Financing Integration

1. Financing Integration Jeff Capobianco, PhD, LLP jeffc@thenationalcouncil.org

2. Financing Integrated Healthcare Models Jeff Capobianco, PhD, LLP

3. Overview of Presentation • Update on SAMHSA/HRSA Center for Integrated Health Solutions • Quick Review of the Basics of Billing • Seven Tips/Opportunities for Billing • Three Tips/Opportunities for Financing Integrated Health Models • Four Tips/Opportunities from the Field

4. About the Center In partnership with Health & Human Services (HHS)/Substance Abuse and Mental Health Services Administration (SAMHSA), Health Resources and Services Administration (HRSA). Goal: To promote the planning, and development and of integration of primary and behavioral health care for those with serious mental illness and/or substance use disorders and physical health conditions, whether seen in specialty mental health or primary care safety net provider settings across the country. Purpose: To serve as a national training and technical assistance center on the bidirectional integration of primary and behavioral health care and related workforce development To provide technical assistance to PBHCI grantees and entities funded through HRSA to address the health care needs of individuals with mental illnesses, substance use and co-occurring disorders

5. AK (2) PBHCI Grantees by HHS Regions – YR3 Region 5 18 Grantees Region 8 5 Grantees Region 10 7 Grantees VT ME (1) WA (3) Region 1 11 Grantees MN NH (1) WI MT ND MI (1) OR (2) Region 2 10 Grantees MA (4) NY(8) ID RI (2) OH (7) SD IL (5) IN (5) WY CT (3) PA (2) NJ (2) VA (3) UT (1) NE (1) IA WV (2) CO (4) DE NV MD (1) DC KS MO Region 7 1 Grantees CA (11) KY (1) Region 3 9 Grantees NC (1) TN (1) SC (1) AZ (1) OK (3) AR AL NM GA (4) MS LA (1) Region 4 15 Grantees TX (4) HI FL (7) Region 6 8 Grantees Region 9 12 Grantees

6. PBHCI Grantees by HHS Regions Region 1 – Boston CT: Bridges…A Community Support System (I) CT: Community Mental Health Affiliates (III) CT: Connecticut State Department of MH/Addictions Services (V) ME: Community Health and Counseling Services (III) ME: Community Health and Counseling Services (V) MA: Behavioral Health Network, Inc. (V) MA: Center for Human Development (V) MA: Community Healthlink (III) MA: Stanley Street Treatment and Resources (V) NH: Community Council of Nashua (I) RI: The Kent Center for Human and Organizational Development (III) RI: The Providence Center (II) Region 3 – Philadelphia MD: Family Services, Inc. (III) PA: Horizon House (III) PA: Milestone Centers (II) VA: Arlington County Community Services Board (V) VA: Norfolk Community Services Board (IV) WV: FMRS Health System, Inc. (V) WV: Prestera Center for Mental Health Services (III) Region 2 - New York NJ: Atlanticare Behavioral Health (V) NJ: Care Plus NJ (I) NJ: Catholic Charities, Diocese of Trenton (III) NY: Bronx-Lebanon Hospital Center (III) NY: Fordham Tremont CMHC (III) NY: ICD-International Center for the Disabled (II) NY: Institute for Community Living, Inc. (V) NY: Lincoln Medical Center and Mental Health Center (V) NY: New York Psychotherapy/Counseling Center (V) NY: Postgraduate Center for Mental Health (III) NY: VIP Community Services (I)

7. PBHCI Grantees by HHS Regions Región 4 – Atlanta FL: Apalachee Center, Inc (III) FL: Coastal Behavioral Healthcare (III) FL: Community Rehabilitation Center (III) FL: Henderson Behavioral Health, Inc. (V) FL: Lakeside Behavioral Healthcare (III) FL: Lifestream Behavioral Center (III) FL: Miami Behavioral Health Center (III) GA: Cobb/Douglas Community Services Board (III) GA: Highland Rivers Community Service Board (V) GA: New Horizons Community Service Board (V) KY: Pennyroyal Regional MH/MR Board (I) NC: Coastal Horizons Center, Inc. (V) SC: South Carolina State Department of Mental Health (III) TN: Centerstone of Tennessee, Inc. (V) Region 5 – Chicago IL: Dupage County Health Department (V) IL: Heritage Behavioral Health Center (III) IL: Human Service Center (I) IL: Trilogy, Inc (III) IL: Wellspring Resources (V) IN: Adult & Child Mental Health Center (III) IN: Centerstone of Indiana (II) IN: Health & Hospital Corporation of Marion County (IV) IN: Regional Mental Health Center (II) MI: Washtenaw Community Health Organization (III) OH: Center for Families & Children (I) OH: Community Support Services (IV) OH: Firelands Regional Medical Center (V) OH: Greater Cincinnati Behavioral Health Services (III) OH: Shawnee Mental Health Center (I) OH: Southeast Inc. (I) OH: Zepf Center (V)

