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Reimbursement for Integrated Behavioral Health in Primary Care: Making it work. Mary Jean Mork,LCSW Quality Counts March 14, 2012. Our Goal: Outcome driven, sustainable integrated practice model for patients and providers. Objectives. Participants will be able to: - PowerPoint PPT Presentation
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Reimbursement for Integrated Behavioral Health in Primary Care:
Making it work
Mary Jean Mork,LCSWQuality CountsMarch 14, 2012
Our Goal: Outcome driven, sustainable integrated practice
model for patients and providers
Objectives
Participants will be able to:I. Describe the factors that affect billing and
reimbursement in an integrated settingII. Identify tools to support reimbursement for
mental health integrationIII. Identify strategies to support financial
sustainability of integrated practice
My Goals for Today
Share information Acknowledge that this is complicated Welcome and learn from your additional
information and questions Be aware of gaps in knowledge Stand corrected, as needed Help us all think about better ways of doing
things
Disclaimer – always seek info from your own agency consultants re: regulations, billing and coding
Poll Question 1 – How long have you been involved with integrated services?
Less than 6 months 6 months to 2 years 2 – 5 years More than 5 years
Best Practice Principles for Integrated Services
Patient and family centered Professional connections: medical and mental
health Integrated mental health clinician – full member of
primary care team Warm hand-offs & timely scheduling Brief focused treatment Access to specialty mental health care
Screening for common mental health conditions
Primary Care Treatment
Integrated mental health services
Consultation services:Collaborative care
Primary & Specialty Medical Health Care Specialty Mental Health Care
Specialty MH care by referral
Mental Health Specialist in Primary Care:
How about those differences?
The Question: How do we pay for it?
Often starts the conversation Comes up frequently as the program
gets started Becomes crucially important when
grant funding runs out Continues to come up as you realize
you’re not getting paid
Meet Denise
Denise
Experiencing great deal of anxiety after separating from husband and starting new job
Has asthma, not managing it well 2 children at home, now a single
parent, no time for herself
Options
Referral: improve asthma management
Health and Behavior Assessment
Medical referral and diagnosis
Brief, focused assessment and intervention
Referral: reduce anxiety
Mental Health Assessment Medical referral
needed? Mental Health diagnosis “Comprehensive”
assessment and treatment
The Codes
Health & Behavior codes 96150: Assessment 96151: Reassessment 96152:
Individual intervention 96153:
Group intervention 96154:
Family intervention
Mental Health Codes 90801:
Initial Assessment 90804, 90806, 90808:
Individual Therapy 90807, 90809:
Ind. Therapy + E/M 90846,90847:
Family Therapy 90853:
Group Therapy 90862:
Med Management
Insurance Ramifications
Health & Behavior codes: Covered by some
insurers, not all Discipline reimbursable
for some, not all Medical benefit: No pre-
auth, no carve-out, no different co-pay
Medical practice bills
Mental Health codes: Covered by most
insurers Generally reimbursable Contract & credentialing
with behavioral health carve-out needed
May eventually need pre-auth
May require larger co-pay
Poll Question 2 – Which codes would you use for Denise?
Health and Behavior Mental Health Both Don’t know It depends
Complicated Financial Arrangements
No one seems to know the best way to get paid
Mental Health regulations and licensing expectations don’t fit the primary care setting
Documentation regulatory issues Actual reimbursement less than
anticipated
Questions to Ask
What are the licensing and reimbursement rules for your setting? FQHC,RHC, provider based, mental health agency
How do these rules affect the following factors? “Employment” of the staff and supervision Patient registration Billing for Behavioral Health Actual reimbursement Documentation
Poll Question 3 – What type of setting do you work in or with?
FQHC RHC Hospital owned practice – Provider
based Private practice – medical
Various Payers and Various Rules
Medicare Medicaid Commercial Insurers Mental Health vs.
Medical codes Licensing rules
Medicaid
States have flexibility in defining covered mental health services
Can choose to contract with managed care Billing requires both a diagnosis and a
procedure code Some states limit procedures, providers and/or
practices that can use these codes
States differ on allowing two services (mental health and medical) on same day
Medicaid - MaineCare
Section 65 – Behavioral Health Services i.e. “Mental Health Agency” and Individual Mental Health Clinician
Section 90 – Private (Medical) Practice i.e. “Doctors’ Office”
Section 45 – Hospital Owned Practice i.e. “Doctors’ Office or Outpatient Clinic”, provider based
Section 31 – Federally Qualified Health Center (FQHC)
Section 103 – Rural Health Clinic (RHC)
Poll Question 4:What MaineCare Section are you using to bill integrated services?
