San Mateo County, California NIATx Summit and SAAS National Conference Boston, MA July 2011 NIATx-SI: Business Practices for the Future Learning Collaborative

San Mateo County Learning Collaborative Designing a fee for service billing system for a new low income health program

Our Primary Aim (Plan)  Establish a Low Income Health Program/Medicaid Coverage Expansion (LIHP/MCE) for County residents with a substance use services benefit. Acquire knowledge of all billing system functions, requirements from Medicaid Acquire knowledge of all billing system functions, requirements from Medicaid Treatment providers will screen for health coverage, facilitate enrollment and secure service authorizations, and provide and document services. Treatment providers will screen for health coverage, facilitate enrollment and secure service authorizations, and provide and document services. Providers will have a paper fee for service (FFS) billing process in place to bill for LIHP/MCE substance use services. Providers will have a paper fee for service (FFS) billing process in place to bill for LIHP/MCE substance use services.

Our Secondary Aims (Plan)  Support Treatment providers to bill private insurance /third party payers.  Explore the feasibility of cross provider sharing of billing functions  Set the groundwork for electronic health record and electronic billing system design.

Change (Do)  System systems changes to increase enrollment in LIHP/MCE coverage County streamlined application and enrollment process, County streamlined application and enrollment process, County obtained provider input into removing enrollment barriers, revised application, County obtained provider input into removing enrollment barriers, revised application, Provided 3 trainings to program staff on process Provided 3 trainings to program staff on process Provider staff now screen for health coverage, verify eligibility, and assist clients with benefits application. Provider staff now screen for health coverage, verify eligibility, and assist clients with benefits application.  Increase treatment authorizations Trained provider staff on effective ways to request treatment authorizations and demonstrate medical necessity and provided technical assistance tailored by levels of care. Trained provider staff on effective ways to request treatment authorizations and demonstrate medical necessity and provided technical assistance tailored by levels of care.

Change (Do)  Trained provider staff on treatment planning and clinical documentation requirements for Medicaid.  Established a paper billing system for LIHP/MCE Service and billing codes determined Service and billing codes determined Service packages and bundled services identified Service packages and bundled services identified County designed scantron form for provider billing County designed scantron form for provider billing Services billed by minute, bundled services billed by dayServices billed by minute, bundled services billed by day Service Tracking and billing (beginning July 1)Service Tracking and billing (beginning July 1)

Change (Do)  Trained provider staff on CPT codes commonly used with other 3 rd party insurers.  Technical support provided to treatment programs to develop a local network to: share information about lessons learned and strategies to increase 3 rd party insurance revenues share information about lessons learned and strategies to increase 3 rd party insurance revenues to obtain 3 rd party insurance contracts as a network of treatment service providers. to obtain 3 rd party insurance contracts as a network of treatment service providers.  Established workgroups for provider input into development of electronic health record and electronic billing system

Results (Study) Increased LIHP/MCE Applications

PROVIDER LIHP/MCE Clients in TX Provider 1 (OP/IOP) 5 Provider 2 (OP) 12 Provider 3 (RTP) 23 Provider 4 (RTP) 10 Provider 5 (Res Detox) 4 Provider 6 (OP, IOP, RTP) 15 Provider 7 (RTP) 30 Provider 8 (RTP) 42 Provider 9 (OP) 18 Provider 10 (NTP) 4 Provider 11 (OP) 8 Provider 12 (OP, IOP, RTP) 13 Provider 13 (OP, IOP) 18 Results (Study) LIHP/MCE Clients Enrolled in Treatment (as of 6/14/11)

Results (Study) LIHP/MCE Clients Enrolled in Care (as of 6/14/11)

Results (Study) Projected Annual Revenue Increases

Next Steps  In-person site visits for T/A and feedback on documentation for medical necessity, service tracking, coding and billing.  Continued learning collaborative meetings Support ongoing systems change and process improvements, Support ongoing systems change and process improvements, 3 rd party billing information sharing and exploration of contracts with 3 rd party payers as a provider network, 3 rd party billing information sharing and exploration of contracts with 3 rd party payers as a provider network,  Use FFS knowledge to inform development billing workflow and design of new electronic health record and billing system.

Impacts  Increased number of residents can access treatment (estimated 800 / year).  Increased revenue and financial stability of treatment programs.  Enhanced partnership and collaboration among providers (history of competition for clients and limited resources).  Greater readiness for Health Care Reform.  Increased ability to work with 3 rd party payers as a health care service provider and to do FFS billing.

Many Thanks to  NIATx and their awesome staff and guest presenters,  Don Holloway, our irresistibly influential coach,  Don Holloway, our irresistibly influential coach,  …and of course, our San Mateo County treatment providers: Asian American Recovery Services Asian American Recovery Services El Centro de Libertad El Centro de Libertad Free at Last Free at Last Latino Commission Latino Commission Hope House Hope House Horizon Services Horizon Services Project Ninety Project Ninety Pyramid Alternatives Pyramid Alternatives Sitike Counseling Services Sitike Counseling Services StarVista StarVista Women’s Recovery Association Women’s Recovery Association

A brighter future…

For more information, contact For more information, contact Clara Boyden, Program Manager Alcohol and Other Drug Services San Mateo County Behavioral Health & Recovery Services Phone: