Public School-Based Medicaid Claiming: Don’t let documentation leave you vulnerable during an audit

Documentation audits seem to be the new norm in healthcare, and public schools participating in Medicaid claiming are likely no exception. Although Medicaid hasn’t yet expanded its audits in this area, it is a possibility this can occur in the future.

According to a September 2015 report published by the Office of Inspector General, two Massachusetts school districts received overpayments due to cost reporting errors in FY 2012. The state Medicaid agency was required to refund thousands of dollars as a result of the investigation.

Going forward, state Medicaid agencies will probably keep closer tabs on public school-based Medicaid claiming programs. Medicaid wants to ensure that schools participating in these programs provide documented records of all Medicaid services that various school health personnel render. Schools must complete this documentation to receive reimbursement for all Special Education health-related Medicaid-covered services provided to Medicaid-eligible children. Services include speech therapy, occupational therapy, physical therapy, audiology services, counseling, nursing services, personal care, behavioral health, and applied behavior analysis (ABA).

If the documentation is omitted—or it doesn’t support the services billed—the school, state Medicaid agency, and/or the municipality in which the school is located could be required to refund the payment. It’s important for school personnel to understand their responsibilities in terms of providing clear and detailed documentation.

4 tips to secure compliant documentation

Consider these four tips to capture documentation most effectively:

  1. Remind personnel to document each time a Medicaid-covered service is provided to a student.
  2. Reiterate the importance of documentation. Although documenting services may take time and effort, the documentation is a critical part of compliance—and it could protect the school and municipality during an audit.
  3. Ensure that the documentation includes the following elements: School district name/provider number, student name, student date of birth, student Medicaid number, date of service, activity/procedure note (including whether the activity/procedure was performed individually or as part of a group), service time, and signatures. In the event of an audit, documenting the activity/procedure as ‘speech therapy’ is not advisable. Instead, encourage providers to document ‘Working with a student related to articulation of the ‘th’ sound for 20 minutes.’
  4. Don’t forget about ABA therapists. In July 2014, Medicaid announced it would begin to cover medically necessary treatment for autism, including ABA. It’s important to capture all documentation for ABA services rendered to Medicaid-eligible students.


Choose your billing vendor carefully

When evaluation third-party billing companies that will perform your Medicaid claiming, be sure to ask the following questions:

  • Can the vendor integrate with the school’s record system to access documentation easily and streamline processes?
  • Is the vendor willing and able to collaborate with information management solutions to develop an electronic system of tracking Medicaid billable hours?
  • Does the vendor review provider documentation to confirm that all required and relevant service data components are present?
  • Does the vendor have access to—and review—all individualized education programs (IEP) to compile a list of missing documentation for each student?
  • Can the vendor assist with obtaining, validating, and tracking parental authorization for Medicaid billing? Can it also assist with RMTS monitoring?
  • Is the vendor able to validate student and provider eligibility?

To learn more about compliant Public School-Based Medicaid Claiming, call Jennifer White at NEMB at 508-297-2068 x233


About NEMB

New England Medical Billing is a fully HIPAA compliant Medical Billing Management and Administrative Service Firm. Our expertise is in program and system design as well as effective implementation and administration. Our multi-disciplinary approach and attention to detail consistently yields the maximum allowable returns on every client project.

Since 1993 NEMB has been built carefully, approaching each new engagement using proven management methods. Our superior, time-tested approach is applied to each and every engagement. We “zero-base” every new proposal to build a process that fulfills the unique requirements and goals of each project.

Our billing administration experience in ambulance & EMS services, emergency departments, school-based Medicaid claiming and private physician practices has honed and streamlined our clients’ operations in capturing and maximizing revenue opportunities on a large scale.

Public School-Based Medicaid Claiming: Don’t let documentation leave you vulnerable during an audit2019-01-02T17:52:51+00:00

Increase Medicaid Revenue for Ambulance Services through Cost Reporting

Did you know that your municipality could potentially gain additional Medicaid reimbursement if it can demonstrate that its allowed costs exceed amounts reimbursed?  More than 35 Massachusetts municipalities with public ambulance/EMS services have already collectively gained approximately $4.6 million in Medicaid reimbursements.

According to the Ambulance Certified Public Expenditure (CPE) Program, approved governmental ambulance providers can submit an annual cost report and receive additional payment if allowable costs for MassHealth services provided on or after April 1, 2013 exceed interim payments. The program is administered by the state’s Executive Office of Health and Human Services.

“Our first responders are doing their part to protect the state’s most vulnerable residents, and these resources provide the additional support to help more individuals in need,” Governor Charlie Baker said in an HHS press release

Lt. Governor Karyn Polito echoed his sentiments. “We are proud to offer this extra level of support to our ambulance and public EMS workers. We hope additional providers and communities will take the initiative to participate and bolster support for emergency services around the Commonwealth,” she said in the press release.

