05/04/16: Medicaid School Program – Eligible Services

Medicaid School Program – Eligible Services

There still seems to be a lot of misinformation regarding the services that are currently reimbursable in the Ohio Medicaid School Program (MSP). In the attached February 3, 2016 memo from Dr. Sue Zake and Mark Smith, the Ohio Department of Education (ODE) clarified that “There is no change in the services provider districts can claim”. The eligible services include:

  • Audiology
  • Counseling
  • Nursing
  • Occupational Therapy
  • Physical Therapy
  • Psychology
  • Social Work
  • Speech-Language Pathology
  • Targeted Case Management
  • Transportation

This misinformation relates to Delegated Nursing and Personal Care Services, which are not currently reimbursable in Ohio. Some districts are being advised to document for these two services because there will be retroactive billing at a later date. In the attached email, ODE makes it very clear that “there will be no retroactive claims for services not yet available for reimbursement”. There was retroactive billing allowed during the initial startup of the MSP, but that was a result of the CAFS lawsuit settlement. The effective date for any new services will be based on the date that Ohio submits its “State Plan Amendment” (SPA) to the Centers for Medicare and Medicaid Services (CMS). “The Ohio Department of Education will notify provider districts about allowed additional eligible services.”

If and when new services are added to the MSP, all billing vendors will work with their client districts to identify, train, and implement the new services based on the specific rules established by the Ohio Department of Medicaid (ODM) and approved by CMS. Documenting any new services prior to the SPA date will not generate any additional MSP reimbursement. I do not like to see districts go through the effort and expense of documenting services that will not result in Medicaid reimbursement. Please let us know if you have any questions regarding billable MSP services, or “Send questions regarding the content of the ODE memo to SchoolMedicaid@education.ohio.gov.”

Healthcare Billing Services, Inc.



04/22/16: MSP Contract Procurement

MSP Contract Procurement

On April 13th, I participated in a presentation at the OASBO conference regarding the Medicaid School Program (MSP) and the Agreed Upon Procedures (AUP) review. I had the pleasure of presenting with Ken Richards of Kennedy Cottrell Richards (KCR) and Zac Morris with Rea and Associates. We had a lot of information to cover in just one hour of time. As we discussed, the costliest area of exposure in the AUP review relates to “Contract Procurement”. Below is a summary of the Related Service Procurement Requirements for the upcoming 2016/17 school year. Please note these requirements as you are entering into 2016/17 service contracts for MSP therapy services (OT, PT, Speech, Psychology, Social Work, and Nursing).

Contracts over $150,000

  • Must be awarded through full and open competition.
  • Contract file must state rationale for vendor selection. (Cost/Price Analysis)
  • If competition is limited, document your efforts and rationale. (Sole Source Vendor)

Contracts under $150,000, but over the district’s procurement threshold.

  • Documentation must exist that show at least 2 price comparisons, which can be obtained through written, verbal, catalog pricing, internet or from other sources. (Cost/Price Analysis)

Competitive Bidding or Price Analysis are not required for contracts less than the micro purchase limit ($3,000).

Sole Source Vendor

  • Competitive Bidding and/or Price Comparisons are not required if you can justify and you document that there is only one vendor in your area that can meet your service needs. You must document your efforts in determining that the services are “available only from a single source”.

Contracts with ESC’s

  • MSP service contracts with ESC’s can also be designated as a Sole Source Vendor and/or a Shared Services Contract. 45 CFR 92.36 (b)(5) encourages “State and Local intergovernmental agreements for the procurement or use of common goods and services”.

Note, when you contract with two separate vendors for the same service, it is hard to justify that either vendor is a Sole Source Vendor.

Therapy contracts must include the following three statements:

  1. Vendor to comply with the requirements of 45 CFR 164.504(e) (1) for safeguarding and limiting access to information concerning beneficiaries.
  2. The representative of the U.S. Department of Human Services, ODM, ODE or their respective designee will have access to the subcontractor’s books, documents and records.
  3. Vendor acknowledges that they or their principles are not suspended or debarred.

