School-Based Health Services October 2015 LIMITED OFFICIAL USE ONLY - PowerPoint PPT Presentation

School-Based Health Services October 2015 LIMITED OFFICIAL USE ONLY DHHS/OIG

Agenda • OIG/OAS – Who We Are • Medicaid Program Overview • OAS SBHS Work • Case Studies • Future Work • Questions 2 LIMITED OFFICIAL USE ONLY DHHS/OIG

OIG/OAS Who We Are • HHS OIG works to fight waste, fraud, and abuse in Medicare, Medicaid, and other HHS programs. • OAS conducts independent audits of HHS programs, grantees, and contractors. • OAS also assists investigations conducted by OIG/OI and the DOJ. 3 10/19/2015 LIMITED OFFICIAL USE ONLY DHHS/OIG

OIG/OAS Who We Are • Overview – Number of employees and reports – Medicaid Work Plan Items – Focus of our audit work • States • Providers • CMS 4 LIMITED OFFICIAL USE ONLY DHHS/OIG

Medicaid Program Overview • Pursuant to Title XIX of the Social Security Act, the Medicaid program provides medical assistance to certain low-income individuals and individuals with disabilities. • The Federal and State Governments jointly fund and administer the Medicaid program. 5 LIMITED OFFICIAL USE ONLY DHHS/OIG

Medicaid Program Background 2014 Expenditure Estimates • Federal and State expenditures of $499 billion. Federal government funding 60 percent • Expenditures are projected to increase at an average annual rate of 6.2 percent and to reach $835 billion by 2023. 6 LIMITED OFFICIAL USE ONLY DHHS/OIG

Medicaid Program Background 2014 Enrollment Estimates • Average Medicaid enrollment of 65 million people • Average enrollment is projected to increase at an average annual rate of 3.0 percent over the next 10 years and to reach 79 million in 2023. 7 LIMITED OFFICIAL USE ONLY DHHS/OIG

OAS School-Based Work • General Overview – Since FY 2002 OAS has issued 35 audit reports concerning school-based health services, related transportation services, and Random Moment Time Studies (RMTS). – $1,077,111,432 in Questioned Costs – $1,142,810 in Funds Put to Better Use – Covering 14 States 8 10/19/2015 LIMITED OFFICIAL USE ONLY DHHS/OIG

Findings • School-Based Health Service Reviews – Billing errors (including duplication and incorrect coding) – Expenses claimed for activities fully funded or reimbursed by sources other than Medicaid – Claims made for students absent or discharged from school – Claims made for out-of-state students – Federal provider requirements not met – Services rendered by unlicensed providers 9 10/19/2015 LIMITED OFFICIAL USE ONLY DHHS/OIG

Findings ( con’t ) – Inappropriate administrative costs – Improper payment rate used – Services not rendered – No or inadequate documentation – No or untimely child’s plan/family plan – Prescription/referral requirements not met – Recoupment and return of reimbursement for duplicate claims not made in a timely manner – Services claimed for student in an institution for mental diseases 10 10/19/2015 LIMITED OFFICIAL USE ONLY DHHS/OIG

Findings ( con’t ) – Claimed services not reimbursable by Medicaid – Services not specified in child’s plan/family plan – State did not remit checks for increased reimbursement rate back to school districts – Student eligibility requirements not met – Transportation requirements not met – Unallowable operating costs 11 10/19/2015 LIMITED OFFICIAL USE ONLY DHHS/OIG

Findings ( con’t ) • Transportation Service Reviews – Received reimbursement for transportation services when, according to State regulations, they were prohibited from doing so at the time – No or inadequate documentation – Services not rendered – Transportation expenses claimed when no associated health service was rendered – Transportation services not included in child’s plan – Services overbilled 12 10/19/2015 LIMITED OFFICIAL USE ONLY DHHS/OIG

Findings ( con’t ) • Random Moment Time Study Reviews – Inaccurate time studies and/or cost reports used – Interim payments were not reconciled with actual costs – Administrative costs overstated – No documentation to support RMTS methodology 13 10/19/2015 LIMITED OFFICIAL USE ONLY DHHS/OIG

Causes • Inadequate or incorrect guidance from State agencies • Inadequate policies and procedures • Insufficient monitoring from State agencies • School-based health providers did not comply with Federal requirements such as maintaining documentation • Third party contractors improperly calculated payment rates, duplicated certain costs, and billed for services on days when students were not in school. 14 10/19/2015 LIMITED OFFICIAL USE ONLY DHHS/OIG

