STATE OF NEW YORK
OFFICE OF THE MEDICAID INSPECTOR GENERAL
259 Monroe Avenue ● Suite 312
Rochester, New York 14607
(585) 238-8166
Fax: (585) 238-8169
GEORGE E. PATAKI / KIMBERLY A. O’CONNORGOVERNOR / MEDICAID INSPECTOR GENERAL
September 29, 2006
Mr. Donald Covell, Superintendent
Warsaw Central School District
153 West Buffalo Street
Warsaw, New York 14569-1295
Re: Warsaw Central School District
Provider # 01432397
SSHSP Corrective Action Review # 06-1204
Dear Mr. Covell:
This letter will serve as a summary of findings for our recently completed review of sample billings by Warsaw Central School District to the School Supportive Health Services Program (SSHSP). As you know, 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.
The purpose of this review was to determine whether Warsaw Central School District was following program requirements, and had the appropriate documentation to support its claims. We reviewed 100 claims representing $37,650.75 in services paid from February 7, 2005 through February 6, 2006. Each type of service billed by Warsaw Central School District was included in our sample claims. Furthermore, after having detected procedural errors in billing for Targeted Case Management services, we expanded the scope of our review to cover payments made from July 1, 2002 through April 17, 2006.
SUMMARY
In general, Warsaw Central School District’s Medicaid claims were supported by adequate documentation. However, we identified $5,118.26 in payments from 10 sampled claims that were either not authorized on the IEP, incorrectly billed, insufficiently documented, or otherwise non-billable. These errors affected 5 other claims totaling $386.07. Furthermore, the errors found in our expanded analysis of Targeted Case Management services increased the amount billed in error by $11,755.00 for 28 claims. In total, $17,259.33 in payments from 43 claims must be voided as detailed on the schedule on page 4 of this report.
An Equal Opportunity/Affirmative Action Employer
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DETAILED FINDINGS
Targeted Case Management
For sampled claims number 57, 58, 59, 64, 81, and 87, the provider incorrectly billed a total of $3,630.00 for Targeted Case Management (TCM) services for Preschool students. As indicated on page 19 of the School Supportive Health Services Medicaid Claiming/Billing Handbook (Update #5), “Preschool TCM may not be claimed until the funding issue for the three types of reviews currently funded through Federal IDEA funds[CPSE Administrative Costs] is resolved.” In addition, page 27 of the School Supportive Health Services Medicaid Claiming/Billing Handbook (Update #6) issued September 2005 states,” TCM is not reimbursable for preschool students.” We expanded the scope of our review for this finding to cover dates of payment from July, 1, 2002, through April 17, 2006, and found another 26 incorrectly billed claims totaling $10,205.00, which brings the total overpayment for this error to $13,835.00.
From our expanded analysis of Initial Reviews, we identified 2 claims totaling $1,550.00 for students already classified as having a disability. As indicated on page 20 of the School Supportive Health Services Medicaid Claiming/Billing Handbook (Update #5), “An initial can only be billed when an unclassified student is referred to the CSE for an initial IEP and a CSE meeting is held.” These claims may be 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 January 2002 Memorandum – Students Transitioning from Preschool to School Age. Re-billing may further be restricted by the requirement that no more than 3 billings in a 9-month period are submitted for an Amended Review, or 1 bill in a 9-month period is submitted for a Re-evaluation Review. For this error, a total of $1,550.00 must be voided for 2 claims.
For sampled claims number 60 and 68, the provider incorrectly billed an Initial Review for $775.00 and an Annual Review for $265.00 in which a CSE meeting was not held. The provider must void these 2 claims totaling $1,040.00.
Special Transportation
For sampled claim number 100, the provider billed $136.26 for Special Transportation services which were not properly authorized on the student’s IEP. This affected 5 other dates of service for the same student with claims totaling $386.07 for the 2004 – 2005 school year. For this error, a total of $522.33 must be voided for 6 claims.
Comprehensive Psychological Evaluation
For sampled claim number 5, the provider billed $312.00 for a Comprehensive Psychological Evaluation without the required social history called for on page 14 of the School Supportive Health Services Medicaid Claiming/Billing Handbook (Update #5). Therefore, this claim must be voided, but may be billable as a Basic Psychological evaluation at the lesser rate.
PROCEDURAL ISSUES
We also noted the following procedural issue which does not require any payments to be voided but requires corrective action by the District.
Provider Agreement and Statement of Reassignment
Four independent providers of Medicaid reimbursable services had not signed a Provider Agreement and a Statement of Reassignment, as required of any agency/provider who is not an employee of the school district, county, or BOCES. This requirement is stated in the School Supportive Health Services Medicaid Claiming/Billing Handbook (Update #5), Page 6 and Appendix C. The District must ensure that these agreements are in place for the required independent providers.
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IMPACT
These issues were presented to your staff at our exit conference held on September 1, 2006. At that time, we requested that $17,259.33 in payments be voided according to the schedule on page 4 of this report, and to be notified when this was done. Within 60 days of this letter, please submit documentation that the claims were voided and also include a copy of the District’s written corrective action plan. The claim documentation should include: the identifying sample number if applicable—or the CIN, rate code and date of service if the void was part of an expanded sample—the date of the voids, and the eMedNY cycle number. Our Office will follow up with the District on the implementation of corrective action procedures as determined necessary. We have requested the Office of the Medicaid Inspector General, Bureau of Revenue Initiatives to grant Warsaw Central School District a waiver to allow re-billings beyond the two-year limitation for those affected claims cited herein. We will notify the District when the waiver has been granted.
If you have any questions related to this review, please contact Mr. Michael DiMauro at (585)2388161
Thank you for the cooperation and courtesy extended to our staff during this review.
Sincerely,
LEC September 29, 2006
Lewis E. Cole, Director
Rochester Office of the
Medicaid Inspector General
cc: Robert Scalise, SED
Cathelene Lyon, Director of Special Services
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