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Budget Presentation (or, how we reversed the downward spiral…)

Budget Presentation (or, how we reversed the downward spiral…). Nevada County Behavioral Health CMHDA Small Counties Annual Meeting May 8, 2008 . Contents. Productivity Measurement & Benefits Review Services Monitor Insurance Cost Report Optimization Staffing and Funding

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Budget Presentation (or, how we reversed the downward spiral…)

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  1. Budget Presentation(or, how we reversed the downward spiral…) Nevada County Behavioral Health CMHDA Small Counties Annual Meeting May 8, 2008

  2. Contents • Productivity Measurement & Benefits • Review Services • Monitor Insurance • Cost Report Optimization • Staffing and Funding • Contract Structure • Other Topics

  3. Financial Turnaround • Nevada County had multiple years of large deficits; exhausting realignment fund balance • Staffing and budget cuts • Received 10% Realignment shift and some County General Fund

  4. Financial Turnaround • For 08-09, minimal County General Fund • Increase staff and contracts • No Realignment shift • Minimal realignment draw

  5. Productivity Expectation • More revenue with minimal increase in costs (low hanging fruit). • Individualized performance agreement, baseline 80% billable service expectation • Re-defined “billable” as productive • Train clinical and admin staff on billable services and correct use of codes • Set clear deadlines for daily documentation

  6. Productivity Monitoring • Cross reference of billing & time card coding • Daily documentation should include all hours worked, productive and non • Weekly reports on late billing documentation • Monthly report & feedback from managers and clinicians • Included in performance evaluations

  7. Productivity • Bill for all assessment services; open the episode early • Focus on billable services • Limit pre-admission services

  8. Capture all Covered Services • Travel time associated with service provision • Documentation of service • Phone calls • Crisis

  9. Review Services Don’t Pay for Services Covered by Other Agencies, Sources & Funds • Ambulance costs from Emergency Room to Hospital for 5150 • Jail medical services • FQHC mental health services • PCP • Crime Victims • Veterans

  10. Review Services Monitor High Cost Treatment & Provide Options • Acute inpatient • State Hospital • PHF • IMD • Board & Care • Day Treatment

  11. Review Services Monitor High Cost Treatment & Provide Options • Develop budget and strategy for placement; consider ACT/wrap team impact • Open all Hospital, PHF, and other residential treatment services to billing system • Monthly report showing actual services and costs

  12. Increase Medi-Cal Enrollment • Assure that eligible beneficiaries are enrolled • SSI, CMSP, HF • Closely review cases for medical necessity if not Medi-Cal

  13. Increase Medi-Cal Enrollment • Decrease services and numbers of private insurance & Medicare • Medi-Cal is priority and mandate • Don’t subsidize for-profit insurance companies with your realignment dollars

  14. Indigent, Private Insurance & Medicare • Prioritize patients that will cost money for IMD, Jail, SNF, Board & Care, etc • Review open cases; close & refer if appropriate • Refer to pcp, church, insurance company, legislators, self help

  15. Insurance Monitoring • Monthly report with insurance status and type for all active clients • Put report in central location for updates • Assign roles and responsibility—case managers primary responsibility; admin staff support • Video eligibility and application technology

  16. Insurance Monitoring • Log actions--“close episode” or “met with client and referred to eligibility worker” • Collaborate with HHSA departments—social services/eligibility workers and Behavioral Health • Crisis Workers—get insurance information and fill out ISAWS 1 at hospital

  17. Cost Report – Maximize $$ • Published charge vs. actual costs vs. SMA • Settle at lower of Costs or Charges (LCC); cap is SMA • Nominal Fee Provider worksheet in Cost report--filling in the boxes resulted in +$175,000 in settlement.

  18. Cost Report • Nevada County’s Published Charge was 15% below SMA • Our Actual Cost per unit was 5% above SMA • Change Published Charges to maximize cash flow and revenue • Nevada County increased Pub Chg to 5% above SMA • Medi-Cal will pay the SMA rates; private insurance and others billed at published chg • Increased Cash flow & reduced amount owed to county at Settlement

  19. Cost Report • Some Counties’ actual costs are less than SMA but they bill Medi-Cal at SMA • High cash flow--keep extra cash in a “savings account”, earn interest and pay back at settlement time • Or, increase Published Charge to be close to Actual to minimize settlement variance

  20. Cost Report – Admin Costs • Optimize Administrative Cost treatment • Maximum Medi-Cal reimbursement is 15% • Nevada County went from 7% admin cost reimbursement in 05-06 to 15% in 06-07.

