1 of 27

Third Party Billing for Beginners

IASC Special Education Cooperative

Thursday May 11, 2023

Jackie Skelly - Director of Special Education

Shauna Dall - Third Party Billing Coordinator and SEDRA Specialist

2 of 27

Agenda Items:

Roles
Timelines
Rates Formula
What Ifs
Takeaways

3 of 27

MA Billing Overview

Third Party Billing (MA Billing) has many moving parts
All parts need to be completed accurately and timely in order to complete MA billing successfully
Maximizing MA revenue includes high levels of collaboration across many different people
Accountability for completing roles and responsibilities is key to ensure the process is completed successfully

4 of 27

Roles for Maximizing Third Party (MA) Billing

5 of 27

Roles

Importance of understanding roles is accountability
Role expectation related to MA billing should be documented within your system to prepare for expected turnover
Training all staff is critical to ensuring accurate and efficient MA billing
Roles listed may need some adjustment based on the people included in your system

6 of 27

Roles

Paraprofessionals/ESP/PCA	Special Education Teachers/Case Manager
Attend required training outlining MA billing expectations Attend/participate in nursing trainings following timelines set by nurse Complete PCA training and turn in certificate Complete PCA logs completely, accurately and professionally Turn in PCA logs by due dates set Ask questions, as soon as you have questions Provide feedback to case managers about actual PCA tasks	Complete IEPs with MA billable language Meet due process timelines Ensure PCA services and related services are written correctly in IEPs Review Time Studies to ensure time spent on ADLs and Behavior are what is expected Obtain initial MA Consent to Bill permission forms, review annually Coordinate service providers and Special Transportation trip logs Understand difference between Educational and Medically Necessary Review Assistive Technology needs

7 of 27

Roles

Related Service Providers	School Nurse/RN
Evaluation and Assessment Document Time and Effort Complete logs and service notes by deadlines set Ask questions Attend trainings to ensure billing logs and service notes are documented appropriately in case of an audit Coordinate changes in frequency and progress/response to treatment with Special Education Teacher/Case Managers Review Assistive Technology needs and provide ongoing assessment of health status via measurable outcomes, treatment plans, behavior plans, etc. Maintain/update ICD-10 codes	Attend trainings to ensure billing logs and service notes are documented appropriately in case of an audit Complete logs and service notes by deadlines set Complete PCA trainings by timelines set by DHS Keep documentation of MA billing trainings and logs organized Write Care Plans Obtain orders annually from student’s primary physician Review Time Studies in relation to Medical Necessity Delegate under Scope of Practice Maintain/update ICD-10 codes

8 of 27

Roles

Principals/Special Education Coordinators	Business Managers
Hold teachers and paras accountable for completing paperwork by deadlines set (follow up when MA billing, Sped Director, Coordinator have corrections or paperwork needed) May need to assist with obtaining MA permission forms or updated MA numbers Enforce FERPA and HIPAA guidelines as cases arise Oversee record retention policy Assist in coordinating Time and Effort schedules Share new hire information	Meet with Third Party Billing Coordinator several times a year to ensure staff are coded correctly in SEDRA and look at FTE accuracy (which impacts the rate) Code incoming TPB revenue Code Assistive Technology and provide invoicing to TPB Coordinator Coordinate discussions with the team when district is affected by changes to the system (overhead, salaries, MOE, new contracts, tuition-indirect cost % changes)

9 of 27

Roles

Third Party Billing (MA) Coordinator	Qualified Professionals (QP)
Work with Director/Coordinator, Business Manager regularly on data and MA rates, trend rates via changes DHS Provider set-up and enrollment Eligibility checks Review, update, document Parental Consent and Release forms Obtain private insurance denials Connect families to MNSure, Navigators, and resources as needed Set-up and maintain EMR (SpEd Forms: MA Forms) system, billing, and reporting Review billing records: authorizations, logs, care plans, training dates, time studies, diagnosis codes Submit claims, appeal unpaid items Review and report Remittance Advice Coordinate TPB audits	Complete PCA trainings and evaluations by timelines set by DHS Keep documentation organized and completed in a timely manner Ask questions Attend trainings to ensure billing logs and service notes are documented appropriately in case of an audit Keep documentation of MA billing trainings and logs organized Review Behavior Plans and Time Studies Stay current on Clinical impacts

10 of 27

Roles

Business Office Staff (admin assistant, SEDRA contact, payroll, AR, AP, etc)	Other
Ensure contracted service invoices are received and paid timely. Keep all procurement documentation together, and send a copy of any student-specific ATD to the TPB team. Keep staff certifications filed and updated annually. After Time & Effort schedules are received, update payroll. Pull payroll reports and update SEDRA accordingly. Retain SEDRA lines and work with Business Manager to meet MOE. Track staffing changes (retirements, new hires). Coordinate calendars and timelines with all departments.

