Sustaining Integration: It’s about more than money

Sustaining Integration: It’s about more than money

Sustaining Integrated Practice

Getting Paid

Always improvingMovers & Shakers

Leadership Support

LeadershipSupport

Who are we and where are we from?

Members

Affiliates

Maine Mental Health PartnersMiles Memorial HospitalSt. Andrews Hospital

Home Health Visiting NursesMaine PHO

Mid-Coast Hospital

MaineGeneral Medical Center

Maine Medical Center

Penobscot Bay Medical Center

Stephens Memorial Hospital

St. Mary’s Regional Medical Center

Waldo County General Hospital

Southern Maine Medical Center

MaineHealth

Objectives:

Participants will be able to: Describe factors that affect the present system of

billing & reimbursement in an integrated setting Identify reimbursement & programmatic elements

that contribute to sustainable integrated programs

Identify strategies to support sustainability of integrated practice

What are you hoping to get out of this session?

Getting started: more than plunking a clinician in the practice and

expecting it to work

Where to start?

“Who was first?”

Start-Up Guide

Where are you in the process?

I. Pre-Hire – clarify financial and billing arrangements

Overview of MHI Clarify facility rules Understand services being delivered

including potential new billing practices Discuss service with commercial insurers Develop contracts Train staff on behavioral health billing Identify resource needs and ongoing

review process

II. Hiring process - Credential and prepare for billing

Credentialing – Behavioral vs. Medical? Help BHC understand link between service

and billing codes Clarify supervision requirements Fill out credentialing paperwork

III. Orient Behavioral Health Clinician (BHC) and prepare for billing

Identify staff needed for behavioral health billing

Connect billers/coders with BHC

Track charges, denials Clarify expectations

Medical vs. behavioral Documentation Prior authorization

IV. Ongoing support - Monitor reimbursement and continuously improve

Review practice level data: Services delivered Charges billed Payments received Charges denied and reasons Other problems

Regular meetings – between BHC and billers to problem solve

Track bills to ensure proper coding, documentation and reimbursement

Getting Paid

Questions to ask:

Licenses? Setting (who is billing, where are pts

registered?) Payers and credentialing

Commercial Medicare Medicaid

Types of Practice arrangements

Mental Health Agency and Individual Behavioral Health Clinician

Independent (Medical) Practice i.e., “Doctors’ Office”

Provider Based - Hospital Owned Practice Federally Qualified Health Center (FQHC) Rural Health Clinic (RHC)

What is your setting and practice type?

Mental Health Agency Bills

Pros No additional:

credentialing behavioral health

contracting Affordable Allows independent

practitioners to be co-located

May link to community mental health

Cons Intended for persons with

severe/persistent mental illness

Intended for longer term treatment

Limited H&B code billing Extensive paperwork May require that practice

get licensed Separate registration

process Separate record Less reimbursement?

Mental Health Agency challenges – continued

Any time you introduce “separate” functions, you are getting away from integrated and coordinated treatment, or at least making it more difficult.

Any time you require a comprehensive treatment plan, you are getting away from brief focused treatment, the treatment of choice in a primary care setting.

Provider Based or Independent Practice Bills

Pros Intended for patients in

medical settings Same medical record Supports link between

medical and mental health Higher reimbursement? Cost of BHC covered by

medical provider Able to bill H&B codes Medical practice

“ownership” for integrated practice

Cons Requires medical practices to:

Credential Contract Bill commercial insurance

Cost is generally with medical provider

May restrict to LCSW’s or psychologists due to Medicare rules

Requires “order” from provider; documentation of ongoing involvement in treatment

FQHC or RHC Bills

Pros Encounter billing for all

services Cost generally covered by

RHC/FQHC Intended for patients in

medical settings Shared record Link between medical and

mental health Able to bill H&B codes Medical practice “ownership”

for integrated practice Reduced documentation

Cons Must be designated

RHC/FQHC Previously some confusion

around coding Requires medical practices to

take on behavioral health billing Credentialing Contracting Commercial insurer

confusion Cost is generally with medical

provider

Conclusion:

Medical practices should do the billing No need for patients to “register” in a new

organization Allowance for additional revenue through

Health & Behavior codes – only allowed in medical billing

Reduced and more reasonable documentation requirements; better matches practice needs

Both parties need to share investment in the successful outcome

Various payers and various rules

Medicare Medicaid Commercial

Insurers Mental Health vs.

