The Do’s and Don’ts of the RMTS Participant List

In special education, there are countless tasks that, while crucial to the day-to-day operations in a school, go largely unnoticed by other departments and the general public. The Random Moment Time Study (RMTS) participant list falls into that category and has come under fire in Texas recently.
 

What is the Random Moment Time Study Participant List? Why does it matter?

 
The RMTS participant list is a position-driven list which includes individuals (or roles) who provide SHARS and/or MAC services to special education students in the district. The participant list is delicately balanced and must be comprehensive enough to include anyone who performs services “routinely,” which is to say weekly, according to the direction of TEA, without adding positions that do not participate in SHARS and/or MAC.
 
Districts run into trouble when they focus more on the individual or the name of someone on the list rather than focusing on the role or position. This issue becomes more prevalent when you consider the turnover that districts experience, especially in student support roles.
 
All of these decisions about participant lists impact the district’s Cost Report, so what might sound like something akin to a slip of paper on your fridge reminding you to pick up oranges on the way home from work grows into a higher stake, higher pressure situation.
 
In Texas, the TEA is auditing participant lists and tightening up those lists due to Medicaid fraud. So, while in the past districts might include anyone who might do SHARS or they might “pad” their participant lists with vacant positions, non-SHARS Personal Care teachers, Delegated Nursing Aides or other special education classroom Aides, that’s no longer an option.
 
Including participants who are not engaged in routine SHARS activity has negative consequences on the statewide Direct Time Study Ratio. The Direct Time Study Ratio is used in the annual Cost Report as a percentage applied against the total amount of state and local expenditures reported in the Direct Medical Costs or Section 3 of the Cost Report.
 

How does putting non-SHARS participants on my participant list impact my Cost Report?

It’s quite simple. When a provider is selected to complete a time study survey, they are asked to answer three questions:

1. Who was with you?
2. What were you doing?
3. Why were you performing this activity?

When responding to these three questions there are several options for non-SHARS reporting. If any of the non-SHARS options are selected the responses are flagged as non-SHARS activity, thus over-and-over, district-by-district reducing the Direct Time Study percentage.
 
Over the past decade, Texas has seen a continual decline in the Direct Time Study percentage. This is not because providers are giving less SHARS services, rather it is due to districts including non-SHARS participants on the RMTS participant list each quarter who are being selected to complete time study surveys.
 

Which positions should I consider putting on my RMTS PL?

 
For information on what qualifies as SHARS Personal Care, refer here to the Texas Medicaid Provider Procudure Manual (TMPPM) guide.
 

Federal findings in the recent SHARS Texas audit.

In 2011, the Office of the Inspector General (OIG) audited the Texas Medicaid program. The result was that Texas received $18.9 million in SHARS reimbursements that were not reasonably, adequately supported, and otherwise allowable in accordance with applicable Federal and State requirements.
 
State Medicaid agencies are increasingly using random moment sampling to allocate school-based health costs to Medicaid, eliminating the need for health care providers to submit claims for services provided in school-based settings. Previous Office of Inspector General reviews of school district administrative costs and health services programs determined that the use of RMTS may allow costs that are not reasonable, adequately supported, and otherwise allowable. The OIG therefore conducted a series of reviews of the use of RMTS for the claiming of direct medical service costs related to Medicaid school-based health services (SBHS), including a review of the Texas Health and Human Services Commission (State agency).  
According to the Implementation Guide, the purpose of the RMTS is to identify the portion of the direct medical service time allowable and reimbursable under Medicaid. After each participating school district reports its actual Federal fiscal year (FFY) costs associated with SHARS to the State agency, the Contractor applies the results of the RMTS to determine the Medicaid-allowable direct medical service costs for each district. The State agency then reconciles the total interim payments for the FFY for the participating school districts to the Medicaid-allowable direct medical service costs determined through the RMTS. After the reconciliation process, the State agency conducts an annual cost settlement.
 

What other impacts does the RMTS participant list have on my district’s SHARS program?

When complying with the HHSC (Health and Human Services Commission) requirements for SHARS, districts must satisfy the following:

1. The district must certify the RMTS participant list before each quarter deadline date.
2. The federal requirement to meet an 85% sample completion rate for the RMTS to be valid.
3. Districts must adhere to the annual state training requirements for Primary and Secondary Program Contacts.

Failure to adhere to these requirements has dire consequences. The school district will be eliminated from the SHARS program for the entire federal fiscal year (FFY) and must forfeit their FFY Cost Report settlement and pay back any interim payments received during the FFY.
 

Can including non-SHARS participants on my RMTS participant list cause me to get audited?

The answer is Yes! Including non-SHARS participants (not including the MAC only category if participant in MAC) can have a negative impact on your district’s compliance and subject the district to multiple audits, investigations and recoupments.
 
First, TEA is conducting audits of district RMTS participant lists. If TEA identifies providers have been placed on the quarterly RMTS participant list and they are not actively submitting SHARS documentation for reimbursement, TEA will request the district complete a Corrective Action Plan. The findings of the audit are turned over to HHSC to conduct additional audits, which can result in financial recoupments.
 
Secondly, through the Cost Report desk review process, HHSC auditors can ask for proof that each participant listed on the RMTS participant list and whose state and local expenses were reported in the Cost Report show proof they participated in SHARS services and documentation throughout the federal fiscal year. If proof cannot be provided, HHSC will recoup those funds from the district’s Cost Report settlement.
 
It is important to understand how the RMTS participant list directly impacts the district’s Cost Report and choose to act appropriately and in compliance with federal and state requirements. Following the guidelines set forth by HHSC and TEA, districts will receive the full amount of their SHARS reimbursements without subjecting the district to federal investigations and state audits.
 

What districts should know about participant lists

Here are a few tips you can use to make sure you stay compliant with participant lists.

1. Position-Driven: Remember, when you add names to your participant list, you’re really adding a position. So if your speech pathologist leaves mid-year and you hire a new speech pathologist in the middle of a quarter, you can simply update the list for the next quarter as long as their credentials or licensure remains the same. We hear often that districts worry about what-if’s (what if our occupational therapist leaves??), but just remember the list is position-driven.
   *Reminder: Participant lists are certified one quarter ahead of the current quarter, so just keep that in mind for any updates you make.
2. Vendor communications: Don’t forget to tell your vendors (like your Medicaid billing partner) about any changes to the participant list so that they can assist you with your cost report and any implications those changes will have on your cost report.
3. Don’t add extra vacancies to your participant list! Vacancies should only be added to the RMTS participant list if the district has the position posted and intends to fill the position in the active quarter. If the position is not filled in the active quarter, HHSC recommends removing the vacant position from the RMTS participant list.

How the right Medicaid vendor partner can help

There are three key ways your vendor can help you with participant lists:

1. Reports that give you at-a-glance information so that you can easily identify if a provider is documenting in a timely manner and if they should be on your participant list.
2. In-depth advice for your participant list so you always know whether the provider who is documenting services should be on the list.
3. Quick insight to action: In real time, your vendor of choice should empower and guide you and always prioritize your compliance.

 
Frontline Medicaid & Service Management offers you the kind of support you need to stay in compliance.