Maximizing Reimbursement in Today’s Fee for Service World:

A Conversation

Mary Jean Mork, LCSWCFHA October 2013Session G5a

Objectives:

Participants will be able to: Describe factors that affect the present system of billing &

reimbursement in an integrated setting Discuss strategies to support sustainability of integrated

practice Identify tools and resources for maximizing reimbursement

Disclaimer: This information does not represent how a payer might

respond to a claim This information does not replace any regulatory

information Always seek information from your own agency consultants

regarding any billing and coding practices

I don’t know where to begin:

How should we set up the practice?

Identify - Level of IntegrationIdentify - type of practice setting Identify - who will do the billing

Comparison of Employment Arrangements for Co-located and Integrated Practice

Level of Collaboration

BHC covers all expenses

Practice offers space

Practice offers space and scheduling

Practice employs

Co-located Practice

Level 3 and 4

BHC billsBHC schedulesSeparate recordsSeparate service

BHC billsBHC schedulesSeparate recordsSome communication with releases

BHC billsSeparate recordsStreamlined referral and scheduling processCommunication with releases

Practice billsSame recordShared responsibility for scheduleStreamlined processesCommunication without need for releases

Partially Integrated

Level 5

BHC billsSeparate recordCoordinated careStreamlined referral and scheduling processReleases part of routineConnected to primary care team

Practice billsSame recordShared responsibilityStreamlined processesImproved coordination and communicationWorking toward becoming part of primary care team

Fully Integrated

Level 6

Practice billsSame recordShared responsibilityStreamlined processesSolid communication and coordinationPart of primary care team

Medical practices and Behavioral Health “employers”

Mental Health Agency or Individual Clinician bills

Independent Medical Practice employs/contracts and bills

Provider Based - Hospital Owned Practice employs/contracts and bills

Federally Qualified Health Center (FQHC) employs/contracts and bills

Rural Health Clinic (RHC) employs/contracts and bills

I have these great staff but:

Who can get reimbursed for services in medical

practices?

Masters level cliniciansPsychologists

NP’s/PA’s

Master Level Clinicians

Medicare - LCSW’s only, and only the mental health codes

Medicaid differs state to state and may allow: LCSW’s, LCPC’s and LMFT’s, as well as conditional. May vary by practice type.

Commercials may also differ but generally more inclusive

Psychologists

Medicare reimburses both mental health and Health and Behavior codes

Generally paid by Medicaid and Commercial insurers

Psych NP’s/PA’s

Need to follow rules for E/M codes Generally paid by all payers Would probably not bill Health and

Behavior codes Often confusion around “medical” vs.

“behavioral” credentialing with the commercial insurers

We are working with patients with medical

conditions: What codes should we

use?

Mental Health codesHealth and Behavior codes

E/M codes

Mental Health and Health and Behavior Codes

Health and Behavior codes

96150: Assessment 96151: Reassessment 96152:Individual

intervention 96153: Group

intervention 96154:Family

intervention

Mental Health Codes 90791: Initial

Assessment 90832, 90834, 90837:

Individual Therapy 90846, 90847:Family

Therapy 90853: Group Therapy

E/M codes and Psych NP’s

90832, Psychotherapy with E/M, 30 mins (16-37)

90834, Psychotherapy with E/M, 45 mins (38-52)

90837, Psychotherapy with E/M, 60 mins (53 or more)

90791, Psychiatric Diagnostic (Dx) Eval.

90792, Psych Dx Eval. with medical services

90791 + 90785, Psych Dx Eval. with interactive complexity

90792 + 90785, Psych Dx Eval. with medical services and interactive complexity

Health & Behavior (H&B) Codes 96150 – 96155

It’s never that simple:Which payers will

reimburse for behavioral health

services?

MedicareMedicaid

Commercial Insurers

Medicare reimbursement rates

NHIC website: www.medicarenhiccom on Fee Schedule page.

Type of Provider

% physician fee

Notes

MD/DO, Psychologist

100% Or actual charge, whichever is less

PA, NP, CNS 85%

CSW (LCSW) 75%

Reduced by any applicable deductible, outpatient mental health limitation

Medicare - Eligible Providers for Behavioral Health Services

Physicians/Psychiatrists Clinical Psychologists Licensed Clinical Social Workers (LCSW) Non-physician practitioners such as NP,

PA, CNS working within scope of practice Independent Psychologists/Non-Clinical

Psychologists recognized for diagnostic services only

Medicaid

States have flexibility: Covered mental health services Two services (mental health and medical) on

same day Contract with managed care

Billing: Requires diagnosis and procedure code Some states limit procedures, providers and/or

practices that can use these codes

For Commercial Insurances

Different expectations by payer Need to clarify whether in-network medical and/or

behavioral health Reimburse for Health & Behavior codes? Confusion about medical vs. behavioral health

service Be clear at point of service Have documentation support service

Recommendation to bill for service, if service was appropriately delivered, to establish “need” for reimbursement

Some key questions

Payment for 2 encounters in the same day?

Reimbursement for Health & Behavior codes?

Pre-authorization required for mental health visits?

Full assessment required before treatment can begin?

I think I understand, but now:

What do we have to do to actually get paid?

Credentialing and contractsBilling processes in place

Plan to get paid

This gives me a headache:

How can I keep track of the rules?

Set up a “grid”Find helpful resources and people

Keep asking questions

Who to go to for help

Billing and coding supervisors Internal auditors Regional or state-wide integrated

policy groups “People who know what they’re

talking about” – where ever you can find them

I know I’ll be asked:Are we able to sustain

the service?

Track the dataThe Administrative Team

Meeting

Measuring and Improving

Initial areas of focus: access and productivity Volume No-shows Time to 1st and 3rd

Charges and collections RVU’s

Later areas of focus Patient/Provider/staff experience Clinical and functional outcomes Financial impact

Sample Dashboard

Measures Oct-11 Nov-11 Dec-11 Jan-12 Total Average

Hrs clinical time available

80 60 80 80 300 75

# Arrived 60 45 65 60 230 57.5

# No show

15 7 12 14 48 12

3rd next available(days)

1 2 1 0 4 1

Charges $14,362 $10,620 $18,700 $16,455 $60,137 $15,034

Administrative Team Meeting:

the “friendly forum”

Clinicians, provider rep, billers/coders, practice managers, leadership

Data - show rates, referrals, volume: What’s working, not working? Targets?

Payment information: Codes reimbursed/ denied

Communication issues/improvement suggestions: R/t patients, providers, practice

Clinical practice issues: E.g. length of sessions, frequency/duration of treatment

We’re optimistic about the future of integrated behavioral health and

primary care:How about you?

Reimbursement Resources

Medicare Links http://www.cms.gov/Manuals/IOM/list.asp http://www.cms.gov/Transmittals/01_overview.asp Medicare Documentation Guidelines for Evaluation and

Managements Services 95 & 97 http://www.cms.gov/MLNEdWebGuide/25_EMDOC.asp

NHIC http://www.medicarenhic.com/ CMS National Correct Coding Initiativehttp://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/

index.html/nationalcorrectcodinited

Other www.thenationalcouncil.org – the National Council for

Community Behavioral Healthcare www.ibhp.org – Integrated Behavioral Health Project www.mainehealth.org/mentalhealthintegration

Contacts

Mary Jean Mork, LCSWProgram DirectorMaineHealth and Maine Mental Health Partners110 Free St.Portland, Maine 04101

morkm@mmc.org, 207-662-2490