Transcript Slide 1
Reimbursement for Integrated
Behavioral Health in Primary Care:
Making it work
Mary Jean Mork,LCSW
Quality Counts
March 14, 2012
Our Goal: Outcome driven,
sustainable integrated practice
model for patients and providers
Objectives
Participants will be able to:
I. Describe the factors that affect billing and
reimbursement in an integrated setting
II. Identify tools to support reimbursement for
mental health integration
III. Identify strategies to support financial
sustainability of integrated practice
My Goals for Today
Share information
Acknowledge that this is complicated
Welcome and learn from your additional
information and questions
Be aware of gaps in knowledge
Stand corrected, as needed
Help us all think about better ways of doing
things
Disclaimer – always seek info from your own agency
consultants re: regulations, billing and coding
Poll Question 1 – How long have you been
involved with integrated services?
Less than 6 months
6 months to 2 years
2 – 5 years
More than 5 years
Best Practice Principles for
Integrated Services
Patient and family centered
Professional connections: medical and mental
health
Integrated mental health clinician – full member
of primary care team
Warm hand-offs & timely scheduling
Brief focused treatment
Access to specialty mental health care
Primary & Specialty Medical Health Care
Specialty Mental Health
Care
Screening for
common mental
health conditions
Primary Care
Treatment
Specialty MH
care by referral
Integrated mental
health services
Consultation services:
Collaborative care
Mental Health Specialist in
Primary Care:
How about those
differences?
The Question: How do we pay for it?
Often starts the conversation
Comes up frequently as the program
gets started
Becomes crucially important when
grant funding runs out
Continues to come up as you realize
you’re not getting paid
Meet Denise
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
Referral: reduce
anxiety
Health and Behavior
Assessment
Mental Health
Assessment
Medical referral and
diagnosis
Brief, focused
assessment and
intervention
Medical referral
needed?
Mental Health diagnosis
“Comprehensive”
assessment and
treatment
The Codes
Health & Behavior codes
Mental Health Codes
96150: Assessment
96151: Reassessment
96152:
Individual intervention
96153:
Group intervention
96154:
Family intervention
90801:
Initial Assessment
90804, 90806, 90808:
Individual Therapy
90807, 90809:
Ind. Therapy + E/M
90846,90847:
Family Therapy
90853:
Group Therapy
90862:
Med Management
Insurance Ramifications
Health & Behavior codes:
Mental Health codes:
Covered by some
insurers, not all
Discipline reimbursable
for some, not all
Medical benefit: No preauth, no carve-out, no
different co-pay
Medical practice bills
Covered by most
insurers
Generally reimbursable
Contract & credentialing
with behavioral health
carve-out needed
May eventually need
pre-auth
May require larger copay
Poll Question 2 – Which codes would you
use for Denise?
Health and Behavior
Mental Health
Both
Don’t know
It depends
Complicated Financial
Arrangements
No one seems to know the best way to get
paid
Mental Health regulations and licensing
expectations don’t fit the primary care
setting
Documentation regulatory issues
Actual reimbursement less than
anticipated
Questions to Ask
What are the licensing and
reimbursement rules for your setting?
FQHC,RHC, provider based, mental
health agency
How do these rules affect the following
factors?
“Employment” of the staff and supervision
Patient registration
Billing for Behavioral Health
Actual reimbursement
Documentation
Poll Question 3 – What type of setting
do you work in or with?
FQHC
RHC
Hospital owned practice – Provider
based
Private practice – medical
Various Payers and Various Rules
Medicare
Medicaid
Commercial Insurers
Mental Health vs.
Medical codes
Licensing rules
Medicaid
States have flexibility in defining covered
mental health services
Can choose to contract with managed care
Billing requires both a diagnosis and a
procedure code
Some states limit procedures, providers and/or
practices that can use these codes
States differ on allowing two services
(mental health and medical) on same day
Medicaid - MaineCare
Section 65 – Behavioral Health Services i.e.
“Mental Health Agency” and Individual Mental
Health Clinician
Section 90 – Private (Medical) Practice i.e.
“Doctors’ Office”
Section 45 – Hospital Owned Practice i.e.
“Doctors’ Office or Outpatient Clinic”, provider
based
Section 31 – Federally Qualified Health Center
(FQHC)
Section 103 – Rural Health Clinic (RHC)
Poll Question 4:What MaineCare Section are
you using to bill integrated services?
Section
Section
Section
Section
Section
65 - Mental Health
90 - Private medical practice
45 - Hospital owned practice
31 - FQHC
103 - RHC
Medicare considerations
Rates for different disciplines (75-100% of
physician)
Outpatient mental health limitation 20102014*
Increased mental health rate toward parity
No mental health reduction for diagnostic
services
Specific rules for different types of
practices, e.g.FQHC, RHC, Provider Based
*Published on the NHIC website at www.medicarenhiccom on the Fee
Schedule page.
