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Mental Health Clinic Restructuring Update

April 2010

Gary WeiskopfNew York State Office of Mental Health

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Purpose of Presentation

General Overview of Clinic Restructuring– http://www.omh.state.ny.us/omhweb/clinic_restructuring/

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Key Objectives of Clinic Restructuring

1. More responsive set of clinic treatment services and greater accountability for outcomes

Clinic is defined as a level of care with specific services

2. Redesign Medicaid clinic rates and phase out of COPSRelate payments to services and policy objectives

Modifiers and payment weights to reflect variations in cost

3. HIPAA compliant procedure-based payment system

4. Provisions for indigent care

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Clinic Program

Required Services– Outreach & Engagement– Initial Assessment (including Health Screening)

Health screening is the gathering and assessing of information concerning the recipient’s medical history and current physical health status (including physical examination) to determine potential impact on the recipient’s mental health diagnosis and treatment, and the need for additional health services or referral.

– Psychiatric Assessment– Crisis Intervention– Psychotropic Medication Administration (Injectables - clinics

serving adults)– Psychotropic Medication Treatment– Psychotherapy (including individual/group/family/collaterals)– Complex Care Management

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Clinic Program

Optional Services– Psychotropic Medication Administration

Optional for clinics only serving children– Developmental and Psychological Testing– Health Physicals– Health Monitoring

The continued measuring of specific health indicators associated with increased risk of medical illness and early death.

– Psychiatric Consultation - offsite

Staffing – Within Scope of Practice

– Psychiatrist– Physician (MD)– LMSW– LCSW – Psychologist– RN/LPN– NPP – LCAT– LMFT – LMHC

– Licensed Psychoanalyst– Licensed Psychologist– Physician’s Assistant –

Physical Health Only– Permitted staff– Students within approved

SED programs– Qualified non-licensed staff

including qualified peers and family advocates

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Staffing

Depending on the extension of the social work licensing law exemption, – Transition period to the new clinician standards

that mirrors the financial phase in.By the end of year 1 uncompensated care pool clinic services (except outreach and engagement) must be provided by appropriately licensed staffBy the end of year 3 all clinic services (except outreach and engagement) must be provided by appropriately licensed staff

– Commissioner has staffing waiver authority as permitted by law.

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Elements of Reimbursement System

Services Billed using Ambulatory Patient Groups (APGs)– based on CPT/HCPC CodesNon Face-to-Face: Bill for non face-to-face time spent coordinating care for complex patients

– Time spent must be medically necessary and documented in the consumer’s chart

Multiple Same Day Services: – Reduce the need for consumers to make multiple trips – Minimize missed appointments – Some limits will be establishedPhysician Billing: For some services the physician component will be billed using the physician fee schedule

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Elements of Reimbursement System

Payment adjustments for:– Visits in a language other than English – CPT – Visits delivered outside of normal business hours - CPT– Visits provided in off-site non-licensed locations – Rate

Code Restricted to services for children up to and including age 18 and for homebound adultsOutreach and engagement will always be done offsite

Medicaid/Medicare cross-over clients will be reimbursed the same as Medicaid fee-for-service clients

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APGs Replace “Threshold Visit”

Uses CPT codes to consolidate related procedures Establishes procedure weights based on factors affecting resource use

– service duration, location, practitioner qualificationsOMH procedure weights will be based on the minimum qualifications for staff permitted under OMH regulations to deliver a particular procedurePayments are the service weights (discounted as appropriate)

times a base rate. – No bundling for mental health

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Base Rates

Base rate is dependent on peer groupEach peer group will have a common base rate Peer groups:

Upstate DownstateLGUUpstate HospitalUpstate D&TCDownstate Hospital/Downstate D&TC

