Your path to maximizing Medicaid reimbursements and compliance
School-based Medicaid claiming is an ongoing process used to help schools recover a portion of the costs associated with providing healthcare and support services to eligible, Medicaid-enrolled students. This is one small part of the State/Federal Medicaid program which provides health insurance to low-income families.
An individualized education plan (IEP) outlines the services, modificationsModifications Changes made to the curriculum or assessments to meet the needs of a student with disabilities, potentially altering what is taught or how success is measured., and
accommodations needed to support a student who is eligible for special educationSpecial Education Instruction designed to meet the unique needs of a student with a disability, provided at no cost to parents, including specially designed instruction and related services. services. This eligibility may be due to cognitive or developmental delays, ADHD, hearing, vision or speech impairment, etc.
Prior to 2014, school districts could only seek Medicaid reimbursementMedicaid Reimbursement The process of receiving payment from Medicaid for services provided to eligible students as part of a school-based program. for eligible services provided to Medicaid-enrolled students with IEPs. State-by-State that guidance has begun to change.
Submitting Medicaid claims for Students without IEPs
In 2014, the Federal Government’s Centers for Medicare and Medicaid Services (CMS) outlined a ruling that reversed the free care rule. This is often referred to as the “free care policy reversal.” While some States are still working to get the infrastructure in place to support this reversal, many others have already begun accepting eligible Medicaid claims for Medicaid-enrolled students without an IEP. Check with your State or contact our team to learn how this applies to your district.
A research initiative by the Campaign for Educational Equity shows that healthier students are better learners. If your district is already providing the health-related servicesRelated Services Support services (such as speech therapy, occupational therapy, or transportation) that are required to assist a child with a disability in benefiting from their educational program. required to help close the achievement gap, taking advantage of school-based Medicaid claiming can help you recover some of the costs associated with those programs.
School districts across the United States receive a total of about $4.5 billion in Medicaid reimbursements each year.
One in every
three school-aged
children is
considered
Medicaid eligible.
Behind Title I of NCLB
and IDEA, Medicaid is
the third largest
source of funding for
school districts.
The old saying goes something like “change is the only constant in life.” Well, in school-based Medicaid claiming, it’s no different. Advances in technology, changes to State and Federal legislation, and macro-environmental factors like the recent COVID-19 pandemic all lead to major shifts and sometimes great
opportunities in the services we provide students and how we approach reimbursement for them. Here are a few of the more recent trends impacting school-based Medicaid claiming:
More States taking advantage of the Free Care Policy Reversal - While it’s been more than 8 years since the Centers for Medicare and Medicaid Services (CMS) outlined a ruling that reversed the free care rule, the benefits are still just being realized in many States. In Arizona, the AZ Health Care Cost Containment System (AHCCCS) predicts 20% growth in school-based Medicaid Claiming for FY22 as a result of their open care transformation.
Behavioral Healthcare Services (ABA) - In March 2022, the White House issued a release announcing a strategy for addressing the National Mental Health Crisis. The release discussed the need for connecting more Americans with care including doubling the number of school based mental health professionals and making it easier to seek reimbursement from Medicaid for their services.
Shift towards Virtual Learning/Virtual Services - The recent COVID-19 pandemic caused disruptions in traditional models of care being provided to students in school settings. With the shift from in-person to virtual learning came an accelerated adoption of telehealth services. Many States adapted, and these services are now eligible for Medicaid claiming.
Speech Therapy
Physical Therapy
Occupational Therapy
Personal Care
Behavioral &
Mental Health
Admin
Transportation
Nursing & Physical Health
These are just some examples of the billable services your district may provide. And remember, when it comes to Medicaid billing in schools, often both the evaluations and the treatment are reimbursable. When in doubt, don’t miss out. Ask!
What’s Billable in my State?
From State-to-State, the services you can bill for as part of your school-based
Medicaid claiming program can vary. While the Centers for Medicare and Medicaid create policy related to School-based Medicaid Claiming, it’s up to each State to implement that policy as they see fit. Check with your State’s Department of Education for the specifics! And feel free to reach out to our team any time if you need additional guidance.
After you implement a process for submitting Medicaid claims for your school district, the next thing you’ll want to do is look at how to optimize your reimbursements. You’re already providing students with many great health-related services, but are you recovering all of the costs you can?
