the greater houston behavioral health affordable care act ... · significant changes to the 2013...
TRANSCRIPT
Financing Integrated Health Care in Texas Thursday, October 9, 2014
webinar presented by
The Greater Houston Behavioral Health Affordable Care Act (BHACA)
Initiative
www.nbhp.org
www.mhahouston.org
Contact: [email protected]
202.684.7457
ww w. TheNat i ona l Counc i l . o rg
Financing Integrated Healthcare Models
Jeff Capobianco, PhD, LLP
Contact: [email protected]
202.684.7457
The Cost of Waste…
• Health care waste exceeds the 2009 budget for the Department
of Defense by more than $100 billion.
• Amounts to more than 1.5 times the nation’s total infrastructure
investment in 2004, including roads, railroads, aviation,
drinking water, telecommunications, and other structures.
• If redirected the funds could provide health insurance coverage
(employer/employee cost) for more than 150 million workers.
• And the total projected waste could pay the salaries of all of the
nation’s first response personnel, including firefighters, police
officers, and emergency medical technicians, for more than 12
years. • IOM (Institute of Medicine). 2012. Best care at lower cost: The path to continuously
• learning health care in America. Washington, DC: The National Academies Press.
Contact: [email protected]
202.684.7457
Basic Principles of Billing and Reimbursement
•
CPT Codes (Current Procedural Terminology)
● Evaluation and Management Codes (E&M)
o Is generally billed by an FQHC or Medical Facility and must have a physical health diagnosis
o Billed by behavioral health for psychiatric services
● Health & Behavior Assessment Codes (HAB)
o Can only be billed by an FQHC or Medical Facility and must have an accompanying physical health diagnosis
o Used to identify the psychological, behavioral, emotional, cognitive and social factors important to the prevention, treatment, or management of physical health problems. The focus is not on mental health, but on the biopsychosocial factors important to physical health problems and treatments.
o Depending on the state the E&M and HAB codes can be billed on the same day
Contact: [email protected]
202.684.7457
Significant Changes to the 2013 Psychiatry CPT Code Set
• • Removal of evaluation and management (E&M) plus psychotherapy
codes from the psychiatry section (90805, 90807).
• • Deletion of pharmacologic management (providers to use
appropriate E&M code).
• • Psychotherapy and E&M services are distinguished from each
other (time spent on E&M services is not counted towards
psychotherapeutic services, and separate codes can be used in
combination with one another).
• • Inclusion of add on codes for psychiatry, which are services
performed in addition to a primary service or procedure (and never
as a stand-alone service).
• • Addition of code 90785 for interactive complexity.
• • New code for psychotherapy for a patient in crisis.
Contact: [email protected]
202.684.7457
Basic Principles of Billing and Reimbursement
•
CPT Codes (Current Procedural Terminology) ● Behavioral Health Codes 908xx series (MH & SU)
o Traditional behavioral codes by an acceptable licensed and credentialed practitioner for that state and setting (Physician, Nurse Practitioner, Masters Social Worker, PhD Psychologist)
● Telemedicine (usually the same code as face to face service with a modifier)
o Typically these services are billable by an acceptable licensed and credentialed practitioner for that state and setting
● Case Management
o Can only be billed by an acceptable licensed and credentialed practitioner for that state and setting
o Generally a CMHC service
Contact: [email protected]
202.684.7457
Tips/Opportunities for Billing
1. Interim Financing Solutions for Integrated
Healthcare Worksheet
2. Two Services in One Day
3. 96000 Series of Codes
4. Case Management
5. Screening Brief Intervention & Referral to Tx
(SBIRT)
6. Dear Medicaid Director State Option
7. Health Home State Plan Amendment Option
Contact: [email protected]
202.684.7457
Interim Financing & Billing Worksheets
• Designed to help agencies understand
billing for integrated health services using
the public safety net system. • Type of Agency (FQHC, CMHC)
• Funding Source (Medicare, Medicaid)
• CPT Code
• Diagnosis
• Practitioner Discipline & Credential
• The worksheets are posted on the CIHS
website under Finance
Contact: [email protected]
202.684.7457
Two Services in One Day
Myth: The federal government prohibits this or Medicaid won’t pay for this!
Reality: This is a state by state Medicaid issue, not a federal rule or regulation – Texas does allow this.
Federal Citations: ◦ Medicare will cover a physical health and mental health visit same day/same
provider – CFR Title 42 Volume 2, Part 405. Section 405.2463
Contact: [email protected]
202.684.7457
Case Management in Texas
• Billable in Texas for Special
Populations.
• If CMHC staff are leased & co-
located in an FQHC clinic they can
bill.
• Peers can bill in Texas for Case
Management.
Contact: [email protected]
202.684.7457
The 96000 Series Codes
• Approved CPT Codes for use with Medicare right now
• Some states are using them now for Medicaid
• State Medicaid programs need to “turn on the codes” for use
• Behavioral Health Services “Ancillary to” a physical health diagnosis (e.g., diabetes)
Contact: [email protected]
202.684.7457
The 96000 Series Codes
Health and Behavior Assessment/Intervention (96150-96155)
Health and Behavior Assessment procedures are used to identify the psychological, behavioral, emotional, cognitive and social factors important to the prevention, treatment or management of physical health problems.
•96150 – Initial Health and Behavior Assessment – each 15 minutes face-to- face with patient
•96151 – Re-assessment – 15 minutes
•96152 – Health and Behavior Intervention – each 15 minutes face-to-face with patient
•96153 – Group (2 or more patients)
•96154 – Family (with patient present)
•96155 – Family (without patient present)
Contact: [email protected]
202.684.7457
Screening, Brief Intervention, Referral for Treatment (SBIRT)
• Approach to the delivery of early intervention and treatment
services for persons with SA disorders or those at risk of
developing these disorders. Primary care centers, hospital
emergency rooms, trauma centers, and other community settings
provide opportunities for early intervention with at-risk substance
users before more severe consequences occur.
