By Holly Christopher

Stellar Therapy services was founded in 2003 by Melissa Christopher, Occupational Therapist. We provide pediatric outpatient occupational therapy, physical therapy, and speech therapy and have 100+ therapists providing services in all types of clinical settings, including hospitals, nursing homes, home health, and schools. We’re currently providing contract therapy services for facilities and schools and Medicaid Reimbursement Services to more than 50 Tennessee School Districts!

OUR MISSION:  

To provide quality services with integrity while maintaining a “life-friendly” corporate environment.

The purpose of this training is:

1. Review parental consent guidelines
2. To provide a basic understanding of the relationship between Medicaid-covered health services and school-based health services
3. Describe the credentialing process for individual therapists to become providers for Medicaid 
4. Educate on Medicaid guidelines for clinical documentation of service provision

MEDICAID REIMBURSEMENT PROGRAM GOALS:

• For every child to receive the services they need in order to participate fully in their education.
• To assist Special Education Departments in obtaining all of the funding that is available for the provision of those services.  

What is a MEDICAID REIMBURSEMENT PROGRAM?

Health services provided by Tennessee public school districts to students with Medicaid coverage are eligible to be reimbursed by Medicaid. In order to receive these reimbursements, schools have to process medical claims. “Medicaid Reimbursement Program” refers to all of the required tasks related to the claiming process. In Tennessee, Medicaid is called “TennCare”

Important Considerations 

• The availability of TennCare reimbursements should not influence the type/frequency of services provided to students.
• Claims should only be submitted for services that meet every billing requirement.
• Parents should be informed of the program and allowed to “opt out.”
• Service providers should be given Medicaid compliance training.
• A system of self-auditing should be in place.

HOW DOES MEDICAID FIT INTO EDUCATION?

Recognizing the important role school health services can play, the Federal Medicaid program has been supportive of school-centered health care as an effective method of providing access to essential medical care for eligible children.

IDEA services, routine preventive care, on-going primary care, and school-based clinics are all recognized by the Federal Medicaid program as essential services for children.

Offering healthcare services to children in the school setting is becoming an increasingly popular method of ensuring children’s access to these essential services. 

Medically necessary services can assist students in meeting their educational goals.  

“TennCare may not disqualify a medically necessary covered service for reimbursement because that service is provided in accordance with an IEP.”

– Interagency Agreement, Tennessee Department of Education, Bureau of TennCare, Tennessee Department of Health, and 6 other agencies,  July 1, 2009; 34 CFR §300.154(b)(1)(i)

What does Medical Necessity mean to a School Therapy Provider?

• Must be necessary to treat the medical problem or condition
• Must be the least costly alternative that is effective
• Must be provided by a licensed health care provider
• Must have a physician order for the service

HOW DO SCHOOLS BENEFIT?

TennCare reimbursements can be used to pay for anything related to special education, allowing better use of resources. IDEA Funds and other State and local funds that would have been spent on therapy or related services may now be used in other needed areas. TennCare reimbursements offer a way to lessen the impact of other funding cuts.

DO THERAPISTS HAVE TO DO THERAPY DIFFERENTLY?

NO! The only change or addition in the therapists’ service delivery to their students is the documentation of the services.  Medicaid requires specific details to be contained in the documentation that support the claim for reimbursement. You may already be documenting according to these requirements.

HOW DO THERAPISTS BECOME MEDICAID PROVIDERS?

If a therapist has the appropriate State Department of Health license, there will be a few documents to fill out and sign.  If a therapist does not have an active health license, Stellar will assist them in obtaining one. Stellar will take care of all of the details for the therapists and assist in making the process as easy as possible.

How it works, the short version

• Stellar signs therapists up to be TennCare providers.
• Therapists document service delivery in user-friendly online system: STELLARDOC. 
• Stellar bills TennCare (submits claims) on the eligible services.
• TennCare pays the claims to the school district.
• Stellar charges a percentage of the amount received by school district.

Therapists’ Responsibilities

• Participate in obtaining licensure and complete all credentialing forms
• Notify Stellar of any communications from state board or credentialing agencies
• Assist in obtaining Consent form & IEP Release form from parents
• Continue to provide services based upon your students’ IEPs
• Supply Stellar with copies of your current student’s assessments, if they aren’t if they aren’t uploaded to EdPlan
• Document service provision in Stellar Doc regularly
• Notify Stellar of any changes/updates to students’ records or IEPs
• Provide proof of payment of health license, ASHA dues, privilege tax, as due, for reimbursement

What therapists can become Medicaid Providers?

• Speech-Language Pathologists – with ASHA Certificate of Clinical Competency (CCC)
• Speech-Language Pathologist Assistants – with Bachelor’s degree in Speech-Language and/or Communication Disorders
• Occupational Therapists
• Certified Occupational Therapy Assistants
• Physical Therapists
• Physical Therapy Assistants
• Audiologists

What about other therapy providers?

