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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:

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Reimbursement for Integrated Behavioral Health in Primary Care: Making it work


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    1. Reimbursement for Integrated Behavioral Health in Primary Care: Making it work Mary Jean Mork,LCSW Quality Counts March 14, 2012

    2. Our Goal: Outcome driven, sustainable integrated practice model for patients and providers

    3. Objectives Participants will be able to: I. Describe the factors that affect billing and reimbursement in an integrated setting II. Identify tools to support reimbursement for mental health integration III. Identify strategies to support financial sustainability of integrated practice

    4. 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

    5. 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

    6. 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

    7. Primary & Specialty Medical Health Care Specialty Mental Health Care Screening for common mental health conditions Specialty MH care by referral Integrated mental health services Primary Care Treatment Consultation services: Collaborative care

    8. Mental Health Specialist in Primary Care: How about those differences?

    9. 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

    10. Meet Denise

    11. 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

    12. 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 Options

    13. 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

    14. 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 Insurance Ramifications

    15. Poll Question 2 – Which codes would you use for Denise? • Health and Behavior • Mental Health • Both • Don’t know • It depends

    16. 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

    17. 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

    18. Poll Question 3 – What type of setting do you work in or with? • FQHC • RHC • Hospital owned practice – Provider based • Private practice – medical

    19. Various Payers and Various Rules • Medicare • Medicaid • Commercial Insurers • Mental Health vs. Medical codes • Licensing rules

    20. 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

    21. 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)

    22. 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

    23. 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.

    24. 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

    25. 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?

    26. 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 Back to Denise – What do you do?

    27. It’s easy to get confused!

    28. Useful Tools

    29. 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

    30. 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

    31. 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

    32. Tracking Sheet –Reimbursement Codes and Values

    33. SAMPLE Reimbursement Tracking Sheet Mental Health Integration Provider ________Annette_________________ Place of Service ______Your Practice_____________

    34. Financial Tracking

    35. The Team makes it work

    36. 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

    37. 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

    38. 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

    39. We’re optimistic about the Future of Integrated Behavioral Health and Primary Care

    40. 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

    41. Contact information: Mary Jean Mork morkm@mmc.org 207-662-2490