Senior Operations and Management Consultant MTM Services · Jan 2017—Dec 2018 Demonstration Phase Oct 2015—Oct 2016 Planning Phase May-Aug 5, 2015 Prepare Planning Grant Applications

Speaker NameTitle

Organization

CCBHC Masters Class: Back Office Management

Michael D. Flora, MBA, M.A.Ed., LCPCSenior Operations and Management Consultant

MTM Services

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Your Faculty for Today

Michael Flora

MTM Services

David Lloyd

MTM Services

Rebecca C. Farley

National Council for Behavioral Health

Steven M Kohler

McBee and Associates

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Becoming a CCBHC might seem like a daunting task with all of the requirements necessary for implementation; never fear, the National Council experts are here to help! We will go through the back office management check list to make sure you have the right structures in place to ensure success.

After this session, your organization will be ready to manage internal utilization management, credentialing, costing reporting, and other processes that are keeping you up at night.

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Source: http://www.merriam-webster.com

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Learning Objectives

• Identify the key elements needed to ensure the right

structures in your back office are in place to guarantee

success as a CCBHC.

• Prepare your workforce infrastructure to handle the new

requirements, paper work, and processes that come

along with becoming a CCBHC.

• Address the contract needs for setting up partnerships

with DCOs, FQHCs, and other community or regional

services.

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• Focus on organizational Revenue Cycle

management needs and back office

infrastructure to support pre-service, point of

service an post service needs to enhance

performance

• Develop strategies to address DCO

contracts, Compliance and Billing

Learning Objectives

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BH Core

Competencies

Recovery/Resilience

GovernanceLeadership

Access &Intake

ServiceScheduling

Billing &Financial

ManagementCompliance

ManagementInformation

OutreachMarketing

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CCBHC Overview

Rebecca Farley

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It Passed!The largest federal investment in mental health and addiction treatment in a

generation.

Representatives

Leonard Lance and

Doris Matsui

Senators Roy Blunt and Debbie

Stabenow

The Vision

• Improve overall health by bolstering community-based

mental health and addiction treatment

• Advance behavioral health care to the next stage of

integration with physical health care

• Assimilate and utilize evidence-based practices on a

more consistent basis

Certified Community Behavioral Health Clinics

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What makes CCBHCs so different?

• New provider type in Medicaid

• Distinct service delivery model:

trauma-informed recovery outside

the traditional four walls

• New prospective payment system

(PPS) methodology

• Requirement to contract with

other organizations

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24 States Selected for Planning Grants

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Timeline

Jan 2017—Dec 2018

Demonstration Phase

Oct 2015—Oct 2016

Planning Phase

May-Aug 5, 2015

Prepare Planning Grant Applications

SAMHSA has granted a 6-month extension for

states that are selected to participate in the

demonstration

• The demonstration start date may be

between Jan. 1 and June 30, 2017

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CCBHC Scope of Services

Must be delivered directly by CCBHC

Delivered by CCBHC or a Designated Collaborating

Organization (DCO)

CCBHC Payment

• Establishment of a Prospective Payment

System

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Breaking through old limitations…

Think creatively!

? In-home services for

newly placed foster

youth

? Post-booking

assessment in jails

? Outreach to homeless

populations

Services are not confined to delivery within the

4 walls of a clinic

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Do I have to be a CCBHC?

• DCOs augment or fill gaps in CCBHCs’ service array…

No! You could

become a…

Designated Collaborating

Organization

• …And can benefit from CCBHCs’ enhanced reimbursement

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Decisions Ahead

• Is the CCBHC model a good fit for my organization?

• What changes to our service array are needed?

• What workforce education/training do we need to do?

• What capital investments do we need to make?

• What back office changes do we need to implement

to make all of this work?

NatCon16: CCBHC Track

• Monday:

– 10:45: CCBHCs 101

– 12:00: Becoming Best Friends: CCBHCs and DCOs

– 3:00: Getting Paid as a CCBHC: Cost Reporting

Principles

• Tuesday:

– 10:00: Quality Reporting and CCBHCs

– 10:00: The Role of CCBHCs in Monitoring &

Managing Chronic Illness

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What About CCBHC?

Alaska Iowa Missouri Oklahoma

California Kentucky Nevada Oregon

Colorado Maryland New Mexico Pennsylvania

Connecticut Massachusetts New York Rhode Island

Illinois Michigan New Jersey Texas

Indiana Minnesota North Carolina Virginia

•Requires participating states to develop a Prospective Payment

System (PPS) for reimbursing Certified Behavioral Health Clinics for

required services provided by these entities. Participating states will

receive an enhanced Medicaid match rate for all of the required services

provided by the Certified Community Behavioral Health Clinics.

•On October 19th SAMHSA confirmed the following states have received

the one year CCBHC planning grant:

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Its no Longer Business as Usual

How does CCBHC change the back

Office and Revenue Cycle Work

Flow and processes?

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Identify the key elements needed to

ensure the right structures in your

back office are in place to guarantee

success as a CCBHC.

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CCBHC

Program Requirements

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“We are trying to create a new provider type, something that has never existed before!”

Chuck IngogliaSr. Vice President, Public Policy and Practice Improvement

National Council for Behavioral Health

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Defining the New Paradigm

CCBHC• Non-Four Walls

• Trauma-Informed Care Model

• PPS Rate Setting Support

Requirements

• PPS-2--Another Level of

Complication

• CCBHC Service Delivery

Operational Requirements

• Compliance with CCBHC

Certification Requirements

Current

Business

Practices

• Payer Verification

• Update

Demographics

• Credentialing

• UM/UR

• Co-Pays

• Pre-service

• Point of Service

• Post Service

• AR Management

Combined Areas

of Focus• Know the State Medicaid

Rules

• Understand How Your

Relationships Translate into

Costs

• DCO Management

• Getting Technology Right

• Fee Scale

• Telemedicine

• Clinical Quality Assurance

• Corporate Practice of

Medicine

• Decision-Making and

Change Management

Support Assessment

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Objectives for the Initiative:

The statute at subsection 223 (d)(4)(A) under which the program is authorized is explicit that preference must be given to selecting demonstration programs where participating CCBHCs will achieve at least one of the following:

• Provide the most complete scope of services as described in the Criteria to individuals eligible for medical assistance under the state Medicaid program; OR

• Improve availability of, access to, and participation in, services described in subsection Criteria to individuals eligible for medical assistance under the state Medicaid program; OR

• Improve availability of, access to, and participation in assisted outpatient mental health treatment in the state; OR

• Demonstrate the potential to expand available mental health services in a demonstration area and increase the quality of such services without increasing net federal spending.

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What is required of the state?

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The statute at subsection 223 (d)(4)(A) under

which the program is authorized is explicit that

preference must be given to selecting

demonstration programs where participating

CCBHCs will achieve at least one of the

following:

Statute under subsection 223 (d)(4)(A)

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CCBHC

Core Requirements

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CBHC Core Requirements

Program Requirement 1: Staffing (“Staffing requirements, including criteria that staff have diverse disciplinary backgrounds, have necessary State-required license and accreditation, and are culturally and linguistically trained to serve the needs of the clinic’s patient population.”)

Program Requirement 2: Availability and Accessibility of Services (“Availability and accessibility of services, including: crisis management services that are available and accessible 24 hours a day, the use of a sliding scale for payment, and no rejection for services or limiting of services on the basis of a patient’s ability to pay or a place of residence.”)

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CCBHC Core RequirementsProgram Requirement 3: Care Coordination (“Care coordination, including requirements to coordinate care across settings and providers to ensure seamless transitions for patients across the full spectrum of health services, including acute, chronic, and behavioral health needs. Care coordination requirements shall include partnerships or formal contracts with the following:

(i) Federally-qualified health clinics (and as applicable, rural health clinics) to provide Federally-qualified health clinic services (and as applicable, rural health clinic services) to the extent such services are not provided directly through the certified community behavioral health clinic. (ii) Inpatient psychiatric facilities and substance use detoxification, post-detoxification step-down services, and residential programs. (iii) Other community or regional services, supports, and providers, including schools, child welfare agencies, and juvenile and criminal justice agencies and facilities, Indian Health Service youth regional treatment clinics, State licensed and nationally accredited child placing agencies for therapeutic foster care service, and other social and human services. (iv) Department of Veterans Affairs medical clinics, independent outpatient clinics, drop-in clinics, and other facilities of the Department as defined in section 1801 of title 38, United States Code. (v) Inpatient acute care hospitals and hospital outpatient clinics.”)

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CCBHC Core Requirements

Program Requirement 4: Scope of Services (“Provision (in a manner reflecting person-centered care) of the following services which, if not available directly through the certified community behavioral health clinic, are provided or referred through formal relationships with other providers: (i) Crisis mental health services, including 24-hour mobile crisis teams, emergency crisis intervention services, and crisis stabilization. (ii) Screening, assessment, and diagnosis, including risk assessment. (iii) Patient-centered treatment planning or similar processes, including risk assessment and crisis planning. (iv) Outpatient mental health and substance use services. (v) Outpatient clinic primary care screening and monitoring of key health indicators and health risk. (vi) Targeted case management. (vii) Psychiatric rehabilitation services. (viii) Peer support and counselor services and family supports. (ix) Intensive, community-based mental health care for members of the armed forces and veterans, particularly those members and veterans located in rural areas, provided the care is consistent with minimum clinical mental health guidelines promulgated by the Veterans Health Administration, including clinical guidelines contained in the Uniform Mental Health Services Handbook of such Administration.”)

