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
May 23, 2006
Mr. Thomas J. Stirning, Superintendent
Webster Central School District
119 South Avenue
Webster, New York 14580
Re: Webster Central School District
Provider # 01429221
SSHSP Corrective Action Review # 06-1039
Dear Mr. Stirning:
This letter will serve as a summary of findings for our recently completed review of sample billings by Webster 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 Webster Central School District was following program requirements, and had the appropriate documentation to support its claims. We reviewed 80 claims representing $28,079.00 in services paid from December 29, 2004, through December 28, 2005. Each type of service billed by Webster Central School District was included in our sampled claims. Furthermore, after having detected procedural errors in billing for Initial Reviews and Audiological Evaluations, we expanded the scope of our review to cover payments made from July 1, 2002 through March 31, 2005; and July 1, 2002 through April 4, 2006 respectively.
In general, Webster Central School District’s Medicaid claims were supported by adequate documentation. However, we identified $1,436.00 in payments from 5 sampled claims that were not authorized on the IEP, incorrectly billed, insufficiently documented, or otherwise non-billable. Furthermore, the errors found in our expanded analysis of Initial Reviews and Audiological Evaluations increased the amount billed in error by $3,959.00 for 18 claims. In total, $5,395.00 in payments from 23 claims must be voided as detailed on the schedule on page 3.
An Equal Opportunity/Affirmative Action Employer
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DETAILED FINDINGS
UNALLOWABLE CLAIMS
Initial Reviews
For sampled claim number 62, the provider incorrectly billed a total of $775.00 for an Initial Review for a student already classified as having a disability. As indicated on page 20 of the School Supportive Health Services (SSHS) 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.” In a statewide analysis, this error represented a systemically incorrect application of claiming instructions. Therefore, we expanded the scope of our review for this finding to cover dates of payment from July 1, 2002 through March 31, 2005, and found another $1,550.00 from 2 Initial Reviews that were improperly claimed, which brings the total overpayment for this error to $2,325.00. Some of 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. 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 bill in a nine-month period is submitted for a Re-evaluation Review.
Nursing Services
For sampled claims number 5, 9 and 10, all of which involved the same student, the District billed a total of $531.00 for Nursing Services that were not supported with a written order. This error affected 7 other dates of service for the same student with claims totaling $1,239.00 for the 2004 – 2005 school-year. For this error, a total of $1,770.00 must be voided for 10 claims.
Audiological Evaluation
For sampled claim number 1, the provider billed $130.00 for an Audiological Evaluation that was not supported by a referral written by a licensed physician, registered physician assistant or a licensed nurse practitioner. No audiological referrals were obtained since both the District and BOCES each believed that the other was obtaining the referrals. Therefore, we expanded the scope of our review for this finding to cover dates of payment from July 1, 2002 through April 4, 2006 and found another 9 claims totaling $1,170.00 which were not supported by a referral. For this error, a total of $1,300.00 must be voided for 10 claims.
PROCEDURAL ISSUES
We also noted the following procedural issue which does not require any payments to be voided but does require corrective action by the District.
Comprehensive Psychological Evaluations and Psychological Evaluations
For sampled claims number 13, 17, 19 and 20, the service was billed based on the month that evaluation was performed, which was not necessarily the month in which the report was signed by the psychologist. Even though these evaluations were prepared, they are not considered complete, and therefore not billable until signed. The District must amend its procedures to ensure that the evaluations are signed by the appropriate psychologists before being billed.
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These issues were presented to your staff at our exit conference held on April 24, 2006, at which time we were provided with the District’s written corrective action plan. Also at that time, we requested that $5,395.00 in payments be voided according to the following schedule, and to be notified when this was done.
Within 60 days of this letter, please submit documentation that the claims were voided. The 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 to determine if future corrective action reviews are necessary to monitor systemic billing errors. We have requested the Office of the Medicaid Inspector General, Bureau of Revenue Initiatives to grant Webster 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)238-8161.
Thank you for the cooperation and courtesy extended to our staff during this review.
Sincerely,
LEC May 23, 2006
Lewis E. Cole, Director
Rochester Office of the
Medicaid Inspector General
cc: Robert Scalise, SED
Kimberly Ganley, Special Services Administrator