OTS 134: Navigating Medicaid Billing for School-Based OTPs

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Welcome to the show notes for Episode 134 of the OT Schoolhouse Podcast.

Have you ever felt overwhelmed by Medicaid billing and unsure of how to navigate the funding process?

In this episode of the OT Schoolhouse Podcast, Elizabeth & Jason will dive into the world of Medicaid billing. You'll have a basic understanding of Medicaid billing and be equipped with the knowledge and confidence to navigate this vital aspect of our profession and have the knowledge to be able to advocate for more support from your supervisors.

Listen now to learn the following objectives:

• Learners will understand the process of Medicaid billing in schools.

• Learners will identify how to advocate for support with their supervisors.

• Learners will identify the importance of completing random moment time studies.

Guest(s) Bio

Elizabeth Duncan, OTR/L is a school-based occupational therapist in Louisiana and started coordinating to help her peers understand Medicaid. She is now the Education Program Consultant of Health Communities for the Louisiana Department of Education.

Jason Coker, Certified Internal Auditor, has extensive experience providing monitoring and agreed-upon procedures (AUP) services to the Louisiana Department of Health (LDH), focusing primarily on time study administration and cost report review for the Louisiana School-Based Medicaid Claiming program.

Leveraging his internal audit experience and training, he manages P&N’s involvement in this program, providing support through quarterly random moment participant sampling, desk review of claims and cost reports, and monitoring of the records supporting the claims for a selected sample. Jason provided critical input in the development of the State Plan and Time Study methodology for CMS approval.

Through his work with LDH, Jason has developed a deep knowledge of numerous Medicaid programs, their requirements, and the various reimbursement methodologies used by CMS, and has experience in the design, development, and implementation of monitoring and compliance initiatives.

Quotes

“We're skilled service providers, and we're also trained to document, so we are providing medically necessary services...when we're evaluating our students and we are treating them based on our plan of care."

-Elizabeth Duncan, OTR/L

"Advocate for your profession, advocate for your services and advocate for your state if they have not already expanded."

-Elizabeth Duncan, OTR/L

"Medicaid does not require documentation. The service that you're providing requires you to document that service."

— Jason Coker, Certified Internal Auditor

"School districts are not allowed to use federal funding to draw down federal funding. It's called double dipping."

— Jason Coker, Certified Internal Auditor

"Medicaid does not require documentation. The service that you're providing requires you to document that service."

— Jason Coker, Certified Internal Auditor

"I think that's important, just from within your own district to make sure that you're doing these right. Make sure you're filling out those random moment time studies because people do see them."

— Jayson Davies, MA, OTR/L

Resources

• Centers for Medicare and Medicaid Services
  

• CMS Guidance/Regulations
  

• AOTA Medicaid

Episode Transcript

Expand to view the full episode transcript.

Jayson Davies   

Welcome school based OT practitioners to another episode of the OT schoolhouse podcast where we bring you all the insights and inspiration you need to confidently navigate your school based occupational therapy career and better support the students and teachers you serve. I'm your host Jayson Davies. And today, we have a very special episode focused on a topic that many of you have been eager to learn more about. I know because you asked me about this on Instagram and emails and everywhere else including at conferences, Medicaid billing, what do we do about Medicaid billing do OTs even bill for Medicaid? Can we bill for Medicaid? Should we be billing for Medicaid? Those are some of the questions I get. And I know just hearing that phrase brings up feelings we want to suppress. Many of us don't understand Medicaid well, and that can cause us to question it or even fear a Medicaid audit. I've even come across some therapists who flat out refused to bill Medicaid because they don't fully understand it. As you probably are aware school based OTPs don't bill in the same way as our counterparts might in a pediatric clinic hospital or whatnot. But the odds are that your district is likely recouping funds from Medicaid to pay for part of your salary or contract if you're contracted therapist and other costs related to your services. That is what today Elizabeth Duncan and Jayson Coker are here to help us demystify Medicaid billing once and for all. Elizabeth is a school based occupational therapist in Louisiana, who took on a role to help her related service provider peers better understand Medicaid billing. And Jason is an expert in the field of school based Medicaid billing and has extensive experience working with school districts to help them navigate the complex world that is Medicaid reimbursement. While none of us became therapists to understand billing practices, Jason and Elizabeth are here to share the basics behind the process, and why we should actually care about it. By the end of this episode, you'll have a basic understanding of Medicaid billing, and be equipped with the knowledge and confidence to navigate this vital aspect of our profession. You might even come up with some creative ways to utilize your newfound knowledge to advocate for more support from your supervisors. All right enough with the introduction, let's all go ahead and hum along to your favorite intro tune. And when we return, we'll dive into Medicaid billing with Elizabeth and Jason. Enjoy the episode. 

Amazing Narrator   

Hello, and welcome to the OT schoolhouse podcast, your source for school based occupational therapy tips, interviews and professional development. Now to get the conversation started. Here's your host, Jayson Davies. Class is officially in session. 

Jayson Davies   

Elizabeth and Jason, welcome to the OT schoolhouse podcast. Thank you so much for joining us today. Elizabeth, we'll start with you. How are you doing today?  

Elizabeth Duncan   

I am doing fabulous. We have nice weather and the Saints won last night. So it's a good day. There you go. There you go. The Saints one. That's always a nice little Monday, Monday Night Football Tuesday feels much better. So awesome. And Jason, how about you how you doing today?  

Jason Coker   

I'm doing great.  

Jayson Davies   

Awesome. Well, thank you so much for joining us. And I really just want to before we dive into talking about Medicaid and school based occupational therapy billing, I want to give you both the opportunity just just kind of share how you fit into the world of school based occupational therapy related services and billing and all of that. So Jason, would you mind kicking us off by just sharing a little bit about how you fit into this public education world of billing?  

Jason Coker   

Yeah, I work at a an accounting firm EisnerAmper, formerly PNN. We do. We help the state Louisiana administer the school based claiming program and a number of aspects. We helped develop the plan, we help implement the plan. We do auditing services, review of cost reports. And we also administer the time study, which is the in Louisiana, that's the cost allocation methodology.  

