Session #E3a
October 28, 2011
Reimbursement of Behavioral Health
Interventions in Primary Care
Colleen Clemency Cordes, Ph.D.
Clinical Associate Professor
Ronald R. O’Donnell, Ph.D.
Program Director
Nicholas A. Cummings Behavioral Health Program
Arizona State University
Collaborative Family Healthcare Association 13th Annual Conference
October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.
Faculty Disclosure
We have not had any relevant financial relationships
during the past 12 months.
Need/Practice Gap & Supporting Resources
• Despite a demonstrated need for behavioral health
providers in primary care, researchers continue to
identify administrative issues such as billing as the
central barrier to service integration
• At last year’s CFHA Conference, we administered
surveys to interested parties on current billing practices
in primary care
Objectives
• Identify administrative barriers to successful
reimbursement of behavioral health services in primary
care
• Review current strategies for service reimbursement,
including the use of E/M codes and H&B codes
• Identify and advocate for and address the need for
reimbursement health interventions in primary care
Expected Outcome
By the end of today’s session, we hope that you will have
the knowledge and skills necessary to bill for behavioral
health services in primary care
The Problem
• Primary care providers are often unable to adequately address
behavioral health concerns with their patients due to:
o Lack of time
o Lack of training
o Inability to get adequate reimbursement
• Meadows et al. (2011) found that when PCP’s deliver behavioral
health interventions in a primary care clinic, they:
o Spent 19.69 minutes with their patients, as opposed to 8.04 minutes spent
on medical complaints, or 17.00 minutes on combined medical & behavioral
concerns
o Were only able to bill under one CPT code, rather than an average of 2.68
codes used in combined medical/behavioral visits
o Were reimbursed at a rate of $4.36 per minute, compared to $18.12 per
minute for medical visits, and $5.86 per minute for medical & behavioral
visits
The Solution
• Integration of behavioral health providers into primary care
leads to improved patient health outcomes and increased
physician productivity, allowing for substantial medical cost
offset
Except…
• Despite strong evidence in support of the integration of
behavioral healthcare into primary care, substantial barriers
exist with regards to billing that prohibit the development and
sustainability of many of these practices
Historical Context
• Healthcare Common Procedure Coding System (HCPCS)
was initially established in 1978
o Goal was to ensure consistent reimbursement practices for Medicaid,
Medicare, and private insurances
o Use of codes became mandatory with passage of HIPAA in 1996
• Current Procedural Terminology (CPT) codes are maintained
by the AMA as part of HCPCS
Reimbursement Options
• Currently, there are three systems of CPT codes which can be
used for reimbursement of behavioral health interventions:
o Evaluation & Management (E & M) codes
• 99201-99443
• Primarily used by medical staff (physicians, nurses, PAs, etc.)
o Health & Behavior (H & B) codes
• 96150-96155
• CMS only reimburses these codes for psychologists
o Psychiatric Services codes
• 90801-90808, 90862, 99241-99245
• Can be used by behavioral health or medical providers
The Challenge…
• Despite the availability of codes to bill under, there is
substantial variability across states regarding appropriate use
of the systems
• Billing opportunities constantly evolving
• Practice type/setting impacts use of codes
o FQHC’s commonly able to bill via H & B codes, even in states that do
not accept these codes
The Challenge Continued
• Carve-in versus carve-out healthcare plans
o The “Infinite Loop” of reimbursement/service rejection (Bruns, 2009)
• Lack of administrative awareness on how to bill for services
Solutions Worth Attempting:
• Advocate for use of H & B codes on the state level
• Develop integration-specific codes on the state level
• Follow the VA example:
o Create a system in which mental health funds are transferred into the
physical health budget and provide payment for services under a single
budget
• Provide administrative template for procedural aspects of
billing
“Identifying Solutions for Overcoming Reimbursement
Barriers to Developing a Financially Sustainable Integrated
Healthcare Program” (Farrell, 2010)
• In an attempt to better understand billing practices nationwide,
Dr. Lesley Farrell, a graduate of the ASU DBH program,
undertook a project to review current practices in use
• Surveyed practices in AZ via structured interview and/or
paper-pencil questionnaire, as well as distributed the
questionnaire at last year’s CFHA Conference in Louisville
o 25 practices participated, representing 5 different practice types
States Represented in the Results
Practice States
9%
4%
4%
NC
4%
PA
4%
OK
4%
25%
MO
NH
CO
IL
IL
13%
NY
ME
CA
4%
4%
VA
PA
4%
9%
4%
4%
4%
AZ
Not Reported
Who Is Providing the Integrated Care?
IBHS Clinician Representation
MD
3%
LPC
LCSW
5%
PSY
8%
Psy NP
other (LAC, DO)
not provided
5%
23%
28%
28%
Practice Type
6
5
# of Practices
4
3
2
1
0
outpatient mental
health
hospital
primary care
specialty care
Practice Settings
primary care &
specialty care
network
not specified
Reimbursement Sources
Not Reported
20%
Medicaid
22%
Not Billing
9%
Patient Self-Pay
2%
Grants
2%
Medicare
9%
Private Insurance
36%
Reimbursement Systems Used
10
9
8
# of Responses
7
6
5
4
3
2
1
0
Psych
H&B
H & B and E & M
Coding Systems
E & M and Psych
Unknown
Reimbursement System by Practice Setting
9
8
7
6
5
Psy Codes
4
H&B
3
E&M
Other
2
1
0
Outpatient
Hospital
PC
Specialty
PC &
Specialty
Other
Provider Use of Reimbursement Code System
9
8
# of Providers
7
6
5
Psy Codes
4
H & B Codes
3
E & M Codes
2
E & M Codes
1
H & B Codes
0
MD
PSY
Psy Codes
LCSW
LPC
Provider Type
Participant Barriers to Reimbursement
•
•
•
•
Covering the uninsured patient
Medicaid does not always reimburse for services
Restrictions on same-day services
Service pre-authorization needed by some insurance
companies
• Specific codes not being recognized or reimbursed
• Psychologists being denied for paneling by insurance
companies due to too many providers in the area.
• Psychologists being denied for paneling by insurance
companies due to not being licensed long enough
Barriers Continued
• Extensive paperwork for minimal reimbursement
• Reimbursement rate a small portion of full rate of service
• Lack of understanding of insurance and legal reimbursement
requirements by agency administration
• Primary care agencies reluctant to pursue reimbursement due
to feared liability if it is not done the “correct” way
• Local Medicaid system wants primary care to only use their
specialty behavioral health services for eligible patients for all
services
• Lack of insurance benefits for IBHS in primary care
• Difficulty communicating with payers
Conclusions
• Social workers and psychologists are the primary providers of
integrated behavioral health services
• Despite past literature, private payers were reported as a
majority payer of services
o This may be due to large rate of “don’t know” responses to payer
questions
• Psychiatric codes appear to be most commonly used codes to
obtain reimbursement
• Increased emphasis should be placed on expanding the
acceptability of using H&B codes
• Questions?
• Comments?