HRSATPR Webcast April 23, 2003

1
Effective Accounts Receivable Management
Billing for Behavioral Health Services in Primary
Care Settings
Web-assisted Audio Conference for HRSA Grantees
and Subgrantees September 17, 2003
Facilitated by Charlotte Kohler and Phil
Hurd Navigant Consulting, Inc.
2
Speakers

• Charlotte Kohler, RN, CPA, CVA, CPAM
• Phil Hurd, MHA, CCP

3
Purpose

• Purpose
• Provide focused technical assistance inresponse
  to questions asked duringHRSAs Third Party
  Reimbursement (TPR) Training sessions.

4
Program Outline

• I. National Overview/Common Issues
• II. State Structures and Variations
• III. Documentation and Coding Issues
• IV. Who Can Bill
• V. Coding, What to Bill and How Much Are You
  Paid?
• VI. Summary of Program Development Steps

5
Audience Profile

• As of 9/12/2003, we had 401 people registered,
  representing 278 organizations
• 206 organizations submitted information about BH
  services
• 80 (164 organizations)are providing BH services,
  and of those, 60 (100) are billing for these
  services

6
Audience Profile

• 38 states, plus the Puerto Rico and the District
  of Columbia are represented Arizona, Arkansas,
  California, Colorado, Connecticut, Delaware,
  Florida, Hawaii, Illinois, Indiana, Iowa,
  Kentucky, Louisiana, Maine, Maryland,
  Massachusetts, Michigan, Minnesota, Missouri,
  Montana, Nebraska, Nevada, New Hampshire, New
  Jersey, New Mexico, New York, North Carolina,
  Ohio, Oklahoma, Oregon, Pennsylvania, South
  Dakota, Tennessee, Texas, Utah, Vermont,
  Virginia, Wisconsin

7
Audience Profile

• All types of provider organizations, including
  - HIV/AIDS Bureau Ryan White and other HIV/AIDS
  programs
• Bureau of Health Professions National Health
  Service Private Practices and Nurse Managed
  Centers
• Maternal and Child Health Bureau Healthy Start
  Programs, Title V Grantees, Healthy Tomorrows and
  Providers to Children with Special Health Care
  Needs
• Bureau of Primary Health Care Community Health
  Centers, Homeless Grantees, Public Housing
  Grantees, Migrant Health Centers and School Based
  Health Centers
• Office of Rural Health Policy Rural Outreach and
  Rural Network Development Grantees

8
Effective Accounts Receivable Management
National Overview/Common Issues
9
Overview

• Behavioral Health includes both Mental Health and
  Substance Abuse services.
• We will be discussing both the somatic medical
  services and psychosomatic psychiatric services

Source The Midwest Clinicians Network Survey,
2000.
10
Overview

• The prevalence of Behavioral Health (BH) Issues
  is large and growing.
• Primary Care Physicians (PCPs) spend 50 of
  average work week directly treating mental health
  and substance abuse.
• PCPs prescribe nearly 2/3
• of medications and 80 of
• anti-depressants.

11
Funding for Behavioral Health

• Most States obtained the waiver process to
  implement Managed Care.
• Following the private sector, most states have
  carved-out Behavioral Health programs.
• The funding options for BH services and billing
  requirements are numerous and varied.

12
Managed Care Prevalence

• 39 States operate 78 managed Behavioral Health
  programs.
• 17.6 million enrollees were treated by Medicaid
  plans with Behavioral Health services in 1999.
• Medicaid remains the largest funding source for
  public managed Behavioral Health care.

13
Medicaid Managed Care

• Ten States account for 80 of the national
  enrollment in Medicaid Managed Care programs 3
  for 50
• California
• Michigan
• Tennessee
• Massachusetts
• Pennsylvania
• Maryland
• Washington
• New York
• Texas
• Oregon

50
14
Reimbursement/Provider Issues

• Payments are made to preferred provider.
• Reject application because panel is full.
• Some states and counties award BH services
  exclusively to the local Community Mental Health
  Center (CMHC)
• Are you one of them?

