Reynolds 2015 Part 3 – Financing

Financing Integrated
Health Care
Kathleen Reynolds, LMSW, ACSW
[email protected]
Future Billing Needs
Transitioning to Supporting Financial Risk,
Accountability, & Utilization Management Practices
Provider Compensation Continuum
(Level of Financial Risk)
Small % of financial risk
a. 100%
case by
case UM
- based
Begin empowerment
b. External
using data
Moderate % of financial risk
Empowerment/mod Accountability
Large % of financial risk
Full empowerment/high accountability Full Accountability
c. Internal engagement in monitoring
of performance using data
Capitation +
d. Internal ownership of
performance using data
Source: Rhonda J Robinson Beale, M.D.
Optum Chief Medical Officer, External Affairs
New Business Model for Integration Must
Include Answers to:
1. The Value Proposition: What will your agency provide to
Consumers, Families, Community Members, Health Network
Partners, & Payers?
2. What are the Start-up Costs? How will it be funded?
3. What is the Model for Linking Outcome Data to Cost (i.e.,
episode of care logic)?
4. How are Operating Costs (i.e., fix & variable costs) met by a
sustainable service model constructed from episodes of
care that can be collapsed into a case rate?
5. How is the episode of care logic mapped to the service
array and embedded in the team work flows?
The Five Core Elements of Bundling
www.TheNationalCouncil .org
(1)Can you agency define episodes of care by diagnosis,
services provided to that diagnosis and length of an
(2)Using historical data, can you cost out the episodes of
care in item 1?
(3)In your costing can you add to the direct costs an
approvable indirect cost rate and spread the costs across
the various costs?
(4)Can staff electronically collect data to verify services
provided to/for each episode?
(5)Can you quality improvement systems monitor bundles
services and rates?
Building the Episode of Care
www.TheNationalCouncil .org
Must define an episode of care including dx, services bundle, and
episode duration.
Using historical data calculate your cost to provide the episode.
Determine how a bundled payment would be divided across staff and
overhead costs.
Design policy, procedures, & training so staff can deliver services
efficiently and effectively (i.e., use of EBP and treat to target).
Care Coordination Elements
Care Coordination Job Duties:
 Accountable for overall care management and care
coordination, and both provide and coordinate all
integrated service.
 Responsible for needs and goals. overall management
and coordination of the consumer's integrated care plan,
including physical health, behavioral health, and social
 Conduct case reviews on a regular basis
 Uses an electronic registry for population management
 Life long services available
National Best Practice
 Whole Person Orientation (physical, behavioral, social service needs)
 Population Management Approach
 Care Transitions
 Evidence Based Protocols for diabetes, heart disease, tobacco, depression
 Data Based Decision Making
 Improvement in health care utilization and social capital
Care Coordination
 The Care Coordination Standard: When I need to see a
specialist or get a test, including help for mental health or
substance use problems, help me get what I need at your
clinic whenever possible and stay involved when I get care
in other places.
 Services are supported by electronic health records,
registries, and access to lab, x-ray, medical/surgical
specialties and hospital care.
Five Core Elements of Care
(1) The organization provides, population based care
(2) The organization has an electronic health registry that
allows us to collect and feedback core elements of
integrated care to care coordinators.
(3) The organization’s care coordination allows for life-span
(4) The organization provides assistance with care transitions
from physical and psychiatric hospitalizations.
(5) The organization has implemented at least two evidence
based, primary care interventions such as diabetes
management, high blood pressure management, etc.
Current Billing Options
The Concept of
“Community Health Money”
 Organizations are stewards of public funding –the money is not owned by any
particular organization – it is the community’s money.
 When money is “pooled” for services return on investment is to the
community services.
 Program from what is best for the consumer & the community, then figure out
who finances it.
Begin with the Consumer In Mind…
Reduce turf wars over money by focusing on the
What is possible in the community &/or what
would you like to be available?
Do not think about “what is paid for”.
Once you’ve determined what you want, convene
finance folks (conservative & creative) to determine
how to pay for it.
Basic Principles of
Billing and Reimbursement
CPT Codes (Current Procedural Terminology)
Behavioral Health Codes 908xx series (MH & SU)
 Traditional behavioral codes by an acceptable licensed and
credentialed practitioner for that state and setting (Physician, Nurse
Practitioner, Masters Social Worker, PhD Psychologist)
Telemedicine (usually the same code as face to face service
with a modifier)
 Typically these services are billable by an acceptable licensed and
credentialed practitioner for that state and setting
Case Management
 Can only be billed by an acceptable licensed and credentialed
practitioner for that state and setting
 Generally a CMHC service
Interim Financing & Billing Worksheets - CIHS
 Designed to help agencies understand billing for integrated health
services using the public safety net system.
Type of Agency (FQHC, CMHC)
Funding Source (Medicare, Medicaid)
CPT Code
Practitioner Discipline & Credential
 The worksheets are posted on the CIHS website:
Tips/Opportunities for Billing
1. Interim Financing Solutions for Integrated
Healthcare Worksheet
2. Two Services in One Day
3. 96000 Series of Codes
4. Case Management
5. Screening Brief Intervention & Referral to Tx (SBIRT)
6. Dear Medicaid Director State Option
7. Health Home State Plan Amendment Option
Two Services in One Day
 Myth: The federal government prohibits this or Medicaid won’t pay for this!
