Overcoming Reimbursement Barriers in Primary Care Behavioral Interventions

1. Session #E3a October 28, 2011 Reimbursement of Behavioral Health Interventions in Primary Care Colleen Clemency Cordes, Ph.D. Clinical Associate Professor Ronald R. O’Donnell, Ph.D. Program Director Nicholas A. Cummings Behavioral Health Program Arizona State University Collaborative Family Healthcare Association 13th Annual Conference October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

2. Faculty Disclosure We have not had any relevant financial relationships during the past 12 months.

3. Need/Practice Gap & Supporting Resources • Despite a demonstrated need for behavioral health providers in primary care, researchers continue to identify administrative issues such as billing as the central barrier to service integration • At last year’s CFHA Conference, we administered surveys to interested parties on current billing practices in primary care

4. Objectives • Identify administrative barriers to successful reimbursement of behavioral health services in primary care • Review current strategies for service reimbursement, including the use of E/M codes and H&B codes • Identify and advocate for and address the need for reimbursement health interventions in primary care

5. Expected Outcome By the end of today’s session, we hope that you will have the knowledge and skills necessary to bill for behavioral health services in primary care

6. The Problem • Primary care providers are often unable to adequately address behavioral health concerns with their patients due to: • Lack of time • Lack of training • Inability to get adequate reimbursement • Meadows et al. (2011) found that when PCP’s deliver behavioral health interventions in a primary care clinic, they: • Spent 19.69 minutes with their patients, as opposed to 8.04 minutes spent on medical complaints, or 17.00 minutes on combined medical & behavioral concerns • Were only able to bill under one CPT code, rather than an average of 2.68 codes used in combined medical/behavioral visits • Were reimbursed at a rate of $4.36 per minute, compared to $18.12 per minute for medical visits, and $5.86 per minute for medical & behavioral visits

7. The Solution • Integration of behavioral health providers into primary care leads to improved patient health outcomes and increased physician productivity, allowing for substantial medical cost offset

8. Except… • Despite strong evidence in support of the integration of behavioral healthcare into primary care, substantial barriers exist with regards to billing that prohibit the development and sustainability of many of these practices

9. Historical Context • Healthcare Common Procedure Coding System (HCPCS) was initially established in 1978 • Goal was to ensure consistent reimbursement practices for Medicaid, Medicare, and private insurances • Use of codes became mandatory with passage of HIPAA in 1996 • Current Procedural Terminology (CPT) codes are maintained by the AMA as part of HCPCS

10. Reimbursement Options • Currently, there are three systems of CPT codes which can be used for reimbursement of behavioral health interventions: • Evaluation & Management (E & M) codes • 99201-99443 • Primarily used by medical staff (physicians, nurses, PAs, etc.) • Health & Behavior (H & B) codes • 96150-96155 • CMS only reimburses these codes for psychologists • Psychiatric Services codes • 90801-90808, 90862, 99241-99245 • Can be used by behavioral health or medical providers

11. The Challenge… • Despite the availability of codes to bill under, there is substantial variability across states regarding appropriate use of the systems • Billing opportunities constantly evolving • Practice type/setting impacts use of codes • FQHC’s commonly able to bill via H & B codes, even in states that do not accept these codes

13. The Challenge Continued • Carve-in versus carve-out healthcare plans • The “Infinite Loop” of reimbursement/service rejection (Bruns, 2009) • Lack of administrative awareness on how to bill for services

14. Solutions Worth Attempting: • Advocate for use of H & B codes on the state level • Develop integration-specific codes on the state level • Follow the VA example: • Create a system in which mental health funds are transferred into the physical health budget and provide payment for services under a single budget • Provide administrative template for procedural aspects of billing

15. “Identifying Solutions for Overcoming Reimbursement Barriers to Developing a Financially Sustainable Integrated Healthcare Program” (Farrell, 2010) • In an attempt to better understand billing practices nationwide, Dr. Lesley Farrell, a graduate of the ASU DBH program, undertook a project to review current practices in use • Surveyed practices in AZ via structured interview and/or paper-pencil questionnaire, as well as distributed the questionnaire at last year’s CFHA Conference in Louisville • 25 practices participated, representing 5 different practice types

16. States Represented in the Results

17. Who Is Providing the Integrated Care?

18. Practice Type

23. Participant Barriers to Reimbursement • Covering the uninsured patient • Medicaid does not always reimburse for services • Restrictions on same-day services • Service pre-authorization needed by some insurance companies • Specific codes not being recognized or reimbursed • Psychologists being denied for paneling by insurance companies due to too many providers in the area. • Psychologists being denied for paneling by insurance companies due to not being licensed long enough

24. Barriers Continued • Extensive paperwork for minimal reimbursement • Reimbursement rate a small portion of full rate of service • Lack of understanding of insurance and legal reimbursement requirements by agency administration • Primary care agencies reluctant to pursue reimbursement due to feared liability if it is not done the “correct” way • Local Medicaid system wants primary care to only use their specialty behavioral health services for eligible patients for all services • Lack of insurance benefits for IBHS in primary care • Difficulty communicating with payers

25. Conclusions • Social workers and psychologists are the primary providers of integrated behavioral health services • Despite past literature, private payers were reported as a majority payer of services • This may be due to large rate of “don’t know” responses to payer questions • Psychiatric codes appear to be most commonly used codes to obtain reimbursement • Increased emphasis should be placed on expanding the acceptability of using H&B codes

26. Questions? • Comments?