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Program Requirement 5: Quality and Other Reporting (“Reporting of encounter data, clinical outcomes data, quality data, and such other data as the Secretary requires.” )

** Note - When partnering with DCO’s, you will have to be able to collect and show the services that they have delivered to you consumers as well, so communication between agencies and their systems will become of paramount importance.

Electronic systems that interface, and/or the ability to collect information from teams not in electronic systems will be a large focus here.

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Program Requirement 6: Organizational Authority, Governance and Accreditation (“Criteria that a clinic be a nonprofit or part of a local government behavioral health authority or operated under the authority of the Indian Health Service, an Indian Tribe, or Tribal organization pursuant to a contract, grant, cooperative agreement, or compact with the Indian Health Service pursuant to the Indian Self-Determination Act [25 U.S.C. 450 et seq.], or an urban Indian organization pursuant to a grant or contract with the Indian Health Service under title V of the Indian Health Care Improvement Act [25 U.S.C. 1601 et seq].”)

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The Data to Drive our Decisions Will Come From:

1. CCBHC Readiness Assessments2. Community Needs Assessment for each CCBHC Clinic

geographic area3. Claims data4. Cost Data5. Persons Served6. Events/Encounter Data7. State level Strengths, Weaknesses, Opportunities and

Threats (SWOT) Analysis8. Other measurement tools as/if deemed necessary.

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CCBHC Prospective Payment System

Under the CCBHC designation we

must be able to understand the PPS

while at the same time maintain our

current and future payers

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New Integrated CCBHC Certification Criteria

Feasibility and Readiness Tool (I-CCFRT)

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Source: New Integrated CCBHC Certification Criteria Feasibility and Readiness Tool (I-CCFRT)

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Assessing your Readiness…

• Does your clinic have the capacity to run

Medicaid population PPS rate scenarios to

determine the financial consequence for the

specific PPS rate established for your clinic?

• Does your clinic have the capacity to develop

internal Service Delivery guidelines and

protocols as well as continuously monitor

compliance with the guidelines to support the

PPS rate model?


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Assessing your Readiness….

• Does your clinic have the capacity to run

Medicaid population utilization trends tied to

costs that will support the PPS rate setting?

• Does your clinic have the capacity to

establish the cost per delivered hour for each

service that you have provided and for

services that you will need to provide in the

new CCBHC non-four walls service delivery

system? .Source: New Integrated CCBHC Certification Criteria Feasibility and Readiness Tool (I-CCFRT)

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• CC PPS-1 Rate: Designated as Certified Clinic Prospective Payment System (CC PPS-1), the first option is a FQHC-like PPS that provides reimbursement of cost on a daily basis (as does the current PPS used for FQHC services reimbursement) with the addition of a state option to provide quality bonus payments (QBPs) to CCBHCs that meet defined quality metrics. QBPs are not a requirement and should not be seen as changing the underlying PPS system. It would only be there as a possibility for additional bonus payments and is at the option of the state.

CC PPS-1

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• The CC PPS-1 rate is based on total annual allowable CCBHC costs divided by the total annual number of CCBHC daily visits and results in a uniform payment amount per day, regardless of the intensity of services or individual needs of clinic users on that day.

• In developing the rates, states may include estimated costs related to services or items not incurred during the planning phase but projected to be incurred during the demonstration.

• States also should include in CC PPS-1 the cost of care associated with Designated Collaborating Organizations (DCOs). A DCO is an entity that is not under the direct supervision of the CCBHC but is engaged in a formal relationship with the CCBHC and delivers services under the same requirements as the CCBHC. Payment for DCO services is included within the scope of the CCBHC PPS, and DCO encounters will be treated as CCBHC encounters for purposes of the PPS. Services of a DCO are distinct from referred services in that the CCBHC is not financially and clinically responsible for referred services.

Section 2.1: Certified Clinic PPS (CC PPS-1)

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• The CC PPS-1 is a cost-based, per clinic rate that applies uniformly to all CCBHC services rendered by a certified clinic, including those delivered by qualified satellite facilities established prior to April 1, 2014.

• It pays CCBHCs a daily rate that is a fixed amount for all CCBHC services provided on any given day to a Medicaid beneficiary.

• In demonstration year one (DY1), the state will use cost and visit data from the demonstration planning phase, updated by the Medicare Economic Index (MEI) to create the rate for DY1.

• The DY1 rate will be updated again for DY2 by the MEI or by rebasing of the PPS rate.

• CMS requires the use of one full year of cost data and visit data, unless a state can justify the use of a shorter period of time.

Section 2.1: Certified Clinic PPS (CC PPS-1)

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• CC PPS-2 Alternative uses a monthly unit of

payment, provides for:

– Required QBPs – CC PPS-2 methodology, the state

is required to incorporate quality bonus payments as

part of the payment made using CC PPS-2.

– Rates that vary, depending on the populations

served by the certified clinic (e.g. patients who are

seriously mentally ill and those with substance use

disorders).

CC PPS-2 Rate

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• The CC PPS-2 is a cost-based, per clinic monthly rate that applies uniformly to all CCBHC services rendered by a certified clinic, including all qualifying sites of the certified clinic established prior to April 1, 2014.

• CC PPS-2 includes these required elements:

• a monthly rate to reimburse the CCBHC for services,

• separate monthly PPS rates to reimburse CCBHCs for higher costs associated with providing all services needed to meet the needs of clinic users with certain conditions,

• cost updates from the demonstration planning period to DY1 using the MEI and from DY1 to DY2 using the MEI or by rebasing,

• outlier payments made in addition to PPS for participant costs in excess of a threshold defined by the state, and

• QBP made in addition to the PPS rates.

Section 2.2: CC PPS Alternative (CC PPS-2)

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• A CCBHC receives the monthly rate whenever at least one CCBHC service is delivered during the month to a Medicaid beneficiary by the CCBHC; states may pay this rate only after a CCBHC service has been delivered.

• Under this methodology states will develop a standard monthly rate and also will develop monthly PPS rates that vary according to users’ clinical conditions. For example, states could set different rates for adults with serious mental illness and co-occurring substance use disorders and children and adolescents with serious emotional disturbance who require higher intensity services. The state has flexibility in determining how PPS rates could vary. An outlier payment is part of the CC PPS-2 and reimburses clinics for costs above a state-defined threshold. This helps to ensure that clinics are able to meet the cost of serving their users. Finally, the CC PPS-2 rate methodology requires the state to select quality measure(s) as permitted and make bonus payments to incentivize improvements in quality of care.


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• States should include in CC PPS-2 the cost of care associated with DCOs. A DCO is an entity that is not under the direct supervision of the CCBHC but is engaged in a formal relationship with the CCBHC and delivers services under the same requirements as the CCBHC. Payment for DCO services is included within the scope of the CCBHC PPS, and DCO encounters will be treated as CCBHC encounters for purposes of the PPS. Services of a DCO are distinct from referred services in that the CCBHC is not financially and clinically responsible for referred services.


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excluding clinic users with certain conditions

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• Under the CC PPS‐2 method, a state must

offer a QBP to any CCBHC that

demonstrates it has achieved all of the six

required quality measures as shown in Table

3 of the PPS guidance.

• The state can make a QBP on the basis of

additional measures provided in Table 3 of

the PPS guidance and may propose its own

quality measures for CMS approval.

Section 2.2.b CC PPS‐2 Quality Bonus

Payments

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Quality Measures

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PPS Rate and Back Office Functions

• PPS will be the same rate paid for any

qualifying CCBHC services provided.

• States will determine what qualifies as a

service and what level of provider(s) is

eligible to bill for that service.

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PPS Rate and Back Office Functions

• Sites will need to be very clear about what

their state counts as a visit and who can

provide the service so that they can make

sure the correct staff is providing the service

• Sites will still need to have a sense of their

costs so that they can continue to ensure that

the service provided is covered by the

payment rate (may want to have productivity

targets/duration targets for practitioners)

•

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In the CCBHC Environment

• Your current third party and other contracts

will still require your attention

• Depending on if your PPS-1 or PPS-2 you

will need to plan for cash flows and service

utilization

• You will need to develop payment structures

and UM/UR for your DCOs

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States have two options for incorporating

PPS rates into Medicaid Managed Care

Programs.

• Option 1: Incorporate cost of the PPS rates

into the Medicaid capitation rates and require

Managed Care Entities to pay PPS rates to

CCBHCs.

• Managed Care Entities must modify their

contracts with CCBHCs to reflect the CCBHC

scope of services and substitute PPS rates in

place of existing compensation levels.

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Source: Susannah Gopalan and Adam Falcone: Feldesman Tucker Leifer Fidell LLP



Programs.

• Option 2: Pay supplemental “wraparound”

payments to what CCBHC’s receive from

Managed Care Entities so that combined

payments equal PPS rates.

• Contracts with Managed Care Entities would

require that these entities pay rates to the

CCBHC equal to what other providers would

receive for similar services.

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Programs.

• The state makes supplemental payments and

performs and annual reconciliation to ensure

that total payments to CCBHCs are equal to

the reimbursement under the CCBHC PPS.

