Effective Accounts Receivable Management

1. Effective Accounts Receivable Management Billing for Behavioral Health Services in Primary Care Settings Web-assisted Audio Conference for HRSA Grantees and Subgrantees September 17, 2003 Facilitated by: Charlotte Kohler and Phil Hurd Navigant Consulting, Inc.

2. Speakers • Charlotte Kohler, RN, CPA, CVA, CPAM • Phil Hurd, MHA, CCP

3. Purpose • Purpose • Provide focused technical assistance inresponse to questions asked duringHRSA’s Third Party Reimbursement (TPR) Training sessions.

4. Program Outline I. National Overview/Common Issues II. State Structures and Variations III. Documentation and Coding Issues IV. Who Can Bill V. Coding, What to Bill and How Much Are You Paid? VI. Summary of Program Development Steps

5. Audience Profile • As of 9/12/2003, we had 401 people registered, representing 278 organizations • 206 organizations submitted information about BH services • 80% (164 organizations)are providing BH services, and of those, 60% (100) are billing for these services

6. Audience Profile • 38 states, plus the Puerto Rico and the District of Columbia are represented: Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Hawaii, Illinois, Indiana, Iowa, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Wisconsin

7. Audience Profile • All types of provider organizations, including: - HIV/AIDSBureau Ryan White and other HIV/AIDS programs • Bureau of Health Professions National Health Service Private Practices and Nurse Managed Centers • Maternal and Child HealthBureau Healthy Start Programs, Title V Grantees, Healthy Tomorrows and Providers to Children with Special Health Care Needs • Bureau of Primary Health Care Community Health Centers, Homeless Grantees, Public Housing Grantees, Migrant Health Centers and School Based Health Centers • Office of Rural Health Policy Rural Outreach and Rural Network Development Grantees

8. Effective Accounts Receivable Management National Overview/Common Issues

9. Overview • Behavioral Health includes both Mental Health and Substance Abuse services. • We will be discussing both the somatic – medical services and psychosomatic – psychiatric services Source: The Midwest Clinician’s Network Survey, 2000.

10. Overview • The prevalence of Behavioral Health (BH) Issues is large and growing. • Primary Care Physicians (PCPs) spend 50% of average work week directly treating mental health and substance abuse. • PCPs prescribe nearly 2/3 of medications and 80% of anti-depressants.

11. Funding for Behavioral Health • Most States obtained the waiver process to implement Managed Care. • Following the private sector, most states have “carved-out” Behavioral Health programs. • The funding options for BH services and billing requirements are numerous and varied.

12. Managed Care Prevalence • 39 States operate 78 managed Behavioral Health programs. • 17.6 million enrollees were treated by Medicaid plans with Behavioral Health services in 1999. • Medicaid remains the largest funding source for public managed Behavioral Health care.

13. Medicaid Managed Care • Ten States account for 80% of the national enrollment in Medicaid Managed Care programs; 3 for 50% • California • Michigan • Tennessee • Massachusetts • Pennsylvania • Maryland • Washington • New York • Texas • Oregon 50%

14. Reimbursement/Provider Issues • Payments are made to “preferred provider”. • Reject application because “panel is full”. • Some states and counties award BH services exclusively to the local Community Mental Health Center (CMHC) • Are you one of them?

15. Coverage Requirements • Meeting “medical necessity criteria” • Can take 2 hours for evaluation --If patient does not meet criteria, often the provider does not get paid for the evaluation

16. Effective Accounts Receivable Management State Structures and Variations

17. Program Structures - Examples • California - Some capitation; contracts w/ county MH Depts./LCSW must have Medicare PIN before MediCal; FQHCs/RHCs can be reimbursed FFS. • Massachusetts – Capitates four MCOs; MCOs subcontract w/ Health Centers/others; some payment arrangements are FFS • Michigan – Capitated contracts w/ CMHSPs; FQHCs do not participate in program but can contract w/ HMOs

18. Program Structures - Waivers

19. Program Structures – Managed Care

20. Program Structures – Provider Issues

21. FQHCs - Examples • California – traditional psychotherapy referred to Mental Community Health Center; visit limits can vary w/in the state • Kansas – FQHCs not eligible as subcontractor for BH services; program specifies the number of hours by service per year. • Michigan – Integrated primary care delivery model experiment for use of new codes – 9615x; model does not limit visits but the Medicaid program has a 20 visit limit

22. FQHCs - General

23. FQHCs – Billable Services

24. FQHCs – Visit Restrictions

25. FQHCs – Reimbursement Issues

26. Program Structures – Summary • Most BH benefits are carved-out. • Contractual arrangements and eligible providers vary widely by stateandby county within the state. • Must work closely with your state structure to clearly define requirements for your program.

