FQHC Behavioral HealthClinical Excellence and Financial Sustainability

Welcome!

Integration

• What is all the buzz about ?

“We should not maintain state systems if the alternative is being partof the mainstream….we must lead to achieve integration of care everywhere…. I believe that a few entrepreneurial leaders will embrace the challenge of true integration..from policy to plan to practice. These entrepreneurs will also succeed in business because the game will come to them”

M.Hogan, Commissioner, NYS OMH”

National Temperature

• Most every FQHC is doing something• Physical spaces are being rethought• Beginning to realize integration is

foundation for other strategic initiatives• Behavioral health is seen as another “core” serviceSupports other initiatives

The Goal

• Operate fiscally sustainable clinics that demonstrate the efficient conversion of resources (employee time and effort) into effective patient care

Collaboration

• “ Un-natural act by two un-consenting adults “

Around we go…….

Integrated Care

CollaborativeCare

InterdisciplinaryCare

MultidisciplinaryCare

Colocated

TransdisciplinaryCare

Staffing

• LMSW• LCSW• LMHC• LMFT• PsyD• PhD• MD• PA• PNP

Staffing

• Need the right people !!!• Need the right training• Benchmark/staffing ratios

Staffing and BillingBilling and Staffing

• Which comes first

Billing

• Billing comes first • Who are the most billable providers in

your setting

Common Billing Codes for Therapy

• 90791- Diagnostic Evaluation/Intake• 90832 - Psychotherapy, 30 minutes• 90834 - Psychotherapy, 45 minutes• 90837 - Psychotherapy, 60 minutes• 90839 - Psychotherapy for crisis• 90853 – Group Psychotherapy• 90846 – Family/Couples Psychotherapy

w/out Pt• 90847 - Family/Couples Psychotherapy

w/ Pt

Common Billing Codes for Psychiatry

• 90792- Psychiatric Evaluation• 99212 -Medication Management• 99213 - Medication Management• 99214 - Medication Management

• Use above E&M Codes and then add on a therapy code if needed

Staffing

• Billing varies greatly with staffing

• What is the licensing of the staff you are hiring or who will be working on this project?

• Billing varies greatly by state

• Do your billing and reimbursement homework BEFORE you hire your staff

• Do you have staff now you cant afford to keep when the grant goes- unlicensed, lmhc

Painting a Picture

• Figuring sustainability has many different pieces

• Productivity is only one- often the one that gets the most emphasis

• Know all of the “colors” in your behavioral health business painting

You Cant Get Paid……

• If you don’t see enough patients• Know the ratios• Productivity needs to support

sustainability

Quantifying Efficiency

EFFICIENCY PERFORMANCE INDICATORS—• Capacity: % of Face-to-Face time

spent with patients producing visits out of the total time available for patient care

• Productivity: Count of Visits Providedrelated through

• Rate of Production: Visits per given time (e.g. hour, standard work day)

Quantifying Efficiency

EFFICIENCY PERFORMANCE INDICATORS—

Necessary Data Points:• Face-to-Face time spent with patients

producing visits• Count of Visits Provided• The total time available for patient care

Scheduling Optimization and Open Access

Scheduling

• Scheduling optimization can be one of the most critical activities for helping with

• Access to care• Productivity• Efficiency • Revenue

Enhancing Efficiency

SCHEDULING PERFORMANCE INDICATORS—• Scheduling Days Out: Count of days

between the date on which an appointment was made and the date for which it is scheduled

• No-Show Rate: % of scheduled appointments for which a patient does not present, or that a patient cancels within 24 hours

Enhancing Efficiency

SCHEDULING PERFORMANCE INDICATORS—

Necessary Data Points:• Date Appointment was Made• Date of Appointment• Appointment Outcome• Cancellation Date ( when is a no show)

Defining Benchmarks

What is your ideal maximum number of days out?Number of “ acceptable” open slots ?

Hotspotting

• Counting slots• When are they –days /times• Shadow scheduling • Same day/ next day

Decrease Days Out--Intakes

Identify high areas of no shows

Decrease Days Out--Intakes

Identify high areas of no shows

Decrease Days Out--Intakes

“Pull Forward” Currently Scheduled Intakes1. Identify high areas of no shows-predictive

modeling2. Create strategic overbooking slots in the

times of frequent no shows- we call them “access slots”

3. Take appointments scheduled furthest out and pull them forward into new slots

4. As show rate increase, adjust number of access slots

Decrease Days Out--Ongoing Care

Discontinue the habit of recurring individual therapy appointments, instead schedule week-to-week.Calls to reschedule morethan two appts Scheduled cancellationsIn same week

Decrease Days Out--Ongoing Care

Consider walk-in only medication management follow-ups.1. Psychiatrist tells patient at end of visit

to walk-in “the week of” and provides available hours

2. Reminders based on who has been instructed to come in “the week of”

Maintain Quick Access

Identify a “right-sized” number of intake slots• How many ongoing cases can you clinic

support at a time given current staffing?• What is your average length of treatment?• What percentage of intake convert into care-

as opposed to case closure?• What is your no-show rates on intakes now?

SUSTAINABLE BEHAVIORAL HEALTH SERVICES

The Front End and the Back End !

Considerations for Sustainability

• Staffing • Productivity/Volume• Direct Revenue • Indirect Revenue• Coding • Contracting • Optimization ( concurrent doc)• Back end-denials, • Dashboard development

Workflows Often Equal $$$$

• There are many different workflows

• Workflows can vary by location or provider

• Not set in stone

• Why do I need to do my reimbursement work before I figure out my workflows?

• Why do workflows matter ?