However, even despite the availability of these funds, New England Medical Billing (NEMB) has found that many municipalities struggle with the program. Some decide not to participate because they incorrectly assume that the task of cost reporting will be too burdensome. However, depending on the municipality’s volume of Medicaid patients, we’ve found that 2%-10% of additional revenue is possible, making it worth the extra effort to pursue. Municipalities receive these funds once annually at the time of cost reconciliation.

To report costs correctly, municipalities must separate the administrative costs of the fire department from those of the ambulance services. This can be difficult, given the fact that operational overlaps often occur. For example, many fire chiefs know that a paramedic could drive the fire truck or a firefighter could perform emergency medical services.

Following are two tips to help you get started with the CPE Program:

  1. Ensure compliant billing. Work with an outsource vendor that understands ambulance the nuances of ambulance coding and billing. This helps avoid overbilling, and it ensures accurate reporting relative to costs and payments. Compliant billing also mitigates the likelihood of a potential overpayment in which the municipality would be responsible for refunding the amount.
  1. Tag costs for EMS vs. the fire department. Track the following:
  • Direct service staff salaries (e.g., paramedics, EMTs)
  • Ambulatory services administration salaries (e.g., non-direct service staff)
  • Direct service support staff salaries (e.g., 911 call techs, QA techs, billing/account reps)
  • Benefits for direct service staff/administration staff/support staff, operating expenses (e.g., fuel, maintenance, repairs, plant operations, utilities)
  • Equipment depreciation
  • Equipment costs

To learn more about the CPE Program and how it can potentially yield greater reimbursement for your municipality, call Nancy Dolgin at NEMB at 508-297-2068 x232.

About NEMB

NEMB understands the importance of building meaningful relationships with entities and individuals within each municipality so we can ensure timely and compliant billing. Not only do we communicate regularly with fire and police departments, but we also take the time to get to know and network directly with town accountants, town managers, mayors, and others. We identify the key individuals within each municipality who can provide the critical information we need to bill ambulance services appropriately and as quickly as possible.

With nearly 10 years of experience in municipal ambulance billing, our credentialed staff members are trained in every aspect of effective municipal service billing. We specialize in auto accident claims that continue to challenge municipalities and result in significant revenue lost. We pursue auto accident claims as quickly as possible so our clients can take advantage of personal injury protection benefits before those benefits are depleted. Our expertise and focus on communication and relationship building help to maximize cash flow and ensure the fastest possible return on investment for the services provided. NEMB’s ambulance billing record has consistently yielded over a 90% collection rate.

Increase Medicaid Revenue for Ambulance Services through Cost Reporting2019-01-02T17:52:52+00:00

Urgent Care Billing: In House or Outsource?

One of the most important things that an urgent care center needs to consider is whether to outsource their billing or take care of it in-house. While in-house medical billing does give a practice more control over their billing practices, many urgent care clinics find that it’s more trouble than it’s worth.

As strange as it may sound, it’s in your best interest to outsource your urgent care clinic’s medical billing to a third party. Here are just a few reasons why.

Consistent Billing

Unpaid or denied claims are common for any medical practice. These can cause a major headache for obvious reasons, not the least of which is the time and effort it takes to address these claims. A medical billing company is contractually obligated to follow up on these claims, which takes most of the stress away from the urgent care clinic itself.

Having a third party handle all billing claims also means that all bills will be sent out on time and at a regular basis. Clinics that handle their billing claims in-house can easily fall behind on their bills and claims if they have a heavy workload. Medical billing companies focus exclusively on billing patients and sending claims to insurance companies, which means they don’t have to worry about treating patients or taking care of any other responsibilities that could cause them to fall behind on their work.


Medical billing companies also submit performance reports to a provider upon request. These reports provide transparency and allow a clinic to know exactly where it stands financially. This also allows an urgent care clinic to evaluate the services of the billing company itself.

Lower Costs

While it can be difficult for urgent care clinics to budget for medical billing companies, outsourcing medical billing can still lead to lower costs for clinics. An urgent care clinic that handles all of its billing in-house simply has a higher overhead. A billing department needs to be created, which means having to hire more employees and paying more in hourly wages and other benefits. There’s also the matter of creating a billing system, which can eat into the clinic’s budget even further. On the other hand, outsourcing work to a medical billing company allows an urgent care clinic to bypass all of this and simply focusing on other matters.


The experience provided by a medical billing company is unparalleled. Since medical billing is at the forefront of the business, medical billing companies have lots of experience in this field. In addition, they are well versed in all the rules and regulation of medical billing.  This minimizes room for mistakes and allows practices to feel confident in the ethics and experience of the medical billing company.

Better Service

Finally, outsourcing billing and claims to a third party allows an urgent care clinic to provide better service to its patients. Doctors and other medical professionals don’t have to worry about processing claims and sending out bills, so they can focus on providing high-quality treatment to those who need it. They may not have all of their billing information on hand at all times, but they can rest assured that it is in good hands while they focus on doing their jobs to the best of their ability.