• Screening quickly assesses the severity of substance use and
identifies the appropriate level of treatment.
• Brief intervention focuses on increasing insight and awareness
regarding substance use and motivation toward behavioral change.
• Referral to treatment provides those identified as needing more
extensive treatment with access to specialty care.
Contact: [email protected]
202.684.7457
Disease Management Payments for Primary Care of Seriously Mentally Ill
• 2005 “Dear Medicaid Director Letter” (precursor to ACA 2703 Health Home Option).
• Currently available to states.
• Allows CMHC’s to draw down disease management funding for SMI and Developmentally Disabled population
• Michigan Project • Tailored to persons with SMI, Developmental Disabilities and Substance
Abuse Disorders
• Disease Management for SMI - dollars to CMH; CMH pays primary care
Contact: [email protected]
202.684.7457
FQHCs are a critical component of the 2010 ACA Grant Funding
will nearly triple over five years
$0
$1,000,000,000
$2,000,000,000
$3,000,000,000
$4,000,000,000
$5,000,000,000
$6,000,000,000
$7,000,000,000
$8,000,000,000
$9,000,000,000
FY2010 FY2011 FY2012 FY2013 FY2014 FY2015
$2.98B$3.86B
$4.99B
$6.45B $7.33B
$8.33B
Proposed FQHC Grant Funding
Contact: [email protected]
202.684.7457
FQHC Standalone Approach
• Behavioral Health Expansion Grant Funding available, often each year, to expand BH services in FQHC settings
• Most recent application January 2011
• All New Starts must have behavioral health services
• Direct Hires
• Contract with local CMH
Contact: [email protected]
202.684.7457
CMHC Standalone Models
• In many states CMHC must apply for a new
Medicaid # to bill for Primary Care Services • Must apply first for Medicare # to get the Medicaid #
• Exception: In Ohio, CMHC’s with Risperdal license can bill for primary
care
• Accreditation Considerations • Depending on accrediting body (Joint Commission, CARF, NCQA)
your organization may need to become accredited as an ambulatory
care facility to provide physical health services.
• This whole process can take 2-3 years
Contact: [email protected]
202.684.7457
FQHC/CMHC Partner Models
• FQHC bill by encounter rates-Perspective Payment
Model. Receive the same amount of funding for a 10
minute visit as they do for a 1 hour visit.
• Contracting with FQHC • Leasing Options for staff
• Psychiatrists
• Consulting Psychiatrist Model (Regional MHC Indiana)
• LICSW/LMSW
• Cost offset approach for Indigent population • FQHC receive federal funds to cover the cost of indigent
• CMHC can provide Case Management
Contact: [email protected]
202.684.7457
FQHC/CMHC Partner Models
You may be surprised for example: • In one Fee for Service state, for psychiatric medication service
90862
• A university medical center clinic is reimbursed $12.50
• The same visit at a CMHC is reimbursed $39.92
• At an FQHC, the visit would be reimbursed at $80-88
• In a nearby Fee for Service and managed care state, for 90862:
• A university medical center is reimbursed $19.53
• The same visit at a CMHC is reimbursed $210.87
• At an FQHC, the visit would be reimbursed $66.82-155.64
Contact: [email protected]
202.684.7457
FQHC/CMHC Partner Model
• 340B Pharmacy benefits • Individual receiving services enrolled in FQHC/CHC
• Broader formulary
• Significantly reduced rate
• FQHC apply for change of scope • Mirror scope of primary location to the new CMHC location
• Original scope has to include Behavioral Health or apply to have it
included
• Allows for FQHC to bill for primary care services not able to be billed by
CMHC
• Consumer needs to be enrolled with the
FQHC
Contact: [email protected]
202.684.7457
Tips/Opportunities From the Field
1. Open-Book Management
2. Process Mapping Billing Work Flow
3. Leadership/Advocacy
4. “Community Health Money Concept”
Contact: [email protected]
202.684.7457
Open-Book Management- The Great Game of Business
• The technique is to train all employees on
relevant financial information about the
company so they can make better decisions as
workers.
• While employees need to be trained to
understand income statements and balance
sheets; open-book's true triumphs are when
employees understand the numbers to a level
that they are able to report predictions to upper-
management.
• Stack, J. (1992). The Great Game of Business. Doubleday
Contact: [email protected]
202.684.7457
Process Mapping Billing Work Flow
• Great Team Building Exercise
• Allows Roles and Procedures to be Defined
• Identifies inefficiencies (e.g., work-arounds, money
left on the table, etc.)
• Helps establish Standard Operating Procedures
• Gains commitment from staff
Contact: [email protected]
202.684.7457
The Concept of “Community Health Money”
• Organizations are stewards of public funding
–the money is not owned by any particular
organization – it is the community’s money.
• When money is “pooled” for services return
on investment is to the community services.
• Program from what is best for the consumer &
the community, then figure out who finances
it.
Contact: [email protected]
202.684.7457
Begin with the Consumer In Mind…
• Reduce turf wars over money by focusing on the consumer.
• What is possible in the community &/or what would you like to be available?
• Do not think about “what is paid for”.
• Once you’ve determined what you want, convene finance folks (conservative & creative) to determine how to pay for it.
Contact: [email protected]
202.684.7457
For Information and Resources
Online: integration.samhsa.gov
Phone: 202-684-7457
Email:[email protected]