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Solutions

• Some solutions are driven by CMS –

– CMS recommends that states consider

assigning all CCBHCs to one managed care

entity that is capable of collecting all data

pertinent to demonstration payment.

– They further recommend that each state’s

contract with a Managed Care Entity must

contain requirements for CCBHC quality

reporting and encounter data.

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What about Managed Care?

• The managed care interaction may depend

on how the state is structuring the PPS

payment with the managed care plans.

– If the state is building the PPS rate into the

managed care rates/contract, then expect

increased scrutiny.

– If however, the state is providing a wrap

around payment directly to the CCBHC, then I

there may be delays in payment from state

government of up to a year or two of this wrap

around payment.

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CCBHC Revenue Cycle Management

• A greater understanding of current and future cash flows and management of billing practices will be needed in the new environment– How long is your billing process?

• Are you billing weekly?

• Can you process third party claims daily?

– What is your percent of denials?

– What is your performance standard on reconciliation of billing errors?

– What work flows and billing structures will need to be in place for your DCOs

– What percent of co-pays and self pay amounts are you collecting daily

• Do you establish a daily collection figure for your front desk?

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Revenue Cycle Management

PRE-SERVICE

Admission Eligibility

Pre-Service Audit

Authorization

Verification

Open to Schedule

POINT OF SERVICE

Co-Pay Collections

Treatment

Post Session Scheduling

Post Service Audit

POST SERVICE

Billing

Denial Management

Account Receivable Management

Cash Posting

Consumer Follow-Up

Key Performance Indicators

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Where are the Revenue Cycle

Impacts?

• Reimbursement reductions

• Increased compliance risk management

• Technological efficiencies

• Compliance program effectiveness

• Quality of care

• New and expanded payment methodologies

• Insurance expansion and availability

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Challenges to the Revenue Cycle

• Effective, Efficient Operations Will Help to

Minimize the Impacts of Health Care Reform

– e.g. compliance, reduced rates, outcomes

focused, integration, and complicated

Medicare and Medicaid rules.

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Processes than Impact the Revenue

Cycle• Referral

• Authorization Process

• Scheduling

• Encounter/Documentation

• Charge Capture

• Billing

• Follow-up Functions

• Cash Posting

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Revenue Cycle – Payer Awareness

• Who are your payers now?

• Who will be your payers moving forward?

• What will the payer requirements be?

• Billing

• Timely Filing

• Modifiers

• Codes etc.

• Documentation standards

• Any other issues that may have an impact?

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Revenue Cycle Solutions-

Referrals

• Expect a SIGNIFICANT increase in demand/referrals

when you increase access to care

• Higher deductible plans will become more common and

may impact consumers in your organization

• Understand the impact of PPS on your revenue cycle

• Providers must gather accurate demographic and payer

information at this point in order to anticipate potential

problem areas

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Referrals

Solutions:• Analyze staffing levels and capabilities now to determine their

ability to complete tasks not only with an increase in referrals but

as it stands today

– What staffing will be needed under the CCBHC?• UM/UR

• Compliance

• RCM

• Organizations with numerous satellites may want to consider

consolidating these functions to one centralized function

• Develop new policies and procedures

• Train staff on new processes

• Education of consumers will be critical at this point

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Authorizations

• Providers should expect that a greater need

to manage UM/UR under CCBHC

• Re-authorizations may be difficult to obtain

– Review DCO issues related to authorization

• Medical necessity will be questioned

• Retro-active authorizations will become less

common

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Authorizations

Solutions• Analyze staffing capabilities today

• Plan and train

• Staff handling the authorization process will need to clearly

communicate consumer needs and medical necessity.

• Staff will need to understand individual payer expectations and

timelines for authorizations and re-authorizations

• Organizations with numerous satellites may want to consider

consolidating these functions to one centralized function

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Authorizations

COMMUNICATION BETWEEN CLINICAL AND

COMPLIANCE STAFF WILL BE MORE

CRITICAL THAN EVER

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Scheduling

• CCBHC will result in a greater demand for staff time– Care Coordination

– Compliance

– RCM

• Address back office needs of CCBHC

• Schedulers will need access to the most up to-date

technology in order get consumers scheduled

• Technology will need to effectively match the

insurance plan to the available authorized clinical

staff for that plan

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Scheduling

Solutions

• Put technology in place that makes matching

plan to clinical staff seamless

• Educate staff

• Review UM/UR and DCO needs

• Centralize functions

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Encounter and Documentation

• INCREASED COMPLAINCE on Claiming

• Billing (back and front office) staff will need to

clearly understand new payer requirements

for documentation and coding of the

encounter

• Reduced timely filing will require that staff

document efficiently

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Encounter and Documentation

• Staffing Consideration

• Do you need to increase clinical and support

staff to handle increase in service and back

office requirements and where will they come

from?????

• Educate clinical staff on documentation,

coding and billing requirements of each

individual payer and those under CCBHC

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Encounters

• Billable Staff

• Work Flow

• Manage costs for Care Coordination?

• Billable vs. Non-Billable

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Revenue Cycle Solutions- Charge

Capture

• Effectively implementing systems and

processes related to the encounter and

documentation will increase efficiencies in the

charge capture process

• Example: Same day access and

collaborative documentation can result in

same day charge capture.

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Revenue Cycle Solutions- Billing

• Numerous new plans will be in place for

consumers in your care

• Understand the CCBHC core requirements

and impact on RCM/Back Office

• New billing rules will be in effect

• Review denial rates and filing times

• Review your billing and denial codes

• Expect higher co-pays and deductibles

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Critical Consideration:

• How will you collect and account for the

expected increase in copays and deductibles

• Front desk/receptions staff?

• Direct care staff?

• Check-out?

• Billing statement?

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Solutions:

• Develop Policies and Procedures

• Implement technology or processes that focus

on communication between revenue cycle staff

and clinical staff

• Clearly communicate to consumers payment

expectations

• Educate…Educate…Educate

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Revenue Cycle Solutions-Follow-up

• Expect a significant increase in pended or

denied claims…..so plan for the impact on cash

flow

Solutions

• IMPROVE FRONT END PROCESSES

• Technology!

• Consider moving staff that had been previously

involved in the billing process to the front end of

the revenue cycle

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Summary• Significantly more covered lives ( including those of your

DCOs)

• Increase in co-payments and deductibles

• Referral and authorization process will be critical

• Potential significant changes to documentation, coding

and billing of services

• Timely filing reductions

• Increase in denied and pended claims

• Cash flow will be impacted

• TECHNOLOGY AND EDUCATION!!!!

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Compliance Program Solutions

• Baseline analysis to determine where problems

are today

• Monitor constantly including medical necessity

reviews

• Ensure clinical staff are trained on changes that

will impact service delivery and documentation

• Monitor denial rates and referral rates to other

providers

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Revenue Cycle Management in

Accessing Third Party Markets:

• Challenge with timely access to treatment to support third party payer referral requirements

• Challenge with Community Awareness and Branding strategies to increase capacity

• Inconsistent Revenue Cycle Management procedures that enhance timely collections

• Inconsistent message to the community

• Understanding of the target markets in our communities

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Identifying RCM Preservice needs for

the CCBHC

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PRE-SERVICE


Pre-Service Audit

Authorization

Verification

Open to Schedule

POINT OF SERVICE

Co-Pay Collections

Treatment


Post Service Audit

POST SERVICE

Billing

Denial Management


Cash Posting

Consumer Follow-Up

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Pre-Service

1. Contract and Enrollment Management

2. Patient Scheduling

3. Medical Necessity

4. Eligibility/Benefits Management

5. Registration

6. Pre-Service Audit

8585

• Develop internal protocols for all Support

team members regarding Contract and

Enrollment Management

• Anchor KPIs and Protocols in Job

Descriptions

Contract and Enrollment Management

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• Assure that all consumers have the

appropriate authorizations, updated treatment

plans and that services scheduled are

ordered on the Treatment Plan PRIOR to

services being scheduled.

• If not Ordered, Assessed, Authorized or

Medically Necessary---DO NOT SCHEDULE

Patient Scheduling

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• Develop Protocols for Client Eligibility and

Benefits management

• Review Third Party Administration to assist

with this back office function

– TriZetto

– Phreesia

Eligibility/Benefits Management

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http://www.trizetto.com/

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http://www.phreesia.com/

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• Develop Protocols and KPIs for Client

Registration into the state or appropriate

payer portals.

• Example: All new consumer will be registered

same day of service 100% of the time

Registration

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Gather financial intake data

• a. Definition: A financial intake package (annual, updates, as status

changes, or as required by program) will be completed on all individuals

requesting services with the center.

• b. Standard: Financial intake paperwork will be entered by support staff into

CMHC/CIS prior to or on the date of clinical intake.

• c. Source: Monthly audit of financial assessments.

• d. Compliance Rating: 100% of these entries made prior to clinical intake

=compliant. Less than 100% = non-compliant.

• e. Solution Plan: Development note and retraining for first non-compliant

rating. A Written Warning and retraining will be offered following the

second consecutive non-compliant period and Separation from employment

upon the third consecutive non-compliant period.

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Pre-Service confirmation/reminder calls

• During the confirmation call the Customer

Service Representative (CSR) not only

confirms the appointment but also confirms

outstanding balance and co-pay as needed.

