FQHC Billing Basics for Behavioral Health Partners

Presented by:

Kathleen Reynolds, LMSW, ACSW

Overview

• FQHC Billing Mechanisms• Implication of FQHC Mechanisms• Two Services in One Day• Health and Behavior Assessment Intervention Codes• 340B Pharmacy Benefits• Uninsured

FQHC Billing Mechanisms• PPS – Prospective Payment System• Cost Based Reimbursement• 330 Funding• Scope of Service (Changes)

• Mirror scope of primary location to the behavioral health 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

Implications of FQHC Billing Mechanisms

• FQHC/CHC bill by encounter rates and receive the same amount of funding for a 10 minutes visit as they do for a 1 hour visit

• Contracting with FQHC/CHC’s• Leasing Options for staff

• Psychiatrists• Consulting Psychiatrist Model

• LICSW/LMSW

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 – Georgia does not allow two services in one day to be billed

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 ◦ 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.

Two Services in one Day

• Medicaid is currently billable in 28 states by one provider

• Two providers can 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

The Health and Behavior Assessment/Intervention Codes (96150 - 96154)

• 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

diagnosisDiabetesCOPD Chronic Pain

340B Pharmacy Benefits

• 340B Pharmacy benefits• Individual receiving services enrolled in FQHC/CHC• Broader formulary• Significantly reduced rate

• Consumer needs to be enrolled with the FQHC/CHC• Prescription needs to be written by/cosigned by an

FQHC physician

Uninsured• FQHC/CHC 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• Masters of Social Work

CONTACT INFORMATION

Kathy Reynolds, LMSW, ACSW

kathyr@thenationalcouncil.org

734.476.9879