Case Studies • Arizona Improperly Claimed Federal Reimbursement for Medicaid School-Based Administrative Costs (A-09-11-2020) • Kansas Improperly Received Medicaid Reimbursement for School-Based Health Services (A-07-13-4207) • New Hampshire Did Not Always Correctly Claim Medicaid Payments for School-Based Transportation Services (A-01-11-00008) 15 10/19/2015 LIMITED OFFICIAL USE ONLY DHHS/OIG

Case Study: A-09-11-2020 Arizona Improperly Claimed Federal Reimbursement for Medicaid School-Based Administrative Costs 16 10/19/2015 LIMITED OFFICIAL USE ONLY DHHS/OIG

Case Study: A-09-11-2020 Objective To determine whether (1) the State agency maintained required documentation to support the RMTS methodology used to allocate school-based administrative costs to the Medicaid program and (2) the RMTS methodology was consistent with Federal requirements. 17 10/19/2015 LIMITED OFFICIAL USE ONLY DHHS/OIG

Case Study: A-09-11-2020 Methodology • Reviewed applicable Federal laws, regulations, and guidance and the State plan; • Reviewed the contract between the State agency and Maximus for the MAC program; • Reviewed the State guides developed in calendar years 2004 (amended in October 2008), 2009, and 2010; • Interviewed CMS officials to obtain an understanding of the RMTS methodology and documentation requirements in the CMS guide; 18 10/19/2015 LIMITED OFFICIAL USE ONLY DHHS/OIG

Case Study: A-09-11-2020 • Interviewed officials from the State agency, Maximus, and selected local education agencies to obtain an understanding of the MAC program and the State agency’s RMTS methodology for allocating school-based administrative costs to Medicaid; • Obtained from the State agency computer-generated data files related to Medicaid school-based administrative costs claimed for the audit period; • Verified the mathematical accuracy of the State agency’s calculations of Medicaid school-based administrative costs reported on the invoices and summary sheets for the MAC program; 19 10/19/2015 LIMITED OFFICIAL USE ONLY DHHS/OIG

Case Study: A-09-11-2020 • Determined whether the State agency’s RMTS results were statistically valid by obtaining a professional opinion from our statistical consultant, who evaluated – our description of the findings as presented in the section entitled “Sampling Methodology Not Fully Consistent With Federal Requirements,” – the result of our analysis showing the sample size and the number of discarded sample items for each quarter (when available), and – CMS’s responses to our questions related to the discarded sample items; 20 10/19/2015 LIMITED OFFICIAL USE ONLY DHHS/OIG

Case Study: A-09-11-2020 • Reviewed the quarterly data files and observation forms to deter mine the number of sample items that Maximus selected but discarded when calculating a statewide Medicaid percentage and to identify activity codes for the discarded sample items; • Recalculated the statewide Medicaid percentages on the basis of our review of the quarterly data files and observation forms; • Used the State agency’s formulas for calculating Medicaid school-based administrative costs and determined the effect on the Federal reimbursement by comparing the original claiming invoices with the revised invoices; and • Shared the results of our review with CMS and State agency officials. 21 10/19/2015 LIMITED OFFICIAL USE ONLY DHHS/OIG

Case Study: A-09-11-2020 Findings • For 2 of the 19 quarters, the State agency did not maintain required documentation to support (1) the universes of total available moments in time and RMTS participants and/or (2) the sample of random moments for selected participants. – Because the State agency did not maintain this documentation, the $5,421,711 in Federal reimbursement that it received for these quarters was unallowable. 22 10/19/2015 LIMITED OFFICIAL USE ONLY DHHS/OIG

Case Study: A-09-11-2020 • For the remaining 17 quarters, the State agency’s RMTS methodology was not fully consistent with Federal requirements: – The State agency inappropriately discarded sample items when calculating the statewide Medicaid percentages. We determined $6,295,139 of Federal reimbursement was unallowable on the basis of the revised statewide Medicaid percentages we calculated. – The RMTS methodology did not meet acceptable statistical sampling standards because the universes from which the sample items were selected were incomplete or incorrect. Because we were unable to determine which portion of the State agency’s claim for Federal reimbursement would have been allowable if complete or correct universes had been used to calculate the statewide Medicaid percentages, we set aside the remaining $18,828,972 for CMS resolution. 23 10/19/2015 LIMITED OFFICIAL USE ONLY DHHS/OIG