Recent audits by the Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services indicate that states are continueing to allow unqualified providers to deliver school-based speech-language pathology services to Medicaid-eligible students.
OIG audits programs to determine whether the state services provided meet federal and state Medicaid requirements (federal regulations supersede those established by the state unless state regulations are more stringent). In most states the federal share of Medicaid payments is substantial, and adherence to federal regulations is essential for coverage.
States that bill the federal Medicaid program for school-based services must comply with federal regulations regarding providers' qualifications. The Code of Federal Regulations [CFR, Title 42, Section 440.110(c)(2)] requires that services for individuals with speech, hearing, and language disorders be provided by or under the direction of a speech-language pathologist who meets the requirements for the CCC-SLP from ASHA.
In a 2006 summary [PDF] of earlier OIG reports ASHA noted that "Lack of documentation and school administration's failure to utilize qualified providers continues to plague the appropriate delivery of Medicaid school-based speech-language pathology services, according to the Department of Health and Human Services Office of Inspector General."
Medicaid has completed audits of school-based programs in 20 states. Although individual states have been cited for a variety of deficiencies, speech and language services audits continue to uncover problems with provider qualifications and issues with service authorization or delivery. Given the OIG's clear intention to continue to audit state Medicaid billing, state and local administrators and school-based SLPs providing services to Medicaid-eligible children should review federal requirements to ensure that only qualified SLPs or those under the direction of qualified SLPs are providing Medicaid services. In addition, school staff and administrators should complete appropriate and comprehensive documentation to ensure that children are receiving authorized services included in the child's Individualized Education Program.
Earlier this year, OIG released two final reports that reviewed two states' school-based Medicaid claims. OIG audited a sample of Arizona Medicaid claims from Jan. 1, 2004, through June 30, 2006; the claims included 1,989 Medicaid school-based health services totaling a federal share of $32,212. For that period, the total Arizona Medicaid expenditure was $184 million, of which $124 million was the federal share.
A March report [PDF] was critical of the state agency, stating that 46 out of 100 student-months (defined as representing all paid Medicaid school-based health services provided to an individual student for a calendar month) had one or more school-based health services that were not allowable.The report listed the following reasons why the services were not allowed:
- Services were not provided or service units were overbilled.
- Documentation requirements were not met.
- Speech-language pathologist provider requirements were not met.
- Unallowable transportation services were provided.
- Prescribing or referring provider requirements were not met.
- Student eligibility requirements were not met.
Based on its findings, OIG recommended that Arizona refund $21.3 billion for unallowable school-based services—a figure that totals more than 16% of Arizona's federal reimbursement. As in past OIG reports, the federal regulation for speech-language pathologist qualifications was cited; OIG found that Arizona was using personnel who held provisional certificates issued by the state Board of Education or limited licenses issued by the Department of Health Services.
The federal government indicated that provider qualifications issued by a state department of education do not meet the federal requirement for Medicaid-covered school health services; a provider who holds a provisional certificate or a temporary or limited license, therefore, must be supervised by an SLP who meets the federal definition.
Arizona argued unsuccessfully that the services could be furnished by providers who acted within the scope of practice as defined by state law. The OIG was clear that speech-language pathology services must be provided by practitioners who meet the specific federal requirements.
Similar findings are reported in the OIG's review [PDF] of New Jersey's Medicaid school-based health claims submitted by Maximus, Inc. This April report was the third in a series on school-based Medicaid claims in New Jersey (the first two were released in 2006 and 2008). The most recent audit covered 86,533 claims totaling approximately $62.5 million ($32.2 million federal share). The OIG sampled claims from July 27, 2003, through Oct. 4, 2006, and found deficiencies in four areas:
- Services not provided or supported.
- Referral or prescription requirements not met.
- Federal provider requirements not met.
- Services not documented in child's plan.
The OIG said that provider requirements were not met because school-based health providers did not comply with state guidance related to federal requirements.
In 1993 the Centers for Medicare and Medicaid Services requested—and received—assurance from New Jersey officials that SLPs would meet federal provider qualifications for school-based services billed to Medicare. In the recent report, however, OIG found that for 13 of the 100 claims in the sample, the provider of speech-language pathology services was neither ASHA-certified nor eligible for ASHA certification. The practitioners in those 13 cases were authorized by the New Jersey Department of Education to serve in the public schools as either a "speech correctionist" or a "speech language specialist." The OIG noted that neither of these credentials requires specific coursework toward a master's degree, a 350-hour clinical practicum, or a clinical fellowship. Moreover, the unqualified practitioners were not supervised by a certified SLP.
Based on the findings, the OIG recommended that New Jersey:
- Refund $8 million to the federal government.
- Provide proper and timely guidance on federal Medicaid criteria to its school-based health providers.
- Improve monitoring of school-based health providers' claims to ensure compliance with federal and state requirements.
States will want to take steps to ensure their personnel and programs are in compliance with federal regulations and to avoid having to return federal reimbursement for Medicaid services.