15
Coverage Requirements

• Meeting medical necessity criteria
• Can take 2 hours for evaluation
• --If patient does not meet criteria, often the
  provider
• does not get paid for the evaluation

16
Effective Accounts Receivable Management
State Structures and Variations
17
Program Structures - Examples

• California - Some capitation contracts w/ county
  MH Depts./LCSW must have Medicare PIN before
  MediCal FQHCs/RHCs can be reimbursed FFS.
• Massachusetts Capitates four MCOs MCOs
  subcontract w/ Health Centers/others some
  payment arrangements are FFS
• Michigan Capitated contracts w/ CMHSPs FQHCs
  do not participate in program but can contract w/
  HMOs

18
Program Structures - Waivers
19
Program Structures Managed Care
20
Program Structures Provider Issues
21
FQHCs - Examples

• California traditional psychotherapy referred
  to Mental Community Health Center visit limits
  can vary w/in the state
• Kansas FQHCs not eligible as subcontractor for
  BH services program specifies the number of
  hours by service per year.
• Michigan Integrated primary care delivery model
  experiment for use of new codes 9615x model
  does not limit visits but the Medicaid program
  has a 20 visit limit

22
FQHCs - General
23
FQHCs Billable Services
24
FQHCs Visit Restrictions
25
FQHCs Reimbursement Issues
26
Program Structures Summary

• Most BH benefits are carved-out.
• Contractual arrangements and eligible providers
  vary widely by state and by county within the
  state.
• Must work closely with your state structure to
  clearly define requirements for your program.

27
Effective Accounts Receivable Management
Documentation and Coding Issues
28
Documentation and CodingFraud and Abuse

• Behavioral Health Services have been subject to
  fraud as have many other services.
• Services that have been billed inappropriately in
  the past include
• Routine screening and periodic testing
• Testing for other than diagnosing a suspected
  mental illness or to evaluate a change in mental
  illness
• Generic psychotherapy (group) not specific to
  patients condition.

29
Documentation and CodingFraud and Abuse

• The biggest problem in Behavioral Health relates
  to medical necessity (determination by payers
  based on a review of services billed)
• Services performed by a non-licensed provider
  particularly as incident to using the PIN of
  the licensed provider.
• Music, game, instrument, pet interaction
  therapies, sing-alongs, arts and crafts, and
  other similar activities should not be billed as
  group or individual activities.

30
Elements of Incident To

• 1.   An integral part of the physicians
  professional service
• 2.   Commonly rendered without charge or
  generally not itemized separately in the
  physicians bill
• 3.   Of a type that are commonly furnished in
  physicians office or clinic
• 4.   Furnished under the physicians direct
  personal supervision

31
Medical Record Documentation

• Complete records contain all pertinent and
  essential information related to the patients
  current encounter.
• Each entry must be able to stand-alone.
• Medical records must indicate that the patient
  has a psychiatric illness or emotional behavioral
  symptoms.

32

• Who Can Bill?

33
Who Can Bill?

• Who can bill for behavioral health services?
• Most States Accept physicians, Clinical
  Psychologists (CP), Licensed Clinical Social
  Workers (LCSW), (Certified, Independent, Licensed
  State defines)
• However, each State has its own rules and many
  will pay for other professionals.

34
Who Can Bill?

• Physicians
• Clinical Psychologists
• Licensed Social Workers (Certified, Independent
  or Clinical different by State)
• Certified Marriage and Family Therapists (CMFT)
• Pastoral Counselors

35
Who Can Bill? (Cont.)

• Registered Nurses
• Nurse Practitioners
• Alcohol and Drug Abuse Counselors
• Clinical Nurse Specialist
• BUT - Every State is different and requirements
  are different

36
Who Can Bill?

• Clinical Psychologist - Medicare Criteria
• Physician supervision not required
• Considered to be an allied health professional
• Services generally covered in independent
  practice or as employee of a physician or
  physician-directed clinic.

37
Who Can Bill?

• Clinical Psychologist - Medicare Criteria
• Agree to consult with patients attending
  physician, unless the patient does not agree to
  the consult.
• Can not bill for monitoring or prescribing
  medication.

38
Who Can Bill?

• State Comparisons
• Arkansas - Providers are licensed with the state
  AND certified by the Division of Mental Health
• Indiana - More restrictive providers must be
  certified as Health Service Provider in
  Psychology
• Nebraska Less restrictive

39
Billable Providers - Examples
40
Targeted Case Management (TCM) - Examples

• Arkansas
• Only the following can bill for TCM
• MSWs
• RNs
• LPNs
• LCSWs
• Licensed Psychiatric Technical Nurse
• Masters Level School Guidance Counselors, School
  Psychology Specialist, and special Education
  Supervisors who are also certified with the Board
  of Education

• Indiana
• Psychologist, MD, OD, SW, OT, Speech Pathologist
  or Audiologist, RN, PT who are qualified Mental
  Retardation Professionals.
• Services are provided by or under the supervision
  of qualified Mental Health Professionals.

41
Arkansas

• Other
• If Medicare covers the service, provider must be
  a credentialed Medicare provider before Medicaid.
• RHCs must be certified by CMS and participate
  with Medicare

42
State Comparison - Summary

• State requirements vary widely
• Different providers have different supervision
  requirements
• Make sure BH Professionals are licensed by the
  right agency and certified, as required.