  21. Cost Report – Admin Costs • Admin Costs should be treated consistently Year-to-Year • But there’s flexibility to optimize methodology; 15% to Medi-Cal is optimal • Can allocate administrative staff other than Director salary • Flexibility with A-87: building costs, computer costs, can be direct program expenses

  22. Cost Report – Manage Costs Try to get actual costs at or just below the SMA: • Increase units, keeping costs constant • OR reduce costs, keeping units constant

  23. Cost Report – Other Thoughts • Charge 15% Admin to Contractors • QA claiming on Cost Report • Track QA work with clinical documentation or time-tracking for non-clinical staff • CMHDA Financial Services Committee; attend and ask questions • Hire consultants; Gary Ernst, Caryl Willard • Average Cost vs. Cost Center reporting

  24. Optimize Staffing and Funding • For small departments, generally adding clinical staff = more units = lower cost per unit • County has high fixed costs per unit of service • Economies of scale – optimize staff levels to lower fixed costs per unit of service, but don’t get too big

  25. Optimize Staffing and Funding • If fully funded by grant money, county staff are a better deal than contractors • County keeps all Medi-Cal, 15% admin, and associated grant funds • Cover all variable costs (salaries, office supplies, computer, etc…) plus portion of fixed costs • Contractor--all Medi-Cal goes to contractor, and county may be limited in getting admin $$

  26. Optimize Staffing and Funding • Incrementally add new staff, slowly • Keep staff fully productive and on their toes, but not overworked and burned out

  27. Optimize Staffing - Do Not Reduce Children’s Staff • EPSDT 95% • SB90+IDEA+3632 allocation • No realignment savings • If you cut staff, you may lose some economies of scale and result in net loss

  28. Contracts – Optimize Structure • For mix-funded contracts (Grant and Medi-Cal), don’t specify amount of each funding source • More Medi-Cal revenue generated = more MHSA, MIOCR, etc…for discretionary dept expenses • Non-Medi-Cal costs are fully funded; saves realignment • Bill Medi-Cal, even for grant funded services and programs

  29. Contracts – Optimize Structure • Include target billable service levels • 90% Medi-Cal eligibility target • Pay 1/12th of the contract if target billable services levels are met • Get monthly reports • Re-negotiate contracts mid year, based on performance

  30. Program Planning & Implementation • With every new grant or program, include all associated costs; direct and indirect, variable and fixed

  31. Program Planning & Implementation • Use existing staff so that minimal “new” costs are generated • Use Time-tracking for all staff involved in project. • Train staff to be aware of importance of coding to funding source/project • Non-clinical admin staff track time in project, using the electronic time-keeping system.

  32. Re-Read MHSA Supplantation Letter • DMH Letter 05-04 • DMH Letter 05-08 • Must be used for: MHSA programs Not replace state or county funds 04-05 New or expanded programs

  33. Re-Read MHSA Supplantation Letter • If possible, cover & allocate MHSA funds to your admin, support, data entry, managers, etc • Use MHSA to pay for as much related travel, training, and supplies as allowed

  34. Other Funding Opportunities Implement SB163 • Wrap services to keep kids out of group homes • May not save dollars • But, services will generate Medi-Cal, and may free up MHSA and/or realignment

  35. Other Funding Opportunities Become the Provider for Medi-Cal kids from Probation & Child Welfare • Court wards & dependents • All Medi-Cal EPSDT • If cash from Probation/Child Welfare is being used to pay outside providers, transfer a portion to BH instead

  36. Housing • Transitional housing and ACT type services may decrease costly IMD utilization

  37. Public Safety Argument for Small, Rural, Conservative Counties • Suicides; we have more suicide than homicide • DUI; much death and injury • Homicide; unique to Nevada County?

  38. Public Safety Argument for Small, Rural, Conservative Counties • Compete with Police & Fire – use their tactics to advocate for county general fund • Lifespan of SMI folks– decreases by 25 years

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