New York City Medicaid Program Faulted by the Inspector General The Office of Inspector General (OIG) for the Department of Health and Human Services has found that another major school system, New York City, is significantly out of compliance with federal Medicaid regulations, citing lack of documentation for services, improper referrals, and a lack of qualified providers. The recent report, ... School Matters
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School Matters  |   August 01, 2005
New York City Medicaid Program Faulted by the Inspector General
Author Notes
  • Susan Boswell, an assistant managing editor of The ASHA Leader, can be reached at sboswell@asha.org.
    Susan Boswell, an assistant managing editor of The ASHA Leader, can be reached at sboswell@asha.org.×
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School-Based Settings / Practice Management / School Matters
School Matters   |   August 01, 2005
New York City Medicaid Program Faulted by the Inspector General
The ASHA Leader, August 2005, Vol. 10, 1-28. doi:10.1044/leader.SCM1.10102005.1
The ASHA Leader, August 2005, Vol. 10, 1-28. doi:10.1044/leader.SCM1.10102005.1
The Office of Inspector General (OIG) for the Department of Health and Human Services has found that another major school system, New York City, is significantly out of compliance with federal Medicaid regulations, citing lack of documentation for services, improper referrals, and a lack of qualified providers.
The recent report, “Review of Medicaid Speech Claims Made by the New York City Department of Education,” was one of the most critical reviews of any state Medicaid program in recent years. As the result of the investigation, the OIG recommended that New York State implement corrective measures to comply with federal and state Medicaid regulations and return the federal portion of the Medicaid payments—nearly $436 million—of the total $870 million in payments the state received.
In its review of one of the largest state Medicaid programs in the nation, the OIG reviewed a sample of the 2.5 million Medicaid claims for speech-language pathology services that were provided for 110,000 students during 1993–2001. The audit found that 86% of 100 claims in its sample did not comply with federal and state requirements, and 68% contained more than one deficiency.
Deficiencies Cited
Among the deficiencies reported:
  • 76 claims did not include services provided by or under the direction of an ASHA-certified individual, or an individual with substantially equivalent qualifications

  • 47 lacked documentation to verify that a minimum of two speech services were rendered during the month billed

  • 43 claims lacked a referral by an appropriate medical professional

  • 42 claims lacked documentation to show that the services billed were rendered

  • 2 claims lacked any documentation at all

  • 1 claim did not include a recommendation for speech services in the child’s plan/family plan

