23 Miss. Code. R. 301-1.3 - Quality Assurance Monitoring Plan

A. The Division of Medicaid will establish and maintain a quality assurance process which ensures the quality management of the program. It is necessary to monitor the SBAC program in order to assure that Medicaid dollars are utilized to make Administrative Claiming available to eligible Mississippi Public School Districts enrolled in the SBAC program.

B. Mississippi Department of Education (MDE) Oversight and Monitoring

1. MDE will implement and provide oversight and monitoring actions to ensure that school districts are in compliance with SBAC requirements. At a minimum, these actions are to ensure that:

a) The time study is performed correctly,

b) The time study results are valid,

c) The financial data submitted is true and correct,

d) Training requirements are met, and

e) Appropriate documentation is maintained to support the time study and invoices.

C. Division of Medicaid Oversight and Monitoring

1. Validation of the program will include the Division of Medicaid performing the following actions quarterly:

a) Randomly select ten (10) percent of the sampled responses,

b) Review the sampled responses and independently code the activities of the ten (10) percent selected, and

c) Validate the accuracy of the original coder.

2. Documentation must be readily accessible and available to the Division of Medicaid or CMS. The MDE agrees to share data as a apart of the quality assurance program timely upon request by the Division of Medicaid. The MDE will make available to the Division of Medicaid the documentation/records/reports maintained for the SBAC program.

3. The Division of Medicaid areas of review include:

a) The time study sampling methodology, the sample, and time study results,

b) Compliance with training requirements,

c) Financial reviews, and

d) Documentation compliance.

4. The school districts will make available to the Division of Medicaid the documentation/records/reports maintained from the SBAC program.

5. These documentation/records/reports include, but are not limited to:

a) Random Moment Sampling (RMS) documents,

b) Methodology that supports the construction of the Administrative Claiming billing process,

c) Revenue projection reports, and

d) School district quarterly reports.

6. The school districts must submit copies of the time logs for each participating school in the area to MDE.

7. The Division of Medicaid will verify a small percentage of time logs quarterly to ensure accuracy. Verification will be through direct face-to-face contact with the sampled participants.

8. Each quarter the Division of Medicaid will audit the following:

a) A percentage of the time logs of the sampled school staff to ascertain if the sampled participants understood the instructions on sampling time forms, and

b) Verify that the time study form turned in was completed by the individual who signed the form and that he/she accurately reported his/her activity at the time he/she was sampled, to the best of his/her knowledge.

D. Monitoring Objectives: Monitors from various organizations review the Administrative Claiming program documents and provide performance standards to validate whether or not the providers and/or Administrative Claiming program have:

1. Complied with federal and state laws, regulations and policies,

2. Complied with the terms of the Administrative Claiming Guide agreement,

3. Billed the Division of Medicaid for those services that were authorized and actually delivered in compliance with the Administrative Claiming Guide, and

4. Provided a service which produced an effective and cost effective outcome for beneficiaries and the Medicaid program.

E. Desk Reviews: Periodically the Division of Medicaid staff may conduct desk reviews of Administrative Claiming services. These desk reviews include, but are not limited to, the analysis of required documentation and various reports.

F. On-Site Visits: The on-site visits will be scheduled periodically to be conducted by Medicaid Administrative Claiming staff. During on-site visits, required records and documents will be reviewed for consistency with claims submitted and with applicable program requirements.

G. Cooperation Required of the Provider During Monitoring Activities

1. The school districts must cooperate fully with monitoring activities, evaluations or other reporting requirements authorized by the Division of Medicaid. Records and supporting information must be made available as required for any authorized monitoring activities.

2. The school districts' Administrative Claiming Coordinator or authorized representatives must cooperate fully with monitoring activities, evaluations or other reporting requirements authorized by the Division of Medicaid. Records and supporting information must be made available as required for any authorized monitoring activities. He/she must also be available to answer questions during the monitoring review and to receive the results of the review.

H. Findings from Monitoring Reviews

1. The Division of Medicaid staff that conducts the monitoring review will prepare a report of monitoring activity. A copy of the report will be forwarded to the school district with a request, when appropriate, for a response to be submitted to the Division of Medicaid within thirty (30) days after the receipt of the report. The response should include a plan of correction, as necessary, which addresses any deficiencies noted in the monitoring report.

2. The staff of the Division of Medicaid will review the response and contact the reviewer within thirty (30) days of the receipt of the response regarding the acceptance of the response and approval of the plan of correction.

3. The school district will be notified in writing by the Division of Medicaid of any administrative noncompliance with provider agreement terms or applicable regulations.

4. If items of noncompliance are not corrected, the Division of Medicaid may take appropriate actions to ensure correction by the school district of noted problem(s), or the Division of Medicaid may terminate the provider's participation in the Medicaid Administrative Claiming program.

5. Erroneous overpayments to providers are subject to restitution. The provider is entitled to notification by the Division of Medicaid of the erroneous payment(s). If the provider has been overpaid, he/she will be contacted regarding the repayment schedule.

I. Technical Assistance Provided by Medicaid

1. Medicaid staff is available to provide technical assistance to the Administrative Claiming provider and SBAC districts in resolving any contractual or performance problems. However, technical assistance visits by the Division of Medicaid staff are not comprehensive reviews of the services under the terms of contracts or provider agreements for services. If deficiencies are not identified during the provision of technical assistance, the provider is still responsible for audit exceptions and correcting any other contractual or performance problems noted during monitoring activities.

2. The Division of Medicaid is not liable for acts or omissions of the Administrative Claiming provider, contracted providers, school districts or their employees. The provider should seek their own legal counsel regarding questions of liability.

J. All records pertaining to the Administrative Claiming program must be maintained for a period of five (5) years after each quarterly claim is filed with the Division of Medicaid, unless an ongoing audit or resolution of an audit exception is in process which requires that the records be maintained until the audit is resolved.

Notes

23 Miss. Code. R. 301-1.3

Miss. Code Ann. § 43-13-121; Section 1903 (a)(7) of the Act; 42 CFR 430.1 and 42 CFR 431.15; OMB Circular A-87