Here are just 4 ways to help optimize Medicaid reimbursements for your district:
As we’ve discussed, this changes from State to State and evolves overtime. However, being unfamiliar with what you can bill for, and which students are eligible might mean you’re leaving reimbursement dollars on the table.
Technology can be a game changer when it comes to optimizing reimbursements. Time-saving features can make it easier for providers to enter services while reports and dashboards can highlight areas of opportunity to administrators and your Medicaid billing team.
Submitting Medicaid claims in a timely manner ensures you and your Medicaid billing partner have time to rebill any fixable denials within resubmissions regulations and you can leverage analytics to make informed decisions in real time.
Without parental
consents, you can’t bill
Medicaid. Take advantage
of new tools for obtaining
electronic signatures to
streamline this process
and enable more billing
opportunities.
Districts participating in a school-based Medicaid reimbursement program should have well defined processes in place that demonstrate an understanding of Medicaid and State regulations. If that seems overwhelming, seek a Medicaid Billing partner with a compliant software solution and a consultative customer success program. They can act as an extension of your team to help you optimize compliance AND reimbursements.
One of the most important pieces of being prepared for an audit is having the right documentation. This includes documenting your policies and procedures and ensuring you have systems in place that enable you to capture relevant data in a streamlined, easy to access, easily reportable way. You’ve put a lot of time and effort in to submitting Medicaid claims and the benefits have been great for your district, you certainly wouldn’t want to have to give it back!
A self-audit is a district-initiated review where you examine the activities related to your Medicaid program. It can be utilized as a means for achieving continuous improvement and optimizing compliance and reimbursement outcomes for your Medicaid program. Self-audits can take courage but welcoming the feedback is key to turning not yet successes into growth. Try this: select a small subset of services provided over the past month and check to see if (1) the student was in school the date the service was logged, (2) the service matches the students IEP, and (3) the service providers credentials were up-to-date at the time of the service. Most often if something is amiss, it’s not malicious but a problem with data entry that can be fixed quickly and easily!
At Go Solutions, our experienced staff routinely helps districts perform risk assessments to define program effectiveness to optimize compliance and reimbursement potential.
School-based Medicaid claiming differs from State-to-State. Here are a few common differences you’ll want to understand.
Medicaid Eligible Services and Students
States that have taken advantage of the Free Care policy reversal can submit claims for eligible services provided to any Medicaid-enrolled student while others are restricted to only students with an IEP. Additionally, some States bill for services like transportation, nursing, etc. while others do not.
Supervision and Provider Requirements
It’s important to be familiar with your State’s regulations for both supervisor and provider requirements. For example, in some States and for some services, the person administering the services must maintain certain credentials while in others the supervisor’s credentials may be satisfactory.
Group Size Limits and Documentation Requirements
Certain types of Medicaid-eligible services may be provided to a group of students, but that group size and the documentation requirements can vary from State to State.
Getting started with, or taking steps to improve, school-based Medicaid claiming for your district may be easier than you think! While there are many ways to optimize Medicaid reimbursement, regulation/ process changes and other nuances can make it a bit of a moving target. The right Medicaid billing partner and easy to use technology can act as an extension of your team, helping your district recover costs associated with the services they provide.
Key features of school-based Medicaid claiming software
Look for a partner that provides both technical support and consultative services to your district
A system and partner that can help validate compliance can provide you and your team peace of mind
Ask about time saving tools like the ability for providers to save and reuse notes or enter multiple sessions at once
Another time saver, integrations with an IEP platform or SIS eliminate the need for double data entry
Getting started and/or optimizing Medicaid claims may be easier than you think!
At a minimum, you’ll want to involve your Special Education Director and a Finance leader as you make your first foray into school-based Medicaid claiming. Depending on your State’s billable services, you may extend this team to include representatives from nursing, transportation, and providers.
Use data like the number of students in your district with IEPs and the percent of students on free/reduced lunch to estimate what optimizing your Medicaid claiming program could mean to your district. Add in open/free care and the benefits could be even greater!
If you have questions about anything presented in this eBook or are interested in better understanding how you can optimize the benefits of a school-based Medicaid program, we’re happy to help. No cost. No obligation.
About Go Solutions
Go Solutions is committed to empowering school districts across the US with innovative solutions that positively impact student success and their school communities. From intervention to reimbursement and everything in-between our IEP and Medicaid software, and Medicaid billing team help ensure your district is optimizing participation in the State’s Medicaid reimbursement program and can continue to provide
exceptional experiences for all students.
Have any questions? Let’s talk.
