Medicaid Audit Results NYS Office of Medicaid Inspector

Medicaid Audit Results NYS Office of Medicaid Inspector General (“OMIG”) May 6 -9, 2014

Background • U. S. Supreme Court ruled @ 20 years ago that school districts must provide many non-physician medical services. • NYS School-Supportive Health Program (“SSHP”) allows for reimbursement through Medicaid of eligible services (e. g. , OT, PT, speech therapy) to Medicaid-eligible students. • Medical payment structure imposed on educational setting; e. g. , need physician prescription to provide OT to assist with handwriting development. • EXTENSIVE, burdensome documentation requirements.

Scope of Audit • “Universe” of 19, 008 billable units (“claims”) of Medicaid-eligible service for which reimbursement was paid to Pioneer in 2013. • The associated $$ claimed was $626, 000 (of which Pioneer actually received about $313, 00). • 100 claims were randomly selected by OMIG for audit. - @ 26 data elements per claim. • Therefore @ 2, 600 ways to make a mistake and get dinged by auditors.

The Stakes • The 100 selected claims represented $3, 229. 18 billed. • If the OMIG audit finds mistaken/deficient claims, they extrapolate the error rate over the “universe” of claims. • $626, 000 claimed universe / $3, 229. 18 = 193. 85 ‘payback’ multiplier. • For example: If 10 claims are found deficient in some way, and the total dollar value of those 10 claims was $323, then $323 x 193. 85 ($62, 614) would be owed to OMIG. • Payback if OMIG finds 3% error rate or higher, based on dollar value of audited claims. For us, that meant we had an error allowance up to $96. 87. (For perspective, see Buffalo News article).

Findings OMIG found one (1) error, valued at $22. 19. (A contracted provider indicated 11: 35 AM-12: 00 PM as the duration of a service. A 30 minute billable unit was claimed, but disallowed upon audit. The 5 minute discrepancy had escaped our scrutiny).

Recognition and Appreciation • OMIG heaped praise on our related service employees and contracted providers and, especially, on Pam Bradford. • Pam is our gatekeeper extraordinaire; undocumented claims simply do not get through. (Our audited error rate was. 006). Pam meticulously collected and organized all the data needed by the auditors and they were very appreciative. • Thanks also to the enhanced Medicaid support provided by Jackie La. Buda and Zita Mattison through a ‘coser’ contract with Erie 1 BOCES. • Pioneer will soon receive an “Audit Summation Letter” from OMIG + a link on their public website , in the “Positive Reports” section, describing our excellent results.