School Districts failed to Claim Reimbursements
The New York State Comptroller office audited Medicaid reimbursements in eight districts throughout northeastern New York State for the period July 1, 2005, to June 30, 2007, to determine if the issues identified in their 2006 audit report had been corrected and if school districts were claiming all the Medicaid reimbursement to which they were entitled. For the purpose of their audit, they examined physical therapy, occupational therapy, speech pathology/therapy, skilled nursing services, and TCM reviews and on-going service coordination. Our audit addressed the following question:
- Are districts claiming the Medicaid reimbursements to which they are entitled for services provided to eligible special education students?
Districts in the region we examined have not claimed all the Medicaid reimbursements to which they are entitled. The eight districts we audited failed to claim at least $3.1 million of Medicaid reimbursement for related services and TCM reviews and ongoing service coordination provided to special education students during our audit period. As a result, the districts did not receive at least $770,000 in Medicaid reimbursement revenues, which represents their share (25 percent) of the eligible services that district officials could have claimed. Our audit covered a two-year period for which the eight districts reported a little more than $3.65 million in revenue from Medicaid reimbursements. If similar conditions exist in the 10 counties covering northeastern New York State, districts within that region could collectively be entitled to receive over $4.3 million more in revenue over the two-year period. Because the State is due an equal share of the Medicaid reimbursements sent to the districts, the State’s share could also potentially amount to more than $4.3 million.
The audit identified a number of reasons why district officials did not claim Medicaid reimbursements for these services.
- Five of the eight districts had difficulty obtaining the proper documentation from service providers including their Medicaid claims processor that was needed to file claims and/or poor communications between departments.
- These problems caused some district officials to file Medicaid claims in an untimely manner.
- Three districts did not bill claims regularly which resulted in a backlog of unfiled claims.
- Untimely identification of Medicaid eligibility, and lack of provider notification in changes in Medicaid eligibility.
- Five districts did not review and investigate claims that were denied for students with an active Medicaid status where the remittances for claims could potentially be re-submitted.
- Four districts made a determination, based on an informal cost-benefit analysis, that the potential revenues did not outweigh the cost of claiming certain reimbursements.
Recommendations to solve these problems:
- District officials should ensure that student eligibility is updated periodically in an effort to claim all potential reimbursements.
- District officials should develop procedures that ensure documentation is obtained from providers and transmitted to the Medicaid claims processor in a timely manner.
- District officials should research student records to determine if the District is entitled to any additional Medicaid revenue for unclaimed related services.
- District officials should reconcile the amounts claimed for Medicaid reimbursement with the amounts received, and review any rejections or disallowances to determine whether the items may be resubmitted with additional documentation or explanation.
The district officials generally agreed with the recommendations and indicated they plan to initiate corrective action.