• Example-Medicare, hand off to open slots

Review Payer Mix

• What payers does your organization or BH services get reimbursement from

• Make a grid to review each payers each service and each provider

• Review guidelines for each payers- are services part of the contract or do they need to be added

• Does the payer reimburse for all credentials, i.e. social workers vs. counselors

• Special payer programs-like depression

Make A Grid

• What payers does your organization bill to or contract with

• List all of your payers Individually- remember some have more then one plan

• List all of your billable staff

• Leave space for contracting possibilities

Contracts

• Can be second source if a provider or code is not billable

• Contrary to popular belief they are negotiable

• If you don’t ask (is this the best rate you are offering in this state ?)

• Check with other integrated projects in your state- what are their arrangements (you cant partner)

• Medicare Advantage

Some Codes for Contracts

96152 Health & Behavior Intervention – Individual (each 15 mins)

96153 Health & Behavior Intervention – Group (each 15 mins)

96154 Health & Behavior Intervention – Family with Patient (each 15 mins)

96155Health & Behavior Intervention – Family without Patient (each 15 mins)

Add ons

90785 Interactive complexity add-on (for psychotherapy codes)

90839 Patient in crisis add-on – 60 minutes

90840 Patient in crisis add-on – Each additional 30 minutes

Credentialing

• Not to be confused with professional appointments

• Why should I bother if most of our patients are Medicaid?

• What if my organization doesn’t credential behavioral health providers?

• Subject to reviews by credentialing organizationsTakes a long time-Delegated credentialing is a goal

Abstract Dollars

• Can help support integration work

• Will vary by organization/setting/payer mix

• Time spent with PCP

• No show rates for PCP, specialty care

• Medication adherence

• Emergency room visits/utilization

• Productivity for behavioral health

Quality Dollars

• Disease Management industry– Potential to have care management

paid for ( at your site vs. by phone )– Special programs, like Aetna

• Brings in additional dollars above wrap

• Showcases your program/project

• Offer to be a “ pilot”

Optimize By

• Knowing what you should be paid for all services

• Reviewing work flows, opportunities to “up code”

• Review same day billing, services

• Different diagnosis for same day visits

• NOS vs MDD

Medicare Does Pay For

• Two Visits on the same day

• Incident too visits

• Behavioral health providers in health centers

• Depression Screenings

• Form Completion

Getting Paid What You’re Due

• Look closely at EOB’s– Not all payments are correct– Review and Track your Denials– Often Dx denials

• Review:– Payer contracts– Self-pay determinations

• Sliding fees• Do you need a different sliding fee for

behavioral health ?

Do You Know ?

• Your cost per visit for behavioral health ?

• Your average reimbursement for behavioral health ?

• How to know how much a staff person costs ?

• If not ………………

• Readable• Useful to:

– Patient– Clinician– Others involved in patient’s care

• Demonstrates clinical necessity

What is an “effective” progress note?

We need to value documentation as a representation of the clinical processes it represents:

• Assessment• Shared Care Planning• Clinician-Client interactions• Clinical progress

Why documentation matters!

PROGRESS NOTES

CMS (Centers for Medicare and Medicaid Services) definition:

“services or supplies that are needed for the diagnosis or treatment of a condition and meet acceptable standards of practice”

In other words…you are treating a diagnosis, and must show how you are addressing the symptoms of that diagnosis in each visit.

Clinical Necessity

Psychosocial Assessments:• Not enough symptom information in

assessment to support diagnosis• Not capturing clinical baselines• No documentation that clients were

given the opportunity to identify their own goals for treatment

*Based on NYSCRI regulatory review

Common “Traps” to Avoid*

Progress Notes• Not tied to care plans in a meaningful

way• No documentation of skilled

interventions provided• No documentation of clinical progress

(symptom resolution, etc.)

Continued…

Evidence Based Practice of Primary Care

• Behavioral Activation• Motivational Interviewing• Problem Solving Treatment• Psychiatric Wellness Self Management

Common Screening Tools Continued Assessment Tool Used to Assess Age

ASQ-SEAGES and Stages Questionnaire – social emotional

Development 2-60 months

AUDITThe Alcohol Use Disorders Identification Test (AUDIT)

Alcohol Abuse & Dependence 18+

CES-DC Center for Epidemiological Studies Depression Scale for Children

Depression 6-17

C-SSRS Columbia Suicide Severity Rating Scale

Suicide 7+

CPSS Child PTSD Symptom Scale

PTSD 8-18

CRAFFT Substance Abuse

14-21

DAST-10Drug Abuse Screening Test – 10 Item

Drug Abuse 18+

DLA-20 Daily Living Activities – 20 Item

Functioning(Activities ofDaily Living-ADLs)

6+

GAD-7Generalized Anxiety Disorder 7-Item Scale

Generalized Anxiety Disorder 18+

M-CHATModified Checklist for Autism in Toddlers

Autism Spectrum 16 to 30 months

Common Screening Tools Continued

MDQMood Disorder Questionnaire

Bipolar Disorder

18+

PHQ-2Patient Health Questionnaire 2 Item

Depression 11+

PHQ-APatient Health Questionnaire for Adolescents

Depression 11-17

PHQ-9Patient Health Questionnaire 9 Item

Depression 18+

SCAREDScreen for Child Anxiety Related Disorders (For children 8 to 11 it is recommended the clinician explain all questions or child sit with an adult in case they have any questions) SCARED-Parent Version

AnxietyDisorders

8-17

VANDERBILT-Parent ADHDODD/ConductAnxiety/Depression

6-12

VANDERBILT -Teacher ADHDODD/ConductAnxiety/Depression

6-12

RADReactive Attachment Disorder Screening Tool

Child Attachment 5 -18

Questions

• Vlittle@institute.org