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• Develop Protocols to

review all services at

least 72 hours prior to

services being rendered

• For Open Access to

care-develop protocols

for Same day review of

eligibility and consumer

fee determination

Pre-Service Audit

94

• Most health insurance policies cover behavioral health and substance abuse services

to some extent. IF YOU HAVE HEALTH INSURANCE, INCLUDING MEDICARE OR

MEDICAID, IT IS IMPORTANT THAT YOU GIVE US THIS INFORMATION RIGHT

AWAY. We will bill your insurance company directly so that they can pay us directly.

Should your insurance company pay us for what you have already paid, we will credit

your account or give you a refund. Your insurance company is billed our full fee. You

are responsible for any deductibles, co-pays, and the balance that is not covered by

your insurance company. Any deductibles and co-pays are not eligible for a

sliding fee adjustment. If your balance after insurance payments reaches $300,

you will be required to make a payment to lower the balance below $300 or

your next appointment will not be scheduled.

• If this is your first visit , we will attempt to verify insurance and co –pay

amounts at the time of service , a minimum fee of $XX.00 is required at the

point of service. You are responsible for any amount of your care not covered

by your insurance carrier.

Health Insurance/Benefit Coverage

95

• If necessary, an Extended Payment Plan may

be arranged. If this approach will assist you

in paying your bill, please arrange to meet

with our Client Accounts staff. Should your

financial circumstances change, we reserve

the right to renew and revise your extended

payment plan at any time.

Extended Payment Plan

96

• If your financial circumstances are such that

paying the full fee is impossible, you may be

eligible for a Sliding Fee, which will allow

payment at less than the full fee rate. If this

approach seems necessary for you, please

discuss it with our Client Accounts staff. If

you are put on a sliding fee schedule,

there is a discount applied to your fee if

you pay at the time of service.

Sliding Fee

97

Assessing your Readiness…

• Is your clinic’s Back Office staff effective in

managing a CCBHC including establishing a

sliding fee scale payment model for non-

Medicaid clients?


98

CCBHC Financial and Cost Expectations

• Cost of services

• Fee Schedule

• Written Policy and Procedures on availability

and accessibility

• “No rejection for services or limiting of

services on the basis of a patient’s ability

to pay or a place of residence.”

99

So in what way will you….

• Monitor this to ensure viability?

• Are there any additional sources of revenue

for indigent care?

• Can you make a case to the state for federal

block grant dollars to pay for indigent care?

100

Sliding Fee ScaleCCBHCs will be required to have a sliding fee

schedule and to make this very publicly available.

You will need to have a process for assessing

everyone in regards to this, uninsured and insured

as well.

Even if person has private insurance that does not

cover CCBHC services, they are still required to

provide them and in this instance would want to

use sliding fee schedule to recover whatever they

can from the cost

101

FEE Policy

Family Size

from to from to from to from to from to from to

1 $0 $11,770 $11,771 $16,243 $16,244 $17,655 $17,656 $23,540 $23,541 $40,607 $40,608 $35,310 $35,311 $64,970

2 $0 $15,930 $15,931 $15,932 $15,933 $23,895 $23,896 $31,860 $31,861 $39,830 $39,831 $47,790 $47,791 $63,728

3 $0 $20,090 $20,091 $20,092 $20,093 $30,135 $30,136 $40,180 $40,181 $50,230 $50,231 $60,270 $60,271 $80,368

4 $0 $24,250 $24,251 $24,252 $24,253 $36,375 $36,376 $48,500 $48,501 $60,630 $60,631 $72,750 $72,751 $97,008

5 $0 $28,410 $28,411 $28,412 $28,413 $42,615 $42,616 $56,820 $56,821 $71,030 $71,031 $85,230 $85,231 $113,648

6 $0 $32,570 $32,571 $32,572 $32,573 $48,855 $48,856 $65,140 $65,141 $81,430 $81,431 $97,710 $97,711 $130,288

7 $0 $36,730 $36,731 $36,732 $36,733 $55,095 $55,096 $73,460 $73,461 $91,830 $91,831 $110,190 $110,191 $146,928

8 $0 $40,890 $40,891 $40,892 $40,893 $61,335 $61,336 $81,780 $81,781 $102,230 $102,231 $122,670 $122,671 $163,568

Income Level Income Level

% DISCOUNT - 0%

Income Level

Sample Agency

SLIDING FEE SCHEDULE

EFFECTIVE 2016

(BASED ON FEDERAL INCOME GUIDELINES PUBLISHED 2016)

% DISCOUNT - 30% % DISCOUNT - 20%% DISCOUNT - 40%

Income Level

Federal Guidelines

Income Level

% DISCOUNT - 80%

Income Level

% DISCOUNT - 60%

Income Level

102

Sliding Fee Based on Income

DRAFT

Discount

% 20.00$ 40.00$ 50.00$ 60.00$ 80.00$ 100.00$ 140.00$ 160.00$ 200.00$

0% 20.00$ 40.00$ 50.00$ 60.00$ 80.00$ 100.00$ 140.00$ 160.00$ 200.00$

20% 16.00$ 32.00$ 40.00$ 48.00$ 64.00$ 80.00$ 112.00$ 128.00$ 160.00$

40% 12.00$ 24.00$ 30.00$ 36.00$ 48.00$ 60.00$ 84.00$ 96.00$ 120.00$

60% 8.00$ 16.00$ 20.00$ 24.00$ 32.00$ 40.00$ 56.00$ 64.00$ 80.00$

75% 5.00$ 10.00$ 12.50$ 15.00$ 20.00$ 25.00$ 35.00$ 40.00$ 50.00$

80% 4.00$ 8.00$ 10.00$ 12.00$ 16.00$ 20.00$ 28.00$ 32.00$ 40.00$

Services Case Mgt 1 hr group Drug 1 1/2 hr group 1 hr Therapy & Psychiatric Psychological Assessment 1 hr Evaluation/ Med Check

1/2 hr therapy Screening Medication Evaluations, Testing with Doctor

Monitoring Crisis

Intervention,

1/2 hr therapy

with Doctor, &

F

e

e

A

m

o

u

n

t

Full Fee Amount

Sample Agency

DISCOUNTED FEE SCHEDULE

EFFECTIVE FY16

103

Assessing the

clients ability to

pay:1) pay stub

2) W-2/Income tax form

3) House Hold size

4) Household Income

104

Understanding your compliance and

RCM risk to address the contract

needs for setting up

partnerships with DCOs, FQHCs,

Encounters and other community

or regional services.

105

CCBHC Readiness

• Readiness to become a CCBHC will require more than simply asking whether or not

you are ready to be a CCBHC provider; instead, you will need to ask whether or not

you are prepared to become a brand-new provider type with the responsibilities

associated with this new role.

• CCBHCs as a provider type have two unique elements that have not been seen in

other provider types: 1) the requirements to include structured meta-data into both

your organization and your relationship with your partners, and 2) the ability to

provide services outside of your CCBHC through relationships with DCOs. These two

requirements create novel complications that must be considered to create

successful relationships and protect you from liability that can come from the

CCBHC's unique provider type structure.

• The following issues will help you to begin thinking about what it means to become a

new provider type with structured-data requirements and novel relationships that

allow you to move your services outside the walls of your facility.

106

DCOs and YOU

• Has your clinic developed procedures to

manage the clinical relationship with DCOs

from both a clinical care and data sharing

requirement?


107

DCOs

• Whether directly supplied by the CCBHC or by a DCO,

the CCBHC is ultimately clinically responsible for all

care provided. The decision as to the scope of services

to be provided directly by the CCBHC, as determined by

the state and clinics as part of certification, reflects the

CCBHC’s responsibility and accountability for the clinical

care of the consumers. Despite this flexibility, it is

expected CCBHCs will be designed so most services are

provided by the CCBHC rather than by DCOs, as this will

enhance the ability of the CCBHC to coordinate services.

• Note: See CMS PPS guidance regarding payment.

108

CCBHC

• The CCBHC ensures all CCBHC services, including those supplied

by its DCOs, are provided in a manner aligned with the requirements

of Section 2402(a) of the Affordable Care Act, reflecting person and

family-centered, recovery-oriented care, being respectful of the

individual consumer’s needs, preferences, and values, and ensuring

both consumer involvement and self-direction of services received.

Services for children and youth are family-centered, youth-guided,

and developmentally appropriate.

• Note: See program requirement 3 regarding coordination of services

and treatment planning. See criteria 4.K relating specifically to

requirements for services for veterans.

