Sustaining Integrated Practice Movers & Shakers Always improving Measuring Quality Getting Paid Getting started Leadership Support Leadership Support
MaineHealth Members Maine Medical Center Southern Maine Medical Center Maine Mental Health Partners Miles Memorial Hospital St. Andrews Hospital Stephens Memorial Hospital Waldo County General Hospital Home Health Visiting Nurses Maine PHO Affiliates MaineGeneral Medical Center St. Mary’s Regional Medical Center Mid-Coast Hospital Penobscot Bay Medical Center
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
Getting started: more than plunking a clinician in the practice and expecting it to work
Where to start? “Who was first?”
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
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)
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 Bills
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.
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 Provider Based or Independent Practice 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 FQHC or RHC Bills
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.
Outpatient mental health treatment limitations Applies to claims for professional services furnished by physicians, clinical psychologists, clinical social workers, and other allied health professionals.
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
2012 codes 90801: psychiatric diagnostic evaluation 2013 codes 90791: 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) Initial Psychiatric Evaluation
2012 Codes (Time is face-to-face with patient) 2013 Codes (Time is with patient and/or family) Outpatient Psychotherapy
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.”
Billing for H&B • Medicaldiagnosis • Medical bill – not mental health • Billed by practice with BHC: • Hospital license • Primary care office • Rural Health Clinic • Federally Qualified Health Center
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.
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