Jayson Davies   

All right, there's a lot of things that I did not understand. But I'm sure by the end of this podcast, we'll have a better understanding of that. So I appreciate you being here. And I know you've worked closely with Elizabeth on this. So Elizabeth, why don't you share a little bit about your role? And maybe how Jason kind of how you brought Jayson into the mix with us a little bit.  

Elizabeth Duncan   

All right. So you know, I started working in a hospital long, long time ago, and from there, jumped into the school setting really liked working with kids really liked working and love the ability to work with students in school, you know, you start with them at three and you're singing them through 21. So working as an OT, from there started coordinating and doing more administrative work with our OT and PT group in our parish in Louisiana, and at some point in time, and there wasn't that we were I was billing, right? So you start working in the school system, and they're like, Okay, you need to bill for Medicaid. And I remember thinking, Well, what do you mean we bill for Medicaid? We don't go for Medicaid. We do that we work in the hospital. But we don't do that in schools. And they're like, No, you really, really do here to scan Tron. So I'm going to date myself, here's the scan Tron, you're gonna fill this out on your students that you provide, you know, skilled services for once a month. And we'll submit that. So Jason's firm, it said they part of what they do is auditing the program. So as he would come to our school district and audit our program, if there were questions regarding OT or PT, I would be called down to who coordinated our services, answer these questions about what this OT or this PT wrote in their documentation. And so that was many moons ago, from there they are our Medicaid coordinator left and our special ed administrator was like, I know you're treating kids, I know you're administering, you know, you're doing OT and PT administration. But guess what, we want you to run our Medicaid program as well. So I added in another hat, and I realized I really needed to catch up and learn more about the Medicaid, billing Medicaid, how does it fit into school. So that's when I really started to reach out and ask for help to learn more, so I could do my due diligence and do this portion of my work. So that's that kind of connected me to Jason, he likes to talk a lot. So he, you know, I learned a lot from him. And he, you know, we've had, we've had personnel changes at the state level, throughout the time I've done this work, but he's him and his firm has been the group that has been there throughout, and been able to really provide us with a lot of both history and knowledge on school claiming for those all the health services. 

Jayson Davies   

That's fantastic. That was a great introduction for this podcast, I really believe because, you know, I have been a school based occupational therapist, I have sat at that table with someone from this company that is an outside agency that that says they do all of our billing for us, and they kind of give us what we need. But obviously, there's so much going on behind the scenes that we don't understand. And you know, this like, Okay, well, if you did this, then check this on the website and then type in a little note or whatnot. And on the flip side, you know, in my role as the OT school house, you know, all thing Oh, T schoolhouse, I get a lot of questions from those who follow me on Instagram, on email in our OT Schools Collaborative like, hey, Jayson Davies, like, what what do we have to do for building like, what is required for billing? Can I bill for consults can OTAs bill? And I'm excited to dive into this now because we're gonna answer, I say answer almost in parenthesis, because every state is different, every situation is a little bit different. But we're gonna try and get in to some of those. So I first want to ask you, Elizabeth is, you know, you, you talked about how you took on this role as someone who was in charge of Medicaid within your area, kind of how did that come to be? And what kind of drove you to doing this deep dive into billing practices for the schools that you worked with? 

Elizabeth Duncan   

So really, it came to be because somebody retired, and they were like, All right, who's next in line, you know, who can maybe handle this? And, I mean, you know, as OTs if we are going to do something, we want to do something, right. And we want to know what we're talking about. We don't want to halfway do our job. And we want to make sure that we can answer the question. So I wanted to make sure one, when they come ask me questions, I know the answer. I want to make sure that when I ask our documentation company, why do we check this box, I know understand the terminology enough to be able to ask the right questions. And I think there's a lot of concern out there from billing providers, especially in the schools about making sure that we're not doing something that's fraudulent or doing something that is against our license or our practice. And so, you know, getting those answers helps me feel confident that when I answered those that asked me there and talk about their concerns. 

Jayson Davies   

Yes. And, and Elizabeth, thank you for that. And I know you actually went a little bit deeper once you have this role. You kind of I don't want to call it necessarily an overhaul potentially. But you really went deep into this and now you have kind of, I think you if I remember right, you kind of overhauled a small area of Louisiana. And then now all of Louisiana is kind of using kind of what you kind of started. And so what made you decide I had to kind of I don't know if overhaul is the right word, but what made you decide to really just dig down deep and say, hey, you know what, there is something going on here that we need to better understand, because we can bring more money into the schools for the related service providers. 

Elizabeth Duncan   

I'm glad you asked that, because I totally almost skipped a step, because I went from working in the school district. It was around the time of COVID. It was March, in April of 2020, when our Louisiana State Plan, and we'll talk about state plans a little bit. But when our state plan changed, and I remember receiving an email stating from our Medicaid agencies, and then Ted, by the way, our state plan has changed. Cam, here's what's different about it. Implement, it basically was like, now it's time to implement this. And thinking, I really don't have time to deal with this. Because we're at home, we're trying to figure out how we're going to provide telehealth services. I don't even know if that's within our license. And I have all of our staff emailing me, like what do we do? We don't know what we can do. And just really like freaking out a little bit, because it was just a lot at once.  

Jayson Davies   

So March 2020, 

Elizabeth Duncan   

correct. Correct. So you went through this chaos, and we were back in school pretty quick. So we were back in school, I was back in the office in May. And we were trying to figure out how we were going to provide our services hands on with students, and also do telehealth for those that weren't attending school. And I think that kind of really made me reach out more to our Department of Health to our Department of Education, to Jason's company to him and his team. Like, I really need help, what are we doing, and they included me in some of the review of some of the documents they were sending out. And I just remember asking question after question after question. And asking, When are y'all going to do training? Like, when's training on this? Like, when are we going to learn how to do this? And, and they were like, you know, oh, well, we sent you all the memo. And I was like, All right, thanks. Um, anyway, but really, from there, I think they quickly realized that we did need to do some training, we needed and they opened up a, as it went through time, they opened up a position at the Department of Education in Louisiana, dedicated to Medicaid, and big climbing and schools, to, you know, to have someone at the Department of Education to partner with our Medicaid agency, to help to do some of the training and help to do some of the informing the stakeholders. And so, you know, once that opened up, and I just kind of took a leap, to kind of answer that call and try to get that information out. In between that we had a couple of hurricanes and a couple of other natural disasters in Louisiana to further muddy, what was going on and where our attention was focused. But that was that's kind of how I ended up trying to get all of this information out, and really trying to learn more and create really what we have is like learning collaboratives and create methods to be able to inform our providers. 