Medical codes Licensing rules

Medicare reimbursement rates

NHIC website: www.medicarenhiccom on Fee Schedule page.

Type of Provider

% physician fee

Notes

MD/DO, Psychologist

100% Or actual charge, whichever is less

PA, NP, CNS 85%

CSW (LCSW) 75%

Reduced by any applicable deductible, outpatient mental health limitation

Outpatient mental health treatment limitations

Applies to claims for professional services furnished by physicians, clinical psychologists, clinical social workers, and other allied health professionals.

Start Date: Jan 1

End Date:Dec 31

Limitation Percentage

Medicare pays

Patient pays

2010 2011 68.75% 55% 45%

2012 2012 75% 60% 40%

2013 2013 81.25% 65% 35%

2014 onward 100% 80% 20%

Medicare mental health limitation exceptions

Diagnostic Services – Limitation does not apply to diagnostic tests

and evaluations Include psychiatric or psychological tests and

interpretations, diagnostic consultations, and initial evaluations (90801)

Diagnosis of Alzheimer’s Disease or Related Disorder

Brief Office Visits for Monitoring or Changing Drug Prescriptions

New Mental Health Code Changes for 2013

The old and the very new

Initial Psychiatric Evaluation

2012 codes90801: psychiatric

diagnostic evaluation

2013 codes90791: psychiatric

diagnostic evaluation (no medical services)

90792: psychiatric diagnostic evaluation with medical services (E/M new patient codes may be used in lieu of 90792)

Outpatient Psychotherapy

2012 Codes(Time is face-to-face with patient)

2013 Codes(Time is with patient and/or family)

Code Service: Outpatient Psychotherapy

Time (min)

90804 20-30

90805 w/ E/M service

20-30

90806 45-50


45-50

90808 75-80


75-80

Code Service: Outpatient Psychotherapy

Time (min)

90832 Appropriate E/M code

30

+90833 add-on code 30


45



60


What do they mean for integrated practice?

Medicaid

States have flexibility: Covered mental health services Two services (mental health and medical) on

same day Contract with managed care

Billing: Requires diagnosis and procedure code Some states limit procedures, providers and/or

practices that can use these codes

Commercial Insurance

Inconsistencies among various insurers Lack of clarity around covered services Difficulty finding “experts” to answer

specific questions about reimbursement Carve outs

Different systems Different reimbursement streams

Other problems?

Tips: Commercial Insurances

Know expectations of payers Clarify whether in-network medical and/or

behavioral health Reimburse for Health & Behavior codes? Confusion about medical vs. behavioral health

service Be clear at point of service Have documentation support service

Recommendation to bill for service, if service was appropriately delivered, to establish “need” for reimbursement

Some key questions

Payment for 2 encounters in the same day?

Reimbursement for Health & Behavior codes?

Pre-authorization required for mental health visits?

Full assessment required before treatment can begin?

Some additional considerations

“Take this and make it much more difficult than it needs to be.”

Health & Behavior (H&B) Codes 96150 – 96155

Billing for H&B

Medical diagnosis Medical bill – not mental health Billed by practice with BHC:

Hospital license Primary care office Rural Health Clinic Federally Qualified Health Center

Examples

Adult H&B examples

55 year-old: Hx of AMI, HTN, cholesterol, family history of CVD. High risk - cardiac complications.

