6685 - Medicaid Compliance


Adoption Date: 4/14/2011
6000 - Fiscal Management

6685 Medicaid Compliance

The Board of Education recognizes its obligation to put a plan and program in place to prevent or otherwise detect fraud, waste and abuse in the Medicaid program.  In general, the Board expects that its officers and employees will operate with integrity and in conformance with its adopted code of ethics.  The Board directs the Superintendent to ensure that the following program elements are in place and are implemented effectively:

1.      Written procedures:  Accompanying this policy, and the cross-referenced policies listed below, are more detailed procedures and descriptions of how each element of the compliance program will be implemented. Written procedures will address how the District will accomplish the following:

a.       Keep informed regarding Medicaid coverage:  The Director of Pupil Personnel will keep abreast of services that are covered by Medicaid so that the District files compliant claims.  The Board expects that District staff and/or contractors and agents will avoid filing false claims which would subject the District to civil and criminal liability.

b.      Prohibit use of “excluded” providers:  Ensure that the District doesn’t hire or contract with service providers who have been excluded from Medicare or the Medicaid program. The Director of Human Resources will check the credential of the provider before the District engages their services.  District employees will be required to sign an agreement that said employee will inform the Compliance Officer and Director of Human Resources upon receipt of any notification or knowledge that the individual’s license has been suspended, revoked or lapsed, or if they have been excluded from participation in the Medicaid program.  Upon notice by the employee, the District will take remedial steps as soon as possible.  Contracts with outside providers will include provisions to address this requirement.

c.       Monthly review of providers:  The Director of Human Resources will check the list of excluded providers monthly to determine if any District employees who deliver Medicaid-covered services, or if any contractors, have been added to the list or have been reinstated.  If any have been excluded, it will be reported immediately to the Superintendent and Compliance Officer who will initiate remedial action.  

2.      Appoint a Compliance Officer, who is an employee, vested with responsibility for the day-to-day operation of the program:  The Board will appoint a Medicaid Compliance Officer at its annual organization meeting.  The role of the Compliance Officer shall be to oversee the compliance program, receive and promptly investigate reports of noncompliance and report findings as appropriate to the Medicaid Inspector General, as well as to the Board of Education and Superintendent. The Compliance Officer will report to the Board fraud, significant findings or patterns of noncompliance.

3.      Training and education of officers and employees:  All employees involved in Medicaid covered services, as well as those responsible for oversight, will receive annual training in accordance with state and federal requirements.  Board members will also receive appropriate training so that they can fulfill their responsibilities.  The District will keep appropriate records documenting the training program.  

4.      Lines of communication:  The District will work towards ensuring that its culture encourages communication among all parties involved in the Medicaid compliance program.  The New York State Education Department and Health Department outlined the requirements of a disclosure mechanism that enables employees to report anonymously any practice or billing procedure that the employee deems inappropriate to the District’s Compliance Officer and/or the State’s Compliance Officer.  The District will inform employees of this mechanism in conformance with that policy.

5.      Disciplinary consequences for school employees:  Failure of District employees to comply with this policy, and the reporting requirements pursuant to policy 9645, may result in a range of disciplinary actions, up to and including termination, in conformance with applicable laws and collective bargaining agreements.

6.      A system to routinely identify compliance risk areas:  Medicaid claims will be included as part of the District’s risk assessment.  The claims will be reviewed as part of the District’s risk assessment as directed by the Audit Committee or Board of Education.  In addition, the Medicaid claims function will be tested and reviewed as part of the District’s internal audit plan routinely, or as directed by the Audit Committee or Board of Education.  When the internal audit reveals weaknesses, a corrective action plan will be initiated by the Director of Pupil Personnel.

7.      Non-Retaliation:  The Compliance Officer and Board is charged with responsibility for enforcing District policy 9645, Disclosure of Wrongful Conduct, which protects individuals who, in good faith, report or investigate suspected cases of fraud, waste or abuse in the District’s Medicaid program from retaliation or intimidation.

The Superintendent is responsible for developing regulations which will further detail the procedures associated with this policy.   The Board will periodically review and update this policy and the associated plan.

Dissemination of Policy

The Board directs the Superintendent to ensure that this policy, as well as the necessary procedures, are disseminated to employees as well as those entities providing Medicaid covered services, with particular attention to those employees involved in administering the programs and services associated with Medicaid and their billing. 

Policy References:
False Claims Act, 31 U.S.C. §3729, et seq.
State Finance Law §§187 et seq. (New York False Claims Act)
Social Services Law §§145-b (False Statements); 145-c (Sanctions);
363-d (Provider Compliance Program)
Labor Law §740 (Prohibits Retaliation)
18 NYCRR §§521.1 et seq. (Provider Compliance Program regulations)

Policy Cross References:
 » 2160 - School District Officer and Employee Code of Ethics
 » 2210 - Board Organizational Meeting
 » 2520 - Board Member Training
 » 6650 - Claims Auditor
 » 6660 - Independent/External Audits
 » 6680 - Internal Audit Function
 » 6690 - Audit Committee
 » 9645 - Disclosure of Wrongful Conduct
 » 9700 - Staff Development