Jayson Davies   

Gotcha, perfect. Well, let's let's dive into Medicaid. I think someone that you and I are both familiar with ape Safra at a OTA he, I think he was the one who might have even gotten us in touch. Originally, he has talked on this podcast about how Ida was never fully funded. And And I'm assuming from everything I know, is that is why Medicaid is so important within the schools. But I want to let you and Jason both kind of speak to this. What it is that the main reason that Medicaid is so important in the school, are there other reasons or what role does Medicaid really play?  

Elizabeth Duncan   

I'll start off and then I'm gonna hand it to Jason to finish kind of off the comment. But yeah, I mean, we have, you know, I think the federal government understand and the state governments understand that we have these kids that come to school that have significant health concerns, health needs, mental health needs. And in order to find that in order to, you know, be able to hire and hire providers and pay for the providers we need. We need to have enough funding to compete and recruit and retain our our therapists, our nurses, our behavioral health providers. And so, you know, Ida does find some of it, but it is not fully funded. And so in order to add additional funding, Medicaid was a stream of funding that can I supply those funds on a on a sustainable, consistent basis, you know, where other other grants aren't sustainable Medicaid is there, and it is a sustainable funding source. And Jason, do you have anything to add to that?  

Jason Coker   

Yeah, I think that the there's a recognition, especially with the new guidance that's come out recently, there's a recognition that schools are the place that services can be provided, it's where students are, helps with attendance that helps with Student Health and helps, you know, it helps with academics, as well as as overall health student. So and I think, I think I think the change has the, the, the shift in thinking has been, if we provide more services in a school setting, we will be able to more sustainable service, funding in school setting, we can provide more of those services.  

Jayson Davies   

Interesting. So if we provide more services, we can get more Medicaid, and therefore the services become more economical in a sense. 

Jason Coker   

So it's, the more services that are provided, especially in Louisiana, when we're dealing with a you're dealing with a call space program instead of a fee for service program. But it's it holds true also, in a fee for service program, the more services you provide, the more funding, the more funding that's going to come in for those services. So in a cost based reimbursement methodology you would have, the more services you're providing, meaning the more time you're spending, providing the services, the more funding you're gonna receive, and a fee for service program or a fee for service methodology. The more services, there's a direct billing for each one of those services that you would provide. 

Jayson Davies   

Gotcha, perfect. I know, we're gonna dive into each of those a little bit more. But that's a good starter to that explanation. Now, before we dive into kind of those terminologies that you just mentioned there. One question that comes up into IEP is whether we ask a parent or sometimes the parent asks us is, if you're billing for Medicaid, then will my doctor also billed for Medicaid? And does it impact one another? And so I do want to ask you that question is, how is Medicaid for schools? Different than maybe what a outside occupational therapist is billing Medicaid for? 

Elizabeth Duncan   

Um, I'll answer that. So one, you're thinking about two different types of served services with different goals, different objectives, different means for why they're providing them. So one of the things that we're required to do with our outside providers is called care coordination. And we shouldn't be doing that anyway. Right? A lot of what ifs, as you dive into school based Medicaid, a lot of what's required through documentation, through developing the need for the medical services, you realize, is really best practice. So a lot of what Medicaid asks you to do is really nothing more than you should be doing anyway. So, you know, we're required to do care coordination, we're required to talk to those outside providers, talk with the parents, and make sure that we're not duplicating services, our goal should be different. In order to establish goals, we should already be doing that care coordination. So that's part of that also the way and of course, every state's a little bit different. But like in Louisiana, the way our funding stream comes through our Medicaid agency, and it's carved out in will like I will talk about that in a little bit, just the way that is split up, it's not going to affect the student's ability to receive outside services. 

Jayson Davies   

Gotcha. Okay. And you did kind of mention there, just some of the things that are required. And if you can just kind of before we get into that carve out, you know, you talked about the fact that we should use the best practices, Medicaid is kind of almost requiring those best practices. And so you talked about coordinating the care plan a little bit. We talked about, you know, just making sure that things are going well, but I kind of want to dive into what that checklist might look like for therapists, if they're like worried that they're not going to get reimbursed for their services. And I know every state is different. But are there a few things that are kind of general that you can mention? Like, these are the things that Medicaid typically requires? 

Elizabeth Duncan   

I'm going to do a big generality, and then also let Jason kind of fill in after but really like is the school your school district is enrolled, right? They're the ones that are billing for your service. They're the ones that are getting paid, you're not getting paid. So that's that's one concern. They're they're an enrolled provider. And then, you know, the student needs to be eligible for Medicaid, then your law. So looking at are you doing any evaluation, you know, is it medically necessary and you are establishing that medical necessity as you do or you have your evaluation as you write your plan of care as you document your services, and as you track progress, and then also, you know, look at Does the student continue to need the services? So part of this diagnosing the medical necessity? Or is everything that you're already doing through your documentation and best practice? Lines of care? So, and then I forgot what the second part of your question was? 

Jayson Davies   

No, I'll pause there, because I have just kind of two questions based on that, like, the most common questions that I get based upon what you said, are a and I'll break this down, we'll do one at a time. What is medical necessity? And why is it medical necessity when when Ida says we're focusing on educational necessity for lack of using the real quotes, but what how does that differ are is everything that we're providing medical necessity, even though we are in the schools? 

