4320/4320-R Instruction – Curriculum – Medicaid Compliance

Medicaid Compliance


The West Genesee Central School District recognizes that Medicaid Billing Compliance Guidelines are an integral part of the district’s ongoing efforts to achieve compliance with federal and state laws relating to Medicaid billing for School Supportive Health Services (“SSHS”) and other school programs. The Medicaid Compliance Policy creates a comprehensive system of oversight for Medicaid billing, reporting and practices. The goal of the Medicaid Compliance Policy is to ensure that Medicaid eligible services are properly documented and accurately billed and that services rendered, but not properly documented are not billed. The district is committed to maintaining the accuracy of every claim processed and submitted.


This policy establishes systematic checks and balances to detect and prevent inaccurate billings and inappropriate practices in the Medicaid Program. It is the responsibility of each individual involved in the provision of services and the billing process to comply with the provisions of the law.

1. Medicaid Compliance Officer –

The District will designate a Medicaid Compliance Officer annually at its Re- Organization Meeting. The Medicaid Compliance Officer is responsible for:

  1. Day-to-day operations of the Medicaid Compliance Policy;
  2. Providing guidance to district employees to ensure Medicaid billing compliance;
  3. Development and delivery of district in-service training on compliance issues, expectations, and maintenance of documentation for the same;
  4. The coordination of system-wide and/or department-specific audits of records on an ongoing basis;
  5. Communications to district employees and to service providers on any changes to the laws and regulations regarding Medicaid billing and this Policy;
  6. The investigation of allegations of improper billing practices and the reporting of the same.

The Compliance Officer reports directly to the Superintendent of Schools and shall periodically report to the Board of Education on the District’s Compliance Policy.

The West Genesee Central School District will maintain an updated database of Medicaid service providers, complete with updated licenses to be secured in the West Genesee District Office Building. The Code of Conduct will be updated on a yearly basis and follow criteria established by the Office of the Medicaid Inspector General. This policy will be listed on the district’s website.

2. Compliance –

In addition to the State Compliance Officer, the Director of Special Education will be the designated employee for the day-to-day compliance program in the West Genesee Central School District.

Billing for Medicaid eligible school services will be done in compliance with all applicable state and federal laws and regulations. No bill for reimbursement will be submitted unless it was actually performed and documented by the service provider. Any false, inaccurate, or questionable claims will be reported immediately to the district’s Medicaid Compliance Officer.

Federal and State rules prohibit knowingly and willfully making or causing to be made, any false statement or representation of a material fact in an application for benefits or payment. The failure to disclose or the concealment of the occurrence of an event affecting the right to payment with the intent to secure payment that is not due is unlawful. In addition to criminal penalties, the federal False Claims Act permits substantial civil monetary penalties against any person who submits false claims. Penalties of triple damages as well as fines of up to $10,000 for each false claim submitted can be imposed. The persons involved in submitting false claims, as well as the district, may be excluded from participating in the Medicaid programs.

Federal laws prohibit false statements or inadequate disclosure to the government and mandate exclusion from Medicaid programs. It is illegal to make any false statement to the federal government, including statements on Medicaid claim forms. It is illegal to use the U.S. Mail to scheme or to defraud the government. Any agreement between two or more people to submit false claims may be prosecuted as a conspiracy to defraud the government.

The Board of Education and West Genesee Central School District promotes full compliance with a strict policy of ethics, integrity, and accuracy in all its financial dealings. Each employee and professional, including outside consultants, who is involved in submitting charges, preparing claims, billing, and documenting services is expected to maintain the highest standards of personal, professional, and institutional responsibility. Individuals who fail to report suspected problems, participate in non-compliant behavior and/or encourage, direct or facilitate non-compliant behavior may be subject to disciplinary action in accordance with the provisions of New York Law and any applicable collective bargaining agreement.

3. Education and Training –

The West Genesee Central School District will send the appropriate members for yearly training as mandated by the Office of the Medicaid Inspector General. These members may include but are not limited to: the Board of Education, Assistant Superintendent for Management Services, Director of Special Education, and Assistant Director of Special Education, School District Treasurer and all Medicare service providers.

The Compliance Officer will ensure that every employee involved with the Medicaid service and billing process is educated about the applicable laws and regulations governing provider billing and documentation. The District’s Compliance Program will be shared with all district employees, be available for inspection and will be published on the district’s website.

The Compliance Officer will also develop, oversee and/or provide in-service training on Medicaid billing and documentation requirements for all staff involved in providing and/or billing for Medicaid services, periodically and at other times, including initial employment or assignment. The training is mandatory and the District will maintain records of all trainings.

4. Reporting and Investigation –

The West Genesee Central School District will provide on its website the name and phone number of the State Compliance Officer in order to maintain an anonymous and confidential means of good faith reporting.

A. Reporting:

Every employee in the District has the responsibility not only to comply with the laws and regulations, but to ensure that others do as well.

Employees must report non-compliance to their immediate supervisors, or the District’s Compliance Officer. Supervisors are required to report these issues through established channels in Human Resources and/or directly to the District’s Medicaid Compliance Officer at (315) 487-4698. Calls
may be made anonymously, although the District encourages employees to provide their name and telephone number so that reports may be more effectively investigated. Every attempt will be made to preserve the confidentiality of reports of non-compliance. All employees must understand, however, that circumstances may arise in which it is necessary or appropriate to disclose information. In such cases, disclosures will be on a “need-to-know” basis only.