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Modifier Chart – Draft

OMH Service Name

Offsite After Hours

Language other than

English

Physician/NPP

Complex Care Management x x xCrisis Intervention Service - Per 15 minutes x x x

Crisis Intervention Service - Per Hour x x

Crisis Intervention Service - Per Diem x x

Developmental and Psychological Testing x x

Psychotropic Medication Administration x x MD payment Included in rates

Psychotropic Medication Treatment - No Time Limit

x x MD payment Included in rates

Initial Mental Health Assessment, Diagnostic Interview, and Treatment Plan Development

x x x x

Psychiatric Assessment - Minimum of 30 Minutes

x x MD payment Included in rates

Psychiatric Assessment - Minimum of 45 Minutes

x x MD payment Included in rates

Individual Psychotherapy - Minimum of 30 Minutes

x x x x

Individual Psychotherapy - Minimum of 45 Minutes

x x x x

Group and Multifamily/Collateral Group Psychotherapy - Minimum of 60 Minutes

x x x

Family Therapy/Collateral w/o patient -Minimum of 30 minutes

x x x x

Family Therapy/Collateral with patient -Minimum of 60 minutes

x x x x

Outreach and Engagement (outside visit) x x x

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General Billing Rules

Multiple off-site procedures - may only bill one off-site modifier for:

– Multiple procedures for 1 client in a day– Procedures provided to more than 1 recipient in the same

location in the same day.– Procedures provided to recipients and their collaterals in the

same visit.

Modifiers for off-site and language other than English cannot be billed together for the same procedure.

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General Billing Rules

Multiple Service Limits– 2 different procedures per client per day - excludes crisis,

medication, physical health visitsLimit 2 outreach & engagement unless

– Clinical staff documents necessity of more

Up to 3 Pre–Admission Assessments– Psychiatric assessment may be included

First visit for an adult can be off-site to– Determine homebound status for adult – medical or physical

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General Billing Rules

Complex Care Management– Provided within 5 working days of a

psychotherapy (face-to-face) or crisis service– Must be performed by a licensed professional– Provided with or without the recipient – Provided in person or by phone– Not to be used for routine follow-up – Requires a minimum of 15 minutes clinician time

doing complex care

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Proposed Weights and Rates

Rates and Weights

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Indigent Care

Uncompensated Care Pool proposed for:– D&TCs licensed by DOH and approved for the pool by

DOH– Free-standing Article 31 mental health clinics

Hospital operated clinics are not eligible for this poolThis does not include any OMH supplemental reimbursement – to be determined

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For participation in the 2010 pool, 2009 data from Article 31 agencies must be provided by March 31st 2010.

Agencies that do not submit annual data by dates to be established by OMH will be excluded from the pool for that year.

Partial payments from the pool will be made monthly.

Indigent Care

Indigent Care Reimbursement

Eligible indigent care visits must equal to 5% of visit volume to qualify. Reimbursement is calculated according to the following schedule.

– First 15% of visits reimbursed 50% of the value of the peer group average Medicaid rate.

– Second 15% are reimbursed at 75% – Visits >30% are reimbursed at 100%

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Indigent Care Pool Covered Services

For APG and indigent care purposes, a visit is defined as all procedures provided to an individual in a day.OMH anticipates that visits can be counted toward indigent care volume if they meet the following conditions:

– Self pay, including partial pay or no pay visits– Required or optional mental health clinic procedures provided but NOT

covered under a clinic’s agreement with an insurer. The service must be provided by a practitioner qualified to deliver the service under state regulations.

– Unreimbursed clinic visits/procedures appropriately provided to an insured recipient by a clinic staff member not “empanelled” by the third party payer in contract with the clinic.

The provider must document that the clinic or recipient received a denial of payment.

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Indigent Care Pool Covered Services

Unreimbursed clinic visits/procedures provided to an insured recipient by a clinic staff member when the procedure is not reimbursed by a third party payer NOT in contract with the clinic.

Clinic must received a denial of payment from the insurer or an attestation from the client Documentation must be retained by the clinicSubject to an audit by the New York State Office of the Medicaid Inspector General.

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Indigent Care Pool Non-Covered Services

Visits will not be counted if they meet the following conditions: – Visits paid in whole or part by a third party payer (including

Medicaid Managed Care).– Visits not authorized (considered not medically necessary)

by an insurer/managed care plan.– Visits provided to a recipient who has coverage from a third

party payer not in contract with the clinic when an insurer does reimburse the insured for the visit.

– Visits delivered by persons unqualified to deliver the services under state regulations.

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Transition

Phased-in over time to enable transition– 1st year – 75% old, 25% new – 2nd year – 50% old, 50% new, etc.

Clinics to submit APG claim only except for COPs OnlyCOPs only claims will phase out over 3 years

– Continue with the current billing process.

Current Status

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Draft regulations ublished March 17thFinalizing ratesProviding ongoing training on clinic restructuring

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