Elizabeth Duncan   

Well, there are, there are some things that you're doing within the schools that may not be medically necessary. I, you know, if I'm consulting with a teacher on how she teaches handwriting to her classroom, to the general public, that's not medically necessary, if I am consulting with a teacher about how she is specifically changing her practice of teaching, specifically for that student to use his adapted grip, and how they're doing it. Yes, that is part of my and that is part of my plan of care. And that is done, because I've done any evaluation that requires my skilled service. So all of that time that you are working with that student, through your direct services, your evaluation, all of that goes back to determine establishing the medical necessity, and backing up your documentation of that as well. So there are definitions of medical necessity, and I can probably put someone to sleep by reading it, but I will spare them that but you know, we're skilled providers, service providers, and we're also trained to document so we are providing medically necessary services, when we're evaluating our students, and we are treating them based on our plan of care. 

Jayson Davies   

Perfect. And yeah, the second question, kind of follow up that I had, I think, if later in our questions, but I'll bring it up. Now, since we're already on that topic. Is that documentation side of things? When it comes to our daily notes, that's the other question that I get a lot like, is there something required in our daily notes? Like, do we have to use SOAP Notes? Or can we use a different form of a note does Medicaid, at least in Louisiana? I know that's what you can speak to? Do. They require any specific documentation aspects? 

Jason Coker   

I can, I can take the first part of that. Medicaid does not required documentation, the service that you're providing requires you to document that service. So your license, your your practice, act, or whatever, decides what documentation is required. Medicaid is there to cover cost, but they're generally not there to ask you to do anything different from what you would already be doing to provide their services. 

Jayson Davies   

That is a great, succinct answer. Thank you, Jason. 

Elizabeth Duncan   

He's a little more succinct than I am, I will say that, I am going to piggyback on that. And say that, you know, we are required and we are trained to do specific documentation, the payer, or just like in other outside agent, you know, if you're working for a hospital, a lot of times the payers will have the services will define what information they want to be reported. So you may be, you know, the CPT code or the fee schedule does require us to list things of what CPT code we've provided, it does require us to, you know, list the have a plan of care, it does require us to list frequency and duration of our of our services within the plan of care. So every state requires different information based, you know, on their on their plan. So you do have to educate yourself on what's required, as part of that submission of the claim.  

Jayson Davies   

Gotcha.  

Jason Coker   

There's one more thing I wanted to, I wanted to clarify, there are there are minimum documentation requirements from Medicaid or CMS, there is a minimum documentation requirement. It's just not really more it's not more than what you're already being asked to do as a provider 

Elizabeth Duncan   

right, and you may be doing it in a little bit different a bit different way. So if I'm working in a school system, I may not always right, the 9753 of CPT code, you know, however, that is what they're going to want. They're going to want those, you know, that instead of, you know, or I'm doing therapeutic exercises, they're going to want you're not going to write that you're going to put the number because that's what they're requiring for their claim documentation.  

Jayson Davies   

Absolutely. Thank you for bringing that up. Because you know, Some outside occupational therapists are not familiar occupational therapy providers who are not familiar with the schools, they'll often ask me like, oh, what CPT codes do you use in the schools? And I'm like, I don't know, I don't use CPT codes in the schools. However, what I don't realize is that I am using CPT codes. I just don't know it, because that checkbox is telling Jason's company a specific CPT code, and that's what they're transferring over to Medicaid. Does that sound correct?  

Elizabeth Duncan   

Probably, yes. You're probably writing, you're probably saying check. I did therapeutic exercises, and that CPT code is being transmitted. Other documentation, you're actually picking the number, it just depends on how they list it. And there was something else I was going to think about that as we related to CPT codes, and my mind just went. So I remember. 

Jayson Davies   

So that's totally fine. So let's continue on, I'm sure it'll come back to you. You've mentioned a few terms earlier, one that stands out to me is carve out so as we dive deeper into the Louisiana Medicaid in particular, because that's of course, what you two know best? What does that term carve out mean in relationship to Medicaid? 

Jason Coker   

So the carve out of school based services just means it's carved out from managed care, which means it's it's not, it's just done under a different methodology. And it doesn't, there's a there's a care coordination component that must that has to be done. But the the services that are provided in the school setting are not are simply just not covered under a managed care methodology. Elizabeth did that cover?  

Elizabeth Duncan   

Yes,  

Jason Coker   

the answer.  

Jayson Davies   

Go ahead. Elizabeth if you wanted to go with it. 

Elizabeth Duncan   

No, I was I was gonna say exactly what he what Jason just said. And it's, it's, you know, it's always also remembering that Medicaid is both a state and federal funding program. And so they're funding the federal portion, or Medicaid is funding the federal and for us, we have a state match, which comes in through a different, which is part of how we're paid through our general funds, which funds our positions.  

Jayson Davies   

So I guess my question, then, sorry, really quickly, the carve out then I think, when I'm understanding is that there's a there's a big pot of money for Medicaid, and a portion of that is carved out specifically for schools and public education. Is that what I'm hearing correctly? Or am I totally off? 

Jason Coker   

I think that's, that's very close. I think that there's a there's a program out there called Managed Care. And a many, many, many, if not all services fall under Managed Care for this population of students or individuals. The school based claiming program is carved out of that plan. Gotcha. handled under a different methodology, and demographics, or it's a similar funding source, but the funding methodology is different. 

Jayson Davies   

Perfect. All right. Thank you for explaining that. That helps me understand a little bit. And so kind of generalizing this. Jason, I think this might be a question for you. Is that similar in many states? Is that very specific to Louisiana? What can people who aren't in Louisiana take away from understanding this carve out method? 

Jason Coker   

That's similar in most states, most states have school based services carved out that are the only state I can think of off the top of my head is Mississippi, I'm sorry, Tennessee that has school based services included and managed care. So I think it's more rare to have school services included in school based services included in managed care the not. 

