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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