35 year-old: diagnosis chronic asthma, HTN, panic attacks. Seen for assessment and follow-up. Original assessment - emotional, social and medical history, including ability to manage problems r/t chronic asthma, hospitalizations & treatments.

Pediatric H&B examples

10 yr-old: Dx - sickle cell anemia. Focus of assessment – biopsychosocial factors r/t pain management and sickle cell disease.

8 yr-old: juvenile rheumatoid arthritis (JRA) for reassessment & treatment. Original referral for nausea, vomiting, panic reactions prior to weekly injections of methotrexate. Assessment: Child - history of JRA, when methotrexate was started, who gives medication, reactions, management of past responses, anxiety & depression questionnaires; Mother - problem-solving skills.

Adolescent H&B examples

16-year-old: fibromyalgia, hx numerous pain episodes, poor school attendance, isolation from peers. Prior to disease: school attendance normal, difficulties with peers not reported. Previous attempts by rheumatology service & pain team: manage pain and facilitate positive school adjustment not successful.

15-year-old: acute lymphoblastic leukemia recently began maintenance phase of treatment. Monthly blood cell counts suggest chemotherapy was not being taken, physician spent considerable time with patient discussing potential consequences. Referral for suspected non-adherence.

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

H&B 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

H&B 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

Back to Denise – What do you do?

Depends on: Needs Diagnosis 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 overwhelmed!

There’s Hope

Many of us: Are successfully working with

integrated practices. Have overcome the challenges of the

complicated system. Have strong support for this work.

We can talk with each other and share what we know.

Measuring Quality

Quality Measures

Quality Measures - Clinician

Building relationships/trust = increased referrals

Training/Measuring core competencies Patient outcomes:

Are patients getting better Are patients engaged in treatment

Quality Measures - Practice

Patient show rate Billing/productivity Access - 3rd next available appt Level of integration– Site Self Assessment

(SSA) www.mehaf.org Screening – yes/no Patient satisfaction

Quality Measures -Program

FTE and type of BHC Process Improvement Provider/staff satisfaction Financial/reimbursement trends/patterns Improved access to community resources

Ongoing Support

Administrative Team Meeting:

the “friendly forum”

Clinicians, provider rep, billers/coders, practice managers, leadership

Data - show rates, referrals, volume: What’s working, not working? Targets?

Payment information: Codes reimbursed/ denied

Communication issues/improvement suggestions: R/t patients, providers, practice

Clinical practice issues: E.g. length of sessions, frequency/duration of treatment

Aim of this meeting: To continue to monitor and promote progress of integrated behavioral health services

Time Item Aim/Action

15 min Review today’s agendaAny updatesPractice concerns

Organization

15 min Review Dashboards Information sharing and planning

15 min Process Improvement:Site Self AssessmentsReview and Set Goal(s)

Information and goal setting

15 min Billing and reimbursement concerns Problem solving

15 min IT/IS issues Problem solving

10 min Larger system connections Information

5 min Plan agenda for next meeting Planning

Sample Agenda

Sample Dashboard

Measures Oct-11 Nov-11 Dec-11 Jan-12 Total Average

Hrs clinical time available

80 60 80 80 300 75

# Arrived 60 45 65 60 230 57.5

# No show

15 7 12 14 48 12

3rd next available(days)

1 2 1 0 4 1

Charges $14,362 $10,620 $18,700 $16,455 $60,137 $15,034

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

To

tal #

of S

essi

on

s

Week

Movers and Shakers(what really makes it sustainable)

Willingness to learn new things

Ability to tolerate bumps and address problems

Capacity 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

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

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/

Contacts

Mary Jean Mork, LCSW, [email protected], 207-662-2490Cynthia Cartwright, MT RN MSEd,

[email protected], 207-662-3529Melissa (Missy) Cormier, LCSW

[email protected], 207-661-7128Neil Korsen, MD MS, [email protected]

Documents

Sustaining Integration: It’s about more than money