Jayson Davies   

Gotcha. All right. So now that we understand kind of where this money is coming from and has carved out, you know, it's kind of set aside for the services. There's two other terms that you mentioned, one was a fee for service, and I can't remember the other one. But can you explain those a little bit deeper, and how those might apply to school based occupational therapy providers when it comes to how they're being reimbursed?  

Elizabeth Duncan   

Alright, 

Jason Coker   

go ahead, Elizabeth. 

Elizabeth Duncan   

I was just going to start as providers of as a provider, I'm used to doing favors or as I'm used to I see a student I write a claim, I submit that claim they send me money back. So if I'm working independently for my clinic, that is how that's that's a quick example of interim claims and fee for service. cost settlement is, you know, you're still doing that documentation. And you're still doing that claiming, but what what Jason is going to talk about in more detail, is that cost settlement is really the school districts have a cost of providing my health care services and their rediem being reimbursed for the cost of providing those Medicaid Services, right Jason? 

Jason Coker   

Right, in our cost base system, you're, you take the salaries and benefits of the individuals who are providing services, you report those on a cost report. And the amount that's allocated to the amount of that cost that's allocated to Medicaid is done through a thorough cost allocation methodology in our state. It's the top study in most states, it's a time study. And we and the time study is meant to to, to show how much time is being spent providing services to students. 

Jayson Davies   

Gotcha. And I think I know the answer to this already. But if someone out there is listening, and they're trying to figure out, Hey, am I fee for service? Versus Am I more that time study side? Is there a way? Or is there something that they might already be doing that they don't even realize? They can kind of point them in the general direction as to which one they're kind of in? Or maybe both? 

Elizabeth Duncan   

I would say if they're answering time study questions, they would I think they would know if they were in a time study. But they can also reach out to their school administrators, their state Medicaid agency to find out exactly what the methodology is for their, for their state.  

Jayson Davies   

Yeah, 

Jason Coker   

I think it's a good point that there are people that are that are answering these types of moments without without knowing I think this happens even in Louisiana, where you're answering, as a provider, you're answering your time study moment, you don't really know the purpose of that time study moment. And what if you know how that goes into a reimbursement for Medicaid services. 

Elizabeth Duncan   

And I think it's a good point that if you are one of those people that, oh, I am getting these questions, I have no idea what they are, why I'm answering them to really educate yourself and reach out and try to gain that knowledge and get that information.  

Jayson Davies   

Yeah, I remember when we started getting those, you know, when I first started as a school based occupational therapist back in 2012, we didn't have those Random Moment Time studies, I think there's what they call them, RM TS maybe. And then I think it was around maybe 2015 or so all of a sudden, you know, it kind of started rolling out, we started hearing, oh, you're gonna get this email 24 hours before you're gonna get another email that tells you to do this time study. And then you're gonna follow up 24 hours after that, if you haven't completed it. And we had no idea why we were getting them. We didn't know if they're, I mean, you know, eventually, we figured it out. But we didn't know what they were coming from the district where they're coming from the billing company, they're coming from the state, like, Who the heck was it that wanted to know all of this about us? And about what we were doing at least? And it's very interesting, and it was kind of a shift and understanding of what was going on? And yeah, that's, that's why I really wanted to have you both on here. And so let's dive more into that Random Moment Time Study to kind of answer that for some of those therapists who are filling this out, but don't quite understand it. I guess who is actually sending out that? Is it like a billing company that's sending that out? Is it the status sending it out? Who Where are these coming from? 

Jason Coker   

Ultimately, it's the responsibility of the Medicaid agency. So in Louisiana, my company sends that out. But it's the time study in itself, along with cost reporting, is the responsibility of Medicaid. 

Jayson Davies   

Gotcha. So Medicaid is basically the saying, Hey, we got this pile of money for you, you, we're gonna pass it off to you Jayson's company to kind of work with the districts that you work with to collect that data, and then send it back to Medicaid. 

Jason Coker   

We are collecting the time study results. And using that data to build cost reports to be able to send out to school districts, it's all part of the calculation to determine how much the state's are responsible and how much Medicaid is responsible for. 

Elizabeth Duncan   

And so really what to piggyback on what Jason said, you know, you're answering these questions. And it's like, what are you doing? Who are you with? Why are you doing you know, what's going on? What are you doing right now, in this one moment of time? Are you doing? Are you providing a Medicaid eligible service? Are you documenting that service? Are you traveling to provide a service? Or are you you know, doing duty, you know, at recess, making sure that as part of your job, are you giving an in service to teachers? So really, it's, you know, asking you to describe what are you doing, and then, and then from there trying, they assign our percentage, and they would say, all right, OTs and OTs are providing services or doing those activities to support those services, like 70% of the day, so sending 70% of their school day, they are supporting our Medicaid students with act either providing services or doing everything that is required to provide the service. And then they take that whatever percentage is determined, and they apply that to the cost report that Jason talked about. Right? So our school district spent XYZ amount of money to hire and pay all of our providers So we're going to reimburse that 70% gets factored into the total amount of money that you receive from Medicaid. 

Jayson Davies   

So I'm just going to use round numbers here, say the district spends a million dollars on speech, OT PT, and they find that speech OT PT spend 70% of their time on Medicaid related services or something relatable to that can be reimbursed, then the district may be reimbursed for up to 70% of that million dollar 700,000, or whatever it might be. I know it's more complex. I'm sure it's more complex than that. But does that sound right?  

Jason Coker   

In a sense that is correct. But there are a few other inputs that go into what  

Jayson Davies   

Yeah, 

Jason Coker   

reimburse for sure. But in a sense, that's correct. 

Jayson Davies   

Okay, so Wow, that just drives my mind in a lot of other places, honestly, because a lot of people are very concerned with, Oh, my district doesn't have funding, we can't, every time I try and ask for more help. They're telling me we don't have funding per se. Is this something that OTs should know more about? When they want to go to their administrators to say, Hey, I'm overscheduled? Can we get support? 

