Page 9 - OPTA Access September 2017 Volume 45, Issue 2

OPTA | September 2017 | 9
Additional Steps to PT Practice Autonomy: An Update on Referral for Medicaid Reimbursement
Cheryl VanHoose, PT, MHS
As a result of recent legislation,
Ohio PTs moved a few
steps closer in the direction of
practice autonomy Medicaid, as a
third-party reimbursement entity,
has been in the national spotlight as
well as the center of some debate
at a state level during the past year
This was particularly true in the
Medicaid Schools Program (MSP)
Since 2009, Ohio schools have
been reimbursed for some of the
services that schools provide to students with disabilities through the Medicaid Schools Program (MSP ) Physical therapy, occupational therapy and speech therapy services represent the major sources of this reimbursement During the past 18 months, there was considerable confusion about some of the key elements that were required for MSP reimbursement This has been a lengthy process but most can now see the nish line in sight.
Physical therapists who work in the school environment follow the PT regulations as indicated in the Ohio Revised Code / 4755 They provide physician notice of the student’s evaluation and service provision within the school environment and any other relevant elements In the past, the Medicaid’s Community Alternative Funding Sources (CAFS) and their current program, MSP, have not required a physician Medicaid practitioner who meets that full criterion of an ordering, referring and prescribing (ORP) provider to indicate that they are referring this service in order to submit for Medicaid reimbursement One of the reasons why this was not a requirement in the past was because of the complex interaction of government programs and services involved in service delivery in this environment School-based physical therapists must integrate the laws and rules related to IDEA (the Individuals with Disabilities Education Act), the State Operating Standards related to students with disabilities, federal Medicaid mandates, Ohio’s laws and rules regulating the Medicaid Schools Program, the laws and rules related
to PT practice including ORC 4755, and individual school district policies There is also the complicated process of the IEP team mandate from IDEA that all members of the team, including parents, teachers, school district administrators, etc are a part of the program and goal development process Last year, it was indicated that Medicaid would have to have an ORP referral if funding in the school environment was
to continue based upon an Affordable Care Act provision This seemed to be an almost insurmountable impasse
as it would cost some school districts close 50% of their reimbursement amounts just to obtain the outside ORP referrals Many options were considered
Through the cooperative efforts of many stakeholder groups, including the OPTA, there was a resolution to this dilemma To address this issue, Ohio Substitute Senate Bill 89 was signed into law by Governor Kasich in December 2016 This law allowed Medicaid to accept the physical therapist’s referral as the validation necessary for Medicaid reimbursement While this is only possible in the school environment, it is an important step in PT autonomy As the OPTA and Montgomery County Education Service Center testimony to the Ohio Senate indicated, the training for PTs is very rigorous indeed and PTs are more than capable of determining which students require PT services, as well as, which students have medically based needs
The most recent obstacle was that of the Medicaid online provider application While the original intent of
the law had been for PTs to become ORP providers, it
was determined that PTs should only become referring entities Therapists were told that they could complete
the application under the ORP category and there was no option considered in having a separate application PTs were required to complete the individual practitioner/sole proprietor section of the online application This produced additional obstacles Attestation was required for application completion that included items such as:
• The applicant did not have any association with a school district
• The applicant was a sole proprietor
• The applicant must attest that they did not provide services to Medicare bene ciaries
• The applicant needed to “af liate” with the different school districts where they provide Medicaid reimbursed services
• Several of the terms and conditions of practice did not correspond well to the role of the PT in school based practice
• Applicants must complete a W-9 form
Again, stakeholders, including OPTA, rallied to make this process work. The statements about not having any af liation with school districts were removed and a work group was used to put together “Step by Step Instructions” that helped to make the application be more applicable
for this practice setting and included some disclaimer statements for MSP applicants This same group also submitted suggested FAQ questions and proposed answers Lesley Scott Charlton, ODM Medicaid School Program Administrator, and Mark Smith, ODE Medicaid Consultant, worked to compile and nalize this information and it is presently available on the ODM website Additionally, the advocacy group, OSHSA (Ohio School Health Services
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