Part Three | Four-Part Executive Thought Leader Series Sponsored By Askesis Development Group
When it comes to funding for programs based upon integrated medical and behavioral service, the truism of “practice follows funding” is certainly relevant. In today’s market, the implementation of collaborative care models is being impeded by the continuation of traditional reimbursement models that one, involve separate payers, preauthorization requirements, clinical necessity criteria, billing and coding procedures, and reimbursement rules and rates for behavioral and medical services; and two, do not routinely cover the consultative behavioral and care management functions that are critical to integrated care delivery.
Defining “Integrated Care”
The behavioral services components of integrated programs are not as readily profitable as their medical service components – potentially driving those programs’ bottom lines into the red and offering little incentive to develop integrated programs. However, there are seven measures that behavioral and medical provider organizations alike can take to maximize the fiscal viability of their integrated service programs:
- Assure Adequate Referrals
- Avoid Grant Funding Dependence
- Utilize Health Behavior & Assessment & Intervention (HBAI) Billing Codes
- Avoid Same-Day Medical & Behavioral Services
- Partner With Other Provider Organizations
- Pursue FQHC Or Look-alike Status
- Negotiate Bundled Payments
1. Assure Adequate Referrals
One of the lessons learned by behavioral organizations that have imbedded primary medical services into their structures is that it may be difficult to generate the numbers of medical referrals needed to support an internal medical practice. One big reason for this is that, unlike behavioral health practitioners who still rely on traditional 50-minute therapy appointments, physicians typically run schedules based on 10-minute appointments and often double or triple book because of the higher cost expense of non-billable medical time.
As a result of this, medical practitioners need to see far more patients to fill their day’s calendar than what many behavioral health providers would anticipate. Additionally, many traditionally trained behavioral health practitioners do not always consider medical factors that could be influencing a client’s status and, as a result, do not initiate medical referrals. This means that it may be necessary to retrain behavioral staff to recognize when medical referral are appropriate, and there must be some element of “internal marketing” to ensure adequate numbers of internal medical referrals occur.
2. Avoid Grant Funding Dependence
Some behavioral health organizations currently in the process of integrating medical services to become “health homes” are doing so with substantial support from grants. In 2009, the Federal Substance Abuse and Mental Health Services Administration (SAMHSA) and Health Resources Services Administration (HRSA) began issuing four-year Primary and Behavioral Health Care Integration (PBHCI) grants of up to $500,000 per year to pilot inclusion of primary medical services into 64 publicly funded community behavioral health settings across the U.S. The goal is to identify the most effective models for improving behavioral health patients’ access to primary care, to provide better prevention and early intervention for medical concerns, and to promote better health and low morbidity among this at-risk population.
Although such funding can be critical to helping integrated health home programs get off the ground, the fact is that, grants are time-limited. Planning for sustainability must begin early in the process if these integrated services are to continue beyond the grant period.
3. Utilize Health Behavior & Assessment & Intervention (HBAI) Billing Codes
Many providers, both medical and behavioral, may be “leaving money on the table” by not realizing that behavioral services are reimbursable even when rendered to patients who do not have a diagnosable mental health or substance use disorder. In fact, the ability of provider organizations to obtain reimbursement for behavioral services in such situations was expanded in 2002 after the Federal Centers for Medicare and Medicaid Services (CMS) introduced HBAI billing codes (CPT codes 96150-96154) for identifying and treating psychological, behavioral, emotional, cognitive and social factors that affect prevention, management or treatment of physical health problems.
Intended for use by physicians, clinical psychologists, clinical social workers, physician assistants, nurse practitioners, and clinical nurse specialists servicing Medicare beneficiaries, the introduction of the HBAI billing codes represents a major step forward for recognizing the importance of psychosocial health factors in medical cases in which no diagnosed behavioral disorder exists. Unfortunately, even though policy and procedures established by CMS are generally adopted by individual states’ Medicaid programs and shape trends among other third party payers, HBAI codes have not yet been adopted by all states. It is important for providers interested in utilizing HBAI billing codes to determine whether their state’s Medicaid program has “switched on” all or part of the HBAI rules.
