Medicaid Billing Updates

Special Education Director’s Academy

October 12, 2022

Christie Guinn, Deputy Bureau Chief

Vanessa Skrehot, School Health Manager

HSD, Medical Assistance Division, Exempt Services & Programs Bureau

Expansion to Billing for Non-IEP Services

CMS Reversal of the “Free Care” Policy

• In December 2014, CMS issued State Medicaid Director Letter #14-006 which stated that states were now allowed to seek reimbursement for services that had previously been ineligible for billing under what was known as the “Free Care Rule”.
• This rule previously stated that if a service was provided free-of-charge to Medicaid beneficiaries and others, then Medicaid reimbursement could not be sought.
• Goal was to facilitate and improve access to quality healthcare services and improve the health of communities.
• Services provided by schools outside of an IEP/IFSP may be billable to the Medicaid program; a particular focus is on Nursing and Behavioral Health services.

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What Should Districts be Thinking About?

• Billing for non-IEP services is optional, however if your district is already providing these services, there is no reason not to bill for them.
• Nursing Services for non-IEP students are likely being provided at most schools across the state. This would include hearing and vision screenings, medication administration and other regular procedures for conditions including diabetes and asthma that are provided to regular education students. This also includes services delegated to other school staff with proper training from school nurse.
• The need for Behavioral Health Services to regular education students is increasing and many districts are beginning to provide these services in addition to those provided through an IEP.
• District employed/contracted staff
• Referred out to the district’s SBHC
• Referred to outside providers

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How Would Schools Bill for Non-IEP Services?

• Billing will likely be very similar to what is currently in place for IEP services.
• Documentation of Medical Necessity through some sort of Service Plan.
• For unplanned/crisis services documenting medical necessity is justified through through service documentation.
• Billing could occur through the same billing systems that the schools are currently using for IEP services.
• Provider documentation requirements would be the same as IEP services.
• 3^rd Party billers are aware of the changes & implementing in their systems.

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How Would Schools Bill for Non-IEP Services?

• New Parental Consent Form
• HSD has created a parental consent form that combines consent for students who receive IEP and non-IEP services.
• Combined consent benefits, as IEP students may need unplanned non-IEP services throughout the year.
• Districts only need to send one parental consent form.
• PCP Notification
• Non-IEP services do not require a PCP notification.
• The PCP notification is still a requirement for IEP-services; the PCP notification process will remain the same for IEP services.

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Behavioral Health for Non-IEP Services

• Under the expansion, districts may seek reimbursement for behavioral health services for non-IEP services.
• Includes unplanned/crisis services
• Non-IEP services (with exception to unplanned services) require a Plan of Care that substantiates medical necessity and is signed by a qualified provider.
• Plan of care template will be available
• Staff participating in the Random Moment Time Study will need to be categorized under their licensure (e.g., LCSW, LPCC) for direct services vs. an administrative category (e.g., behavioral specialist).
• Previously, Providers servicing general education students were listed in an Administrative category to prevent them from populating on the Cost Report.

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Non-IEP Behavioral Health and Confidentiality

• Whereas, for IEP services, parental involvement and IEP meetings mean parents/guardians are aware of services provided; Non-IEP services do not have the same parental inclusions built in.
• Under FERPA, parents/guardians have the right to access educational records, which include behavioral health service documentation.
• Districts are encouraged to consult with their legal counsel regarding release of documentation of confidential services.
• Ensure notification to students regarding the limitations of confidentiality.
• Emphasis will be for providers to be intentional in how their service documentation is written, especially for minors that are consenting to treatment, and they do not have/want their parents involved.
• Providers be aware of what meets the definition of sole possession records.
• https://studentprivacy.ed.gov/faq/what-records-are-exempted-ferpa
• HSD has been engaged in conversations with General Counsel from HSD & PED regarding release of information for these confidential services. Additional guidance will be forthcoming.

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Potential Changes to Current Systems for Behavioral Health Services

• Districts will need to consider their current system for providing non-IEP Behavioral Health Services and determine if the best methodology going forward may include providing these services within the district so that Medicaid reimbursement can be sought
• HSD and PED have been discussing the need for additional providers across the state and the need for additional funding for schools to be able to hire additional providers to meet their needs
• This will need to be a district decision that will be based on local needs and availability of providers and funding

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Ordering, Referring and Rendering Provider NPI on Claims

What is ORP?