Urgent Care Billing: In House or Outsource?2016-07-11T16:26:21+00:00

How We Help Credentialing for Your Urgent Care Center

An urgent care center is a good halfway point for those who need treatment for acute illnesses and non-life-threatening injuries yet don’t need to go to an emergency room. The wait time at urgent care centers is significantly shorter than what you would find in an emergency room, there’s always at least one licensed physician on staff, and it’s much less expensive. The only problem is that insurance companies can make it very difficult for urgent care centers to become credentialed.

What is Credentialing?

An urgent care center requires the proper licenses to operate in a particular jurisdiction, but it also needs to be affiliated with major insurance companies so it can accept third party reimbursement. This is known as credentialing, and it allows a center to receive steady payments and treat a greater number of patients. In other words, it is essential for the operation of any urgent care center.

Credentialing may seem like a simple matter, but it can be a major obstacle for an upstart urgent care clinic. First of all, the process can take as long as six months, so a center needs to get a head start on it if it is going to have a steady cash flow as soon as it opens. Second of all, the credentialing process varies from one payer to the next. The staff at New England Medical Billing stays up to date on the ever changing requirements for each payor.

How New England Medical Billing Can Help You

If you’re concerned that your urgent care center won’t be properly credentialed, you can always go to a medical billing service to assist in the process for you. That’s where New England Medical Billing can help you. We expedite every step of the credentialing process for urgent care centers. We can help you fill out all the proper paperwork, handle the communication between you and the insurance companies, make sure that all submitted claims are paid and generally ensure that you have a steady cash flow.

Running an urgent care center is a lot of work, and we want to help make things a little bit easier. Contact New England Medical Billing to find out how we can help you with all of your medical billing needs including credentialing.

How We Help Credentialing for Your Urgent Care Center2016-07-11T16:26:41+00:00

ICD-10 Training Course

As of October first, ICD-10 coding will be mandated by Centers for Medicare and Medicaid Services. With the release date quickly approaching, we know you’re doing everything you can in advance to get ready for the transition. To further help you prepare, New England Medical Billing is offering a training course in ICD-10 and Ambulance documentation requirements! This two hour course is complimentary to NEMB clients and is approved for two CEU credits.

We will be covering extensive information to prepare you for transition. Topics that will be covered are an ICD-10 background, the effect on documentation, common documentation examples, as well as ICD-9 to ICD-10 examples. The different areas that are being covered will continue to build your ICD-10 knowledge and familiarize you with the material.

HIPAA is requiring this for transition to ICD-10, so it is important to make this a priority. As previously mentioned, this course is complimentary for NEMB clients. All others who would to attend this training course should contact Patricia Packard at 508-297-2068 x 229. Remember, this is only one step of many your practice should be making in order to prepare for the transition to ICD-10!

Visit to learn more!

ICD-10 Training Course2019-01-02T17:52:52+00:00

ICD-10 and its Effect

Many people in the healthcare profession are familiar with ICD-9, and also familiar with the fact that it will be replaced by ICD-10 on October 1st, 2015. ICD-10 stands for International Statistical Classification of Diseases and Related Health Problems – 10th Revision.

This change is well overdue, as ICD-9 has been in effect for over 30 years. While ICD-9 has been useful, it can no longer keep up with today’s fast paced technological changes. It supports only 14,315 codes, while ICD-10 is set to support 69,101 codes. This massive increase in the number of codes will allow the service provider to be far more detailed and specific when entering the codes.

The new medical classification list, by the World Health Organization, is programmed to provide higher-quality information in all areas of the medical field. It will make it easier to keep track of diagnoses, patient abnormalities, complaints, and medical information. The code sets will lead to more efficient, accurate and informative data.

The biggest change being implemented in ICD-10 is the ability to keep up with new advances in the medical field. The alphanumeric format is designed to allow for future updates and revisions. This malleable system is less restricting and will stop the overlap and confusion that ICD-9 would cause. As a result, there will be endless opportunities to improve the system.

Structurally, the codes will be set up similarly to the codes of ICD-9, but will be more efficient than before. ICD-10 codes will range from 3-7 digits, allowing for two digits more than ICD-9. The very first digit will be alpha, including all letters except U. The next two digits will be numeric, and the 4th, 5th, 6th and 7th digits can be either alpha or numeric. The decimal appears after the first three digits, as it does with ICD-9. After the decimal point, the next three digits represent etiology, anatomic site and severity. The last digit will be an extension, with any extra information.

While making the switch seems daunting to many healthcare professionals, the new system is designed to be easier and more practical to use. The improvements that are being made will prove to be extremely useful. It is understandable that many people are extremely apprehensive, but the effect that ICD-10 will have on medical documentation will be nothing but positive.

If you have any questions about converting to ICD-10, please contact Nancy Dolgin with New England Medical Billing.

ICD-10 and its Effect2016-07-11T16:27:14+00:00