109

Required Quality Data Elements for Clinics

and State

110

1. Number/Percent of clients requesting services who were determined to need routine care

2. Number/percent of new clients with initial evaluation provided within 10 business days, and mean

number of days until initial evaluation for new clients

3. Mean number of days before the comprehensive person-centered and family centered diagnostic and

treatment planning evaluation is performed for new clients

4. Number of Suicide Deaths by Patients Engaged in Behavioral Health (CCBHC) Treatment

5. Documentation of Current Medications in the Medical Records

6. Patient experience of care survey

7. Family experience of care survey

8. Preventive Care and Screening: Adult Body Mass Index (BMI) Screening and Follow-Up

9. Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC)

(see Medicaid Child Core Set)

CCBHC Data and Quality Measures

Required Reporting – Clinic List

111

10. Controlling High Blood Pressure (see Medicaid Adult Core Set)

11. Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention

12. Preventive Care and Screening: Unhealthy Alcohol Use: Screening and Brief Counseling

13. Initiation and engagement of alcohol and other drug dependence treatment (see Medicaid Adult Core Set)

14. Child and adolescent major depressive disorder (MDD): Suicide Risk Assessment (see Medicaid Child Core Set)

15. Adult major depressive disorder (MDD): Suicide risk assessment (use EHR Incentive Program version of measure)

16. Screening for Clinical Depression and Follow-Up Plan (see Medicaid Adult Core Set)

17. Depression Remission at 12 months

112

1. Housing Status (Residential Status at Admission or Start of the Reporting Period Compared to Residential Status at Discharge or End of the Reporting Period)

2. Number of Suicide Attempts Requiring Medical Services by Patients Engaged in Behavioral Health (CCBHC) Treatment

3. Follow-Up After Discharge from the Emergency Department for Mental Health or Alcohol or Other Dependence

4. Plan All-Cause Readmission Rate (PCR-AD) (see Medicaid Adult Core Set)

5. Diabetes Screening for People with Schizophrenia or Bipolar Disorder who Are Using Antipsychotic Medications

6. Diabetes Care for People with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control (>9.0%)

7. Metabolic Monitoring for Children and Adolescents on Antipsychotics

8. Cardiovascular health screening for people with schizophrenia or bipolar disorder who are prescribed antipsychotic medications


Required Reporting – State List

113


Required Reporting – State List

9. Cardiovascular health monitoring for people with cardiovascular disease and schizophrenia

10. Adherence to Mood Stabilizers for Individuals with Bipolar I Disorder

11. Adherence to Antipsychotic Medications for Individuals with Schizophrenia (see Medicaid Adult Core Set)

12. Follow-Up After Hospitalization for Mental Illness, ages 21+ (adult) (see Medicaid Adult Core Set)

13. Follow-Up After Hospitalization for Mental Illness, ages 6 to 21 (child/adolescent) (see Medicaid Child Core Set)

14. Follow-up care for children prescribed ADHD medication (see Medicaid Child Core Set)

15. Antidepressant Medication Management (see Medicaid Adult Core Set)

114

IT requirements for CCBHC Compliance

115

Health Information Technology-

Telehealth

• NOTE: To the extent that CCBHC Clinics use DCO agreements to deliver the required CCBHC services, the same quality reporting data will be required of each DCO.

116

• The state has the capacity to annually report any data or

quality metrics required of it, including but not limited to

CCBHC‐level Medicaid claims and encounter data. The

data include a unique consumer identifier, unique clinic

identifier, date of service, CCBHC service, units of service,

diagnosis, Uniform Reporting System (URS) information,

pharmacy claims, inpatient and outpatient claims, and any

other information needed to provide data and quality

metrics required in Appendix A of the criteria. Data are

reported through the Medicaid Management Information

System (MMIS/T‐MSIS).

Program Requirement 5: Quality and Other

Reporting

117

• Does the clinic have the capacity to collect, report, and

track encounter, outcome, and quality data, including all

data and quality measures that Appendix A of the criteria

requires be reported by clinic s rather than the state?

• Do clinical data reporting systems have the capacity to

track the following elements: (1)consumer

characteristics; (2) staffing; (3) access to services; (4)

use of services; (5) screening, prevention, and

treatment; (6) care coordination;(7)other processes of

care; (8) costs; and (9)consumer outcomes?

Questions

118

• The state has capacity to provide Treatment

Episode Data Set (TEDS) data and other

data that may be required by HHS and the

evaluator.


Reporting

119

• Reporting is annual and data are required to

be reported for all CCBHC consumers, or

where data constraints exist (for example, the

measure is calculated from claims), for all

Medicaid enrollees in the CCBHCs.


Reporting

120

• Do reports reflect data for all clinic

consumers?

• If data constraints exist, do reports at a

minimum include all Medicaid enrollees in the

clinic?

Questions

121

• CCBHCs evidence the ability (for, at a

minimum, all Medicaid enrollees) to collect,

track, and report data and quality metrics as

required by the statute, criteria, and PPS

guidance, and as required for the evaluation

and annually submit a cost report with

supporting data within six months after the

end of each demonstration year to the state.


Reporting

122

• To the extent possible, these criteria assign to the state responsibility for data collection and reporting where access to data outside the CCBHC is required. Data to be collected and reported and quality measures to be reported, however, may relate to services CCBH Consumers receive through DCOs. Collection of some of the data and quality measures that are the responsibility of the CCBHC may require access to data from DCOs and it is the responsibility of the CCBHC to arrange for access to such data as legally permissible upon creation of the relationship with DCOs and to ensure adequate consent as appropriate and that releases of information are obtained for each affected consumer.


Reporting

123

Requirement for States - Part III – Data

Collection and Reporting Planning

124

CCBHC Readiness

• Readiness to become a CCBHC will require more than simply asking whether or not

you are ready to be a CCBHC provider; instead, you will need to ask whether or not

you are prepared to become a brand-new provider type with the responsibilities

associated with this new role.

• CCBHCs as a provider type have two unique elements that have not been seen in

other provider types: 1) the requirements to include structured meta-data into both

your organization and your relationship with your partners, and 2) the ability to

provide services outside of your CCBHC through relationships with DCOs. These two

requirements create novel complications that must be considered to create

successful relationships and protect you from liability that can come from the

CCBHC's unique provider type structure.

• The following issues will help you to begin thinking about what it means to become a

new provider type with structured-data requirements and novel relationships that

allow you to move your services outside the walls of your facility.

125

DCOs and YOU

• Has your clinic developed procedures to

manage the clinical relationship with DCOs

from both a clinical care and data sharing

requirement?

126

DCOs

• Whether directly supplied by the CCBHC or by a DCO,

the CCBHC is ultimately clinically responsible for all

care provided. The decision as to the scope of services

to be provided directly by the CCBHC, as determined by

the state and clinics as part of certification, reflects the

CCBHC’s responsibility and accountability for the clinical

care of the consumers. Despite this flexibility, it is

expected CCBHCs will be designed so most services are

provided by the CCBHC rather than by DCOs, as this will

enhance the ability of the CCBHC to coordinate services.

• Note: See CMS PPS guidance regarding payment.

127

CCBHC

• The CCBHC ensures all CCBHC services, including those supplied

by its DCOs, are provided in a manner aligned with the requirements

of Section 2402(a) of the Affordable Care Act, reflecting person and

family-centered, recovery-oriented care, being respectful of the

individual consumer’s needs, preferences, and values, and ensuring

both consumer involvement and self-direction of services received.

Services for children and youth are family-centered, youth-guided,

and developmentally appropriate.

• Note: See program requirement 3 regarding coordination of services

and treatment planning. See criteria 4.K relating specifically to

requirements for services for veterans.

128

• Does the clinic have a relationship with DCOs

that allows for collection of data and quality

measures following consumer consent for

releases of information?

Questions

129

• CCBHCs have policies and procedures in place requiring and enabling annual submission of the cost report within 6 months after the end of the demonstration year.

• CCBHCs have formal arrangements with the DCOs to obtain access to data needed to fulfill their reporting obligations and to obtain appropriate consents necessary to satisfy HIPAA, 42 CFR Part 2, and other requirements.


Reporting

130

• As specified in Appendix A, some aspects of data reporting will be the responsibility of the state, using Medicaid claims and encounter data. States must provide CCHBC-level Medicaid claims or encounter data to the evaluators of this demonstration program annually.

• At a minimum, consumer and service-level data should include a unique consumer identifier, unique clinic identifier, date of service, CCBHC-covered service provided, units of service provided and diagnosis. These data must be reported through MMIS/T-MSIS in order to support the state’s claim for enhanced federal matching funds made available through this demonstration program.


Reporting

131

• For each consumer, the state must obtain and

link the consumer level administrative Uniform

Reporting System (URS)information to the claim

(or be able to link by unique consumer

identifier).CCBHC consumer claim or encounter

data must be linkable to the consumer's

pharmacy claims or utilization information,

inpatient and outpatient claims, and any other

claims or encounter data necessary to report the

measures identified in Appendix A.

132

Program Requirement 5: Quality

and Other Reporting

• These linked claims or encounter data must also be

made available to the evaluator. In addition to data

specified in this program requirement and in Appendix A

that the states to provide, the state will provide such

other data, including Treatment Episode Data Set

(TEDS) data and data from comparison settings, as

maybe required for the evaluation to HHS and the

national evaluation contractor annually.

133

Program Requirement 5: Quality

and Other Reporting

• The clinic has agreed to and demonstrates

the ability to report data listed in Criteria

Appendix A, CCBHC Required Measures and

such other data as the state requires to

participate in the demonstration program.

• The clinic agrees to participate in discussions

with the national evaluation team.

Questions

134

• CCBHCs annually submit a cost report with

supporting data within six months after the

end of each demonstration year to the state.

The state will review the submission for

completeness and submit the report and any

additional clarifying information within nine

months after the end of each demonstration

year to CMS.


Reporting

135

• Does the clinic have procedures in place to

submit an annual cost report with supporting

data to the state within 6 months after the

end of the demonstration year?

