Policy 5571 – Medicaid Compliance Program

I. Policy

It is the policy of the Board of Education of the Greater Johnstown School District (“the Board of Education”) to comply with all applicable federal and state laws and regulations established to maintain the integrity of New York’s Medicaid program by preventing  fraud, waste and/or abuse in its School and Preschool Supportive Health Services Program (“SSHSP”).  In furtherance of its Policy, the Board shall appoint a Compliance Officer who will be responsible for the implementation of the Board’s Medicaid Compliance Program established in accordance with Social Services Law §363-d and 18 NYCRR  Part 521.

In furtherance of its Policy, the Board shall establish and maintain an internal system of reporting potential fraud, waste or abuse that encourages its employees, agents and contractors to come forward with their concerns to allow the Board of Education to address proactively and, if necessary, through corrective action, any noncompliance. In order to do so the Board directs its Superintendent and designees to establish a confidential line of communication that ensures any Complainant anonymity and protection against retaliation or intimidation for such reporting.

II. Appointment of Compliance Officer

In accordance with its Policy, the Board of Education appoints the District’s Business Manager to the position of Medicaid Compliance Officer who shall be responsible to the Superintendent and the Board of Education for the full implementation of the Medicaid Compliance Program (“the Compliance Program”) as outlined below.

  • In accordance with law and regulation the Compliance Officer shall provide oversight for the day to day operations of the Compliance program which shall include:
    • The dissemination of information to all employees, management, contractors and agents regarding their obligations to comply with the laws and regulations and the penalties for noncompliance;
    • Maintenance of an environment that encourages employees, agents and contractors to report to the Board of Education through the Compliance Officer any concerns regarding noncompliance to allow the Board, in the first instance, to take the necessary corrective action to address any issues of noncompliance;
    • A reporting system that provides for the confidentiality of the reporter and protects against retaliation or intimidation regarding such reporting.
  • In accordance with law and regulation the Compliance Officer shall oversee:
    • Payment reviews and internal audits by staff assigned to that function by the Board of Education which shall follow an approved protocols and sampling methodology;
    • Arranging for an independent audit of its SSHSP at least annually which shall include a statistically valid sample of claims to test the effectiveness of internal controls, and a report of findings and recommendations for the Board’s review regarding its compliance with relevant state and federal laws and regulations governing the provision and billing for  services under the SSHSP.
  • Overseeing the annual training and education necessary to ensure that all members of the Board of Education including all staff, contractors and agents involved directly or indirectly in the provision or billing of services provided under the SSHSP are knowledgeable about:
    • The laws which govern Medicaid Compliance;
    • The standards of conduct for participation in the SSHSP;
    • The responsibilities of the individuals involved in the delivery of services directly or indirectly for Medicaid Compliance law;
    • The reporting obligations under the law and the penalties for non-reporting;
    • The means of reporting suspected abuse or fraud and the Board’s guarantee of confidentiality and protection against retaliation; and
    • The penalties for noncompliance.
    • Overseeing the thorough internal investigation of any credible disclosure and ensuring timely follow up and resolution:
  • The Compliance Officer shall be directly responsible for:
    • Providing to the Board of Education copies of certified copies of any Payment Reviews and Audits;
    • Payment reviews shall include reviews of the following services: physical therapy, occupational therapy, speech pathology, audiological evaluations, nursing services, psychological services, transportation, targeted case management services, initial and annual IEPs, all evaluations and ongoing service coordination.
    • Reporting directly to the Superintendent of Schools and his/her designee on a quarterly basis, and more frequently upon the request of the Board of Education, on the status of reporting noncompliance, investigation of findings in response to complaints, and oversight of the Medicaid Compliance Program;
    • Issuing a report quarterly to the Board of Education which includes a listing of the number, nature, investigation and findings on all Complaints received, reporting of any compliance issues not reported but discovered through other means, including steps to encourage the reporting of potential noncompliance, and recommendations for improving the system;
    • Reporting to the Board of Education, at its next meeting, any findings of probable cause that abuse or fraud has occurred with recommendations on the steps necessary to address them; and
    • Reporting to the Office of the Medicaid Inspector General findings of noncompliance and arranging for required repayments, where necessary.