

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Identify and Prevent FrequentlyNoted ViolationsViolation 7: Service not identified on practitioner’s authorization or prescription

Proactive Compliance Hints:• Health-related services billed to Medicaid must be

prescribed by a practitioner within their scope of practice, either by prescription or the SBAP Medical Practitioner Authorization form

• Before submitting a claim, confirm that the service is identified on the practitioner’s authorization or a prescription and that it covers the dates to be billed

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Identify and Prevent FrequentlyNoted Violations

Violation 7: Service not identified on practitioner’s authorization or prescription

Proactive Compliance Hints:• If the student’s health related service has

changed, do not bill for newly added services until those changes/services are authorized

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Violation 8: Service frequency exceeds IEP recommendations and/or practitioner’s authorization

Example:• IEP and practitioner’s authorization identify

individual speech therapy for 30 minutes/week; 60 minutes/week is billed


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Identify and Prevent Frequently Noted ViolationsViolation 8: Service frequency exceeds IEP

recommendations and/or practitioner’s authorization

Proactive hints:• Before submitting a claim, confirm that the frequency to

be billed is the same as identified in the IEP and practitioner’s authorization or prescription;

• If the student’s needs change, do not submit a claim for a greater frequency of service until an updated IEP and practitioner’s authorization or prescription reflecting the change is obtained. 45



Violation 9: No documentation for the services and date billed

Examples:• No service log, or daily progress note, or

monthly summary in the record for the services and dates billed

• No transportation logs in the record for the services and dates billed

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Violation 9: No documentation for the services and date billed

Proactive hints:• Require submission of documentation for

review before services are billed• Compare documentation before submitting

a claim

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Violation 10: Monthly summary fails to fully describe treatment rendered and response to treatment Examples:

• PCA services billed 5 days a week for 5 consecutive months. The monthly documentation for each month billed states: Student has shown some improvement in staying on task for the month.

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Violation 10: Monthly summary fails to fully describe treatment rendered and response to treatment

Examples (continued):• Occupational Therapy services are billed

2 times a week for the month of January. Monthly documentation states: Student had demonstrated slight improvement with his coordination skills.

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Violation 10: Monthly summary fails to fully describe treatment rendered and response to treatment

Proactive hints:• Documentation must give a full picture of the

services provided• A person who does not know the student

should be able to read the notes and understand what treatment was provided, what goals were addressed, what activities occurred, and what progress was made

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Identify and Prevent Frequently Noted ViolationsViolation 10: Monthly summary fails to fully

describe treatment rendered and response to treatment

Proactive hints:• At a minimum, daily and/or monthly notes must

document:• Treatment services performed• Activities performed during each treatment

episode• Description of student’s participation and

interactions during treatment 51


Violation 11: Failure to maintain records that were readily available

Example:• Provider is unable to provide copies of

records to BPI upon request.


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Violation 11: Failure to maintain records that were readily available

Proactive hints:• Providers must retain records for 4 years and

make them readily available for review by State and Federal officials or their authorized agents;

• Readily available means that records are made available at the provider’s place of business or, upon written request, are forwarded in the specified time.


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• Administrative cooperation and participation

• An outline of internal procedures

• Internal monitoring procedures

• Sufficient allocation of time and staff

• Annual staff trainings (minimum)

• Maintain centralized location for SBAP records

• Understand MA regulations (see DPW handout pg. 4-5)

• Perform routine self-audits; disclose errors

Keys to a Successful Program


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Self-Audits/Monitoring ActivitiesThrough self-monitoring activities, schools can identify inappropriate billing

Self-audit activities include:• Periodic self-auditing of service delivery and

billing• Comparison of what was billed with MA

recipient (student) records• Review of regulations and requirements to

ensure that services were rendered and billed correctly


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Self-Audits/Monitoring Activities• Some benefits of self audit activities are:

• Identification of overpayments and underpayments;

• Identification of individuals that might be implementing services inappropriately;

• Identification of individuals that might be submitting time inappropriately;

• Schools, not DPW, conduct the review;• DPW will not seek double damages for self-

reported inappropriate payments.


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Self-Audits/Monitoring Activities

• A few examples of self-audits are:

A school discovers that:• Services were billed that were not in the IEP

and/or not prescribed;• Undocumented services were billed;• Services were billed by an employee who did

not meet SBAP provider qualifications.


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Monthly Management Reports

• Comprehensive reports provided to LEAs by Leader

• Available online within WebSDS and WebPSL


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Withdrawing Funds

• Funds are deposited into a PDE-restricted account, which earns no interest;

• Review your account balance prior to requesting a funds withdrawal;

• Funds must be used to enhance or supplement special education services, or cover costs incurred to administer SBAP.


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Withdrawing Funds • ACCESS funds requests must be submitted on PDE 352

or PDE 352M (EI) form;

• The LEA six-digit LEC number must appear on the form;

• The Comptroller’s office will not process requests under $1,000;

• Submit the ACCESS Funds Request Form to PDE along with a short narrative describing how the SBAP funds will be used and how they will enhance special education.


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Requests to Withdraw Funds

PA Department of Education

333 Market Street, 7th Floor

Harrisburg, PA 17126-0333

ATTN: Elizabeth Zeisloft

Date post:	27-Dec-2015
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