11 of 27

Roles

Superintendent	Director of Special Education
Collaborate on hiring Set expectations for Principals to follow timelines Be aware of the MA revenue your district receives to assist with budgeting and/or future staffing needs Ensure systems are in place Enforcement/Support	Provide training on Third Party Billing to everyone involved - may be more than one training Provide examples on language that needs to be written in IEPs to MA bill Complete re-certification for CTSS by timelines (DHS) Implement policy updates and changes Ensure compliance of billing systems, IDEA, FERPA, HIPAA, and establish and understand contracts with staff and billing agents and activities necessary to maximize reimbursement Identify missing links Identify new hire’s roles, training needs and % in Sped Ensure Fiscal Monitoring requirements are met

12 of 27

Timeline Information and Requirements

13 of 27

Timelines

Timeline expectations are critical to have established
Accountability for following timelines needs to be addressed in each program
Multiple people have different timelines, all timelines rely on each other to be followed.

14 of 27

Timelines - Documentation

Trainings

When is the most beneficial time to train staff?

August, follow up in September - provide access to ongoing support throughout the year (videos, site visits, planned PLC training, etc)

Supervision

OT supervising COTA (every 10th visit or 30 days, whichever comes first)
PT supervising PTA (every 6th visit) (PTs can only supervise 2 PTAs)
SLP supervise SLPAs (currently not billable for SLPAs)
MH Professional supervise CTSS Practitioner - (supervision requirements vary)
Nursing/PCA - care plan within the first week, supervision logs

15 of 27

Timelines - Documentation cont.

PCA and Special Transportation Logs Due in SpEd Office

Set timelines

End of month: by 10th of following month
End of year: set dates to complete MA

IEP Service Dates

Mental Health date coordination
Time Study updates

Time and Effort

Time and Effort of staff must align with the FTE of SpEd Time in SEDRA. Payroll is updated with that breakout.

This is the FTE used to establish the MA rate for the service.

16 of 27

QP/Nurse and PCA Billing

Time Study Requirements

Required every 2 years for PCA services OR when services change
Annual completion of the IEP PCA Activities Checklist
Start and End Times are required for all PCA services - time study allows for billing a 10 day average time instead of actual time with start and end times every day
Signatures of PCAs and QP/Nurses need to be on each form

Training Requirements

Care Plan training within the first 14 days
Training of PCAs on Care Plan every 90 days after and 180 days - training dates must be documented and signatures obtained for each training

Ongoing Monitoring and Training

Supervision log must be in place for the QP/nurse to document their training and supervision of billable services
Special education teacher must be aware of what PCAs are billing - if IEP changes or needs to change, a new time study must be completed

17 of 27

Timelines - Revenue Cycle

July - Sept: Annual Data Report to DHS, receive and review new rates
Sept - Oct: Appeal any incorrect rates and reset as needed
Oct - Nov: Review current year staff with Business Managers (SEDRA)

Check and review IEP status

Dec - Jan: Admin Fee reimbursements sent

Settle Up from DHS (difference in projected rate vs actual rate)

March: Review SEDRA and comparing data with Sept-Oct

Two options if SEDRA is different - plan for pay back/gain or work to reset rates

April - May: Check IEP status, send out end of year reminders and reports

18 of 27

Timelines - Revenue Cycle - cont.

Monthly basis -

MA Eligibility Update
MA Billing Logs Due
PCA Logs Due
Special Transportation Trip Logs Due
Consent to Bill - who still needs consents on file
Payment Reports - revenue districts have received broken out by service via MHCP Payment & Claim Cut-off Calendar

By Need:

TPB Health Reports - ROIs, Reconciliation, Rate Comparison
New Staff onboarding and training

19 of 27

Timelines - DHS

CTSS Re-Certification - every 3 years (can be sooner) - Option 1, 2 or 3
Annual Data Report Form (Rates) - first week of July for previous year
Audits - annually;

HEDIS dictated by National Committee for Quality Assurance/RAC, SIRS

Must adhere to CMS and MN State guidelines
Multiple purposes - including monitoring quality of care, evaluates population needs, and recommends improvements

Review of State Aid payments - to comply with statute 256B.04

Internal/Self Audits

What safeguards can you put into place that will assist in other areas? Trend Reports/Statistical Metrics, Medical Record testing, Compliance adherence, Contract Costs comparison

20 of 27

Timelines - MDE

Spring Forum - Training! - April
Documentation Memos and Revisions - ongoing
IEP Dates - annual dates
Consent Start and Signature Dates - 1 signed consent per enrollment
SEDRA - November and March (include new hires)
Childcount (MARSS) - December 1
Free/Reduced

21 of 27

MA Rate Formula

22 of 27

Rate Formula

Salaries
Fringe
Contract Expense
FTE
Days in the Year
Hours in the Day
MA Direct Hours
MA Encounters
MDE Unrestricted Indirect Cost Percentage

= MA Rate

23 of 27

Rate Sheet

Each district has a rate sheet laying out all the different rates.

24 of 27

“What If” Scenarios

25 of 27

What If….?

What if you add or lose staff throughout the year??
What if you add or lose high need students??
What if there are IEP placement changes??
What if you have big purchase items/AT items??

26 of 27

Takeaways from Today

27 of 27

Take Away

Know your resources for MA enrollment - high need students should have MA coverage
All players need to be committed to the process in order to maximize revenue
Empower your Building Principals
Prioritize/review SEDRA coded staff
Look to bill for Assistive Technology purchases