4. Avoid Same-Day Medical & Behavioral Services
Although a minority, some states’ Medicaid programs will not reimburse for behavioral services if delivered on the same day as a medical service. This restriction can cause scheduling headaches, delays in care and, if same-day services must occur because of clinical necessity, financial losses for integrated programs operating within such states. Again, providers must check with their states’ Medicaid programs to verify whether same-day medical and behavioral services (which, in an ideal world, would always be clinically advisable) are reimbursable.
5. Partner With Other Provider Organizations
Some behavioral health organizations are not in a position to absorb the cost of insourcing medical services or able to ensure enough referrals to keep an internal primary medical practice sufficiently busy; these providers might consider partnering with other local medical service provider organizations to share referrals and costs of providing integrated care. In a bartering fashion, behavioral providers can contract for services from a medical provider organization (e.g., a hospital, private practice group, or Federally Qualified Health Center (FQHC)) and, in exchange, deliver integrated on-site behavioral services for that medical organization.
Even though the concept seems relatively straightforward, care should be given to the amounts and types of services to be exchanged, the ability of both the medical and behavioral staff involved to work effectively in an integrated environment, how clinical information will be documented and shared, and how protection from clinical risks and legal liabilities will be managed. Such partnerships can lead to viable integrated programming for all partner organizations and perhaps even to future business expansion through merger and acquisition activity.
6. Pursue FQHC Or Look-alike Status
Rather than simply partner with FQHCs, which by Federal regulation must provide primary medical, obstetrics, pediatrics, dentistry, and behavioral services for Medicaid populations, some behavioral health organizations have elected to pursue either their own FQHC status, or what is known as “FQHC Look-Alike” status. The advantages of going the full FQHC route are that, if approved, the provider organizations can receive ample start-up grant funding, higher levels of cost-based Medicaid reimbursement and no-cost malpractice protection. Look-Alike status is less arduous to obtain and carries the same reimbursement advantages, but not the same grant or liability coverage benefits as full FQHC status.
7. Negotiate Bundled Payments
Some integrated programs have been able to become profitable by negotiating with payers for bundled reimbursement of medical and behavioral services into a single payment, which simplifies billing and allows coverage for the costs of case management and consulting activities not covered under typical reimbursement systems. In 2007, the Institute for Clinical Systems Improvement (ICSI), operating initially upon grants from HealthPartners Research Foundation and the National Institute of Mental Health (NIH), initiated a five-year trial called the Depression Improvement Across Minnesota, Offering a New Direction (DIAMOND) program to evaluate the effectiveness of treating depression in various primary care clinics. Results showed that, of over 2,400 depressed patients, at least 43% were in remission at six-months (five to six times better than for patients receiving standard primary care). The study’s authors cite one key element to their success as their ability to persuade a number of private health plans to issue bundled per-case payments to cover case management and consulting services typically not covered in traditional reimbursement systems.
Although many collaborative care programs have initially relied upon grants to support their operation, discovering ways to achieve fiscal independence from grants is essential to long-term viability. With careful, proactive strategic planning, flexibility in billing practices, an openness to new partnering arrangements, a willingness to pursue new certification initiatives and to advocate for removal of state-specific Medicaid reimbursement barriers, integrated care programs can flourish in both medical and behavioral health care settings across the U.S.
By ellise hayden, Senior Associate, OPEN MINDS; 163 York Street, Gettysburg, Pennsylvania 17325-1933; Telephone 717-334-1329; Fax 717-334-0538; Web site: www.openminds.com.
hayden, ellise. (2012, September). Thinking About Integration? Seven Measures To Create A Sustainable System. OPEN MINDS Management Newsletter.