SUMMARY OF FINDINGS

 

DOH claimed Federal Medicaid reimbursement for some OPWDD waiver program services provided by New York City providers that did not comply with certain Federal and State requirements. Of the 100 beneficiary-months in our random sample, DOH properly claimed Medicaid reimbursement for OPWDD waiver program services during 86 beneficiary-months. However, DOH claimed Medicaid reimbursement for services that did not comply with certain Federal and State requirements for the remaining 14 beneficiary-months.

 

Of the 14 beneficiary-months with services for which DOH improperly claimed Medicaid reimbursement, 2 contained more than 1 deficiency:

• For 6 beneficiary-months, DOH claimed reimbursement for service units billed that exceeded service units provided.

 

• For 4 beneficiary-months, DOH claimed reimbursement for OPWDD waiver program services that were not supported by adequate documentation.

 

• For 3 beneficiary-months, DOH claimed reimbursement for OPWDD waiver program services that were not provided.

 

• For 3 beneficiary-months, DOH claimed reimbursement for services that were not provided pursuant to a written plan of care.

 

The claims for unallowable services were made because DOH and OPWDD’s policies and procedures for overseeing and administering the waiver program were not adequate to ensure that (1) providers claimed reimbursement only for services actually provided and maintained all the required documentation to support services billed and (2) OPWDD waiver program services were provided only to beneficiaries pursuant to written plans of care.

 

Based on our sample results, we estimate that DOH improperly claimed $7,772,807 in Federal Medicaid reimbursement for OPWDD waiver program services during calendar years 2006 through 2008.



RECOMMENDATIONS

 

We recommend that DOH:

• refund $7,772,807 to the Federal Government and

 

Link:

http://oig.hhs.gov/oas/reports/region2/21001027.pdf

In the search for the best software solution, provider agencies regularly come across EMR (Electronic Medical Record) and EHR (Electronic Health Record) systems. For most agencies, EMRs are not the best fit based on the types of services that make up the bulk of agency offerings. An Agency Management Platform (AMP) is a better choice in most cases. Below is a quick guide to understand the difference between EMRs and AMPs.

 

-Clinical in Nature. EMRs are not intended for the unique requirements of a waiver provider agency. Instead it is for more clinical agencies. Most EMRs are off the shelf, which means that it is intended to be used as-is, without a lot of modifications. A typical provider agency would have to make many modifications based on their unique workflows and demands.

 

-Episodes of Care. EMRs are a system that’s based on a workflow that clearly has a beginning, middle and end. It is clinical by nature, so the focus is on records management and the creation and documentation of patient assessments and treatment plans on the front end. The work flow clearly follows a path that an agency would treat the “patient” and eventually discharge them. In fact most have a module called Discharge and Transfer Management. We all know that with an Agency Management Platform, the workflow is about providing a lifetime of service and support to the individuals they serve. Goal plans and service notes replace assessments and treatments and managing employees to help individuals reach fulfilled lives are what is important in our system. The bottom line: a provider agency would have a bunch of modules and workflows that have no relevance to them or they would have to change some of their processes to fit the system- which is risky and costly.

 

-Disconnected schedules and shifts. Because EMRs are not targeted to provider agencies, they don’t treat their schedules or appointments, clients, employees and service programs in the same capacity as an AMP. Most have schedules that seem more like an Outlook calendar where you can schedule “events” with a client similar to scheduling a meeting in Outlook but those “events” don’t bring billable hours, service notes, and pay rates together. With most EMRs, it seems like everything is floating on its own, whereas AMPs tightly integrate everything through its platform to ensure tight audit controls, premium service delivery, and trackable payroll and billing information. Most don’t mention anything about error free scheduling- the ability to eliminate double bookings or unqualified staff which an AMP schedule engine does. This goes back to the fact that the average clinical agency that an EMR is serving does not have the home and community based schedules that a provider agency has.

 

-Not focused on waiver specific compliance. Another big piece of an Agency Management Platform is the compliance packs that come standard. So an agency using an AMP is always in compliance with all federal, state and local requirements automatically. Both from a billing and documentation standpoint. This is huge for Medicaid supported services, which is our focus. That is not a focus with EMRs.

 

-Paying for irrelevant functionality. There are some similar functionalities when it comes to certain things like their billing – both EMRs and AMPs integrate with general ledger and payroll software, reporting, HIPAA security measures, we’re also SureScripts certified for e-prescribing. EMRs are more medically slanted, which doesn’t really benefit most provider agencies and it definitely takes the cost of a much higher. Both offer medications management but it’s not a focus for us or most of our customers.

 

Ultimately, most EMRs are geared for agencies that deal with episodes of care that have a beginning and an end. Agency Management Platforms are completely built around supporting agencies that provide a continuum, or lifetime, of care. That affects the functionality and purpose of the software as explained above.

MediSked, the nation’s leader in Agency Management Platform solutions for Disability Provider Agencies, will present on Transitioning to Paperless Using Technology at the 17^th Annual NAQ Conference.

Rochester, NY (PRWEB) Aug 6, 2012 – MediSked, LLC has served disability provider agencies for over ten years by providing web based solutions to manage the operations, records, billing, and HR functionalities within provider agencies. They will share their knowledge on the benefits and challenges of transitioning to technology in a presentation at the NAQ Conference entitled “Transitioning to Paperless: How Technology Assists in Improving Care and Maintaining Compliance While Reducing Costs”


NAQ is the National Association of Qualified Developmental Disability Professionals. NAQ was formed in 1996 to establish a strong resource for research, networking and addressing issues that concern Qualified Developmental Disability Professionals (QDDP) today. A chief concern amongst professionals is managing and navigating through the changing regulatory environment that surrounds them as most agencies are funded through Medicaid waivers. Managing Medicaid dollars efficiently and effectively to provide the highest quality of care to the individuals they serve has become more difficult in recent years as state budgets have seen significant cuts and regulations have grown. A survey conducted by MediSked, LLC to over 1,200 respondents shows that less than 13% of provider agencies use a comprehensive software solution to manage their electronic records and operational data. Brian White, Business Development Manager at MediSked, has been asked by NAQ to discuss the benefits and challenges that face provider agencies in transitioning from paper based systems to a complete web based platform.

“This is a turning point in the home and community based service industry. Disability Provider Agencies have more pressure than ever to be ultra- efficient with Medicaid dollars. At the same time, the demand for real time data on the individuals they serve and the staff serving them will only increase,” stated Brian White. “It’s about making technology work in an easy to use format that’s highly accessible and captures all of the operational moving parts to agencies serving the developmentally disabled.”

For more information on the 17^th Annual NAQ conference, please visit http://www.qddp.org/. Agencies looking for information on using technology to reduce costs, increase capacity, perform better in the event of an audit and increase the quality of care can visit MediSked at www.medisked.com or call 866-633-4753.