• Speech Therapists with a Master’s Degree but no CCC – not eligible
• CFYs – not eligible
• Speech Teachers – not eligible
• Parapros – not eligible
• Therapy Technicians – not eligible
• Student Therapists – not eligible

REVIEW OF CLINICAL DOCUMENTATION GUIDELINES

Most of you learned these guidelines in college – this will be a refresher.  More detailed instructions will be given during the user training.  

Clinical Documentation Guidelines

• Goals and objectives are measurable
• Must include the medical condition or problem you are treating
• Include therapeutic intervention
• Must demonstrate measurable progress
• Plan for follow up
• The IEP must identify the length, frequency, and duration of the services.

Goals

• Reasonable 
• Attainable
• Meaningful
• Measurable
• Specific
• For example: “Sally will be able to complete her written work in the time allotted, legibly, on wide ruled paper, 80% of the time.

Medical Condition or Problem

• This is what you are treating: fine motor delay, speech delay, ataxia, gait abnormality, language disorder
• It is also why there is a problem, if known: autism, CP, muscular dystrophy, sensory processing disorder
• Listed in the “Area of Need” in the IEP

Therapeutic Intervention

• Demonstrate the skill of the therapist
• Focused on the therapy not the result
• Usually includes an action word: cued, instructed, modeled
• In our system it’s documented in the categories “this therapist…” and “therapeutic intervention”
• For example: OT provided verbal and tactile cues to hold pencil in correct tripod grasp.
• For example: SLP modeled proper tongue and lip placement while working on the /k/ sound.

Progress

•  This is where you describe the result of your therapeutic intervention, as it relates to your student
•  Written in terms of the goal areas from the IEP
•  If the connection isn’t clear, draw the map
•  Include both progress and lack of progress
• Ways to Measure Progress:
  •   Percentages
  •   Number of times 
  •   Level of assist

For example: Johnny produced the /th/ blend in the initial position 6/8 times today, with min verbal cues.

Plan for Follow Up

• Based on today’s treatment session, what are you going to do next time?
• Changes needed to plan of care
• Activities to work on next session
• Consult or communication needed with other providers, family
• Equipment needs
• If anything unusual happened today, be sure to mention how you’re addressing it
• It’s ok to select “continue plan of care” if no changes are needed

Frequency & Duration

• Be sure your sessions exactly match the frequency in the IEP – no more, no less, because:
  • The IEP is a legal document
  • Your sessions completed should match the doctor’s order, for billing and liability reasons

Assessments

• Prior or current therapy by school or other providers
• Medications
• Medical conditions
• Developmental and medical history
• Reason for referral to therapy
• Other persons who contribute to the assessment data
• Date and time of assessment
• How do you document if you don’t know the answers?

BILLING MEDICAID FOR IEP Services

1. The student receiving the service must be enrolled in the Medicaid program. (Stellar will check for this.)
2. The services must be in the student’s IEP. (Stellar will check for this.)
3. The services must have a current physician’s order. (Stellar obtains the orders.)
4. The service must be furnished by a provider who is qualified to provide the service under applicable State licensure or certification requirements. (Stellar assists therapists with this.)
5. The school district must obtain a signed parental consent to bill Medicaid for covered IEP services provided to the student. 
6. Service provision records must be maintained. 

Reimbursement for Services Performed by Assistants

• PTAs, OTAs and SLP-As services can be reimbursed by Medicaid
• Co-signature is required for SLP-A documentation
• All must have a have a health license
• All must have a clinical supervisor and follow the supervision guidelines
• Know your state licensure practice act!

FORMS TO DISTRIBUTE TO AND COLLECT FROM PARENTS:

1. Consent to Access to Information
2. Physician/Insurance Info Page
3. Notice of Access to Information

Distribute & collect these forms on all students with an IEP who receive therapy.

• Distribute the packet at each IEP meeting.
• Obtain signed consent forms one time.

Benefits of adding a standardized clinical documentation system into special education:

• Allow school district to submit claims for reimbursement with appropriate documentation
• Provide consistency in documentation
• Easy access to records
• Track frequency of service delivery & missed visits
• Easy transition to new or interim therapist
• Document implementation of the IEP
• Supervisor or Director has quick access to your work (can answer parent questions without having to contact therapist)
• Easily identify trends, problems, and successes
• Demonstrate readiness for discharge

FREQUENTLY ASKED QUESTIONS:

• Will TennCare still pay for services outside the school if the district bills for school services?
  • YES
• Will TennCare pay for school services not in the IEP?
  • NO
• Aren’t schools already paid by IDEA to provide these services? 
  • YES –BUT IDEA FUNDS ARE INTENDED TO BE UTILIZED AFTER MEDICAID FUNDS ARE OBTAINED. 

Isn’t Medicaid always the “payer of last resort?”

“Although Medicaid is traditionally the payer of last resort for health care services, it is required to reimburse for IDEA-related medically necessary services for eligible children before IDEA  funds are used.” 

–The Medicare Catastrophic Coverage Act of 1988 enacted this requirement, which is currently codified at 42 U.S.C. 1396b(c).

Would you like more information? 

CONTACT: 

Holly Christopher

 (423) 622-1551 ext. 9-128

holly@stellartherapy.com

http://www.stellartherapy.com