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San Francisco Community Clinic Consortium Behavioral Health Presentation

San Francisco Community Clinic Consortium Behavioral Health Presentation. Presented by HFS Consultants Regina Boyle January 14, 2010. Behavioral Health Training. Today’s Topics Overview of Behavioral Health Services Federal & State Health Regulations (BH)

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San Francisco Community Clinic Consortium Behavioral Health Presentation

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  1. San Francisco Community Clinic ConsortiumBehavioral Health Presentation Presented by HFS Consultants Regina Boyle January 14, 2010

  2. Behavioral Health Training Today’s Topics • Overview of Behavioral Health Services • Federal & State Health Regulations (BH) • Legal Issues Regarding Behavioral Health • Billing & Coding Issues for Behavioral Health • Charting • State Plan Amendment • Licensing and Intermittent Clinic Issues • HRSA Change of Scope Issues • State Change of Scope Rate Request • Medicare Enrollment • Reimbursement and Allowable Expenses

  3. Today’s Format • Four Presentations • Legal • Billing, Coding, Charting • PPS, HRSA, Licensing, Enrollment • Reimbursement • Facilitate Questions During & After Presentation • Wrap Up and Follow up Questions • Tool Kit Reference

  4. FQHC and the Provision of Mental Health Services:Key Legal Issues Regina M. Boyle Attorney at Law 2220 Capitol Avenue, Second Floor Sacramento, California 95816 Tel: (916) 930-0936/Fax: (916) 930-0938 Email: cliniclaw@gmail.com

  5. Key Legal Issues Behavioral Health Services May Be Delivered By: • Physicians – primary care or psychiatrists • Clinical Psychologists • Licensed Clinical Social Workers • Nurse Practitioners • Physicians Assistants

  6. Key Legal Issues Medicare/Medi-Cal Qualifications for Mental Health Providers Physicians, Clinical Psychologists, Licensed Clinical Social Workers, Nurse Practitioners and Physician Assistants are providers of FQHC “core services” and are defined by Medicare law for both Medi-Cal and Medicare.

  7. Key Legal Issues Be certain that the professional delivering the services: • Meets licensing requirements; • Meets Medicare/Medi-Cal professional training qualifications; • Is delivering services within the scope of their professional license.

  8. Key Legal Issues Contracting with Health Care Professionals • State and federal law contain various prohibitions on self-referral and compensation of health care providers and certain others for the referral of patients (unearned compensation). • Generally, these rules are intended to limit the impact of health care provider conflicts of interest, and to reduce financial incentives which may result in the provision of medically unnecessary services to patients.

  9. Key Legal Issues Legal Counsel’s Review • FQHC staff should be familiar with the requirements for meeting the Stark exception/Anti-Kickback Safe Harbors for employment and personal services agreements. • However, these rules are complicated, and in many respects counter-intuitive, and violations may result in ruinous civil and criminal fines and penalties, including possible mandatory exclusion from Medicare/Medicaid. • It is therefore essential that FQHCs have proposed contracts prepared or reviewed by competent legal counsel who is familiar with State and Federal Fraud and Abuse laws in order to ensure that agreements are in full compliance with state and federal referral and compensation laws.

  10. Key Legal Issues Outpatient Mental Health Treatment Limitation • Impacts reimbursement of a specific range of services that are provided to Medicare beneficiaries – does not limit coverage of services outside this range • Phased out from 2010 – 2014 (Section 102 of the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008)

  11. Key Legal Issues Outpatient Mental Health Treatment Limitation Does Not apply to Medi-Cal, but: • FQHCs must ensure that Medi-Cal is not attributing phantom income for visits for mental health services paid at the discounted rate; • DHCS Audits and Investigation is aware of the problem; • This awareness does not mean that A&I staff will avoid making the mistake.

  12. Key Legal Issues Mandatory Medicaid Coverage of Behavioral Health Services: Clinical psychology (CP) and Licensed Clinical Social Worker (LCSW) services must be reimbursed in an FQHC/RHC regardless of whether or not they are otherwise covered by the State Medicaid Plan.

