Maximizing Reimbursement in Today’s Fee for Service World: A Conversation

1. Mary Jean Mork, LCSW CFHA October 2013 Session G5a Maximizing Reimbursement in Today’s Fee for Service World:A Conversation

2. Objectives: Participants will be able to: • Describe factors that affect the present system of billing & reimbursement in an integrated setting • Discuss strategies to support sustainability of integrated practice • Identify tools and resources for maximizing reimbursement Disclaimer: • This information does not represent how a payer might respond to a claim • This information does not replace any regulatory information • Always seek information from your own agency consultants regarding any billing and coding practices

3. I don’t know where to begin:How should we set up the practice? Identify - Level of Integration Identify - type of practice setting Identify - who will do the billing

5. Medical practices and Behavioral Health “employers” Mental Health Agency or Individual Clinician bills Independent Medical Practice employs/contracts and bills Provider Based - Hospital Owned Practice employs/contracts and bills Federally Qualified Health Center (FQHC) employs/contracts and bills Rural Health Clinic (RHC) employs/contracts and bills

6. I have these great staff but:Who can get reimbursed for services in medical practices? Masters level clinicians Psychologists NP’s/PA’s

7. Master Level Clinicians Medicare - LCSW’s only, and only the mental health codes Medicaid differs state to state and may allow: LCSW’s, LCPC’s and LMFT’s, as well as conditional. May vary by practice type. Commercials may also differ but generally more inclusive

8. Psychologists Medicare reimburses both mental health and Health and Behavior codes Generally paid by Medicaid and Commercial insurers

9. Psych NP’s/PA’s Need to follow rules for E/M codes Generally paid by all payers Would probably not bill Health and Behavior codes Often confusion around “medical” vs. “behavioral” credentialing with the commercial insurers

10. We are working with patients with medical conditions:What codes should we use? Mental Health codes Health and Behavior codes E/M codes

11. Mental Health and Health and Behavior Codes Health and Behavior codes 96150: Assessment 96151: Reassessment 96152:Individual intervention 96153: Group intervention 96154:Family intervention Mental Health Codes 90791: Initial Assessment 90832, 90834, 90837: Individual Therapy 90846, 90847:Family Therapy 90853: Group Therapy

12. E/M codes and Psych NP’s 90832, Psychotherapy with E/M, 30 mins (16-37) 90834, Psychotherapy with E/M, 45 mins (38-52) 90837, Psychotherapy with E/M, 60 mins (53 or more) 90791, Psychiatric Diagnostic (Dx) Eval. 90792, Psych Dx Eval. with medical services 90791 + 90785, Psych Dx Eval. with interactive complexity 90792 + 90785, Psych Dx Eval. with medical services and interactive complexity

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

14. It’s never that simple:Which payers will reimburse for behavioral health services? Medicare Medicaid Commercial Insurers

15. Medicare reimbursement rates NHIC website: www.medicarenhiccom on Fee Schedule page.

16. Medicare - Eligible Providers for Behavioral Health Services Physicians/Psychiatrists Clinical Psychologists Licensed Clinical Social Workers (LCSW) Non-physician practitioners such as NP, PA, CNS working within scope of practice Independent Psychologists/Non-Clinical Psychologists recognized for diagnostic services only

17. 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

18. For Commercial Insurances Different expectations by payer Need to 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

19. 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?

21. I think I understand, but now:What do we have to do to actually get paid? Credentialing and contracts Billing processes in place

22. Plan to get paid

23. This gives me a headache:How can I keep track of the rules? Set up a “grid” Find helpful resources and people Keep asking questions

27. Who to go to for help Billing and coding supervisors Internal auditors Regional or state-wide integrated policy groups “People who know what they’re talking about” – where ever you can find them

28. I know I’ll be asked:Are we able to sustain the service? Track the data The Administrative Team Meeting

29. Measuring and Improving • Initial areas of focus: access and productivity • Volume • No-shows • Time to 1st and 3rd • Charges and collections • RVU’s • Later areas of focus • Patient/Provider/staff experience • Clinical and functional outcomes • Financial impact

30. Sample Dashboard

31. 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

32. We’re optimistic about the future of integrated behavioral health and primary care:How about you? http://lifehacker.com/5905499/make-small-talk-less-awkward-and-painful-by-sharing-small-details

33. Reimbursement Resources 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 & 97http://www.cms.gov/MLNEdWebGuide/25_EMDOC.asp NHIC http://www.medicarenhic.com/ CMS National Correct Coding Initiative http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html/nationalcorrectcodinited Other www.thenationalcouncil.org – the National Council for Community Behavioral Healthcare www.ibhp.org – Integrated Behavioral Health Project www.mainehealth.org/mentalhealthintegration

34. Contacts Mary Jean Mork, LCSW Program Director MaineHealth and Maine Mental Health Partners 110 Free St. Portland, Maine 04101 morkm@mmc.org, 207-662-2490