B. Investigation:

The Compliance Officer will, personally or through his/her designee, investigate every report of non-compliance as soon as practicable. Investigations may include interviewing employees and/or reviewing documentation. Each employee must cooperate with such investigations.

Once the Compliance Officer completes an investigation, he/she will make a report to the Superintendent of Schools. The report will be the basis for the Compliance Officer’s Program or recommendation of corrective action and/or discipline. Reports will be retained for a period of six years.

5. Non-Retaliation –

The West Genesee Central School District will seek disciplinary measures for failure to report non-compliant behaviors. Such measures will be consistent with the Office of Medicaid Inspector General’s Whistle Blower’s Law, and Board of Education Policy 6600 – Fiscal Accountability & Reporting.

It is the policy of the district that no person shall retaliate, in any form, against a person who reports in good faith, an act or suspected act of non-compliance (although employees may be disciplined for making intentionally false reports of non-compliance). Any person who is found to have retaliated against the maker of such a report shall be subject to discipline. The Federal False Claims Act and New York State Law provide certain protections to individuals who are discharged, demoted, suspended, threatened, harassed or discriminated against by their employer in retaliation for assisting in the investigation, initiation or prosecution of a False Claims Act violation which constitutes health care fraud under the New York State Penal Law.

6. Corrective Action/Sanctions –

The Compliance Officer for the district will routinely look at the Medicaid website for updates regarding compliance issues. The Compliance Officer will also look at available work plans listed on the Medicaid website to ensure the compliance plan for the District is up-to-date.

The Compliance Officer has the authority to impose corrective action, including correcting any such problems promptly and thoroughly and implementing procedures, policies and systems as necessary to reduce the potential for recurrence. If a service provider or employee is found to be non-compliant in a single instance or relatively insignificant percentage of cases over a short period, the Compliance Officer may require that person to undergo a session of education or training.

If a provider or other employee fails to comply with billing or documentation requirements repeatedly, sanctions may be more severe.

Plans of correction and discipline may include, but are not limited to:

  1. A requirement to undergo training;
  2. A period of required supervision or approval of documentation before bills can be issued;
  3. Expanded auditing, internal or external, for some period of time until compliance improves;
  4. Self-reporting of violations; and
  5. In sufficiently egregious cases, discipline.

In addition, the Compliance Officer may recommend some other appropriate course of action to correct non-compliance including reporting compliance issues to the Department of Social Services or the Office of Medicaid Inspector General; and refunding overpayments.

7. Auditing/Review –

The District’s Compliance Officer will keep accurate records of billing reports and the amount of such records will be recorded in his/her office.

Monitoring of compliance with billing rules is essential. The Compliance Officer will ensure compliance through an understanding of current regulations and overall levels of compliance throughout the district at any given time.

Under this Plan, there will be both internal and external (i.e; by an independent consultant or other professional) auditing of Medicaid billing documentation. Internal auditing is done by the professional staff of the Compliance Officer, who will conduct periodic reviews.

The Compliance Officer may engage an external auditing firm as deemed necessary to assess the district’s overall compliance. All employees will cooperate fully with this effort by making themselves and/or any pertinent documents available.

The external auditor will report to the Compliance Officer concerning the results of its investigation. The Compliance Officer will report, in turn, to the Superintendent of Schools and the Board of Education.

8. Ongoing Assessments

The district will maintain a non-intimidation and non-retaliation for good faith participation and stay within the framework of the Whistle Blower Law.

The Compliance Officer will make an annual assessment of the success of this Compliance Program. That assessment will be based on the examination of results of internal audits and investigations, reports of any outside audits that may have been conducted, and or his/her own personal experience with the functioning of the Program over the previous year. A summary of this assessment shall be provided to the Superintendent of Schools and the Board of Education.


The Superintendent or his/her designee has the responsibility for enforcing this policy by communicating it to all relevant parties, and by providing necessary instruction and guidelines to appropriate administrators.


All necessary or required reports pertaining to the implementation of this policy will be distributed, completed and forwarded to the appropriate administrative personnel involved.


This policy is to be reviewed annually, or as significant legal decisions become available.


18NYCRR, Part 521
Medicaid False Claims Act
Board of Education Policy 6600 – Fiscal Accountability & Reporting

Presentation: 1/3/18
First Vote: 1/17/18
Second Vote: 2/28/18

Medicaid Compliance – Regulation

Medicaid Billing Procedures
West Genesee Central School District

Step 1: Determine if student is Medicaid eligible based on status in MedWeb.

Step 2: Check to see if provider services are grant or STAC funded. If they are, do not bill Medicaid for students they service.

Step 3: Script is obtained by certified service provider, if applicable.

Step 4: Permission to bill Medicaid is obtained from parent when evaluations are completed or services initially begin.

Step 5: Notify appropriate service provider that the child is eligible.

Step 6: Notify appropriate service provider that they need to log into IEP Direct and submit therapy notes, as well as, quarterly reports. Service providers are reminded to check their calendars and only bill on days when services were rendered. Verify your calendars to be sure there are not days included when a student was absent or days when school was not in session.

Step 7: Service providers log into IEP Direct and electronically document and sign their notes daily.

Step 8: When all service provider contacts for that month are imported into IEP Direct, they are billed using the MedWeb service.

Step 9: The Business Office Accountant receives a copy of the report that shows total amount billed and amount paid from MedWeb reports.

Step 10: The Business Office Clerk gives a report to the Director of Special Education that shows amount of Medicaid Reimbursement received.

Step 11: All records are retained indefinitely.