New Jersey Schools Violate Medicaid Rules A report by the Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services indicates that New Jersey school officials continue to allow unqualified providers to deliver school-based speech-language pathology services to Medicaid-eligible students and recommends that New Jersey repay more than $5 million to ... Policy Analysis
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Policy Analysis  |   November 01, 2010
New Jersey Schools Violate Medicaid Rules
Author Notes
  • Steven C White, PhD, CCC-A, director of health care economics and advocacy, can be reached at swhite@asha.org.
    Steven C White, PhD, CCC-A, director of health care economics and advocacy, can be reached at swhite@asha.org.×
Article Information
Regulatory, Legislative & Advocacy / Policy Analysis
Policy Analysis   |   November 01, 2010
New Jersey Schools Violate Medicaid Rules
The ASHA Leader, November 2010, Vol. 15, 1-9. doi:10.1044/leader.PA.15132010.1
The ASHA Leader, November 2010, Vol. 15, 1-9. doi:10.1044/leader.PA.15132010.1
A report by the Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services indicates that New Jersey school officials continue to allow unqualified providers to deliver school-based speech-language pathology services to Medicaid-eligible students and recommends that New Jersey repay more than $5 million to the federal government.
According to the September report—the fourth in a series on Medicaid audits in New Jersey—16 of 100 Medicaid claims sampled included speech-language services provided by an unqualified practitioner (see The ASHA Leader, Aug. 3, 2010). The audit covered Medicaid claims paid from April 6, 2005, through June 27, 2007.
OIG audits programs to determine whether Medicaid services provided by the states—and funded by the states and the federal government—meet federal and state requirements; federal regulations supersede those established by the state unless state regulations are more stringent. In most states the federal share of Medicaid payments is substantial, and adherence to federal regulations is essential for coverage.
The Code of Federal Regulations [CFR, Title 42, Section 440.110(c)(2)] requires that Medicaid services for individuals with speech, hearing, and language disorders be provided by or under the direction of a speech-language pathologist who meets the requirements for the CCC-SLP from ASHA.
In 1993 the federal Centers for Medicare and Medicaid Services requested—and received—assurance from New Jersey officials that SLPs would meet federal provider qualifications for school-based services billed to Medicaid. Four subsequent audits (in 2006, 2008, and two this year), however, revealed claims for services by individuals who were neither ASHA-certified nor had the equivalent educational requirements and work experiences necessary to be eligible for ASHA certification.
In the 16 claims with speech-language services in the most recent audit, the individuals who provided the services were authorized by the New Jersey Department of Education to serve in public schools as either a “speech correctionist” or a “speech-language specialist.” Neither of these positions requires specific coursework toward a master’s degree, a 400-hour clinical practicum, or a clinical fellowship. In addition, the unqualified providers in the 16 claims were not “under the direction of” an SLP.
Other Findings
Overall, the sampled claims included 36 non-compliant claims (11 of which had more than one deficiency) with deficiencies in four areas:
  • 16 lacked a referral or prescription (15 of which were for speech-language service claims)

  • 16 did not meet federal provider requirements (all of which were for speech-language service claims)

  • 14 contained services that were not provided or supported

  • One contained services not documented in the student’s educational plan

Recommendations
The OIG recommended that New Jersey:
  • Refund $5.6 million to the federal government.

  • Consider the results of the review in its evaluation of the OIG’s prior recommendations to ensure that its school-based health providers comply with federal and state requirements.

The OIG reduced the recommended refund level after receiving a rebuttal statement from the New Jersey Department of Human Services, which administers the state’s Medicaid program through its Division of Medical Assistance and Health Services. The OIG did not accept all of the explanations in the rebuttal statement, including those related to speech-language pathology services, nor did it indicate the amount of adjustment.
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FROM THIS ISSUE
November 2010
Volume 15, Issue 13