Transcript Council of Community Clinics CFO Quarterly Meeting

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)
• 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
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
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: [email protected]
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
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.
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.
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.
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.
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)
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.
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.
Key Legal Issues
Medicaid & Medicare “Visits” Reimbursable at the All
-Inclusive Rate
Medicaid
Medicare
•Physician (MD, DO, DDS, Optometrist,
Chiropractor)*
•Physician Assistant
•Nurse Practitioner
•Certified Nurse-Midwife
•Clinical Psychologist
•Licensed Clinical Social Worker
•Visiting Nurse in CMS Home Health Shortage
Area
•Comprehensive Perinatal Services
Practitioner
•ADHC Visit (four-hour minimum)
•Physician, (MD, DO, DDS, Optometrist,
Chiropractor)
•Physician Assistant
•Nurse Practitioner
•Certified Nurse-Midwife
•Clinical Psychologist
•Licensed Clinical Social Worker
•Visiting Nurse in CMS Home Health Shortage
Area
•Also, under certain circumstances,
encounters with qualified providers of
medical nutrition therapy services; or a
qualified provider of outpatient diabetes selfmanagement training services (see Medicare
Benefit Policy Manual, Ch. 13, section 30)
*At
present, DHCS only recognizes medical
doctors, and dentists, as capable of
providing “physician” services which may be
reimbursed at the PPS rate.
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.
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)).
Key Legal Issues
Key Legal Issues
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.
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.
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).
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).
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.
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.
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.
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.
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.
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).
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.
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 MediCal 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).
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.
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
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.
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.
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.
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.
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, MediCal 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.
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).
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.
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
FQHC Mental Health
Documentation, Coding and Billing
Carrol Hope
Manager
HFS Consultants
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.
Psychology Service
Defined
“Service” Defined means all care,
treatment or procedures provided to
a recipient by an individual
practitioner on one occasion
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.
Medical Records
Documentation
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.
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
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
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
Coding
CPT, HCPC, ICD9
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 pervisit codes to bill for services rendered
to Medi-Cal
Billing FQHC All
Inclusive Per Visit Codes
Code
Description
Explanation
01
Medi-Cal Per
Visit Code
Requires
medical
justification for
more than one
visit per
recipient per
day.
11
LCSW
A mental health
services
rendered by a
LCSW for a
recipient of any
age
12
Psychologist
A mental health
services
rendered by a
psychologist for
a recipient of
any age
• FQHC’s bill with a
two digit code
• The unique two
digit codes used
for billing services
are not billable to
other health
coverage (OHC)
Current Procedural
Terminology (“CPT”) Codes
• HCPCS is a three-level coding system
that incorporates Physicians’ Current
Procedural Terminology (CPT-4),
• HCPCS National Level II codes
(formerly non-physician procedures
and services) and
• HCPCS Local Level III codes
(California-only)
Medi-cal HCPC
Level II Codes
Medi-cal Codes
HCPC II
Cross-Walk CPT Codes
CPT
• X9500
Individual onehalf hour25
minutes
• 90804
Individual
psychotherapy,
20-30 minutes
• X9502
One hour50
minutes
• 90806
Individual
psychotherapy,
45-50 minutes
• X9504
One and one-half
hour
(maximum) 80
minutes
• 90808
Individual
psychotherapy,
75-80 minutes
Documentation
and Coding
Example:
• A psychiatric diagnostic interview
examination (90801) includes a
•history,
•mental status exam, and
•a disposition,
•as well as ordering and medical
interpretation of laboratory or other
medical diagnostic studies.
Documentation and Coding
Diagnostic Interview 90801
The diagnostic interview may
include communication with
• family or
• other sources,
• and in certain circumstances, other
informants will be seen in lieu of the
patient.
Documentation and Coding
Diagnostic Interview 90801
• The psychiatrist obtains a complete
medical and psychiatric history
from the patient and/or family and
establishes a tentative diagnosis.
• Two digit FQHC code 13 Psychiatrist
for FQHC billing, 1 Unit or
• CPT 90801 for other health coverage
• Medi-cal fee-for-service
UB04 Example
Psychiatrist
• Billing for the
services of a
Psychiatrist
• Code 13
Evaluation and
Management
An evaluation and management
(E/M) service may be substituted
for the initial interview procedure,
provided all required elements of
the E/M service billed are fulfilled.