• The Affordable Care Act (ACA) and CFR Title 42, Part 455 require that attending, ordering, referring, rendering and prescribing providers be enrolled in the Medicaid program in order to meet ACA program integrity requirements designed to ensure that all attended, prescribed, ordered referred or rendered services, items and admissions for Medicaid beneficiaries originate from properly licensed provider who have not been excluded from Medicare or Medicaid.
• The expectation is that most services and items will only be paid by the Medicaid program if the individual provider who attends, prescribes, orders, refers or renders a service is enrolled in the Medicaid program. Otherwise, the claim will be denied in accordance with federal regulations.

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Who is the “Referring” Provider?�

• CMS has provided guidance to HSD that “The state having the authority to determine scope of practice through state law, may broaden a provider’s scope of practice to allow, in this case, the professional that was an existing member of the IEP team (e.g. OT, PT, SLP or Audiologist) the authority to order the specified services and act as the ORP provider and be identified as such on claims for services furnished pursuant to the IEP.”
• In plain English…the OT, PT, SLP or Audiologist that participates in the IEP team (writes the therapy specific goals & objectives) and represents the district in determining such services are needed by the child can serve as the “referring” provider for those specific services for the term of that IEP.

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What Does This Mean for MSBS?

• The majority of rendering providers in MSBS are already enrolled and their NPI is populated on all claims submitted by the schools for these providers.
• ASL, COTA and PTA bill under their supervisor’s Medicaid and NPI numbers which populate on their claims.
• Effective July 1, 2022, HSD is requiring the NPI of the referring provider on MSBS claims for SLP, OT, PT and Audiology.
• The lack of the referring provider NPI on MSBS claims has been a PERM finding for the last several cycles.
• CMS is now requiring that HSD find resolution and begin requiring the referring provider NPI for OT, PT SLP and Audiology claims. Failure to do so could result in the recoupment of payments for the non-compliant services billings.

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Discussions Related to Implementation

• HSD has been in contact with CMS, PED and the main 3^rd Party Biller (SSG) to discuss this requirement and implementation timeline.
• The majority of school providers are already enrolled and MSBS Coordinators should have their NPI information easily accessible.
• The SSG system is capable of capturing this information and can accommodate the requirement.
• Manual entry of the referring NPIs can be easily accomplished for smaller districts provided that the MSBS Coordinator has access to the IEPs and can see which providers were part of the IEP team (Signature Page of IEP).
• All of the large districts in the state are doing data dumps from their Student Information/IEP Systems to populate MAXCapture.
• HSD has provided CMS with a summary of the steps we feel are necessary and approximate timeline for full implementation.

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Medicaid Referring Provider Form

• HSD has worked with PED to create the Medicaid Referring Provider Form for School-Based Services.
• Will be a stand-alone form for FY23.
• Incorporated into Elementary and Secondary IEP templates in FY24.
• Districts will need to complete independently of IEP until fully incorporated into IEP template.
• Communicated to IEP vendors as a required form for each IEP.
• Can be populated with information provided by MSBS Coordinator.
• Drop-down boxes will allow for Provider Name, Credentials & NPI to be populated.
• Shared by SPED Bureau via email on October 2, 2022.

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Implications of Districts Using Data Dumps to Populate Billing System

• HSD is going to continue collaboration with the PED, SPED Bureau on changes to the IEP template that would be state required in order for the IEP vendors to then implement for all school clients.
• IEP template changes are typically done at the beginning of a school year, so we would be looking for an implementation date of July 1, 2023.
• Form released in 2022 would be incorporated without additional changes.
• Districts may be able to get form implemented in a way that could populate data dump for FY23.
• HSD will continue to communicate with CMS on our proposed implementation and potential changes that they may request to meet their requirements.

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What Should Districts Be Doing Now?

• Smaller districts that will be doing manual entries into the billing system should start making arrangements to get access to IEPs.
• Ensure all providers that are doing evaluations/IEPs but may not be providing regular services are enrolled with Conduent.
• It is ok if these providers are paid with IDEA or other funds. Their NPI will populate on the claims, but they do not have to be providing regular services.
• Start taking with providers about the expectation that if they are the provider representing their service type at the IEP, their NPI will be utilized, and they will be identified as the “referring” provider for that IEP cycle.

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Questions??

MSBS Program Staff

• Vanessa Skrehot, SHO Manager

505-795-3343

vanessa.skrehot@state.nm.us

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• Ashley Zamora, MSBS Program Manager (Districts M-Z)

505-469-5775

Ashley.zamora1@state.nm.us

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• Kacey Kim, MSBS Program Manager (Districts A-L)

505-795-3895

Kacey.kim@state.nm.us

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• Ashley Garcia, PED Medicaid/Health Services Coordinator

505-690-3842

ashley.garcia@ped.nm.gov

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