8. PBHCI Grantees by HHS Regions Region 6 – Dallas LA: Capital Area Human Services District (IV) OK: Central Oklahoma Community MH Center (I) OK: Family and Children’s Service, Inc. (V) OK: NorthCare Community Mental Health Center (III) TX: Austin-Travis County Integral Care (III) TX: Lubbock Regional MH & MR Center (II) TX: Mental Health Mental Retardation Tarrant County (V) TX: Montrose Counseling Center (II) Region 9 - San Francisco AZ: CODAC Behavioral Health Services (I) CA: Alameda County Behavioral Health Care Services (II) CA: Asian Community Mental Health Services (III) CA: Catholic Charities of Santa Clara County (IV) CA: Didi Hirsch Community Mental Health Center (V) CA: Glenn County Health Services Agency (III) CA: Mental Health Systems, Inc (I) CA: Monterey County Health Department (V) CA: Native American Health Center, Inc. (V) CA: San Francisco Department of Public Health (IV) CA: San Mateo County Health System (III) CA: Tarzana Treatment Centers, Inc. (III) Region 7 - Kansas City NE: Community Alliance Rehabilitation Services (V) Region 8 – Denver CO: Aspenpointe Health Services (V) CO: Aurora Comprehensive Community Mental Health Center (V) CO: Jefferson Center for Mental Health (V) CO: Mental Health Center of Denver (I) UT: Weber Human Services (III) Region 10 – Seattle AK: Alaska Islands Community Services (III) AK: Southcentral Foundation (IV) OR: Native American Rehabilitation Association of the Northwest (II) OR: Cascadia Behavioral Healthcare, Inc. (V) WA: Asian Counseling and Referral Service (III) WA: Downtown Emergency Service Center (III) WA: Navos (IV)

9. The Cost of Waste… • Health care waste exceeds the 2009 budget for the Department of Defense by more than $100 billion. • Amounts to more than 1.5 times the nation’s total infrastructure investment in 2004, including roads, railroads, aviation, drinking water, telecommunications, and other structures. • If redirected the funds could provide health insurance coverage (employer/employee cost) for more than 150 million workers. • And the total projected waste could pay the salaries of all of the nation’s first response personnel, including firefighters, police officers, and emergency medical technicians, for more than 12 years. • IOM (Institute of Medicine). 2012. Best care at lower cost: The path to continuously • learning health care in America. Washington, DC: The National Academies Press.

10. Basic Principles of Billing and Reimbursement CPT Codes (Current Procedural Terminology) Evaluation and Management Codes (E&M) Is generally billed by an FQHC or Medical Facility and must have a physical health diagnosis Health & Behavior Assessment Codes (HAB) Can only be billed by an FQHC or Medical Facility and must have an accompanying physical health diagnosis Used to identify the psychological, behavioral, emotional, cognitive and social factors important to the prevention, treatment, or management of physicalhealth problems. The focus is not on mental health, but on the biopsychosocial factors important to physical health problems and treatments. Depending on the state the E&M and HAB codes can be billed on the same day

11. Basic Principles of Billing and Reimbursement (con’t) 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

12. Tips/Opportunities for Billing • Interim Financing Solutions for Integrated Healthcare Worksheet • Two Services in One Day • Paying for Case Management • 96000 Series of Codes • Screening Brief Intervention & Referral to Tx (SBIRT) • Dear Medicaid Director State Option • Health Home State Plan Amendment Option

13. Interim Financing & Billing Worksheets • 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 • Diagnosis • Practitioner Discipline & Credential • The worksheets are posted on the CIHS website under Finance

14. 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 (See Finance Tool Kit for this section) • Medicaid confirmation received from Peggy Clark, (CMS/CMSO) – “In terms of FQHC’s/RHC’s there are no applicable, current (federal) Medicaid regulations, but some States follow Medicare requirements pertaining to same day billing. In terms of same day billing in the Community Mental Health Centers and Outpatient Hospital setting, there are no specific Medicaid statutes or regulations on this matter. (See Finance Tool Kit for confirming email)

15. Two Services in One Day • Two providers bill for the services they provide on the same day – Contractual Business Model • Behavioral Health Provider bills for BH service under their provider number • Primary Care bills for their services under their provider number

17. Case Management in Texas • Billable in Texas for Special Populations. • If CMHC staff are leased & co-located in an FQHC clinic they can bill. • Peers can bill in Texas for Case Management.