Evaluation and
Management Factors
The selection of the appropriate Evaluation
and Management (E&M) service code is
based upon the evaluation of the service
provided by the physician against the
following seven criteria:
•
•
•
History
Examination
Medical Decision Making
Counseling
Coordination of Care
Nature of Presenting Problem
Time
© HFS Consultants July 2007
Diagnostic Coding
• Only ICD-9-CM diagnosis codes will be
accepted on claims
• On Medi-Cal claims. Do not use DSM
IV (Diagnostic Statistical Mental
disorders) codes.
• Diagnosis documented as “probable,
possible, suspected” cannot be coded.
• In the absence of a definitive diagnosis the
signs or symptom is coded.
Mental Health
Diagnosis
• ICD-9-CM Codes
295.00 – 298.9
302.8 – 302.9
311
– 313.82
299.1 – 300.89
307.1
313.89 - 314. 9
301.0 – 301.6
307.3
787.6
301.8 – 301.9
307.5 – 307.89
302.1 – 302.6
308.0 – 309.9
• Diagnosis codes are updated
annually
• New codes are released
October 1, of each year
• Carefully review the
information in the ICD9 code
book when selecting the
diagnosis
Abuse and
Dependence ICD9
ICD-9-CM classifies these
conditions as mental disorders and
includes the following categories:
• 303.xx, Alcohol dependence
• 304.xx, Drug dependence
• 305.xx, Nondependent abuse of
drugs
Example ICD9 Drug
Dependence
Drug dependence is classified to
category 304. The fourth-digit
subcategory identifies the type of
drug involved as follows:
• 304.0, Opioid type dependence
• 304.1, Sedative, hypnotic, or
anxiolytic dependence
• 304.2, Cocaine dependence
Overview of the
Coding Process
Review the:
• Medical Record for codeable service
• ICD-9-CM diagnostic codes assigned to the
highest degree of specificity
• ICD-9-CM diagnostic codes for validity
• HCPCS/CPT codes assigned to ensure that
they are correct
• ICD-9-CM codes assigned correlate
© HFS Consultants July 2007
• It is important to
remember that
the medical record
documentation
must support the
ICD-9-CM and CPT
codes selected.
© HFS Consultants July 2007
BILLING
Billing FQHC
FQHC’s bill with two digit codes
• UB04 claim forms, codes are entered
into the field number 44
•Enter the two digit code that identifies
the services provided in the FQHC
FQHC’s bill
per visit codes
Mental Health
Provider types:
• 11 LCSW
• 12 Psychologist
• 13 Psychiatrist
• 17 Heroin Detox
UB04 Example
FQHC
• Example of billing
for a Clinical
Psychologist
• Code 12
Psychologist
or LCSW
• Psychology services are reimbursable for all
eligible beneficiaries when rendered by a
licensed psychologist or by a licensed clinical
social worker in the FQHC.
• Medical justification is required to be
documented in the Remarks field (Box
80)/Reserved for Local Use field (Box 19) or
as an attachment to the claim for psychology
services for FQHCs.
Billing Example Remarks
Code 80 for Psychology
• The following is an example of
documentation required in the
remarks on the claim or as an
attachment for psychology
services:
• Example: “The psychology service
visit is provided as a core service
for an FQHC.”
• Encounters are billed in units
• Encounters with more than 1
health professional and multiple
encounters with same health
professional which take place on
same day and location are billed as
1 unit
UB04 Example
FQHC
• Billing for the
services of an
LCSW
• Code 11
FQHC
Bill Types
• 0521–Clinic visit by member to
FQHC
• 0522–Home visit by FQHC
practitioner
• 0524–Visit by FQHC practitioner
to
member in covered Part A stay at
SNF
Deductible and
Coinsurance
• No Part B deductible is applied to FQHC
services
• Coinsurance is 20% of billed charges
• FQHC can waive collection of all or part
of coinsurance
CMS IOM Publication 100-02, Medicare Benefit Policy Manual,
Chapter 13, Section 20
UB04 Billing
Medicare
Billing for Medicare
services prior to
Medi-cal
Bill with revenue code
900
Billing for Beneficiaries With
Other Health Coverage
• Providers may not refuse to
provide Medi-Cal-covered services
to eligible recipients with other
health coverage (OHC).
