Office of the Medicaid Inspector General s1

STATE OF NEW YORK

OFFICE OF THE MEDICAID INSPECTOR GENERAL

250 Veterans Highway, Room 4A12

Hauppauge, New York 11788

(631) 952-6386

Fax: (631) 952-6415

March 16, 2006

Dr. Charles Murphy, Superintendent

Sachem Central School District

245 Union Ave.

Holbrook, NY 11741

Re: CAR #05-1482

Provider #1383366

Dear Dr. Murphy:

This letter is the final notification of our findings from our recently completed review of the documentation supporting claims that Sachem Central School District submitted under the School Supportive Health Services 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 was 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.

The scope consisted of a review of 77 sample cases representing each type of service for which Sachem Central School District received Medicaid payments, totaling $27,935.61 during the period March 31, 2004, through March 30, 2005.

SUMMARY

Sachem Central School District records were very well organized and usually provided required documentation. There were 3 speech therapy cases identified, without proper recommendations, in which the claims, totaling $1,296.00, must be voided. In addition 26 other claims for speech therapy not covered by an order for the school year, in the amount of $11,232.00, must be voided. This error resulted in a total overpayment of $12,528.00. In addition, we found speech therapy services to have systemic errors (2 or more of the same type of error within a service category).

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DETAILED FINDINGS

UNALLOWABLE CLAIMS

Improper Recommendation

For sample claims #16, 17 and 22, speech therapy services were provided without a recommendation from a Speech Language Pathologist. The recommendation was signed by a Teacher of the Speech and Hearing Handicapped.

The Medicaid Claiming/Billing Handbook states, “Services must be recommended by one of the following professionals: Licensed Physician, Registered Physician Assistant, Licensed Nurse Practitioner, Licensed Speech–Language Pathologist.”

Update # 5, page 8

This error resulted in an overpayment of $1,296.00. The school district is to void these claims. There were an additional 26 speech therapy claims related to the sample error claims totaling $11,232.00, which must be voided, where the services for the school year were provided without proper recommendations. This brings the total amount to be voided to $12,528.00. These claims were for services provided by Eastern Suffolk Board of Cooperative Education Services (ESBOCES). However the error is still considered the district’s responsibility because ESBOCES is a contracted provider. Due to the systemic determination of this error, the school district is to review all ESBOCES speech therapy services for proper recommendations retroactive to July 1, 2002, and to void any inappropriate claim.

The attached Exhibit provides a summary of unallowable claims.

CORRECTIVE ACTION

Incorrect Number of Services Claimed

The school district claimed the incorrect number of services in 2 separate service months:

·  Sample claim #35, 9 psychological counseling services were billed, while 10 were actually received.

·  Sample claim #38, 2 psychological counseling services were billed, while 3 were actually received.

The errors with incorrect monthly service amounts had no dollar impact and do not require any claim adjustments since the threshold payment for each month was reached. However, it is important that the number of claims be reported correctly because they are used in formulating school district reimbursement amounts.

Billed Prior to Written Order

The school district claimed for nursing services before a written order was in place. For sample claim #8, 8 of 19 services were provided prior to the written order of September 15, 2003. This error had no dollar impact and does not require any claim adjustments since the threshold payment for the month was reached.

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The Medicaid Claiming/Billing Handbook states, “Skilled nursing services must be supported by a written order by a licensed physician, a registered physician assistant, or a licensed nurse practitioner within the scope of their practice. Orders are required when the student enters school for the first time during the school year and new orders are required when there are any significant changes in the student’s condition.”

Update # 5, page 13

IMPACT

These issues were discussed with responsible school district staff at our exit conference of January 20, 2006. We were informed that the District would void all inappropriate claims and initiate corrective action. Within 60 days of the issuance of this letter, please submit to Sander Levine:

·  Documentation of claims voided including identifying sample number, date(s) of service, eMedNY cycle number and date voided.

·  A written explanation of corrective action taken by the school district.

The Office of the Medicaid Inspector General will follow-up with the Sachem Central School District to determine if the needed corrective action identified during this review has been implemented.

Thank you for your cooperation in this matter. If you have any questions related to this review, please contact Sander Levine at (631) 952-6394.

Sincerely,

D.B.M. by Sander Levine

D. Bruce Malito, Director

Long Island Regional Office

Office of the Medicaid Inspector General

cc: Robert Scalise, SED

Paul A. Stellino, Coordinator Student Services