  13. Key Legal Issues Medicaid & Medicare “Visits” Reimbursable at the All -Inclusive Rate

  14. Key Legal Issues Mandatory Medicaid Coverage of Behavioral Health Services • HRSA PIN 2004-05 and attached letter from Dennis Smith, CMS’ Director of the Center for Medicaid & State Operations; • Clarified that so long as the services of CPs and LCSWs were within the practitioner’s scope of practice, State Medicaid Agencies were required to pay FQHCs/RHCs for their services.

  15. Key Legal Issues California’s Elimination of Optional Psychology Benefit • Neither LCSW nor CP services are otherwise covered by Medi-Cal; • Only covered by Medi-Cal by virtue of federal law (42 U.S.C. § 1396a(a)(10)(A), 1396d(a)(3)(C); Calif. Welfare & Inst. Code § 14132.100(a) and (g)).

  16. Key Legal Issues

  17. Key Legal Issues

  18. Key Legal Issues HRSA Scope of Project Approval • Sites/services are not eligible for enhanced Medicare/Medi-Cal reimbursement unless they have first been added to the FQHC’s Scope of Project. • Approval is only retroactive to date complete application is received by HRSA.

  19. Key Legal Issues HRSA Scope of Project Approval HRSA PINs/PALs: • New Scope Verification Process, PAL# 09-11; • Policy for Special Populations-Only Grantees Requesting a Change in Scope to Add a New Target Population, PIN # 09-05; • Specialty Services and Health Centers’ Scope of Project, PIN 09-02; • Defining Scope of Project and Policy for Requesting Changes, PIN # 08-01 and Technical Revision 09-03; • FQHC Look-Alikes follow PIN # 09-06 and Technical Revision 09-07.

  20. Key Legal Issues HRSA Scope of Project Approval • BPHC PIN # 2009-02 addresses policy regarding the addition of “Specialty Services” to an FQHC’s Scope of Project; • “Specialty Services” are defined by BPHC as services that are not within the definition of “required primary health services” set out in 42 U.S.C. § 254b(b)(1).

  21. Key Legal Issues HRSA Scope of Project Approval • HRSA views the following as “specialty services” that are subject to the additional requirements of PIN 2009-02: • Psychiatry services; • LCSW services; • Clinical Psychology services; • As well as any services falling within the definition of “additional health services” in 42 U.S.C. sec. 254b(b)(2).

  22. Key Legal Issues Medi-Cal Utilization Controls • Medi-Cal Provider Manual states that FQHCs must follow the “Medi-Service” limitations. • Refers to 22 CCR § 51304 – interpreted by DHCS as limiting beneficiaries to 2 visits in any calendar month from the following list: • Chiropractors, Acupuncturists, Psychologists, Physical Therapists, Occupational Therapists, Speech Pathologists, Audiologists Podiatrists, Practitioners of Prayer or Spiritual Healing.

  23. Key Legal Issues Medi-Cal Utilization Controls There is NO emergency exception from the Medi-Service quantity limit – there may be a professional obligation to a patient needing services in excess of the quantity limits.

  24. Key Legal Issues Medi-Cal Utilization Controls Adoption of NPI numbers now permits FQHCs to use Automated Eligibility Verification System (AEVS) for making Medi-Service reservations.

  25. Key Legal Issues Medi-Cal Utilization Controls Psychiatrists subject to the utilization control in 22 Calif. Code of Regulations § 51305(d), limiting non-emergency psychiatry services to a maximum of eight visits in any 120-day period without prior authorization.

  26. Key Legal Issues Medi-Cal Utilization Controls • FQHCs must maintain in their records documentation in lieu of obtaining a TAR, since they are exempt from the TAR process, but not the recordkeeping requirements. • For emergency psychiatry visits, documentation must demonstrate services are “emergency services” and meet requirements of 22 CCR § 51056 that are applicable to emergency services.