27. Effective Accounts Receivable Management Documentation and Coding Issues

28. Documentation and Coding:Fraud and Abuse • Behavioral Health Services have been subject to fraud as have many other services. • Services that have been billed inappropriately in the past include: • Routine screening and periodic testing • Testing for other than diagnosing a suspected mental illness or to evaluate a change in mental illness • Generic psychotherapy (group) not specific to patient’s condition.

29. Documentation and Coding:Fraud and Abuse • The biggest problem in Behavioral Health relates to medical necessity(determination by payers based on a review of services billed) • Services performed by a non-licensed provider particularly as “incident to” using the PIN of the licensed provider. • Music, game, instrument, pet interaction therapies, sing-alongs, arts and crafts, and other similar activities should not be billed as group or individual activities.

30. Elements of “Incident To” 1.   An integral part of the physician’s professional service 2.   Commonly rendered without charge or generally not itemized separately in the physician’s bill 3.   Of a type that are commonly furnished in physician’s office or clinic 4.   Furnished under the physician’s direct personal supervision

31. Medical Record Documentation • Complete records contain all pertinent and essential information related to the patient’s current encounter. • Each entry must be able to “stand-alone”. • Medical records must indicate that the patient has a psychiatric illness or emotional behavioral symptoms.

32. Who Can Bill?

33. Who Can Bill? Who can bill for behavioral health services? • Most States Accept physicians, Clinical Psychologists (CP), Licensed Clinical Social Workers (LCSW), (Certified, Independent, Licensed – State defines) • However, each State has its own rules and many will pay for other professionals.

34. Who Can Bill? • Physicians • Clinical Psychologists • Licensed Social Workers (Certified, Independent or Clinical – different by State) • Certified Marriage and Family Therapists (CMFT) • Pastoral Counselors

35. Who Can Bill? (Cont.) • Registered Nurses • Nurse Practitioners • Alcohol and Drug Abuse Counselors • Clinical Nurse Specialist BUT - Every State is different and requirements are different

36. Who Can Bill? Clinical Psychologist - Medicare Criteria • Physician supervision not required • Considered to be an “allied health professional” • Services generally covered in independent practice or as employee of a physician or physician-directed clinic.

37. Who Can Bill? Clinical Psychologist - Medicare Criteria • Agree to consult with patient’s attending physician, unless the patient does not agree to the consult. • Can not bill for monitoring or prescribing medication.

38. Who Can Bill? State Comparisons • Arkansas - Providers are licensed with the state AND certified by the Division of Mental Health • Indiana - More restrictive; providers must be certified as Health Service Provider in Psychology • Nebraska – Less restrictive

39. Billable Providers - Examples

40. Targeted Case Management (TCM) - Examples Arkansas Only the following can bill for TCM: MSWs RNs LPNs LCSWs Licensed Psychiatric Technical Nurse Masters Level School Guidance Counselors, School Psychology Specialist, and special Education Supervisors who are also certified with the Board of Education Indiana Psychologist, MD, OD, SW, OT, Speech Pathologist or Audiologist, RN, PT who are qualified Mental Retardation Professionals. Services are provided by or under the supervision of qualified Mental Health Professionals.

41. Arkansas Other • If Medicare covers the service, provider must be a credentialed Medicare provider before Medicaid. • RHCs must be certified by CMS and participate with Medicare

42. State Comparison - Summary • State requirements vary widely • Different providers have different supervision requirements • Make sure BH Professionals are licensed by the right agency and certified, as required.

43. State Comparison - Summary • Make sure you understand practice location requirements • Reimbursement methodology and amounts vary by practice setting-know the differences.

44. Coding, What to Bill and How Much are You Paid?

45. What To Bill?

46. What To Bill?

47. How Much Are You Paid? Reimbursement • Reductions in reimbursement rates by provider type • Physician - not discounted • Clinical Psychologist - discounted • LCSW - further discounted • Other - discounted if covered

48. State Reimbursement Example Ranges by Provider Type

49. How Much Are You Paid? • Reimbursement Ranges 1 1) Unadjusted

50. How Much Are You Paid? • Reimbursement Ranges 1 1) Unadjusted