Questions

136

• Documents to Review Onsite or in Advance:

• (1) Continuous quality improvement (CQI) plan for clinical services and clinical management (not administrative management) with CQI projects identified,

• (2) clinic policies and procedures related to CQI, (3) job description of personnel responsible for CQI plan,

• (4) data on consumer suicide attempts and completed suicides, and

• (5) data on consumer 30-day hospital readmissions for psychiatric or substance use reasons

137

5.B Continuous Quality Improvement Plan (

CQI)

• The CCBHC develops, implements, and maintains an effective, CCBHC-wide data-driven continuous quality improvement (CQI) plan for clinical services and clinical management. The CQI projects are clearly defined, implemented, and evaluated annually. The number and scope of distinct CQI projects conducted annually are based on the needs of the CCBHC’s population and reflect the scope, complexity and past performance of the CCBHC’s services and operations.

• The CCBHC-wide CQI plan addresses priorities for improved quality of care and client safety, and requires all improvement activities be evaluated for effectiveness.

• The CQI plan focuses on indicators related to improved behavioral and physical health outcomes, and takes actions to demonstrate improvement in CCBHC performance.

• The CCBHC documents each CQI project implemented, the reasons for the projects, and the measurable progress achieved by the projects. One or more individuals are designated as responsible for operating the CQI program

138

5.B Continuous Quality Improvement Plan (

CQI)

• A, Does the clinic develop, implement, and maintain a clinic -wide data-driven CQI plan for clinical services and clinical management?

• B. Does the CQI plan identify CQI projects that are based on the needs of the clinic population and reflect the scope, complexity, and past performance of the clinic’s services and operations?

• C. Does the CQI plan address priorities for improved quality of care and client safety?

• D. Are the CQI projects evaluated annually and for effectiveness?

• E. Does the CQI plan focus on indicators related to improved behavioral and physical outcomes and call for actions designed to improve clinic performance in those areas?

• F. Does the clinic document each CQI project implemented, the reasons for the projects, and measurable progress achieved by the projects?

• G. Whom has the clinic designated to be responsible for operating the CQI program?

139

Questions

• Although the CQI plan is to be developed by the CCBHC and reviewed and approved by the state during certification, specific events are expected to be addressed as part of the CQI plan, including:

• (1)CCBHC consumer suicide deaths or suicide attempts;

• (2) CCBHC consumer 30 day hospital readmissions for psychiatric or substance use reasons; and

• (3) such other events the state or applicable accreditation

140

• A. Does the clinic CQI plan address

consumer suicide deaths and suicide

attempts?

• B. Does the clinic CQI plan address

consumer 30-dayhospital readmissions for

psychiatric or substance use reasons?

• C. Does the clinic CQI plan address events

that the state or applicable accreditation

bodies deem appropriate?

141

Questions

• Develop Protocols to review services

delivered verses Services ordered on the

treatment plan

• Develop Audit functions to review Medical

Necessity and compliance to report back to

leadership, managers and direct care staff

Utilization Management

142

Audit Functions

• Quantitative Measures of Compliance

• Qualitative Measures of Compliance

• Contractual Compliance

• Clinical Key Performance Measures

• Non-Clinical Key Performance Measures

143

144

Compliance, Accountability &

Monitoring

Why is this important?

• Increased Accountability

• UM UR

– If we find that UM UR reviews

provide unsubstantiated claims

this will impact your CCBHC and DCO audit risk

– Horizontal and vertical accountability

– KPIs for clinical and non clinical team members

• Follow your UM UR/Corporate Compliance policy

145

• Just because we have passed a state audit is no guarantee that we are not open to problems.

146

Documentation

Get the CheckWithstand the audit

Keep the MoneySo, you can do it again.

Find the clientAssess the clientTreat the ClientDocument it all

Give the info to the next part of the process

SubmitThe

Claim for Payment to the Correct payer(s)

147

148

Performance Standard Model

UM/UR- Corporate Compliance

• Is the set of structures or methods that provide for authorization of care, using particular criteria.

– These are usually determined by the payer.

• Corporate Compliance Programs are structures and methods to review and monitor federal and state guidelines for quantitative and qualitative compliance

149

OVERVIEW

• AGENCY will employ a Corporate Compliance Officer to perform monthly reviews of all agency and DCO programs. Each program (including Crisis, Adult Mental Health, Substance Abuse, C&A Mental Health, Psychiatry, DCO, and others) will have at least 5% of its charts reviewed a minimum of 4 times each year.

• UR reports will be generated following each of these reviews and distributed to the manager of the affected programs. The managers will be responsible for instructing staff to amend what they can and will also search for trends of non-compliance that need further corrective action.

• Annually, the consultant will review each program and make recommendations on systemic improvement and assess each program’s strengths.

150

NEW CLINICAL STAFF/DCOs

• For the first six weeks of active clinical work, QA will review each chart weekly. They will then provide a personal review to the staff member and DCO regarding their paperwork timeliness and accuracy. At the end of this four week period, QA will either sign off that the clinician/DCO is competent or that the clinician requires another two weeks of review.

• Once the clinician has been signed off on, QA will review one week of charts once per month for the next nine months. QA will provide a written assessment of their performance to their supervisor, which will be reviewed during supervision, signed off on by both supervisor and employee, and placed in the employee’s personnel file.

151

EXISTING STAFF

• All staff/DCOs will have 20% of their charts audited the month before their annual contract review. QA will provide a written evaluation to assist the manager with the review process. If their compliance is above 95%, they will be placed in the “A” category. If less than 95% compliance is noted on this annual review, the clinician will be put into the “B” category. If less than 85% compliance is noted, the clinician will be placed in the “C” category.

152

Category A:

• Clinicians/DCOs in this category will receive semi-annual spot audits in addition to their annual review audit.

153

Category B:

• Clinicians/DCOs in this category will be required to adjust any incorrect documentation in the audited charts. They will also be subjected to once-per-month spot audits that will be documented and reviewed in supervision. They will have to make any necessary adjustments to the documentation and will need to have their supervisor sign-off on their spot-audit sheet verifying that this is done. This will continue monthly until compliance meets 95% or until 6 months have passed. If 95% compliance is not reached within 6 months, the clinician/DCO will be put into category C.

154

Category C:

• Clinicians/DCOs in this category will be required to submit all documentation daily to Compliance Review Staff. They will evaluate it for completeness and accuracy and will provide the supervisor with a daily report.

• They will be available to provide additional training to the clinician if required to ensure compliance. This will continue for 30 days, at which time compliance should reach 95%. The clinician will then be placed in Category B, although they will have expanded evaluation of treatment plan compliance for the first three months. If compliance does not reach 95% within 30 days, further disciplinary action will need to be taken at the discretion of the supervisor or termination of the DCO contract

155

Manage risk of unexpected losses or expenses

caused by regulatory action

◦ Prevent large payback sums, costly attorney’s

fees, negative public relations, employee

resources committed to response

◦ Civil/criminal liabilities

Implement proactive Corporate Compliance

initiatives to meet increased scrutiny from state

and federal funders

Meet our ethical obligations of quality care

Why incorporate CORPORATE

COMPLIANCE with your CCBHC?

156

• Compliance risk assessment

– Train employees and DCO contractors

– Review documents (UR: billing and coding,

medical necessity documentation)

– Identify risk areas (CI, CM, Family and Group

Rx, Fidelity to EBP, etc.)

• Infrastructure review– Review program components (self-disclosure,

corporate compliance log, removing billings that are unsubstantiated)

CORPORATE COMPLIANCE

157

Document and Claim Services Accurately

◦ Meet credentialing requirements

◦ Signatures must be original, dated and

accompanied by credentials (or meet e-

signature standards)

◦ Document actual time, date, duration

◦ Reflect service provided as required

◦ Include required documentation elements

◦ Include medical necessity, “golden thread”

SAMPLE CORPORATE COMPLIANCE

Elements

158

Understanding your Cost Reporting

Structure and Infrastructure needs

Steve Kohler

McBee and Associates

159

Speaker NameTitle

Organization

CCBHC Masters Class

Back Office Management

Steve KohlerDirector

McBee Associates, Inc.

160

Cost Report Basics

• What specific type of information is gathered?

– Facility characteristics (ownership status, type

of facility)

– Statistical Information ( Volume statistics by

payer)

– Financial Data, primarily P&L data, revenue

and expense

– Wage related data

161

Cost Report Basics

• Why is a Cost Report Important?

– The cost report is a financially report that identifies

the cost, charges, and volume statistics related to

healthcare treatment activities

– Cost Reports Impact Reimbursement

• Today

• Future Reimbursement – Prospective Payment

System Implementation; Monitoring; and rate

adjustments

– Congressional / CMS policy and rate setting

162

PPS Rate Development

• Facility specific base year cost as it stands now

would be utilized to develop a facility specific

rate per visit. The base year rate would be

updated, by the MEI (Medicare Economic Index)

or other state determined factors

• At this time, updates would not be provided for a

change in services or service mix.

• Budgetary constraints can also impact future

payment rates

163

PPS Benefits

• Predictability of Cash Flow and Receipts

• Shared Risk between the Payer and the

Provider

• Offers Reward (Profit) where costs are less

than reimbursement and Loss where cost

exceeds the PPS payments

164

Cost Report Preparation

• Assemble your team

• Develop a plan and timetable

• Know the regulations

• Compile all required records

• Keep in mind the cost data is based on

accrual accounting

• Keep and provide all backup supporting

statistical records

165

Who Are the Team Members

• CFO/Director of Finance

• Payroll

• Finance Department Staff

• Compliance Officer

• Operations

166

Additional Staffing

• Will I need more staff???