  27. Key Legal Issues Medi-Cal Utilization Controls For non-emergency psychiatry services beyond the limit of 8, the medical record must include a “total treatment plan” including the specific information required by 22 CCR sec. 51305 (d)(2).

  28. Key Legal Issues Importance of Recordkeeping • OIG Report “Medicare Payments for 2003 Part B Mental Health Services: Medical Necessity, Documentation and Coding” (http://www.oig.hhs.gov/oei/oeisearch.html); • The report concluded that forty-seven percent of the mental health services allowed by Medicare in 2003 did not meet program requirements, resulting in approximately $718 million in improper payments.

  29. Key Legal Issues Importance of Recordkeeping • Medi-Cal providers are required to keep, maintain, and have readily retrievable, such records as are necessary to fully disclose the type and extent of services provided to a Medi-Cal beneficiary. • 22 CCR section 51476 sets out the basic recordkeeping requirements, and includes additional requirements applicable to psychiatric and psychological services (patient logs, appointment books or similar documents showing the date and time allotted for appointment of each patient or group of patients, and the time actually spent with such patient).

  30. Key Legal Issues Importance of Recordkeeping • Joint Commission Resources: “A Practical Guide to Documentation in Behavioral Health Care.” • Accredited or not, FQHCs can benefit from adopting standards developed by either the Joint Commission or AAAHC for ambulatory settings, and specific to behavioral health services.

  31. Key Legal Issues Facility Licensing requirements for Community Clinics Clinic policies and procedures should be updated to reflect new or expanded services; • See 22 C.C.R. §§ 75026 – 75039 in particular

  32. Key Legal Issues Facility Licensing Requirements for Community Clinics Policy regarding reporting “unusual occurrences” should be reviewed and updated if necessary – 22 C.C.R. §§ 75030 and 75053: • Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, deaths from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. • An incident report shall be retained on file by the facility for one year.

  33. Key Legal Issues California Department of Health Care Services’ Four Walls Rule • The provider (physician, nurse practitioner, physician assistant, nurse- midwife, clinical psychologist, clinical social worker, and visiting nurse) has a written contract with the FQHC to provide the services; • The services are furnished only to FQHC patients at the location other than the FQHC (i.e. the FQHC is sending their staff off-site to treat the patient); • The patient must be treated at that location rather than at the FQHC for health or medical reasons; and • The services provided are of the type commonly furnished in the FQHC setting.

  34. Key Legal Issues California Department of Health Care Services’ Four Walls Rule • Like the application of the Medi-Service limit to FQHC “core services”, the legality of the four walls rule has been repeatedly questioned. • DO NOT IGNORE THESE RULES. • If you question the rules, challenge them in court before acting contrary to CDHCS stated policy.

  35. Key Legal Issues Contracting with Counties & CMSP Short-Doyle – FQHCs that have contracts with counties to provide behavioral health services should be certain to include language in contracts ensuring that the county is not making a claim under Medicaid for the patients that are being treated by the FQHC – avoid risk of double-payment by CMS.

  36. Key Legal Issues Contracting with Counties & CMSP • CMSP policies on what are and are not covered services is particularly vague in the area of mental health. Key problems are: • CMSP reliance on, and confusion about, Medi-Cal rules relating to Short-Doyle; • CMSP confusion about differences between Medi-Cal FQHC and “clinic services” benefits; • FQHCs should define covered services in contact before providing services to CMSP beneficiaries.

  37. Key Legal Issues Sliding Fee Scale Requirements • Discounts to all patients below 200% FPL; • Patients between 101-200% FPL receive a discount; • Patients below 100% FPL receive a 100% discount, however most organizations require a nominal fee; • Nominal fee varies, but $10 seems to be the most common fee for medical services; • “Nominal fee” cannot serve as barrier to care and no patient may be turned away due to inability to pay for services; • Ryan White HIV patients are eligible for the sliding fee scale and an annual payment cap (cap is set at a % of patient’s annual income).

