Initiating and Sustaining Mental Health Services in Primary Care

Neil Korsen, MD, MScMary Jean Mork, LCSWApril 16, 2009

Outline

Getting Started Leadership buy-in Practice level

Support Supervision, marketing, relationships

Financial Sustainability Shared responsibility Tracking the work The Grid The Value of a Work Group

Impacting policy and regulations – state and national level

Objectives

1. Identify steps for starting an integrated practice

2. Describe barriers to financial sustainability and methods of working within and around those barriers

3. Obtain tool for tracking reimbursement

4. Learn strategies for advocacy

Getting Started

Aim for Buy-in at Every Level

Leadership Need to engage organizational leaders

and front line leaders Organizational leaders provide support

and resources to the teams working on integration

Front line leaders champion the change and provide energy and momentum.

Aim for Buy-in at Every Level

Practice Importance of champion(s) – clinical and

administrative Involve representatives of all groups

affected by integration Plan for spread within a practice

Getting Started – the Practice Level Pieces

Pre-”Hire”

Preparation with Practice Staff Contract Hiring (Identifying) MHP Licensing, credentialing, insurance Supervision Billing

Orientation and Pre-Patient

Space Staff support Registration and scheduling Shadowing Consents Documentation

Ongoing Support to MHP and Practice

Marketing Integration efforts Community connections Supervision Reimbursement

Relationships

Supervision and Support

“Hiring” the right person for integrated work

Ongoing availability of clinical and administrative supervision– Surprises will happen

Marketing – Start-up and access – the balance If you build it, they may, or may not come”

“Spreading” the resource – when and how

“Hire” someone who:

Is dissatisfied with specialty MH Is intrigued with the idea of helping a patient

“function” better Thinks it’s better to spend 10 minutes with a

patient than zero Is comfortable with noise and rooms with sinks

(and uncomfortable furniture) Has training in behavioral and brief interventions Is willing to help a patient of any age Wants to take a team approach to patient care

Financial Sustainability

Our GoalOutcome Driven, Sustainable Integrated Practice Model for

Patients and Providers

The Problems with Integrated Care

No one seems to know how to get paid Mental Health regulations and licensing

expectations don’t fit the primary care setting Confidentiality vs. “shared records” Lack of clarity and understanding about present

practices Complicated licensing and reimbursement rules

without accessible experts

Concerns about Carve Outs…

Carving out Behavioral Health means: Different systems Different reimbursement streams

Potential for barriers to integration

Understanding the Big Picture

Medicare - Regional Fiscal Intermediaries Medicaid – States vary

Flexibility in defining covered mental health servicesSome limit procedures, providers and/or practices

Commercial – Inconsistencies Lack of clarity around covered servicesDifficulty finding “experts” Carve outs

Understanding Potential Reimbursement

“The Grid”

Components within “the Grid”

Coding Category Coding number for service Discipline of Provider allowed to bill

for service Codes by insurer Psychiatric Services by type of license Practice site able to bill for code,

funding source, provider and license

Where to begin

What is the discipline of your mental health practitioner?

What service will they deliver and what code will be used?

Under what license? Where will the service be delivered? Which insurance will be billed?

What are the rules for that insurer?

Tracking the Work

Why track billing data?

To provide rapid feedback on financial aspects of integration

Because we are increasingly able to estimate reimbursement from billing

So that teams working on integration can use data to assess whether the mix of services being provided is sustainable

Tracking Sheet

Records services delivered Billable Non-billable

Records Insurances Assigns relative “factors”

For services - based on approximate time units For insurances – based on general reimbursement

comparisons

Multiplies Service x Insurance Arrives at total for time period Allows tracking in relation to budget. Shows

change overtime

Mental Health Codes

Health and Behavior Codes

E&M Codes Non-Billable Activities

90801 = 4Initial Assess

96150 = 2-4H&B Assess

99201- 99201= 4

New Pt

DI - Dual Interview with Physician = 0

90804 = 1Ind Therapy

96151 = 1-4H&B Reassess

99211-99215= 1-2

Established Pt

PO – Parents only before 90801 = 0

90806 = 2Ind Therapy

9615296153 = 1-4H&B Intervention

99401- 99404 = 1-2

Prev Med

Ind Counseling

C - Consult to Provider = 0

90847 = 4

Family Tx /w pt

96154 =1-4

H&B Intervention with Family & Pt

99411 -99412 = 1-4

Prev Med

Grp Counseling

M – Meeting = 0

MaineCare = 1 Medicare = 2 Commercial = 3 Self Pay = 1

Tracking Sheet –Reimbursement Codes and Values

DRAFT

Date of Service Service Code Billed

Reimbursement Factor

Insurance Factor

Total

3/9/09 90801 4 2 8

3/9/09 C (Consult to PCP)

0 2 0

3/9/09 90847 4 1 4

3/9/09 DI (Dual Interview)

0 3 0

3/9/09 90806 2 1 2

Total 14

SAMPLE

Reimbursement Tracking SheetPrimary Care Mental Health

Provider ________Annette_________________Place of Service ______MMP - Westbrook_____________

Questions???Suggestions!!!

The Value of aTask Force on Regulation, Funding

and Licensing

The Members

Billing and Coding Experts Credentialing and reimbursement

experts with links to licensing Physicians Mental Health practitioners

including Psychiatrists Administrators from mental health

and primary care Program Managers Director of Health Information

Monthly Meetings

Sharing information about billing and reimbursement

Different perspectives Clarifying, explaining,

investigating, and re-clarifying Data gathering Shared understanding of the

present landscape

Task Force Strategies

Understand the current rules Identify opportunities and barriers that

affect sustainability Use understanding of current rules to:

Recommend most effective way to organize services

Maximize reimbursement for integrated care Target barriers with highest priority

and/or are most likely to be able to change

How it really feels during the meetings…

…and then there are those moments!

Impacting Policy and Regulationsat the State Level

Workgroup Participants

DHHS Leadership Licensing and Regulation – licensing

rules Funding – Medicaid Rules

State Psychiatric Medical Directors Other Mental Health Providers Other Hospital Providers Maine Health Access Foundation

Workgroup Activities

Agree on Goals Agree on Standard Elements of integrated

care Compare present Medicaid rules with what

is needed to support integrated care. (“We don’t need an ICU at the front door”)

Define outcome measures Support financial incentives

Our Next Steps

Gather reimbursement information Seek input from other organizations

in our state doing integrated work Involve employers, insurers and state

government Compare and link to other Regions Advocate for change

We’re optimistic about the Future of Integrated Mental Health and

Primary Care