Article 31 Clinic Fiscal Viability Workgroup

1. Article 31 Clinic Fiscal Viability Workgroup September 18, 2015

2. Workgroup Agenda • Review latest Clinic data 15 min • Update on Clinic Initiatives 45 min • APG Updates • CHP Government Rates • VAP Initiative • Best Practices re: Billing

3. Workgroup Agenda • Mandate Relief/New Services 60 min • Standards of Care • New Tools for Clinics • Integrated Services • Telepsychiatry • Intensive Outpatient Treatment • Next Steps/Follow-up 60 min • Commercial Insurance • Managed Care Implementation • Alternative Payment Methodologies/ Value Based Payment

4. Not included above: Open and Closed since 10/1/10 – 3 clinics Closed and reopened since 10/1/10 – 31 clinics

7. APG Updates • Rate Increases in 2015 • 5% payment increase for 30 & 45 min. psychotherapy services (CPTs 90832/90834) when provided to a child (effect. 1/1/15) • APG base rate increases for free-standing and LGUs (effect. 1/1/15) • Downstate – 3.3%, Upstate – 1%, LGU – 1% • 2% funding increase for salary and salary related fringe benefit costs for free-standing and LGUs (effect. 4/1/15) • This has resulted in an additional 1% base rate increase • Change to the definition of a 45 min. psychotherapy service (CPT 90834) (effective 1/1/15)

8. APG Updates • Allow for a 20 minute visit (effective 1/1/15) • About 1,600 claims • Complex Care Management (CPT 90882) enhancements (effective 10/1/14) • Utilization threshold exemption for court-mandated services (effective 1/1/15) • No providers have used these rate codes yet!!!

10. Child Health Plus (CHP)Government Rates Article VII language as follows: “Notwithstanding any contrary provision of law, the fees paid by managed care organizations licensed under article 44 of the public health law or under article 43 of the insurance law, to providers licensed pursuant to article 28 of the public health law or article 31 or 32 of the mental hygiene law, for ambulatory behavioral health services provided to patients enrolled in the child health insurance program pursuant to title one-A of article 24 of the public health law, shall be in the form of fees for such services which are equivalent to the payments established for such services under the ambulatory patient group (APG) rate-setting methodology. The commissioner of health shall consult with the commissioner of alcoholism and substance abuse services and the commissioner of the office of mental health in determining such services and establishing such fees. Such ambulatory behavioral health fees to providers available under this section shall be for all rate periods on and after the effective date of this chapter through December 31, 2017, provided, however, that managed care organizations and providers may negotiate different rates and methods of payment during such periods described above, subject to the approval of the department of health. The department of health shall consult with the office of alcoholism and substance abuse services and the office of mental health in determining whether such alternative rates shall be approved…”

11. Child Health Plus (CHP) Government Rates • The 2015-16 budget requires that the fees paid by MCOs to Article 28, Article 31 or Article 32 providers for ambulatory behavioral health services provided to CHP enrollees be equivalent to the payments established for such services under the Ambulatory Patient Group (APG) rate-setting methodology. • The fees will be in effect through December 31, 2017. • CHP Plans were formally notified of this provision by DOH on June 15, 2015. • OMH will be sending out a survey to all OMH–licensed clinics to get feedback on whether or not the CHP plans are complying with the government rates mandate. • Based on the replies received, OMH will contact DOH and DFS for guidance/follow-up as necessary. • The yearly impact of this change is estimated to be an additional $2M paid to CHP providers.