  38. Key Legal Issues 340B Discount Drug Program • California recently eliminated the Medicaid carve-out for FQHCs and other “covered entities”, impacting providers with patients utilizing costly pharmaceuticals. • The Impact was muted by the October 28, 2009, Medi-Cal Pharmacy Provider Bulletin #714 DHCS stated the following: • Covered entities do not have to dispense 340B program drugs when a payment is made to a covered entity as part of a bundled, composite or all-inclusive rate. Reimbursement will be based on applicable rates for the services rendered (i.e. your PPS rate). • The requirement to dispense 340B program drugs applies to the Medi-Cal FFS program and rebate-eligible County Organized Health System (COHS) plans. Reimbursement is based on the applicable contract rates with the individual plans. • A 340B program contract pharmacy may dispense non-340B program drugs to Medi-Cal recipients even if the beneficiary is considered a “patient” of the covered entity. The pharmacy can bill for such non-340B program drugs under the billing requirements in W&I Code, Section 14105.455. This applies to Medi-Cal FFS and rebate-eligible COHS plans.

  39. Key Legal Issues Patient Privacy Protections Specific to Mental Health Records – Key Provisions • Lanterman-Petris-Short (LPS) Act (California Welf. & Inst. Code sections 5328, et seq.), applies to provision of mental health services. • Confidentiality of Medical Information Act (CMIA)(Civil Code sec. 56.10, 56.103 and 56.104). • State and federal limits on medical information regarding alcohol and drug treatment (42 C.F.R. sections 290dd, et seq., and 2.1, et seq.; Health & Safety Code sections 11812, 11977 and 123125). • HIPAA (45 C.F.R. Part 164) and in particular protection of “psychotherapy notes” (45 C.F.R. sec. 164.501 and 164.524(a)(1)(i)). • New penalties and disclosure requirements for community clinics: • $25,000 – Initial violation (per patient) • $17,500 – Subsequent occurrence • $250,000 – Maximum penalty • $100 per day for late reporting

  40. FQHC Mental Health Documentation, Coding and Billing Carrol Hope Manager HFS Consultants

  41. Psychological Services Psychology services are federally required core services for FQHCs and remain reimbursable for all beneficiaries when rendered by a licensed psychologist, or by a licensed clinical social worker in the FQHC.

  42. Psychology Service Defined “Service” Defined means all care, treatment or procedures provided to a recipient by an individual practitioner on one occasion

  43. Supporting Documentation • The documentation retained in the beneficiary’s medical record must contain legible and complete details of the psychology service visit. • To meet the requirements for both compliance and medical billing.

  44. Medical Records Documentation

  45. PRINCIPLES OF MEDICAL RECORD DOCUMENTATION • Medical records contain treatment history and relevant experiences pertaining to the care of the individual. • Medical records are a legal document supporting the services rendered and billed.

  46. PRINCIPLES OF MEDICAL RECORD DOCUMENTATION • Key elements of the medical record • The reason for the patient encounter; • All services provided to the patient; • Clearly explain services, procedures, and supplies; • Clearly provide for a reasonable medical rationale for the setting ; and • Should be sufficient for another provider to take over the care of the patient. © HFS Consultants July 2007

  47. Psychiatric Documentation Each outpatient visit must include: • Symptoms or complaints • Progress to date in objective, observable terms • Functional status • Assessment, clinical impression, or diagnosis • Plan for future care • Prognosis

  48. HIPAA and Medical Records HIPAA laws require specific guidelines on the patient’s right to access his or her medical records. • For as long as the records are maintained • Request must be in writing (State law) • Summary may be substituted for copies Some exclusions apply-Exclusions to patient rights to access medical information • Psychotherapy notes as defined by HIPAA • Psychiatric records (state law) • Information may cause the patient to harm self or others

  49. Coding CPT, HCPC, ICD9

  50. Unique Billing Method Billing Psychology services rendered in an FQHC • Federally Qualified Health Clinics (FQHC’s) use unique two digit procedure codes that have a rate per visit on their provider master file record • FQHC facilities use the following per-visit codes to bill for services rendered to Medi-Cal

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