Commercial Insurances
Develop contracts with behavioral health
Carve-outs confusing for medical practice
Reimburse for Health & Behavior codes?
Different disciplines?
Medical or behavioral health service?
Be clear at point of service
Document to support service
Know expectations of payers
Recommendation to bill for service to establish
“need” for reimbursement
Some key questions
Payment for 2 encounters in the
same day?
Reimbursement for Health and
Behavior codes?
Pre-authorization required for mental
health visits?
Full assessment required before
treatment can begin?
Back to Denise – What do you do?
Depends on her needs
Depends on her diagnosis
Depends on service delivered
Reimbursement will depend on
insurance and discipline of clinician
Can go from H&B to mental health,
but not both together
It’s easy to get confused!
Useful Tools
Develop and continue to modify a
Start-Up Guide
I. Pre-Hire – clarification of financial and
billing arrangements
II. Hiring process - Credentialing and
preparation for billing
III. Orientation of Mental Health Clinician
(MHC) and preparation for billing
IV. Ongoing support - Monitoring
reimbursement and continuous
improvement
Tracking the Work
To provide rapid feedback on financial
aspects of integration
Waiting for reimbursement data takes
too long
We are increasingly able to estimate
reimbursement from billing
Teams working on integration can use
data to assess whether the mix of services
being provided is sustainable
Track the work
Record services
Billable
Non-billable
Record Insurances
Optional - Assign relative
“factors”
Services - time units
Insurances – general
reimbursement comparisons
Multiply Service x Insurance
Total for time period
Tracking Sheet –
Reimbursement Codes and Values
Mental Health Codes
Health and
Behavior Codes
Non-Billable
Activities
90801 = 4
Initial Assess
96150 = 2-4
H&B Assess
DI - Dual Interview
with Physician = 0
90804 = 1
Ind Therapy
96151 = 1-4
H&B Reassess
PO – Parents only
before 90801 = 0
90806 = 2
Ind Therapy
96152
96153 = 1-4
H&B Intervention
C - Consult to
Provider = 0
90847 = 4
Family Tx /w pt
96154 =1-4
H&B Intervention
with Family & Pt
M – Meeting = 0
Medicaid = 1
Medicare = 2
Self Pay = 1
SAMPLE
Reimbursement Tracking Sheet
Mental Health Integration
Provider ________Annette_________________
Place of Service ______Your Practice_____________
Date of Service
Service Code
Billed
Reimbursement
Factor
Insurance
Factor
Total
3/9/11
90801
4
2
8
3/9/11
C (Consult to
PCP)
0
2
0
3/9/11
90847
4
1
4
3/9/11
DI (Dual
Interview)
0
3
0
3/9/11
90806
2
1
2
3/9/11
90801
4
3
12
Total
26
Financial Tracking
40
35
Total 'Points'
30
25
20
15
10
5
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Week
16
17
18
19
20
21
22
23
24
25
26
27
28
The Team makes it work
Recommendations
Acknowledge link between providers and coders
Focus on the front end
Know rules for setting, payers, discipline
Train all staff – start-up and ongoing
Work with MHC re: coding and documentation
Billing requires time, resources and connections
to “experts”
Internal auditors as helpful monitors
Track the money from day one
Acknowledge and support everyone’s role in
making it work
Provide a “friendly forum” to focus on this work
Administrative meeting: the “friendly forum”
Clinicians, provider rep, billers/coders, practice
managers, leadership
Data on show rates, referrals, volume. What’s
working, not working? Targets?
Payment information: codes getting reimbursed/
denied
Communication issues and improvement
suggestions: related to patients, providers and
practice
Clinical practice issues: e.g. length of sessions,
frequency and duration of treatment
What really makes it work
Willingness and drive to learn new things
Ability to tolerate bumps
Proficiency in addressing problems
Ability of team to work together to move
this forward
Leadership willing to take risk, create
vision, support process improvement, and
believe in the purpose of the integrated
service
We’re optimistic about the Future of
Integrated Behavioral Health and
Primary Care
Resources
MaineCare Links
http://www.maine.gov/sos/cec/rules/10/ch101.htm
http://portalxw.bisoex.state.me.us/oms/proc/pub_proc.asp
Medicare Links
http://www.cms.gov/Manuals/IOM/list.asp
http://www.cms.gov/Transmittals/01_overview.asp
Medicare Documentation Guidelines for Evaluation and Managements
Services 95 & 97
http://www.cms.gov/MLNEdWebGuide/25_EMDOC.asp
NHIC http://www.medicarenhic.com/
Other
www.mehaf.org – Maine Health Access Foundation
www.thenationalcouncil.org – the National Council for Community
Behavioral Healthcare
www.ibhp.org – Integrated Behavioral Health Project
www.mainehealth.org/mentalhealthintegration
Contact information:
Mary Jean Mork
[email protected]
207-662-2490