12. Best Practices re: Billing • Know what you should be paid • Look at what you’re actually being paid • CPT Procedure Weights and Rates Schedule: • http://www.omh.ny.gov/omhweb/clinic_restructuring/projection_tools.html

14. Psychiatry Time What has the data shown? • Failure to use Modifiers for Doctor/NPP • Adding a Modifier of AF (Psychiatrist) or SA (NPP) to qualifying services = 45% Rate Increase • Qualifying Services: • Initial Assessments (90791, 90792) • Psychotherapy (Individual and Group) • Psychiatrist/NPP must be present for a minimum of 15 minutes • Failure to use Psychiatric ADD ON Codes • 90833/90836

15. 90791 or 90792 w/Modifier (AF/SA)

16. What do Psychiatric Services Pay?

17. Physician Add-Ons • 90833 – Psychiatric Assessment – 30 mins – ADD ON • 90836 – Psychiatric Assessment – 45 mins – ADD ON

18. Clinic Modifiers • Clinic open after 6PM or on the weekends? • Add the After Hours Modifier (99051) = .0759 of base rate ($10.26 - $15.33) • Staff providing service in Language other than English? • Add U4 Modifier for 10% increase • Offsite for Children &/or Crisis-Brief • Use Base Rate Code 1507 for 50% increase

19. Add’l Revenue Maximization Strategies • Read the 599 Regulations & Guidance Docs • Complex Care Management • Crisis Intervention • Use CTAC - ctacny.com • Sign up for upcoming business initiatives • Look at archived webinars

20. New Tools for the Clinic “Tool Box” • Integrated Outpatient Services • Implemented January 1, 2015 • Telepsychiatry • Implemented February 11, 2015 • Intensive Outpatient Program • In Development

21. Integrated Outpatient Services • Furthers the core principles of the Integrated Licensure Pilot: • Allows a provider to deliver the desired range of cross-agency clinic services at a single site under a single license; • Requires the provider to possess licenses within their network from at least 2 of the 3 participating State agencies; • Allows the site’s current license to serve as “host”; and • Facilitates the expansion of “add-on” services through a single request to the “host” State agency, with input/recommendation provided by agency currently possessing primary oversight responsibility for such services. • To date, 9 providers approved for “Integration” at 16 sites • 12 OMH “host” sites – 6 adding SUD, 5 adding primary care, and 1 incorporating both SUD/primary care. • Additional information available on OMH website: • http://www.omh.ny.gov/omhweb/clinic_restructuring/integrated-services.html

22. Telepsychiatry • New Section 599.17 permits clinic providers to obtain approval to provide telepsychiatry services. • Defined as the use of two-way real time-interactive audio and video equipment to provide and support clinical psychiatric care at a distance. • Does not include a telephone conversation, electronic mail message or facsimile transmission between a clinic and a recipient, or a consultation between two professional or clinical staff. • Can be utilized for assessment and treatment services provided by physicians or psychiatric nurse practitioners (NPP) from a site distant from the location of a recipient, where both the recipient and the physician or NPP are physically located at clinic sites licensed by OMH. • Additional information available on OMH website: • http://www.omh.ny.gov/omhweb/guidance/telepsychiatry-guidance.pdf

23. Intensive Outpatient Program • OMH providers have inquired about providing “intensive outpatient” services (IOP), due to limited treatment options for individuals who require more than traditional weekly sessions, yet may not necessarily meet the criteria for inpatient hospitalization (or partial hospitalization). • IOP can offer short-term day or evening programming consisting time-limited, multidisciplinary, multimodal, structured treatment in an outpatient setting. • Nationally, IOP is typically provided 3 or more hours per day, 2 to 4 times per week. • Treatment modalities typically include individual, couple and family psychotherapy, group therapies, medication management, and psychoeducational services. • Adjunctive therapies such as life planning skills and special issue or expressive therapies may also be provided but must be standardized in content or duration; that is, they must have a specific function within a given client's treatment plan.

24. Next Steps / Follow-Up • Commercial Insurance • Managed Care Implementation • Alternative Payment Methodologies/Value Based Payment

25. COPS was eliminated entirely on October 1, 2013. CSP (not shown) was eliminated on November 1, 2013 There percentage of all kids visits that are covered by commercial insurance is approximately 30% System-wide, the average kids cost per visit was $147 in 2013. The estimated 2015 Medicaid rate excluded COPS and CSP and includes all new MA rate enhancements.