FQHC Behavioral Health
Clinical Excellence and Financial
Sustainability
Welcome!

• What is all the buzz about ?

“We should not maintain state systems if the alternative is being part of the mainstream….we must lead to achieve integration of care everywhere…. I believe that a few entrepreneurial leaders will embrace the challenge of true integration ..from policy to plan to practice. These entrepreneurs will also succeed in business because the game will come to them”
M.Hogan, Commissioner, NYS OMH”

• Most every FQHC is doing something
• Physical spaces are being rethought
• Beginning to realize integration is foundation for other strategic initiatives
• Behavioral health is seen as another “core” service
Supports other initiatives

• Operate fiscally sustainable clinics that demonstrate the efficient conversion of resources (employee time and effort) into effective patient care

• “ Un-natural act by two un-consenting adults “

Multidisciplinary
Care
Colocated
I ntegrated Care
Collaborative
Care
Interdisciplinary
Care
Transdisciplinary
Care

• LMSW
• LCSW
• LMHC
• LMFT
• PsyD
• PhD
• MD
• PA
• PNP

• Need the right people !!!
• Need the right training
• Benchmark/staffing ratios

Staffing and Billing
Billing and Staffing
• Which comes first

• Billing comes first
• Who are the most billable providers in your setting

• 90791- Diagnostic Evaluation/Intake
• 90832 - Psychotherapy, 30 minutes
• 90834 - Psychotherapy, 45 minutes
• 90837 - Psychotherapy, 60 minutes
• 90839 - Psychotherapy for crisis
• 90853 – Group Psychotherapy
• 90846 – Family/Couples Psychotherapy w/out Pt
• 90847 - Family/Couples Psychotherapy w/ Pt

• 90792- Psychiatric Evaluation
• 99212 -Medication Management
• 99213 - Medication Management
• 99214 - Medication Management
• Use above E&M Codes and then add on a therapy code if needed

• Billing varies greatly with staffing
• What is the licensing of the staff you are hiring or who will be working on this project?
• Billing varies greatly by state
• Do your billing and reimbursement homework
BEFORE you hire your staff
• Do you have staff now you cant afford to keep when the grant goes- unlicensed, lmhc

• Figuring sustainability has many different pieces
• Productivity is only one- often the one that gets the most emphasis
• Know all of the “colors” in your behavioral health business painting

• If you don’t see enough patients
• Know the ratios
• Productivity needs to support sustainability

EFFICIENCY PERFORMANCE
INDICATORS —
• Capacity: % of Face-to-Face time spent with patients producing visits out of the total time available for patient care
• Productivity: Count of Visits Provided related through
• Rate of Production: Visits per given time
(e.g. hour, standard work day)

EFFICIENCY PERFORMANCE
INDICATORS —
Necessary Data Points:
• Face-to-Face time spent with patients producing visits
• Count of Visits Provided
• The total time available for patient care

• Scheduling optimization can be one of the most critical activities for helping with
• Access to care
• Productivity
• Efficiency
• Revenue

SCHEDULING PERFORMANCE
INDICATORS —
• Scheduling Days Out: Count of days between the date on which an appointment was made and the date for which it is scheduled
• No-Show Rate: % of scheduled appointments for which a patient does not present, or that a patient cancels within 24 hours

SCHEDULING PERFORMANCE
INDICATORS —
Necessary Data Points:
• Date Appointment was Made
• Date of Appointment
• Appointment Outcome
• Cancellation Date ( when is a no show)

What is your ideal maximum number of days out?
Number of “ acceptable” open slots ?

• Counting slots
• When are they –days /times
• Shadow scheduling
• Same day/ next day

Identify high areas of no shows

Identify high areas of no shows

“Pull Forward” Currently Scheduled Intakes
1. Identify high areas of no shows-predictive modeling
2. Create strategic overbooking slots in the times of frequent no shows- we call them
“access slots”
3. Take appointments scheduled furthest out and pull them forward into new slots
4. As show rate increase, adjust number of access slots

Discontinue the habit of recurring individual therapy appointments, instead schedule weekto-week.
Calls to reschedule more than two appts
Scheduled cancellations
In same week

Consider walk-in only medication management follow-ups.
1. Psychiatrist tells patient at end of visit to walkin “the week of” and provides available hours
2. Reminders based on who has been instructed to come in “the week of”

Identify a “right-sized” number of intake slots
• How many ongoing cases can you clinic support at a time given current staffing?
• What is your average length of treatment?
• What percentage of intake convert into careas opposed to case closure?
• What is your no-show rates on intakes now?