• Providers are required to exhaust
the recipient’s OHC before billing
Medi-Cal.
Example HCFA 1500
• Billing other
health coverage
(OHC) on HCFA
1500
• Billable provider
services are not
accepted on UB04
to carriers other
than Medi-cal or
Medicare
Claim Billing
Time Limits
• Claims must be submitted to Medical within six months form the date
of service.
• Commercial carriers such as Blue
Cross, Blue Shield for example, are
billed on a HCFA 1500 claim form.
• The general rule is sixty days from
the date of service.
Resources
Web site addresses
• DHS Medical Manual
http://files.medical.ca.gov/pubsdoco/Manuals_menu.asp
• CMS
www.cms.hhs.gov/Manuals/IOM/list.asp/
www.cms.hhs.gov/Transmittals/
– Access transmittals
– Provider updates and CMS forms
PPS, Licensing &
Scope Issues
PPS
SPA
BH Impact on PPS
HRSA Scope Change
Scope Change Enrollment
Steve Rousso
Principal
HFS Consultants
What is PPS?
• “Prospective Payment System”
• Definition: Method of reimbursement
for Rural Health Clinics and Federally
Qualified Health Centers (FQHC)
• Does not apply to FQHCs that
participate under the 1115 Medicaid
Demonstration project for Los Angeles
County
State Plan
Amendment
• “SPA”
• Defines eligible visits
• Defines eligible providers
• Defines reimbursement system
• Defines change in scope for rate requests
including qualifying events
• “A must read”
State Plan
Amendment
State Plan
Amendment
Is PPS Just a
Medi-Cal Process?
• It is, but there is a separate
system for Medicare enrollment
and Medicare rates
• Upper Payment limit for urban
FQHCs is: (everybody in this room)
•$125.72 per visit
•What are you billing now for BH?
PPS Rate Setting
PPS Rate Setting
Licensing Issues
• Welfare and Instit. Code 14043.15 exempts
intermittent and mobile clinics from separate
enrollment in Medi-Cal
• Intermittent clinic must be operated by a primary
care clinic, that provides all staffing, protocols,
equipment, supplies and billing services
• Must give notice to CDPH of the separate locations,
premises, intermittent sites or mobile health care
units
• 20 hours or less
• N/A for Medicare
• No separate issues for behavioral health services
Licensing Options
Other Licensure Options & Alternatives
•Temporary
•Provisional
•Intermittent
•Affiliate
•Exempt
•Full application as community clinic
•No more hospital based FQHC’s after April
22, 1999
HRSA
Scope of Project Policy
TO:
All Bureau of Primary Health Care Grantees
Attached is an update of the scope of project policy as it applies to the
Bureau of Primary Health Care (BPHC) grantees awarded funding under
section 330 of the Public Health Service Act. This Policy Information Notice
(PIN) supersedes PIN 2000-04 “Scope of Project Policy,” and is intended
to clarify scope of project issues, improve consistency, and provide
guidance concerning change in scope requests. It addresses changes in
scope of project that do not require additional Federal funds. If additional
Federal support will be required to implement the changes, the Center
should consider submitting an application for competitive funds.
This PIN describes the policy and procedures for requesting approval for
changes in sites or services. Although included as part of the approved
scope of project, changes in target population, service area, and providers
do not need prior approval unless they are accompanied by a change in
sites or services. The following are highlights of the major changes:
•
To obtain approval for a change in service delivery sites and/or services
provided, health centers must prepare a change in scope request as outlined in
this PIN. Change in scope requests will no longer be accepted as part of the
continuation grant application, but must be submitted as a separate request.
Scope Changes
• What is a scope of service rate change
• California only!
• How does behavioral health services affect
a scope of service rate change?
• Can you do a scope change for an
intermittent clinic?
• If you move the clinic, should you do a
scope change?
• Qualifying event?
Scope of Services
Change Instructions
Scope Changes
Some Basic Rules
• Need final PPS rate
• Qualifying event
• Our costs went up, who cares!
• PPS vs. cost/visit – 1.75% increase?