Elizabeth Duncan   

Absolutely. And I think you bring up a fabulous point, because a lot of times I do tell OT and PT coordinators that come to me, like, we need more, we need more people, I have 100 people on my caseload. And then in addition to that, my workload is going to attending meetings and working on RTI. So, you know, what can I do? And I say, alright, let's look at let's give your people some answers, right? Let's give them some funding answers. And Medicaid is one way to do that. And so, in Louisiana, the someone, not myself, but someone else built a reimbursement calculator, so that you can, you know, take some of the calculations, and it's a very, it's an estimate, but it's something that you can take in and say, Alright, if we hire somebody at this amount, you can estimate that you would get XYZ amount back. So that you could, you know, employ more, hire more, recruit more, retain your providers, through the Medicaid funds. And really it it also highlights the importance of the answers to the Random Moment Time Study. So making sure that when you do answer it, that you're answering it accurately, and that you answer it within the timelines that you're given, right, because I think you mentioned, oh, they give you, you know, 24 or 48 hours to be able to answer your email. And just making sure that you take it seriously and that you get your, you answer it and get it done.  

Jayson Davies   

Yeah, absolutely. And, I mean, I sat on a committee, I can't even remember what the name of the committee was. But we were in charge of kind of looking at proposals for funding from teachers, and from OTs, and PTs and SLPs, and whatnot. And we had the power, I guess you could call it to, to grant some of those funding requests. And a lot of times we would look at, we didn't have access to the Random Moment Time studies at that point. But we would look at who's doing their billing and who's actually, you know, getting things completed, when we would say, hey, sure, we'll fund your 200 $300,000 requests for materials and whatnot. And I think that's important just from within your own district to make sure that you're doing these right, like, make sure you're filling out those RM Random Moment Time studies, because people do see them. And maybe it's not your direct supervisor or whatnot. But, you know, there is a sense, I'm sure, at somewhere in the district level. They know what percent of OT or PT, or speech therapist submitted, there are Random Moment Time studies. So I just encourage everyone to make sure that you do fill those out if you are getting them. Now, Elizabeth, when we're getting those Random Moment Time studies, you know, I'm not telling anyone don't lie on it, of course, but are there any kind of words of guidance that you can share with people to make sure that they're completing it out fully, and to the best of best of their ability that gives them the, I guess, most opportune chance to receive that as a positive time study? Moment? I guess? I don't know how I'm saying that. 

Elizabeth Duncan   

Um, well, one is yes, you're definitely going to answer it accurately based on what you're doing. It is a good read. It is a reflection of your professionalism. So make sure when you free write something, know that someone's actually reading what you're writing. So making sure that you are professional. And also to understand that most of the time that people that are reading your answers are not therapist, right there are probably from possibly an auditing firm there or you know, from somebody that so they may not understand the language or the job or Oregon or that you're using so explain it, be brief, that explain it in layman's terms so that they can understand what you're doing so that they can make sure that it's accurately reflected. If I said I went to an IEP to write a five, oh, you know, to write 504 and IEP, they will understand, but a lot of the school jargon that we use it, they may or may not be understood. 

Jayson Davies   

Gotcha. Okay. And so you kind of started to use the term 504, whatnot. In the school based OT realm, we tend to provide services through an IEP through a 504. Some others will do something through like a student study team, which is, you know, oftentimes it's before a student may need an IEP, so it's not necessarily an IEP, but a step below, potentially, when it comes to Medicaid doesn't matter whether or not that student has an IEP or a five, a four, or potentially if they're receiving something like an RTI or MTS's service. 

Elizabeth Duncan   

So this is this is going to depend on your state and where your state is on the process. So right now, Louisiana, we back remember, I mentioned it in 2020. So I'm gonna circle back. That was when Louisiana expanded their Medicaid school based services to free care. And what that allows is for services outside of the IEP to be reimbursed. So there are some states that have not expanded and so they're only reimbursing for the IEP services, and other states that have expanded like Louisiana, that now it is, you know, are they met, they have to be medically necessary, they have to be provided based on a written plan of care, and you meet all of the other requirements of our state plan. So if you're not sure what your state allows for reimbursement, that would be something to ask. And then, in addition, I think Jason also mentioned that the he mentioned guidance that came out. So back in May of 2023. So a couple of months ago, the federal government in CMS came out with new guidance to school districts on school based Medicaid, it had been I don't know, Jason 20 years, maybe since the guidance had been updated. So this guidance, yeah, and this guidance has directed states to update their state plans to look at expansion. And to look at decreasing administrative burden. They want to make this easier to give school districts and states money for their school based providers and their school health services. So advocate for your profession, advocate for your services and advocate for your state, if they have not already expanded. 

Jayson Davies   

Great. Jason, do you have anything to add to that?  

Jason Coker   

No, I think that's that, that covered it. 

Jayson Davies   

Perfect. Now, I do want to come to you Jason really quickly, because whenever I have met with the billing specialists, you know, they have always told me, like, it doesn't matter whether or not a student has Medicaid doesn't have Medicaid, you're gonna do things exactly the same when it comes to your evaluation, your your notes, your documentation, everything. Does that still hold true? That's something that you often share with people or do you have any other advice? 

Jason Coker   

No, that's, that's absolutely correct. At the end of the day, we're not from, from a service standpoint, we're not asking you to do anything that you're not already doing. We're not asking you to do more services or less services. You know, as Elizabeth was saying, advocate for your for your program. But understand that I don't think anyone is asking you at this point to do anything different to hire more people. It's what they're trying to do is expand the allowable reimbursements of the things that are reimbursable. So that the things that you're already doing become reimbursable. So that's what so there's not a push to add more to your plate. Essentially, you're doing exactly the same thing. You're, you're you've always done just now, some of those things are reimbursable. 

Jayson Davies   

Gotcha. Perfect. All right, I want to kind of want to take a step back and do a little bigger picture here, because we've talked a lot about you know, getting this money and making sure that we do a random time study so that we have access to that pot of money and carving it out so that we have access to it. But let's talk about more at that district level, you know, we using round numbers or whatever, we only need to really use numbers, but that money that does come from Medicaid, what can it be used for? What is it actually used for what does it often use for what our districts actually doing with this money? I think you mentioned maybe salary reimbursement but what else?  