 Reality: This is a state by state Medicaid issue, not a federal rule or regulation –
Texas does allow this.
 Federal Citations:
Medicare will cover a physical health and mental health visit same day/same provider –
CFR Title 42 Volume 2, Part 405. Section 405.2463
Case Management
Billable for Special Populations.
If CMHC staff are leased & co-located
in an FQHC clinic they can bill.
The 96000 Series Codes
Approved CPT Codes for use with Medicare
right now
Some states are using them now for Medicaid
State Medicaid programs need to “turn on the
codes” for use
Behavioral Health Services “Ancillary to” a
physical health diagnosis (e.g., diabetes)
The 96000 Series Codes
Health and Behavior Assessment/Intervention (96150-96155)
Health and Behavior Assessment procedures are used to identify
the psychological, behavioral, emotional, cognitive and social
factors important to the prevention, treatment or management of
physical health problems.
96150 – Initial Health and Behavior Assessment – each 15 minutes faceto- face with patient
96151 – Re-assessment – 15 minutes
96152 – Health and Behavior Intervention – each 15 minutes face-to-face
with patient
96153 – Group (2 or more patients)
96154 – Family (with patient present)
96155 – Family (without patient present)
Screening, Brief Intervention, Referral
for Treatment (SBIRT)
 Approach to the delivery of early intervention and treatment services for
persons with SA disorders or those at risk of developing these disorders.
Primary care centers, hospital emergency rooms, trauma centers, and
other community settings provide opportunities for early intervention with
at-risk substance users before more severe consequences occur.
 Screening quickly assesses the severity of substance use and identifies
the appropriate level of treatment.
 Brief intervention focuses on increasing insight and awareness regarding
substance use and motivation toward behavioral change.
 Referral to treatment provides those identified as needing more extensive
treatment with access to specialty care.
Disease Management Payments for Primary
Care of Seriously Mentally Ill
 2005 “Dear Medicaid Director Letter” (precursor to ACA 2703 Health Home
 Currently available to states.
 Allows CMHC’s to draw down disease management funding for SMI and
Developmentally Disabled population
 Michigan Project
Tailored to persons with SMI, Developmental Disabilities and Substance Abuse
Disease Management for SMI - dollars to CMH; CMH pays primary care
FQHCs are a critical component of the 2010 ACA Grant Funding will
nearly triple over five years
Proposed FQHC Grant Funding
FY2010 FY2011 FY2012 FY2013 FY2014 FY2015
FQHC Standalone Approach
Behavioral Health Expansion Grant Funding
available, often each year, to expand BH
services in FQHC settings
Most recent application January 2011
All New Starts must have behavioral health
• Direct Hires
• Contract with local CMH
CMHC Standalone Models
 In many states CMHC must apply for a new Medicaid # to bill for
Primary Care Services
Must apply first for Medicare # to get the Medicaid #
• Exception: In Ohio, CMHC’s with Risperdal license can bill for primary care
 Accreditation Considerations
Depending on accrediting body (Joint Commission, CARF, NCQA) your
organization may need to become accredited as an ambulatory care
facility to provide physical health services.
 This whole process can take 2-3 years
FQHC/CMHC Partner Models
 FQHC bill by encounter rates-Perspective Payment Model.
Receive the same amount of funding for a 10 minute visit
as they do for a 1 hour visit.
 Contracting with FQHC
Leasing Options for staff
• Psychiatrists
• Consulting Psychiatrist Model (Regional MHC Indiana)
 Cost offset approach for Indigent population
FQHC receive federal funds to cover the cost of indigent
 CMHC can provide Case Management
FQHC/CMHC Partner Models
You may be surprised for example:
 In one Fee for Service state, for psychiatric medication service 90862
A university medical center clinic is reimbursed $12.50
The same visit at a CMHC is reimbursed $39.92
At an FQHC, the visit would be reimbursed at $80-88
 In a nearby Fee for Service and managed care state, for 90862:
A university medical center is reimbursed $19.53
The same visit at a CMHC is reimbursed $210.87
At an FQHC, the visit would be reimbursed $66.82-155.64
FQHC/CMHC Partner Model
 340B Pharmacy benefits
Individual receiving services enrolled in FQHC/CHC
Broader formulary
Significantly reduced rate
 FQHC apply for change of scope
Mirror scope of primary location to the new CMHC location
• Original scope has to include Behavioral Health or apply to have it included
• Allows for FQHC to bill for primary care services not able to be billed by CMHC
 Consumer needs to be enrolled with the FQHC
Tips/Opportunities From the Field
1. Process Mapping Billing Work Flow
2. Leadership/Advocacy
3. “Community Health Money
Process Mapping Billing Work Flow
 Great Team Building Exercise
 Allows Roles and Procedures to be Defined
 Identifies inefficiencies (e.g., work-arounds, money left on
the table, etc.)
 Helps establish Standard Operating Procedures
 Gains commitment from staff