3
/ STATE OF NEW YORKDEPARTMENT OF HEALTH
584 DELAWARE AVENUE, BUFFALO, NEW YORK 14202
Antonia C. Novello, M.D., M.P.H., Dr.P.H. / Dennis P. Whalen
Commissioner / Executive Deputy Commissioner
February 28, 2006
Mr. James K. Brotz, Superintendent
West Seneca Central School District
1397 Orchard Park Road
West Seneca, New York 14224
Re: West Seneca Central School District
Audit #05-1283
MMIS #01380950
School Supportive Health Services Program
Dear Mr. Brotz:
This letter is the final notification of our findings from our recently completed review of the documentation supporting claims that West Seneca Central School District submitted under the School Supportive Health Service Program (SSHSP). The SSHSP assists school districts in obtaining federal Medicaid funds for certain diagnostic and health related services that traditionally have been funded exclusively through educational resources.
PURPOSE AND SCOPE
The purpose of this Corrective Action Review is to ensure compliance with applicable Federal and State laws, regulations, rules, and policies governing the New York State Medicaid Program and to verify that:
· Medicaid reimbursable services were rendered for the dates billed;
· Appropriate rate codes were billed for services rendered; and
· Student-related records contained the documentation required in the SSHSP Medicaid Claiming Handbook (#5) and all applicable updates.
We reviewed 80 claims representing $31,660.63 in services paid from December 21, 2003 through December 20, 2004. Each type of service billed by the West Seneca Central School District was included in our sampled claims. Furthermore, since a procedural error in billing for Initial Individualized Education Program (IEP) Reviews have been a problem in reviews of other school districts, we expanded the scope of our review to include payments to West Seneca Central School District for Initial IEP services paid from July 1, 2002 through March 31, 2005.
SUMMARY
In general, West Seneca Central School District’s Medicaid claims were supported by adequate documentation. However, we found 3 sample claims, totaling $1,296.00 which were insufficiently documented, mostly due to missing or incomplete orders for SSHS (School Supportive Health Services). These missing/incomplete orders, along with additional errors, affected 27 additional claims totaling $11,664.00 that were not included in our sample and must be voided.
In addition, due to an incorrect application of claiming instructions for Initial IEP Reviews, the school district incorrectly billed 10 claims, totaling $7,750.00 that must be voided.
The amount of payments that must be voided totals $20,710.00. (See attached Schedule of Payments to be Voided).
DETAILED FINDINGS - CLAIMS TO BE VOIDED
Insufficiently Documented Claims
In 3 sample claims, there was inadequate documentation to support $1,296.00 in Medicaid payments made to the school district, as follows:
· For sample claims #2, 3, and 10, there was either no written order for speech therapy services, or the order was not signed. These paid services must be voided for the entire period where a written order was lacking or incomplete. Overpayments for sampled speech therapy services total $1,296.00. In addition, the errors cited for claims involving missing orders and other errors also affect 27 dates of service totaling $11,664.00. Claims to be voided for speech therapy services total $12,960.00
State Education Department Medicaid Claiming/Billing Handbook
(Update #5) – Page 9
The overpayment for Insufficiently Documented Claims totals $12,960.00.
Due to a significant error rate with missing/incomplete orders for speech therapy services, the West Seneca Central School District must review all claims for speech therapy services paid from July1, 2002 forward for Medicaid recipients outside of our sample review. These services must be voided for the entire period where a written order was lacking or not signed. The district must provide our office with the detail of the voided claims after they are processed.
Incorrectly Billed Claims
From our expanded review, we identified 10 claims for Initial Reviews totaling $7,750.00 that were billed for students already classified as having a disability. These claims must be voided. “An initial can only be billed when an unclassified student is referred to the CSE (Committee on Special Education) for an initial IEP and a CSE meeting is held.”
State Education Department Medicaid Claiming/Billing Handbook
(Update #5) – Page 20
Some of these claims are billable at the lesser rate for either an Amended/Requested Review ($520.00), or a Re-evaluation Review ($492.00), as outlined in the SED (State Education Department) January 2002 Memorandum – Students Transitioning from Preschool to School Age. Re-billing may further be restricted by the requirement that no more than three billings in a nine-month period are submitted for an Amended Review, or one billing per nine-month period is submitted for a Re-evaluation Review.
The overpayment for Incorrectly Billed Claims totals $7,750.00.
CORRECTIVE ACTION
We also noted the following procedural issue which does not require any payments to be voided at this time, but does require corrective action by the West Seneca Central School District.
Dated Orders for Services
For some students, the written orders for speech therapy, physical therapy, and occupational therapy services were signed but not dated. Dated orders are necessary to verify that an order is in place prior to the school district providing SSHS to a student.
State Education Department Medicaid Claiming/Billing Handbook
(Update #5) – Pages 9, 11 and 12
BILLING FOR SSHS
During our sample review, we noted that this district was not billing for Basic and Comprehensive Psychological Evaluations. These services were documented in some of the student’s records. We recommend that the district bill for the evaluations performed and properly documented. All reports must be signed and dated by the psychologist/psychiatrist. The billing date is the date of the completed report.
State Education Department Medicaid Claiming/Billing Handbook
(Update #5) – Page 14
IMPACT
These issues were presented to school district staff at our exit conference held on November18,2005. At that time, district staff were instructed to void $26,586.90 in payments. After review of additional documentation, the revised amount of claims to be voided totals $20,710.00 according to the attached Schedule of Payments to be Voided.
We have requested the Office of Medicaid Management’s Division of Medicaid Fraud Control and Program Integrity, Bureau of Revenue Initiatives, to grant the West Seneca Central School District a waiver to allow re-billings beyond the two-year limitation for those affected services cited herein. This waiver has been granted until March 27, 2006 for eMedNY Payment Cycle #1495 processing to the district’s Regional Information Center. Within 60 days of the issuance of this letter, please submit notification to Ms. Deborah Acanfora when the claims have been voided and any re-billings have been made. The submission should include the date of the voids/re-billings, the eMedNY cycle number, and an explanation of corrective actions.
The Department will follow up with the school district to determine if future corrective action reviews are necessary to monitor systemic billing errors.
If you have any questions related to this review, please contact Ms. Deborah Acanfora at (716)847-5090.
Thank you for the cooperation and courtesy extended to our staff during this review.
Sincerely,
GEM
George E. Meeks, Director
Buffalo Medicaid Audit Office
Western Region
Office of Medicaid Management
GEM:pam
Attachment
cc: Robert Scalise, Medicaid Service Unit Coordinator, NYS Education Department
Brian L. Schulz, District Treasurer
Charles Lehman, Assistant Superintendent Pupil Services