18. Paying for Case Management – Another Option Wisconsin Model Wisconsin Medicaid covers initial primary care treatment and follow-up care for recipients with mental health and/or substance abuse needs provided by primary care physicians, physician assistants, and nurse practitioners. Wisconsin. Medicaid will reimburse the previously listed providers for Current Procedural Terminology (CPT) evaluation and management (E&M) services (procedure codes 99201-99205 and 99211-99215) with an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code applicable for mental health and/or substance abuse services.

20. 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)

21. 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 face-to-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)

23. 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.

25. Disease Management Payments for Primary Care of Seriously Mentally Ill • 2005 “Dear Medicaid Director Letter” (precursor to ACA 2703 Health Home Option). • 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 Disorders • Disease Management for SMI - dollars to CMH; CMH pays primary care

26. Approved Health Home Planning Requests • Alabama Arkansas • Arizona California • District of Columbia Idaho • Maine Mississippi • Nevada New Jersey • New Mexico North Carolina • Washington West Virginia • Wisconsin

27. Tips/Opportunities for Financing Integrated Health Models • FQHC Standalone • CMHC Standalone Approaches • CMHC/FQHC Partnership Approaches

28. FQHCs are a critical component of the 2010 ACA Grant Funding will nearly triple over five years

29. 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 services • Direct Hires • Contract with local CMH

30. 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

31. CMHC Becomes an FQHC • Cherokee most famous for this approach. • Best option for a CMHC to apply to become an FQHC Lookalike first. • Like the standalone model is time intensive to apply & requires completely new business model.

32. 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) • LICSW/LMSW • Cost offset approach for Indigent population • FQHC receive federal funds to cover the cost of indigent • CMHC can provide Case Management

33. FQHC/CMHC Partner Models (cont.) 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

34. FQHC/CMHC Partner Model (cont.) • 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

35. Partnership Approaches to Managing Cost of the Uninsured • FQHC federal funding to cover uninsured • Increased # of insured can help offset cost of uninsured • State Health Plans • Discuss the ability to add a Behavioral Health Benefit • Partner with Universities to be Student Teaching location • 3rd year medical students • Nurse Practitioners Faculty Providers • Masters of Social Work Interns

37. Tips/Opportunities From the Field • Open-Book Management • Process Mapping Billing Work Flow • Leadership/Advocacy • “Community Health Money Concept”

38. Open-Book Management-The Great Game of Business • The technique is to train all employees on relevant financial information about the company so they can make better decisions as workers. • While employees need to be trained to understand income statements and balance sheets; open-book's true triumphs are when employees understand the numbers to a level that they are able to report predictions to upper-management. • Stack, J. (1992). The Great Game of Business. Doubleday

39. 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

40. Intake and Screening • Intake - Front Desk – Reception generally not reimbursable • Initial Screening/Assessment and/or /Existing Consumer Visit With A Clinician • Is this a billable BH service? • For what credential? • Are you billing for it? • What can you do to make this billable? • Different clinician credentials • Include billable services (i.e., collecting vitals for all patients on BH side)

41. Leadership & Advocacy is Required • Most vital to building a continuously learning organization is leadership and governance that defines, disseminates, and supports a vision of continuous improvement. • -Cosgrove et al., 2012. A CEO checklist for high-value health care. Discussion Paper, Institute of Medicine, Washington, DC. http://www.iom.edu/CEOChecklist • Now more than ever State and Federal governments need provider leadership/advocacy to define how best to move forward with health reform.

42. 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.

43. Begin with the Consumer In Mind… • Reduce turf wars over money by focusing on the consumer. • 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.

44. Significant Changes to the 2013 Psychiatry CPT Code Set • • Removal of evaluation and management (E&M) plus psychotherapy codes from the psychiatry section (90805, 90807). • • Deletion of pharmacologic management (providers to use appropriate E&M code). • • Psychotherapy and E&M services are distinguished from each other (time spent on E&M services is not counted. • towards psychotherapeutic services, and separate codes can be used in combination with one another). • • Inclusion of add on codes for psychiatry, which are services performed in addition to a primary service or procedure (and never as a stand-alone service). • • Addition of code 90785 for interactive complexity. • • New code for psychotherapy for a patient in crisis.

45. SAMHSA/HRSA Center for • Integrated Health Solutions • The resources and information needed to successfully Integrate primary and behavioral health care For information, resources and technical assistance contact the CIHS team at: Online: integration.samhsa.gov Phone: 202-684-7457 Email:Integration@thenationalcouncil.org

46. The resources and information needed to successfully Integrate primary and behavioral health care For information, resources and technical assistance contact the CIHS team at: Online: integration.samhsa.gov Phone: 202-684-7457 Email:Integration@thenationalcouncil.org