• Staffing
• Productivity/Volume
• Direct Revenue
• Indirect Revenue
• Coding
• Contracting
• Optimization ( concurrent doc)
• Back end-denials,
• Dashboard development

• There are many different workflows
• Workflows can vary by location or provider
• Not set in stone
• Why do I need to do my reimbursement work before I figure out my workflows?
• Why do workflows matter ?
• Example-Medicare, hand off to open slots

• What payers does your organization or BH services get reimbursement from
• Make a grid to review each payers each service and each provider
• Review guidelines for each payers- are services part of the contract or do they need to be added
• Does the payer reimburse for all credentials, i.e. social workers vs. counselors
• Special payer programs-like depression

• What payers does your organization bill to or contract with
• List all of your payers Individually- remember some have more then one plan
• List all of your billable staff
• Leave space for contracting possibilities

• Can be second source if a provider or code is not billable
• Contrary to popular belief they are negotiable
• If you don’t ask (is this the best rate you are offering in this state ?)
• Check with other integrated projects in your state- what are their arrangements (you cant partner)
• Medicare Advantage

96152
96153
96154
96155
Add ons
90785
90839
90840
Health & Behavior Intervention –
Individual (each 15 mins)
Health & Behavior Intervention –
Group (each 15 mins)
Health & Behavior Intervention –
Family with Patient (each 15 mins)
Health & Behavior Intervention –
Family without Patient (each 15 mins)
Interactive complexity add-on (for psychotherapy codes)
Patient in crisis add-on – 60 minutes
Patient in crisis add-on – Each additional 30 minutes

• Not to be confused with professional appointments
• Why should I bother if most of our patients are
Medicaid?
• What if my organization doesn’t credential behavioral health providers?
• Subject to reviews by credentialing organizations
Takes a long time-
Delegated credentialing is a goal

• Can help support integration work
• Will vary by organization/setting/payer mix
• Time spent with PCP
• No show rates for PCP, specialty care
• Medication adherence
• Emergency room visits/utilization
• Productivity for behavioral health

• Disease Management industry
– Potential to have care management paid for
( at your site vs. by phone )
– Special programs, like Aetna
• Brings in additional dollars above wrap
• Showcases your program/project
• Offer to be a “ pilot”

• Knowing what you should be paid for all services
• Reviewing work flows, opportunities to “up code”
• Review same day billing, services
• Different diagnosis for same day visits
• NOS vs MDD

• Two Visits on the same day
• Incident too visits
• Behavioral health providers in health centers
• Depression Screenings
• Form Completion

• Look closely at EOB’s
– Not all payments are correct
– Review and Track your Denials
– Often Dx denials
• Review:
– Payer contracts
– Self-pay determinations
• Sliding fees
• Do you need a different sliding fee for behavioral health ?

• Your cost per visit for behavioral health ?
• Your average reimbursement for behavioral health ?
• How to know how much a staff person costs
?
• If not ………………

• Readable
• Useful to:
– Patient
– Clinician
– Others involved in patient’s care
• Demonstrates clinical necessity

We need to value documentation as a representation of the clinical processes it represents:
• Assessment
• Shared Care Planning
• Clinician-Client interactions
• Clinical progress
PROGRESS
NOTES

CMS (Centers for Medicare and Medicaid
Services) definition:
“services or supplies that are needed for the diagnosis or treatment of a condition and meet acceptable standards of practice”
In other words…you are treating a diagnosis, and must show how you are addressing the symptoms of that diagnosis in each visit.

Psychosocial Assessments:
• Not enough symptom information in assessment to support diagnosis
• Not capturing clinical baselines
• No documentation that clients were given the opportunity to identify their own goals for treatment
*Based on NYSCRI regulatory review

Progress Notes
• Not tied to care plans in a meaningful way
• No documentation of skilled interventions provided
• No documentation of clinical progress
(symptom resolution, etc.)

• Behavioral Activation
• Motivational Interviewing
• Problem Solving Treatment
• Psychiatric Wellness Self Management

Assessment Tool Used to Assess Age
ASQ-SE
AGES and Stages Questionnaire – social emotional
Development 2-60 months
AUDIT
The Alcohol Use Disorders Identification Test (AUDIT)
Alcohol Abuse & Dependence 18+
6-17 CES-DC
Center for Epidemiological Studies Depression Scale for Children
Depression
Suicide C-SSRS
Columbia Suicide Severity Rating Scale
CPSS
Child PTSD Symptom Scale
CRAFFT
DAST-10
Drug Abuse Screening Test – 10 Item
DLA-20
Daily Living Activities – 20 Item
GAD-7
Generalized Anxiety Disorder 7-Item Scale
M-CHAT
Modified Checklist for Autism in Toddlers
PTSD
Substance Abuse
Drug Abuse
Functioning
(Activities of
Daily Living-ADLs)
Generalized Anxiety Disorder
Autism Spectrum
7+
8-18
14-21
18+
6+
18+
16 to 30 months

Bipolar Disorder MDQ
Mood Disorder Questionnaire
PHQ-2
Patient Health Questionnaire 2 Item
Depression
18+
11+
11-17 PHQ-A
Patient Health Questionnaire for Adolescents
PHQ-9
Patient Health Questionnaire 9 Item
Depression
Depression
SCARED
Screen for Child Anxiety Related Disorders
(For children 8 to 11 it is recommended the clinician explain all questions or child sit with an adult in case they have any questions)
SCARED-Parent Version
Anxiety
Disorders
18+
8-17
VANDERBILT-Parent
VANDERBILT -Teacher
RAD
Reactive Attachment Disorder Screening Tool
ADHD
ODD/Conduct
Anxiety/
Depression
ADHD
ODD/Conduct
Anxiety/
Depression
Child Attachment
6-12
6-12
5 -18

• Vlittle@institute.org