The report comes on the heels of a 2004 audit of Medicaid reimbursement in school districts across the state. The audit of possible errors in Medicaid claims for speech-language pathology, physical therapy, psychological counseling, and transportation for students with disabilities would have cost the districts $173 million.
The New York City school system audit is the most recent in a series of approximately 20 audits of school-based Medicaid programs over the last five years. In at least five of these audits, the OIG found that speech-language pathology services were not compliant with federal provider qualification requirements.
“ASHA is committed to actively educating members about Medicaid eligibility and billing,” said Dolores Battle, ASHA president. “We have resources on Medicaid requirements to help members who provide services to qualified children with speech, language, and hearing disorders.”
The OIG report raises specific questions about the school district’s documentation, communication, and supervision of services, according to ASHA members familiar with the Medicaid speech-language pathology program in New York.
The New York City audit focused on the early and mid-1990s, a time when the state lacked clear direction for Medicaid requirements, noted Fran Grady, program director of Speech and Hearing in BOCES, Monroe and Fairport, NY. “Medicaid didn’t get started until 1994. At that point, there was a need for more specific guidelines about how the process had to happen and what documentation needed to be kept,” she said.
“But this is not an excuse for not doing proper record keeping and having a process in place to be in compliance with state and federal regulations,” she said. “It all comes down to people connecting with each other. There are so many different levels of bureaucracy and so many different levels of providers, staff, and students that it’s difficult.”
The OIG has indicated in its most recent work plan that it will continue to audit Medicaid school-based services.
School Administration Often Poorly Informed
School administrators and billing agents are often poorly informed about federal and state Medicaid requirements for provider qualifications, supervision, and documentation related to obtaining reimbursement for speech, language, and hearing services to children in schools.
“Many kids are not getting appropriate services because they’re treated by providers with lesser qualifications,” said Sheila Bernstein, president of the New York State Speech-Language-Hearing Association. “The schools are hiring one person to do paperwork and sign off on numerous cases.”
However, the lack of Medicaid direction for “under the direction of” for speech-language pathology services remains one of the biggest challenges in providing Medicaid services, noted Lissa Power-deFur, chair of the ASHA Working Group on Medicaid Reimbursement.
“Medicaid doesn’t identify the qualification requirements for a provider who is qualified to provide services under the direction of someone else who is qualified, nor does Medicaid identify the type and amount of direction that should be provided. In the absence of such direction, the types of providers and the amount of direction varies widely from school district to school district.”
When working under Medicaid, school-based providers must assume a health care mindset, said Power-deFur. “Medicaid requirements follow a medical model, which is unfamiliar to many education personnel. Some education administrators do not have an appreciation for the need to strictly adhere to Medicaid-qualified provider requirements, especially with respect to ‘under the direction of.’ This can create an opportunity for speech-language pathologists to educate their administrators to assure compliance with Medicaid.”
Guidance for Service Delivery
ASHA has addressed Medicaid service delivery in the schools on several fronts. Medicaid funding is part of ASHA’s 2005 Focused Initiative on Health Care Reimbursement that will increase access to information and tools to help navigate state-funded insurance programs such as Medicaid.
ASHA’s School Finance Committee is charged with helping members understand complex funding mechanisms involved in school-based services from a federal, state, and local perspective. The committee plans to develop a funding flow chart to help members understand and develop strategies to access funds, including Medicaid funds, at the local/district level. More information will be available on the School Finance Committee Web page later this fall.
A position statement and technical report on providing Medicaid services “under the direction of” has been developed by ASHA’s Working Group on Medicaid Reimbursement.
Specific information for ASHA members that they can use to facilitate school administrators’ understanding and compliance with Medicaid regulations regarding appropriate billing for speech-language pathology and audiology services is available in the Reimbursement section of the ASHA Web site.
For more information on the OIG report, contact Ingrida Lusis by phone through the Action Center at 800-498-2071, or by e-mail at ilusis@asha.org.
What Can We Learn From the OIG Report?

by Nancy Huffman

The issue isn’t one of speech “therapy,” but rather, relates to the school district’s fulfillment of reimbursement requirements to secure Medicaid funding for services rendered. While I cannot speak to the specific New York City issues, the report is thought provoking and frankly, instructive as to OIG audits. What can we learn from this 105-page report? Three key words leap out—communication, documentation, and recordkeeping:

  • The importance of communication between state health and education agencies and the CMS, particularly in a state that issues multiple credentials affecting speech-language pathology practice in school settings

  • The importance of communication between state credentialing entities, departments of health, departments of education, and ASHA whose practitioners under their aegis are affected by the requirements for accessing Medicaid reimbursement

  • The importance of informed practitioners on what their credential(s) allow them to do or not do in terms of fulfilling Medicaid reimbursement requirements for their school district

  • The importance of a school district’s union to be informed of policies implemented by the district for accessing Medicaid reimbursement given the speech-language pathologist’s ethical and legal responsibilities

  • The need for commitment on the part of the district to put into place and monitor a record-keeping procedure that can be responsive to regulatory clarifications and interpretations over time

  • The importance of meticulous documentation and record keeping at all levels

  • The need for a district to involve individuals (i.e., SLPs and special education personnel), beyond their billing and data collection experts, in planning and interpreting the reimbursement program and how it fits into the speech-language service delivery program and IDEA requirements

  • The knowledge that “under the direction of” is fraught with issues concerning qualifications of providers and direction from CMS and the state on how to deal with providers deemed not qualified by CMS

Nancy Huffman is retired from Monroe County Board of Cooperative Educational Services (BOCES) #1 in Fairport, NY where she was supervisor of speech-language pathology and audiology services. She is currently a member of ASHA’s School Finance Committee.

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August 2005
Volume 10, Issue 10