Section 65 - Mental Health Section 90 - Private medical practice Section 45 - Hospital owned practice Section 31 - FQHC Section 103 - RHC
Medicare considerations
Rates for different disciplines (75-100% of physician)
Outpatient mental health limitation 2010-2014* Increased mental health rate toward parity No mental health reduction for diagnostic
services Specific rules for different types of
practices, e.g.FQHC, RHC, Provider Based
*Published on the NHIC website at www.medicarenhiccom on the Fee Schedule page.
Commercial Insurances
Develop contracts with behavioral health Carve-outs confusing for medical practice
Reimburse for Health & Behavior codes? Different disciplines? Medical or behavioral health service?
Be clear at point of service Document to support service
Know expectations of payers
Recommendation to bill for service to establish “need” for reimbursement
Some key questions
Payment for 2 encounters in the same day?
Reimbursement for Health and Behavior codes?
Pre-authorization required for mental health visits?
Full assessment required before treatment can begin?
Back to Denise – What do you do?
Depends on her needs Depends on her diagnosis Depends on service delivered Reimbursement will depend on
insurance and discipline of clinician Can go from H&B to mental health,
but not both together
It’s easy to get confused!
Useful Tools
Develop and continue to modify a Start-Up Guide
I. Pre-Hire – clarification of financial and billing arrangements
II. Hiring process - Credentialing and preparation for billing
III. Orientation of Mental Health Clinician (MHC) and preparation for billing
IV. Ongoing support - Monitoring reimbursement and continuous improvement
Tracking the Work
To provide rapid feedback on financial aspects of integration Waiting for reimbursement data takes
too long We are increasingly able to estimate
reimbursement from billing Teams working on integration can use
data to assess whether the mix of services being provided is sustainable
Track the work Record services
Billable Non-billable
Record Insurances Optional - Assign relative
“factors” Services - time units Insurances – general
reimbursement comparisons
Multiply Service x Insurance Total for time period
Mental Health Codes Health and Behavior Codes
Non-Billable Activities
90801 = 4Initial Assess
96150 = 2-4H&B Assess
DI - Dual Interview with Physician = 0
90804 = 1Ind Therapy
96151 = 1-4H&B Reassess
PO – Parents only before 90801 = 0
90806 = 2Ind Therapy
9615296153 = 1-4H&B Intervention
C - Consult to Provider = 0
90847 = 4
Family Tx /w pt
96154 =1-4
H&B Intervention with Family & Pt
M – Meeting = 0
Medicaid = 1 Medicare = 2 Self Pay = 1
Tracking Sheet –Reimbursement Codes and Values
Date of Service Service Code Billed
Reimbursement Factor
Insurance Factor
Total
3/9/11 90801 4 2 8
3/9/11 C (Consult to PCP)
0 2 0
3/9/11 90847 4 1 4
3/9/11 DI (Dual Interview)
0 3 0
3/9/11 90806 2 1 2
3/9/11 90801 4 3 12
Total 26
SAMPLE
Reimbursement Tracking SheetMental Health Integration
Provider ________Annette_________________Place of Service ______Your Practice_____________
Financial Tracking
0
5
10
15
20
25
30
35
40
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
Week
To
tal '
Po
ints
'
The Team makes it work
Recommendations
Acknowledge link between providers and coders Focus on the front end Know rules for setting, payers, discipline Train all staff – start-up and ongoing Work with MHC re: coding and documentation Billing requires time, resources and connections
to “experts” Internal auditors as helpful monitors Track the money from day one Acknowledge and support everyone’s role in
making it work Provide a “friendly forum” to focus on this work
Administrative meeting: the “friendly forum”
Clinicians, provider rep, billers/coders, practice managers, leadership
Data on show rates, referrals, volume. What’s working, not working? Targets?
Payment information: codes getting reimbursed/ denied
Communication issues and improvement suggestions: related to patients, providers and practice
Clinical practice issues: e.g. length of sessions, frequency and duration of treatment
What really makes it work
Willingness and drive to learn new things Ability to tolerate bumps Proficiency in addressing problems Ability of team to work together to move
this forward Leadership willing to take risk, create
vision, support process improvement, and believe in the purpose of the integrated service
We’re optimistic about the Future of Integrated Behavioral Health and
Primary Care
Resources
MaineCare Links http://www.maine.gov/sos/cec/rules/10/ch101.htm http://portalxw.bisoex.state.me.us/oms/proc/pub_proc.asp
Medicare Links http://www.cms.gov/Manuals/IOM/list.asp http://www.cms.gov/Transmittals/01_overview.asp Medicare Documentation Guidelines for Evaluation and Managements
Services 95 & 97 http://www.cms.gov/MLNEdWebGuide/25_EMDOC.asp NHIC http://www.medicarenhic.com/
Other www.mehaf.org – Maine Health Access Foundation www.thenationalcouncil.org – the National Council for Community
Behavioral Healthcare www.ibhp.org – Integrated Behavioral Health Project www.mainehealth.org/mentalhealthintegration
Contact information:Mary Jean Morkmorkm@mmc.org207-662-2490
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