• Been asked to lower PPS rate
• 20% decrease in difference
• 5 months after fiscal year end
• Effective first day of new fiscal year
Medicare Enrollment
Where to Begin?
• Do you have an NPI for the site?
• If not, enroll here:
https://nppes.cms.hhs.gov/NPPES/StaticForward.do
?forward=static.npistart
• NPI’s should be site specific – multiple
sites, get multiple numbers (easier to track
payments).
• NPI is primary identifier for each site and
physician
Medicare Enrollment
Need an application?
• Go here:
http://www.cms.hhs.gov/MedicareProviderSupEnroll/0
2_EnrollmentApplications.asp#TopOfPage
• Which application to use?
• What do you need to enroll?
• Provider location? (855A)
• Part B services? (855B)
• Add/link a physician to a group? (855R, maybe 855I)
CMS 855I Enrollment
Individual Practitioner
Questions?
•PPS
•SPA
•Licensing
•HRSA
•Scope Change Rate Requests
•Medicare Enrollment
•Other
Reimbursement
for Behavioral Health
John Pfeiffer
Principal
HFS Consultants
Reimbursement
Cost Reporting - Allowability of MH Cost
& Visits
• No separate rate for MH services – existing rate gets
adjusted
• Medicare and Medi-Cal both allow encounters with Clinical
Psychologists (CPs) and Clinical Social Workers (CSWs) as
billable visits.
• What about other mental health personnel (e.g. Marriage &
Family Therapists)? Their cost may be allowable under the
"incident to" rules, but the encounter is not billable.
• Medicare does not allow “group or mass information
programs, health education classes, or group education
activites.”
Reimbursement
Handling of MH Services in Cost Reports
Staff
Cost Allowed?
Count Visits?
Clinical
Psychologists
Yes
Yes
Clinical Social
Workers
Yes
Yes
Other MH
Personnel
Maybe, under the
“incident to” rule
No
Reimbursement
Medicare Cost Reporting
• Productivity standards do not apply (i.e., 4,200
visits per FTE for physicians and 2,100 for PAs &
NPs)
• Outpatient mental health service limit applies
(therapeutic services only, not initial diagnostic
services):
• 2009 & prior: 62.5% of cost
• 2010 & 2011: 68.75%
• 2012: 75%
• 2013: 51.25%
• 2014 & future: 100%
Reimbursement
Medi-Cal Scope of Services Rate Change
• Adding MH services is a qualifying event for a new PPS rate
• New rate is not effective until the fiscal year after MH services
are added
• Getting the money for a new rate can take a year or more!
Sample timeline:
• June 2009: Clinic adds MH services
• Dec. 2009: Clinic’s fiscal year closes
• May 2010: Clinic submits rate change request
• Nov. 2010: DHCS audits and finalizes new rate
• Feb. 2011: EDS pays retro money for Jan. 2010 thru Nov.
2010
• Keep good documentation of when MH services were added
(contracts, payroll records, etc.)
Reimbursement
Medi-Cal Scope of Services Rate Change
Financial modeling is needed for planning when to add
MH services. Considerations:
•
•
•
•
•
Additional costs and billable visits from MH services
Cost PV of MH services relative to existing services
Effective date of new rate (year after adding MH)
Delays in getting retro cash for the higher rate
Other dynamics affecting a rate change:
• MEI doesn’t reflect true cost inflation
• Changes in existing clinic costs and visits since last rate
was set
• 20% reduction in increased costs
Reimbursement
Medi-Cal Scope of Services Rate Change
• If MH services have a lower cost PV than the clinic’s existing
cost PV, then adding them will lower the rate. Thus, it would
appear best to add services near the end of the fiscal year.
BUT ON THE OTHER HAND…
• If you add MH services at the beginning of the year, you will
have more billable Medi-Cal visits, albeit at the existing
(presumably lower) rate.
SO WHICH IS BETTER: ADDING THE SERVICES
EARLIER OR LATER?
Reimbursement
Other Cost Reporting Issues
• Medi-Cal Code 18 (Medi-Cal mgd. care) and
Code 20 (Medicare Advantage) rates
• Medi-Cal PPS reconciliations
• Home Office Cost Reports – required by
Medi-Cal
• Appeals