South East Needs Your Cooperation with Eligibility and Funding Requirements

Hello Everyone,  This is Jerry Peters from the South East Consortium and this blog hopefully will be a new and effective way to communicate with our families.  I hope to share with you some of the exciting things we're doing and solicit your suggestions on were we need to go.  I want to start with our biggest concern and try to clear up confusion surrounding OPWDD non-waiver eligibility, Medicaid Waiver and our relationships with Medicaid Service Cordinators.

As you know New York State converted our funding about 5 years ago to included Medicaid.  They also tightened regulations on reimbursement for non-waiver people.  With that came a hurricane of paperwork and compliance issues, most of which we are still learning about.  This entire process of how to successfully help with making people eligible for services so we can request reimbursement for services has been essentially self-taught and "hit and miss."  The eligibility process and subsequent Front Door process is extremely slow and can be confusing, but I feel we now have a handle on it.  A good example is our summer camp program this past summer.  We enrolled 10 kids who did not have eligibility under the assumption a determination could be made within 3-4 months.  This was also done because we didn't want 10 kids sitting at home during the summer with nothing to do.  Not only did we not get this kids through the process by the end of camp, for many reasons, most of them are still "not determined".  Consequently South East was not able to "bill" New York State for providing the services.

In regards to Medicaid Waiver.  The Office of the Medicaid General (OMIG) requires certainly documentation/authorization be complete and in our files in order to properly "bill" Medicaid for services provided.  If its not there it is considered fraud.  Most of this we did not know until very recently so we have been scrambling to get the paperwork up-to-date.  This is critical because if Medicaid performs an audit on South East (and they will) we stand to receive incredibly harsh penalties which would threaten our very existence.  When Medicaid performs an audit if it finds one error with one person there is an assumption that the entire sampling is wrong.  There's a cute word called "extrapolation" and you throw that into the mix it's a real problem.

So that's why we need the help from families to work with Medicaid Service Coordinators to get this paperwork to us.  Most MSC's are very cooperative and great to work with.  Some not!  Sometimes in the past we have requested information and had no response.  Sometimes we are just ignored.  That can't be tolerated and that's why I made the decision that parents need to help us get what we need or we will temporarily "block" registration.  I cannot place this agency at risk because we do not have copies of paperwork that should be readily available.

That said, we look to the future and the possibility of being of service to you.