Elizabeth Duncan   

So you know, once they receive and it is their recouping the funds that they've already spent, but then they are they are charged with taking these bonds and putting back into health services. So how Are they actually do that and dot you know and track those funds, eight school district has their mechanism for tracking it but it is there to be able to be put back into health services and everything that is required to provide those services. 

Jason Coker   

One thing I will say, I will add to that is the funds that you're receiving for this program are a reimbursement to your general fund. So it's interesting, it's dollar spent from your general fund. So it's a reimbursement to your general fund.  

Jayson Davies   

that is, you know, for everyone who doesn't know, that's actually Jason, can you explain that a little bit further, for people who don't understand the difference between er-a what funds schools have, and the difference between those funds. 

Jason Coker   

So the funding, there's different funding sources for a school district, some some of those funds are state and local, state local taxes or state funding through the Department of Education. And some of those funds are through the federal government through things like Ida, school districts are not allowed to use federal funding to draw down federal funding. So it's called double dipping. So in order to draw down funds for this program for the school based climbing program, you have to use general funds to do that. So you expended in a reimbursement methodology you're expending those funds. So any funds that you receive from Medicaid is going to be a reimbursement to that to those general funds. 

Jayson Davies   

Yeah, and you just opened up a whole can of worms with this conversation because I mean, I think the way that I best understand is that general funds can be used, maybe, for instance, like for a special education fund, but you can't go the opposite direction, often because the federal money is going directly into that Special Education Fund in some cases. Does that sound correct?  

Jason Coker   

I think so. Certainly Ida funds are used. Those are the funds that we see most often those funds are being excluded. And I Cost Report methodology, you're excluding those those Ida funds through funding percentages on a cost report. So you're definitely removing those funds out, you're just and keeping only state and local dollars, and, does that answer your question? 

Jayson Davies   

Yeah, yeah, absolutely. And I know something. It's been in my circle of people that are more at the district level, I hear a lot about special education, depleting the general education funds, you know, it costs a lot more to educate a student that is identified as, as a special education student, as opposed to your general education peers. And we're seeing a lot of districts that, you know, in the reporting, they're saying, hey, the General Education Fund is just kind of going into special education, whether it be because of lawsuits or the need to hire more people, whatever it might be. We're seeing that and is that something that? Are you seeing that a in Louisiana or even more broadly, 

Jason Coker   

from a district level? I'm not sure that I would see that, I would certainly see that. Special Ed does generate some, some revenue, and in terms of Ida funds, and through these this Medicaid Services program, so there is some generation of revenue for the derived from the special education department. How rest of the funding works in the school districts? That's not my expertise.  

Jayson Davies   

Gotcha, gotcha. Yeah, I guess just from my experience here in Southern California, I've heard of the special education departments, just kind of the budget just isn't there because of Ida because maybe they're not using Medicaid to the, to the extent that they can and should be potentially, but they're encroaching on that General Education Fund, because there's just not enough allocated to special education. And maybe it's unique to hear maybe, you know, there's certain sounds like everything, right, it's unique to wherever you are. But that kind of begs the next question, which I think is, you know, if your school district and this is for the OTs out there and the end of the question for you all, you know, if you don't feel like if OTs out there or a PTS speech, whatever, they don't feel like their district is using Medicaid to the best of their ability to, you know, recoup some of that funding. What can an individual employee at a district do? What should they do? Should they step up and say something to their director or to have a board meeting? Is there anything that you can recommend on that level?  

Elizabeth Duncan   

I'll come in on that, you know, I'm one big on chain of command, you know, so really, ask your coordinator ask your supervisor, Hey, I heard there's this thing called Medicaid we're not doing that are are we doing it and I just don't know about it, you know, find out where your school district stands to start with and then you know, from there if you find out that they're not, yes, you know, you're a stakeholder in their in their head Education. So, you know, you can talk with school board members, you can talk with your legislators, you can talk it, you know, with your state education Energy Agency and state Medicaid agency to advocate for expansion of these services. And see where the end asked, you know, where are you, you know, we heard, look, there's this guidance, and there's a good to want to say is like two or several page document that is a synopsis of the guidance, the guidance itself, that just came out is 170 pages, but there's a good synopsis of it. So if you're interested, you can look on the CMS website, that will, you can, you know, review that information. So again, arm yourself with knowledge. And then reach out to other stakeholders, maybe you have an you know, a group of OTs and other parts of your state that you meet with, you know, ask them what they're doing, collaborate with them, talk to your state, and local OT agencies. You know, an AO ta also has some very good information around Medicaid claiming and documentation. So if you're looking for more information, they have more information as well.  

Jayson Davies   

That's great to know, we'll definitely tag those resources in the show notes. So that's at OTSchoolHouse.com slash Episode 134, you'll be able to find some of those links that Elizabeth just discussed. All right, well, we're gonna wrap up here in a moment. But there's one question that I like to ask not in relationship to the podcast, I don't think I've ever used it on here. But whenever I like to make important decisions, and I'm talking to people who I really believe know, more than I do about a topic, and that is, what questions have I not asked that might be helpful to someone listening today? Is there anything that we haven't covered that maybe we should have? 

Jason Coker   

I think the the one thing that I would, that I would not so much a question that that could be asked, but it's important to what Elizabeth was just saying, it's important to educate yourself on how your particular program works. We can talk about Louisiana and how Louisiana works all day. But that doesn't mean it works the same in your state, it doesn't mean it works the same and anyone else's state, so your situation is going to be somewhat unique. It's maybe similar, but reach out, reach out to the people who reach other people who have the information that you're looking for, or at least can guide you. 

Jayson Davies   

Yeah, and that might be you know, your coordinator might be a specific person that has the role of Medicaid reimbursement secretary or something like that. But yeah, reach out to them. Or if they're, if you know that the district has a billing specialist that they work with, and I know sometimes they do a training at the beginning of the year, that's the perfect time to ask questions. 