– Consider roles and responsibilities of current

finance department staff.

• Depending on the complexity and size of the

organization this will take time to prepare for

and to complete the cost report.

• Discussion

167

Assess

• Current accounting software

– Is it flexible to add new accounts?

– Rename accounts and assign new account

numbers?

• Current billing system capabilities

– Capturing all visits data?

– Does that visit data match what the

regulations indicate are to be counted as

enumerated visits?

168

Assess

• Current payroll process

– Can your system accurately assign worked in

a program or is it a manual process?

• Consider

– Do you need do have staff do time studies?

169

Plan and Timetable

• Assign responsibilities to address:

– General Ledger Mapping

– Salary Schedule

– Visit Enumeration

– Job Descriptions

– Regulations Impacting Your State

170

Job Descriptions

Take Credit Where the Credit is Due

• You may need to revise several job

descriptions.

• Why?

– Do you really know what everyone does in the

organization and are they actually doing what

the job description says

171

Get it Right!

• Why Get it Right?

– You may have to live with the rate you

establish

• When setting your rate consider:

– Budgeting for growth

– Potential new staffing requirements

– New documentation or collaboration

requirements

172

Preparing for the Cost Report

• Direct and Allowable Cost (as defined by

regulations)

• Allocation of Overhead Cost

• Determination of Cost of Services (Cost per

Unit)

• Determination of Cost of Services related to

Medicaid Patients

• Provides for Cost Basis to Develop a

Prospective Payment System (PPS)

173

Cost Report Essentials

• Commonly Used Data in a Cost Report

– General Ledger (Summary Trial Balance)

– Payroll Register

– Statistical Reports of Services by Payer with a

detailed review required – Patient Census

– Overhead Allocation Statistics

– Other Specific Purpose Data

174

The CCBHC Cost Report

• Costs must adhere to:

– 45 Code of Federal Regulations (CFR) 75

Uniform Administrative Requirements, Cost

Principles, and Audit Requirements for the

U.S. Department of Health and Human

Services (HHS) Awards, and

– 42 CFR 413 Principles of Reasonable Cost

Reimbursement

175


• CCBHC records must be:

– Detailed

– Orderly

– Complete, and

– AVAILABLE for REVIEW or AUDIT

176


• Supporting documents must be maintained

for all costs reported;

– Cost report package and source

documentation (e.g. invoices, patient records,

cancelled checks) must adhere to federal and

state record retention requirements.

177


• Accrual basis of accounting required

• All information requested in the cost report

tabs must be furnished

• Failure to complete applicable tabs properly

will result in rejection and return to the

CCBHC for correction and re-submission

178


• Part 1 – Provider Information Tab

– Basic information Gathered

• Part 2 – Provider Information For Clinics

Filing Under Consolidated Cost Reporting

– Must be completed for each site included in

the consolidation

• If more than 1 satellite exists, create a new tab

179

Trial Balance Tab

• Purpose:

– Record amounts from the trial balance

expense accounts

– Perform necessary reclassifications and

adjustments to adhere to Medicare and

Medicaid cost principals

– Record estimates of anticipated changes in

costs

180

The General Ledger

• General Ledger – Summary Trial Balance

– The General Ledger serves as the source

document for initial reporting on the cost

report

– A properly established General Ledger will

serve to categorize expense and revenue

related to the specific departments / types of

services provided that will ease the burden of

completing the cost report without the need

for post year-end analysis, or at least

minimize it.

181

The General Ledger

• General Ledger – Trial Balance (cont’d)

– With a properly detailed general ledger (accounts /

departments / etc. mapping expenses to the cost

report becomes easy, okay, easier.

– With an overly simplistic general ledger, one which is

constructed just with natural accounts, e.g. salary

expense, benefit cost, supply expense, etc. and not

on a cost center basis, be prepared for late hours for

analysis and breakdown of expenses to meet the cost

reporting requirements.

182

Trial Balance Tab

• Cost elements of an expense category

maintained separately must be reconciled to

the worksheet expense

• Working Trial Balance must be submitted with

Cost Report

• MATERIALS ARE SUBJECT REVIEW or

AUDIT

183

• Key Column Descriptions

– Column 4 – Reclassifications

– Column 6 – Adjustments

– Column 8 – Anticipated Costs

Direct CCBHC Expenses

184

Anticipated Costs

• What are “Anticipated Costs”?

– Costs you expect to incur to meet the

expectations of operating as a CCBHC!

• Discussion of Anticipated Costs

185

Expense Line Descriptions

• Key Line Descriptions

– Part 1A- CCBHC Staff Costs

– Part 1B- CCBHC Staff Costs Under

Agreement (these are your DCO costs)

– Part IC – Other Direct Expenses

186

Indirect Costs

• Part 2A – Site Costs• What are Overhead Costs?

– Depreciation / Rent

– Insurance

– Interest Expense

– Utilities

– Housekeeping and Maintenance

– Property Taxes

– Administrative Salaries

– Office Supplies

– Legal

– Accounting

– Insurance

– Telephone

– Fringe Benefit Costs, including Payroll Taxes

187

Direct Costs for Non-CCBHC Services

• Part 3A- Direct Costs for Services other than

CCBHC Services

– This is the subtotal of direct costs for non-

CCBHC services “COVERED” by Medicaid

“EXCLUDING” overhead and “SPECIFY” in

the comments tab.

• Part 3B – Non-Reimbursable Costs

– Is the subtotal of direct costs for Non-CCBHC

services “NOT REIMBURSABLE” by Medicaid

and “SPECIFY” in comments tab.

188

Trial Balance Reclassifications Tab

• Reclassifies expenses to determine proper

cost allocation

– Must be identifiable in accounting records

– Use when expenses apply to more than 1

expense category

• Example Staff Psychiatrist

• Narrative must support reclassification of

expense

189

Trial Balance Adjustment Tab

• Used to Adjust Expenses in the Trial Balance

• Made on the basis of cost or revenue

• If an adjustment is made on the basis of cost

the provider may not adjust the expense on

the basis of cost in future cost reporting

periods

• If total direct and indirect cost can be

determined us cost as the basis of the

adjustment ….revenue as basis if not

190

Common Adjustments

• Investment income on restricted and

unrestricted funds

• Home office costs

• Services provided by National Health Service

Corps

• Depreciation Expense

191

Unallowable Costs

• Found in 45 CFR 75

• Examples

– Related Party Transactions

– Bad Debts

– Certain Advertising and Public Relations

Costs

192

Anticipated Costs Tab

• Additional costs for services needed to be a

CCBHC

• Costs expected to increase as a result of

offering CCBHC services

• Costs should support Medicaid and Non-

Medicaid patients

• Allowed only in year demonstration year 1

193

Indirect Cost Allocation Tab

• Used to identify the method used for

calculating allocable indirect costs to CCBHC

services using:

– Indirect rate approved by a cognizant agency

– A 10% rate

– Calculated indirect cost allocable to CCBHC

– Other method

194

Allocation Descriptions Tab

• Used to describe calculations and methods

that support the allocation methodology

• Additional documentation supporting

allocations must be kept on file

• Allocation of direct costs must be detailed

– Time Study

• Home office adjustments

195

Time Studies

• Why do a time study?

– Allows you to accurately attribute costs to the correct

cost center

– Identifies how much administrative time is dedicated

to those duties versus directly program related duties

– Reduces your administrative costs

196

Daily Visits Tab

• PPS-1 only

• Visits by one patient to multiple locations on

the same day may only be counted 1 time.

• Unique visit days directly from the CCBHC

• Unique visit days from DCO

• Anticipated unique visits

197

Monthly Visits Tab

• Used for PPS-2

• Patient Demographics Consolidated

– Patient visits to multiple locations counted 1

time

• Categorize costs according to whether

monthly outlier threshold and whether they

were allocated to certain conditions

198

Services Provided Tab

• Used to record FTE’s and # of services

provided for CCBHC services for each type of

practitioner

• This should be the units of service not days

• Must provide:

– CCBHC staff services

– CCBHC services under agreement

– Services by site

199

Additional Tabs

• Comments Tab- used for considerations

• PPS-1 Rate Tab –auto populated

– * Enter applicable Medicare Economic Index (MEI)

• PPS-2 Rate Tab

• Certification Tab

– Must be an officer or other authorized administrator

• CEO or CFO

200

Questions

• ????

201

Point of Service and Post Service

needs in the new environment

Michael Flora

202


PRE-SERVICE


Pre-Service Audit

Authorization

Verification

Open to Schedule

POINT OF SERVICE

Co-Pay Collections

Treatment


Post Service Audit

POST SERVICE

Billing

Denial Management


Cash Posting

Consumer Follow-Up

203

Point of Service

1. Collection of Co-Pays

2. Clinical Care Documentation

3. Charge capture

4. Coding

5. Utilization Management

204

• You will be expected to pay your fee each

time you receive service. Credit cards may

be accepted. If, however, you are unable to

remain current with your account, a different

approach may be necessary. Please discuss

such circumstances with our Client Accounts

staff or your clinician. If you do not, and

payment is not made, we reserve the right to

turn your account over to a collection agent.

Collection of Co-Pays

205

• Clinical Documentation must support the

services provided for the day

• Services provided must be on the Treatment

Plan and Assessment of need

• Documentation must be completed and

accurately submitted with in 24 hours after

service is rendered.

