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