43
State Comparison - Summary

• Make sure you understand practice location
  requirements
• Reimbursement methodology and amounts vary by
  practice setting-know the differences.

44

• Coding, What to Bill and How Much are You Paid?

45
What To Bill?
46
What To Bill?
47
How Much Are You Paid?

• Reimbursement
• Reductions in reimbursement rates by provider
  type
• Physician - not discounted
• Clinical Psychologist - discounted
• LCSW - further discounted
• Other - discounted if covered

48
State Reimbursement Example

• Ranges by Provider Type

49
How Much Are You Paid?

• Reimbursement Ranges

1
1) Unadjusted
50
How Much Are You Paid?

• Reimbursement Ranges

1

1) Unadjusted
51
How Much Are You Paid?

• Reimbursement Ranges- Physicians

1

• Unadjusted

52
How Much Are You Paid?

• Reimbursement Ranges

1
Medicaid
The state of Alaska is the only state currently
reimbursing for these new codes
1) Unadjusted
53
Reimbursement Issues

• Reimbursement Issues/Problems
• EM codes are limited to physicians, NP, Nurses
• The same is true for the 90805, 90807, 90809
  codes
• The new codes as of Jan. 1, 2002, 96150-96155,
  are for use by clinical psychologists, only.

54
Coding and What to Bill

• Reimbursement Issues/Problems
• Two big problems
• An EM (992XX) and a therapy (908XX) cannot be
  billed on the same date of service to most
  Medicaid programs.
• Alaska is the only state, to date, that approves
  payment for Medicaid recipients for the
  96150-96155 health and behavioral assessment
  codes.

55
Summary

• Coding and reimbursement can be tricky
• Understand the reimbursement rates by provider
  BEFORE moving forward the program may not be
  financially viable

56
Effective Accounts Receivable Management
Summary of Program Development Steps
57
So What Does All This Mean?

• Behavioral Health Services may be a service
  option for you and your patients.
• Program location and mix of providers will
  dictate reimbursement opportunities.
• Behavioral Health is very large and demand likely
  to increase.
• Reimbursement challenges are difficult.

58
So How Do You Get Started?

• Program Design
• State Program Coverage Issues
• Providers
• Reimbursement Estimates
• HIPAA
• Marketing
• Medication Management
• Regulatory Changes

59
So How Do You Get Started?

• A. Program Design
• Define the Behavioral Health Services your
  patients are receiving.
• Determine what Behavioral Health Services you
  want to provide.

60
So How Do You Get Started?

• B. State Program Coverage Issues
• Research State Program Information.
• Contact State Medical Assistance Program and
  determine specific Behavioral Health Service
  requirements.
• Invite Medicaid Representatives to your facility
  or visit them to present Behavioral Health
  Program and clearly understand the requirements.

61
So How Do You Get Started?

• C. Providers
• Determine eligible providers.
• Determine provider credentialing and Licensing
  requirements.
• Determine managed care panel and credentialing
  issues.
• Identify supervision Incident to. Independent
  criteria for billing by provider.

62
So How Do You Get Started?

• D. Reimbursement Estimates
• Obtain reimbursement rates by provider type for
  state and other programs.
• Understand billing rules by payer, e.g. billing E
  M visit same day as Behavioral Health visit,
  number of visits limits, auth/pre-authorizations,
  etc.
• Assure you have a complete understanding of
  program parameters re Individual Therapy, Case
  Management, Special Behavioral Health Services,
  etc.
• Use the HRSA TPR Business model to estimate
  potential revenue.
• Consider supervision issues and how to best
  handle.

63
So How Do You Get Started?

• E. HIPAA
• Assure patient confidentiality.
• Review space requirements.
• Assure electronic files are compliant.

64
So How Do You Get Started?

• F. Marketing
• Consider referral source of patients.
• How do your physicians refer to your Behavioral
  Health Professionals?

65
So How Do You Get Started?

• G. Medication Management
• Incorporate appropriate medication management
  supervision intoprogram procedures as required.
• What physician, internal/external will be
  managing medications?

66
So How Do You Get Started?

• H. Regulatory Charges
• Stay abreast of State policy changes regarding
  Behavioral Health Carve out services, eligible
  providers, etc.

67
Helpful Websites

• www.cms.govMedicare Regulations
• www.medicarenhic.comPart B Billing Resource
• www.aswb.orgSocial Worker Requirements by State
• Search by state by Department of Health or
  Department of Mental Health to find state
  Specific Information.

68

• Thank you for participating in HRSAs
  web-assisted audioconference!
• Additional questions can be directed to
• tpr_at_hrsa.gov
• or
• 1-866-877-8439

69
Program Evaluation

• If you cannot stay for the Q A portion please
  complete the online evaluation that follows and
  submit your comments regarding this event.
• Thank you for your participation.