Elizabeth Duncan   

And a lot of states have technical assistance available, or you know, they have a specific page related specifically to school based Medicaid. So you may also look for that on some of their websites. So really, just, you know, arm yourself of knowledge. 

Jayson Davies   

Yeah, definitely. You know, I, as I'm kind of winding down and coming to terms with everything that we talked about today. I think this is, you know, great arming yourself with knowledge. We learned a lot today. But at the end of the day, I think a lot of OTs are just scared because they don't know this information, and they're afraid of doing something wrong. And if nothing else, I hope this episode with Jason, and Elizabeth, I hope you were able to, you know, share with everyone listening how this isn't something to be scared of. I think Jason earlier you said Remember, it's your district that is being billed and whatnot, it's not you, you're not the one that's actually, you know, no one's paying you for the service that you did. It's all within your district. And I think that OTs in general, especially OT practitioners in the school, we just need to have a little less fear and a little bit more trust in that system. Right? When you get that time study. It's nothing against you or anything, it's just something that we have to do. So that way we can get that reimbursement. Jason, one thing did come to mind, though, really quickly, audits, because I said that word fear, right, like people are fearful when it comes to an audit, like, are the OTs even involved in that? Should they worry about that? Is this Is that something we should even have a discussion about? 

Jason Coker   

We do we do review. So we do a sample of time study moments during our audits at each district. And we ask for documentation. We ask for documentation as it relates to the time study. So if you answered your moment, as you were providing a service to a student, we're going to look for those service notes and see if you are you are during that time period that she said you are providing a service or you're providing a service to a student, but you do have to remember that from a financial audit, generally the financial auditor is not going to look and see if that node is includes all the information that's necessary it we're looking for. Do you have Have a note that a reasonable OT if another OT came and read your notes, would they understand what this is there? There are times where we as auditors read notes. And we're like, that's, that doesn't make any sense to me at all. And I can go to someone like Elizabeth. And I can say, hey, this is what they said in this note, does this make sense to you? And she's like, Yep, absolutely. And she rattles off everything that happened in that service. And it's amazing to me, but I think that I think he made a good point that there's this isn't a, this isn't a fear situation, it's, it's a time for us to come in. And for, frankly, it's a time for you to educate me on some of the things that you do. And it's not for me to educate you on the things that I do. So if I'm going to a school district, and I see, I see service notes that I don't understand, I'm happy to sit down and talk to you and say, Hey, this does, this doesn't make any sense to me at all, this looks incomplete. This doesn't look like a complete service node. It has all the other elements, but the actual service documentation itself doesn't really make sense. It's your chance to walk me through exactly what you wrote there. And say, this is what this was, this is what this means in any OT would would understand that. So you know, a lot of what I do, when I go out to a school district, and I'm doing monitoring or doing audits at a school district, most of the time, as I usually have a staff with me that is actually performing the audit. And while I'm there, I do a lot of training of the business managers, and usually the the time sorry, coordinators or someone like that, it's their time to ask me any questions that they have, too. So I think it would be really wise to ask your auditor questions when they come out. And, you know, if you have any, you know, this might be a person or another one of those people that you reach out to, when you're, when you're trying to get questions answered, or you're you know, you're trying to figure out what type of program your your state has, or what your what, you know, how the funding mechanism works, or whatever, that's a really good time to ask, because that's a good person to ask. 

Jayson Davies   

Right, Yeah, you know, I often say that documentation just comes down to cya covering your own behind, right. And when it comes to an audit, that's exactly what it's doing, you know, and 99% of cases, no one's ever gonna read your your note your session note, but that 1% Where it's an audit or something, it covers you, it covers the district by making sure that you are documenting fully what you actually did during that session. So thank you, Elizabeth, do you have any final notes before we sign off for the for the day? 

Elizabeth Duncan   

Um, just one quick thing that Jason reminded me of is something that we always recommend. And it's like doing a peer review, you know, reader has the time set aside where you and your other OT friend, you swap each other's nerves, you read them, you give them feedback? And again, you know, are you following best practices, and if you do all of that, there's no reason to fear the auditor, because I really used to, you know, be or the auditor, and I've learned more now to not be quite so scared, not just like them quite so much. So it's, it's a little bit, you know, either that, or you can make some banana bread or something and bring it with you, and maybe, maybe a little 

Jayson Davies   

banana bread always helps. So, all right, Jason, Elizabeth, thank you so much. It's been a pleasure talking to you and I look forward to this episode, going live is gonna help so many people. And I know it's gonna help them have a little less fear. And I think that might be the biggest takeaway from this, just have a little bit less fear, trust the system, but also know the system right, get information. So thank you again, I really appreciate it. And we'll definitely have to keep in touch on future guidance changes. So thank you. Absolutely. Thank you. Thanks. Thank you one more time to Elizabeth and Jason, for coming on to share everything about Medicaid billing. I hope you now feel like you have a better understanding of Medicaid billing and why it is so important for you to spend time documenting your services and filling out those Random Moment Time studies. I know sometimes they seem to come in batches, and you get three within maybe like a two week period. Sometimes they come once a year, but whenever they come, they are important to fill out so that your district can be reimbursed for the services you are providing. As Jason and Elizabeth mentioned, if you have any questions specific to your state or your district's Medicaid practices, be sure to find the person at your district or at your co op or at your county who is in charge of Medicaid reimbursement. They would likely love to have a chat about this with you. I can't imagine that they have a lot of people coming to them, asking them about Medicaid. So my guess is they would actually like to have that chat with you. Thank you so much for listening. And if you have not already, please do subscribe to the OT schoolhouse podcast wherever you are listening right now and leave us a review. Your feedback helps us to continue to bring you valuable content and connect with other OT practitioners in the field. Thanks again for tuning in and I will catch you next time on the OTs podcast. Take care 

Amazing Narrator   

Thank you for listening to the OT schoolhouse podcast. For more ways to help you and your students succeed right now, head on over to OT school house.com Until next time, class is dismissed. 

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ep 134 - navigating medicaid billing for school based otps

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