Clinical Care Documentation

206

Roles of Clinical and Financial Staff In

Third Party Billing

1. Completion and submission of all required

clinical documentation by direct care staff will

be needed to support authorizations after

Intake (if required) and re-authorizations

2. Filing timely and accurate claims will be

critical

3. Monitoring level of unreimbursed third party

care – determine reasons for non payment

and correct issues

207

• Review current coding Policy and procedures

to assure compliance

• Review current denial rates by CPT code

• Develop KPIs to reeducate denied claims

with in 24 hours

Coding

208

Coding Correctly

• Proper coding is necessary to ensure

appropriate reimbursement and avoid audit

liability

• Correct coding implies the selection is the

most accurate description of “what” services

were provided and “why” they were provided

209 209

Coding Correctly

• Per CPT, any procedure or service in any

section of CPT can be used by any qualified

physician or health care professional

– E/M codes can be reported by psychiatrists

– Psychiatric codes can be billed by other

qualified providers

210 210

Coding Correctly: HCPCS Codes

• Alpha-numeric codes and modifiers used by some payers such as Medicaid or Medicare

– H0031- Mental health assessment by non-physician (Medicaid)

– J codes for injectable medications (Medicare and Medicaid)

– Medicare modifier AJ for services provided by clinical social worker

• Code and modifier determines reimbursement level

211 211

Coding Correctly in

Integrated Care Setting

• General guidelines:

– Psychiatric services codes should be

reported by behavior health professionals

– E/M codes should be reported by

physicians, NPs, PAs, etc.

• Psychiatrist may report services from either

category depending on service provided

• Payers may have different coverage and

payment policies!

212 212

Coding Correctly in

Integrated Care Setting• Distinguish medical and mental health

diagnoses

• Providers select diagnosis (es) that’s chiefly

responsible for services provided

• Report only codes you treat or that impact

treatment

• Use codes for signs and symptoms until

diagnosis has been determined

213 213

Roles of Support Staff In Third

Party Billing

Centralized Scheduling is needed to ensure referral is

made to clinician on the appropriate insurance panel or

approved CCBHC PPS rate

– Ability to know at all times the availability of clinical

staff that are credential on third party panels will

be critical to timely acceptance of new referrals

Re-think Front Desk functions/needs

– Collection of Co-Pays prior to Service

– Confirmation of Insurance via copy of Insurance cards prior

to service

214

Point of Service Contact• Collection of Co-Pay/Reimbursement for services

• a. Definition: collection for all billable service co-pays provided by the center staff will be executed at each customer visit.

• b. Standard: CSR staff will accurately collect bill for services at the point of service

• c. Source: Review of financial reports.

• d. Compliance Rating: 98% or greater of these entries made at the POS =compliant. Less than 98% = non-compliant.

• e. Solution Plan: Development note and retraining for first non-compliant rating. A Written Warning and retraining will be offered following the second consecutive non-compliant period and Separation from employment upon the third consecutive non-compliant period.

215


PRE-SERVICE


Pre-Service Audit

Authorization

Verification

Open to Schedule

POINT OF SERVICE

Co-Pay Collections

Treatment


Post Service Audit

POST SERVICE

Billing

Denial Management


Cash Posting

Consumer Follow-Up

216

Post Service

1. Billing

2. Collections Management

3. Denial Management

4. Data Warehouse Analytics

217

Accelerating Cash Collection

• What are your days of sales outstanding?

• After services are delivered behavioral healthcare organizations revenue cycle needs to assess and maximize revenue capture and streamline the billing and collection process.– electronic claim processing,

– direct entry of Medicare/Medicaid claims,

– automatic secondary/Waterfall billing,

– remittance posting,

– contract and denial management,

218

Non-Clinical Performance Indicators

• Billing statements

•

• a. Definition: Client statements will be accurate and issued to each individual via mail each month.

• b. Standard: Client statements will be reviewed for accuracy and mailed out no later than the 20th day of each month.

• c. Source: Client statement spreadsheet

• d. Compliance Rating: 98% or higher of the statements are accurate and mailed = compliant. Less than 98% accuracy and distribution = non-compliant

• e. Solution Plan: Development note and retraining for first non-compliant rating. A Written Warning and retraining will be offered following the second consecutive non-compliant period and separation from employment upon the third consecutive non-compliant period.

219

Improving Access Management

• Assess the workflow processes and eliminate

redundancies in collection and rework.

• Providers will need to accurately:

– Obtain authorization for services,

– Determine, validate coverage for payment,

– Assess payment risk

– Schedule resources prior to the consumer’s

arrival.

220

Roles of Support Staff In Third

Party Billing

1. Centralized Scheduling is needed to ensure referral is made to clinician on the appropriate insurance panel or is enrolled with Medicaid/Medicare

– Ability to know at all times the availability of clinical staff that are credential on third party panels will be critical to timely acceptance of new referrals

2. Re-think Front Desk functions/needs

– Collection of Co-Pays prior to Service

– Confirmation of Insurance via copy of Insurance/Medicare cards prior to service

– Obtain and validate at each visit the demographic information from consumers. Make this a KPI.

221

Information

Capture at the

Front Desk

222

Third Party Payer Assessment Sheet

Revenue Enhancement Work Sheet

223

Non-Clinical Performance Indicators

• FINANCE:

• Goals:

1. Accurate billing statements will be generated and issued to consumers

no longer than 10 business days after month end 100% of the time

2. Based on the number of consumers billed, substantiated customer

complaints will not exceed 2%

3. Third party fees will be billed 100% of the time

4. 100% of complete and accurate invoices will be paid within 30 days of

receipt

5. Financial reports will be generated and distributed to management staff

within 15 business days of month end 90% of the time

6. Consumer satisfaction survey rating for financial matters/charges will

not fall below a score of 90%.

224

What about the payers?

• Improving Payer Performance

– Knowing Payer expectations

– What payers are in your market

– What is the % of Medicaid ?

– What is the % of Medicare?

– What is the % of uninsured?

– What is the % of Insured?

225

Identifying your work force needs in

the new CCBHC Revenue Cycle

Has your clinic developed a plan to

re-classify personnel to most

effectively leverage the PPS cost-

based reimbursement methodology?Source: New Integrated CCBHC Certification Criteria Feasibility and Readiness Tool (I-CCFRT)

226

Do You Have the Right Team?

• This is the most common question that asked

by Managers, Supervisors, Owners, and

CEOs. What do you think of your

management team? How do their skills

compare with those of other managers in

competitive organizations?

227


– Does your team perform “excellently” today?

Are they the team to implement your plans for

the next few years?

– Does your team have the skill sets needed to

manage CCBHC back office requirements?

228


– Who do you think is the most qualified to take

on your next major strategic initiative?

229


– Are any members of your team ever being

able to be promoted?

230


– If so, how long will it take for them to be

prepared? What should you do to make it

happen? If not, what are you going to do to

make it happen

231

The steps for ensuring that you have the

right staff with the right skills at the right

time are fairly straightforward:

232


• #1. Conduct an assessment of the

competencies and knowledge requirements

for critical executive, management and line

positions - for the present and for your

business’s long-term strategic future.

233


• #2. Assess current employee performance,

capabilities, and potential along the CCBHC

requirements and other key dimensions.

234


• #3. Develop a plan to either buy or build the

competencies you need for organizational

success.

235

Questions and Feedback

• Questions?

• Feedback?

• Next Steps?

236

237

Resources

I-CCBHC Feasibility and Readiness Assessment FINAL REVISED

E-FORM12-8-15…

Demo State Proposal Guidance_100515f_revised

101515_submitted with OMB # attached

Requirements of States for CCBHC Demonstration Program –

Clean – 1-7-16

CCBHC State-Certification-Guide 7-15

State Level Community Needs Assessment Check List FINAL 1-21-

16-1

CCBHC Certification Criteria Checklist 1-7-16

CCBHC Demonstration Application Guidance Analysis 1-5-

1601062016

238

http://www.thenationalcouncil.org/mtm-services/wp-content/blogs.dir/8/files/2016/01/I-CCBHC-Feasibility-and-Readiness-Assessment-FINAL-REVISED-E-FORM12-8-15....docx

http://www.thenationalcouncil.org/mtm-services/wp-content/blogs.dir/8/files/2016/01/DemoStateProposalGuidance_100515f_revised-101515_submitted-with-OMB-attached.pdf

http://www.thenationalcouncil.org/mtm-services/wp-content/blogs.dir/8/files/2016/01/Attachment-A-Requirements-of-States-for-CCBHC-Demonstration-Program-Clean-1-7-16.docx

http://www.thenationalcouncil.org/mtm-services/wp-content/blogs.dir/8/files/2016/01/CCBHC-State-Certification-Guide-7-15.pdf

http://www.thenationalcouncil.org/mtm-services/wp-content/blogs.dir/8/files/2016/01/State-Level-Community-Needs-Assessment-Check-List-FINAL-1-21-16-1.pdf

http://www.thenationalcouncil.org/mtm-services/wp-content/blogs.dir/8/files/2016/01/CCBHC-Certification-Criteria-Checklist-1-7-16.pdf

http://www.thenationalcouncil.org/mtm-services/wp-content/blogs.dir/8/files/2016/01/CCBHC-Demonstration-Application-Guidance-Analysis-1-5-1601062016.pdf