“Medicaid to Schools” Top 10 Audit Findings
The following list is not intended to be exhaustive, but rather to highlight the most typical problems discovered in Medicaid audits by the New Hampshire Department of Health and Human Services. In each case, the Special Education Director should be involved in determining how the district will address the IEP language so that IEPs are within IDEA compliance. Medicaid regulations do not circumvent IDEA requirements, but rather may require further clarification in order to be considered a “prescription” for services.
- Services that are billed are not ordered in students’ IEPs.
Result – State automatically recoups money from the districts.
Action – IEP teams and case coordinators must make sure all IEPs are up to date and “order” services when appropriate and when provided at district expense.
- Covered, allowable services are not billed to Medicaid.
Result – Districts are underutilizing the Medicaid program.
Action – IEP teams and case coordinators must pay closer attention to ordering services that a student IS receiving and communicating to the qualified practitioner(s) when services are in the IEP.
Example – Many times nursing services, counseling services, specialized transportation and rehabilitative assistance are not “ordered” in the IEP but are being provided to the student.
- The appropriate order, recommendation or referral for Speech, OT, PT, Vision, and Rehabilitative Assistance are not completed and signed by qualified professionals or are not dated prior to the commencement of service delivery.
Result – State will recoup money for these services from the district(s).
Action – IEP teams and case coordinators must make sure that authorizations are completed and signed at IEP meetings and filed in the students’ files.
Example – Student has a one-to-one aide for personal care and assistance with communication objectives (Rehabilitative Assistance), but the district has not completed a “Recommendation for Rehabilitative Assistance” signed by a licensed practitioner of the healing arts prior to the commencement of service delivery.
- Transaction logs (service records) do not have original, handwritten signatures, including signatures of Licensed Practitioners of the Healing Arts providing direction to assistants (OT, PT and Speech).
Result – State may recoup money for these services from the district(s).
Action – Practitioners and special education should send original logs in to MSB™ for billing.
- Rehabilitative Assistance transaction logs are not signed by a qualified licensed practitioner of the healing arts, and/or the licensed practitioner of the healing arts is not able to indicate weekly consultation is occurring between the licensed professional and the Rehabilitative Assistant.
Result – State may recoup money for these services if not corrected.
Action – Districts will need to correct transaction logs to have a licensed professional sign the form or sign a separate statement indicating weekly consultation occurred throughout the year.
- Covered services are being provided by unqualified professionals as defined by the “Medicaid to Schools” Program rules.
Result – State will recoup money for these services.
Action – Districts must make sure that all services are provided by appropriately qualified professionals when billing Medicaid for those services. Districts must maintain copies of professionals’ credentials; if credentials are in question, districts should consider requesting a “waiver of credentials” from the NH Department of Health and Human Services.
Example – 1) Occupational Therapy services were provided by a licensed occupational therapist that is not certified by the NBCOT. These services cannot be billed to Medicaid under the OT procedure code, because the practitioner is not a qualified practitioner. 2) Nursing services were provided by a certified nursing assistant (CNA) and were billed to Medicaid. This money would be paid back to the state in an audit, because a CNA is not listed as a qualified nursing professional.
- Out of district (OOD) services are not ordered in IEPs, or OODs do not follow other “Medicaid to Schools” rules.
Result – Districts are still responsible. Districts cannot bill for services that are being provided at the placement or, if billed, the state will recoup.
Action – IEP teams, placement teams, OOD Coordinators and Directors must ensure good communication between the LEA and the facility to make sure all ordered services, especially those that are part of the program are ordered in IEPs and that all documentation requirements of the Program are met.
Example – As part of an OOD program, students are provided a one-to-one aide to reinforce behavioral objectives and plans; however, the IEP does not indicate Rehabilitative Assistance services. Even though it may be a recognized part of the OOD program, the district cannot bill for Rehabilitative Assistance unless the IEP is amended to include this service.
- Districts are billing for days when school is not in session (e.g., snow days, holidays), for days when a student is absent, or for students who are no longer enrolled by the district.
Result – The state will recoup money for days the child was absent or the school was not in session or for days the student was no longer enrolled by the billing district.
Action – 1) School attendance secretaries must communicate unexpected days off to MSB monthly. 2) Practitioners must pay close attention to filling out their forms to make sure units are not indicated on days when students are not receiving services. 3) Special Education staff must report to MSB when children enroll with a district or leave a district. 4) Practitioners must remove names of students from the caseload on transaction logs when those students are no longer receiving services in the billing district.
- Services are not considered “ordered” but rather “allowed” in the IEP.
Result – The state may recoup money due to IEP language merely suggesting that a service “may” take place versus “will” be provided as needed or for scheduled times each week.
Action – Avoid using language such as “student may access…;” rather, what, who and why questions should be addressed with regards to what the service is and who WILL provide the service. Also, indicate frequency and duration in place of “as needed.” A good rationale as to why a child needs a covered service in relationship to the disability is also crucial.
- Districts are not including orders for assessments in IEPs.
Result – Districts cannot bill Medicaid. State may recoup the money for triennial evaluations.
Action – IEP teams and case coordinators should make a statement in the triennial IEP that specifies that specific assessments will be conducted per the evaluation plan and parental authorization. The specific service area that is the subject of the assessment must be identified in the IEP with proper orders/recommendations/referrals filled out where necessary.
Should you have questions regarding implementation of these suggestions in IEP language, please consult your Director. MSB is willing to explain the nature of the above findings but does not replace the direction that should ultimately come from your district’s Special Education Director.