All vendor invoices are required to provide a listing of students served. (It is extremely important that your therapy vendor provide this information for every invoice)


Contracts over $150,000 require Competitive Bidding, unless the contract is with an ESC, or you can justify Sole Source Vendor designation.

Contracts under $150,000 require Price Comparisons, unless ESC contract, Sole Source Vendor, under district’s procurement threshold, or under the Micro Purchase limit.

Include the three statements on therapy contracts.

Require all vendors to provide “Students Served” listing with each invoice.

See Attachment “Medicaid School Program – Contract Procurement Checklist

Healthcare Billing Services, Inc.



04/08/16: IEP Care Coordination/Physician Referral Form

IEP Care Coordination/Physician Referral Form

From the start of the Ohio Medicaid School Program (MSP) back in 2009, there has been a program requirement that districts must document their efforts to coordinate IEP Related Services with each Medicaid student’s Primary Care Physician (OAC 5160-35-06(E)(7)). Some districts have been doing this “Care Coordination”, but most have not, and I think that with the latest “Order, Refer, Prescribe” (ORP) controversy, this may be a requirement that the State may start enforcing. We have developed a simple procedure that would meet the Care Coordination requirements of 5160-35-06, while at the same time initiate the process of obtaining an ORP referral from the student’s physician.

We looked at forms used by various districts and in other States, and have come up with a one-page “IEP Care Coordination/Physician Referral Form”. The form is designed to be sent to the parent for coordination consent, then the parent would give the signed form to the physician for referral, who would then send the signed form back to the school. I know that the likelihood of getting all of these forms to the physician and back from the physician are slim, but just sending the forms out would meet the requirements of 5160-35-06, and could be the initial step in getting the ORP referral. Although we still have very few answers to our ORP questions, here are some assumptions that we have made:

  • You are only required to coordinate services and obtain a physician referral for your Medicaid Related Service students. Typically, billing vendors do not share student Medicaid eligibility information with districts, but with the Parental Consent and ORP requirements, it has become necessary to share this information so districts are not running down forms for students that do not even qualify for Medicaid. You would only need to send the ‘Care Coordination/Physician Referral Form” for your IEP Related Service Students that have Medicaid insurance. Your billing vendor should be able to provide you a list of all Medicaid Related Service Students, and then track Medicaid students that need a referral.
  • We have purposely left off a beginning date and an ending date on the Referral Form. It is assumed that the order will be valid for no longer than one year from the signature date, but the IEP effective date may be a factor also. This is one of the questions that we are still waiting to have answered, and until we know for sure, we have left off any effective dates.
  • Some physicians may sign the Referral Form with no questions asked, while others may want to see the IEP or ETR testing. Others may actually want to see the student, if they have not been seen in a while. Keep in mind that this is only for Medicaid students, and any additional services provided by the physician would be billed to Medicaid directly by the physician. This will be a good test to see what type of response and cooperation you receive from the students’ primary physicians.
  • Some students may not have an actual primary care physician, or their physician may be an Urgent Care or Hospital. This initial request will not net 100% of the Medicaid student referrals, and districts may eventually need to develop a relationship with physicians in their area who can provide the referral in situations where there is not a primary care physician. Many ESC’s are looking into providing this service for their districts, and some county health departments can also provide physician referrals.

I recommend that you put the attached form on your district’s letterhead. There are four areas on the form that you will need to change from the sample school district name to your specific district. The student name is listed one time on the form above the Physician Signature, and will need to be changed with each student. Check the box next to each service that the student is receiving. ETR testing does not require a physician referral. Be sure to put your specific “Please return to” information on the bottom of the form.

I still have not given up on the possibility that the State may reverse their ORP decision and restore the MSP therapist’s ability to “Order, Refer, and Prescribe”. If the State does reverse their decision, this will still be a worthwhile process, as this type of Care Coordination is a requirement of the program. Some districts have already developed a similar form and process. What I have attached is just a sample, and you can customize the form to fit your district’s needs. We will make modifications to the process and form as we get more direction from the State and feedback from physicians.

When you are ready to start this process, contact your billing vendor and get a listing of you IEP Related Service Medicaid Students. We will continue to keep you informed of any new information and the result of the extension request.

Healthcare Billing Services, Inc.


Sample Physician Referral Form