1. Eric Haram, LADC Mary Jean Mork, LCSW Quality Counts October 3, 2018
Planning for Sustainability of MAT/R Efforts: Maximizing Reimbursement and Building a Case for Support
Eric Haram, LADC
Mary Jean Mork, LCSW
Quality Counts October 3, 2018

2. Objectives Participants will be able to:
Articulate the key principles and foundation for building a business case for MAT services for practices and health systems
Identify the methods of group billing for MAT, as well as other basics of billing MAT services
Plan for next steps in building their program budgets, including resources available to them
Disclaimer:
This information does not represent how a payer might respond to a claim
This information does not replace any regulatory information
Always seek information from your own local agency consultants regarding any billing and coding practices

3. Where are you in your program development
Where are you in your program development? Where are your present barriers/questions/concerns?

4. Making The Business Case
Eric Haram, LADC
Principal, Haram Consulting

5. Five Key Principles Evidence-based predictors of change
Understand and involve the customer.
Focus on key problems.
Select the right change agent.
Seek ideas from outside the field and organization.
Do rapid-cycle testing.

6. The Sixth Principle? The Business Case is the Key to Sustainability
Economics really do drive an organization’s ability to offer services and an organization’s ability to be paid for services.
A positive economic position and/or better clinical outcomes is a better leverage point for clinical and/or organizational change.
Organizations that can offer little or no wait time, and good retention are more attractive to both customers and payers.

7. Using Treatment Resources Wisely
Many persons who make important decisions about how substance abuse treatment and mental health care get funded don’t really know what we do all day.
It is OUR JOB to communicate with them, in terms they do understand: business principles like efficiency (such as reduced wait time or reduced no-shows), and improved outcomes are a common language.
Remember, at the same time, we are talking about real people.

8. Illustrating the Business Case
Increased money by service line – usually due to volume (fee for service or improved payer mix).
Improved efficiency in a program – more people being served for the same money, but not always more revenue (i.e., capitation) or an improved process that saves a lot of time.
Improved productivity and/or staff retention.

9. Reimbursement is Complex
Make a simple argument.
Your job is to translate between business interest and clinical interest – they need to be parallel.

10. Calculating Improved Revenue
Keep it simple.
Average Reimbursement = Total Reimbursement/Units of Service billed
Average Reimbursement x Number of Improved Units of Service = New Revenue

11. Kennedy Center Moncks Corner, South Carolina
Went to all walk-in assessments, five days/week until 3 p.m. each day.
Initial results – went from an average of 3.3 assessments each business day to an average of 6.7 per business day.

12. Kennedy Center A Risk Pays Off
The AVERAGE reimbursement for an evaluation is $50/person. Some do not pay at all, some pay more. Clients are told during the initial call that they will be seen even if they can’t pay AND asked to bring money if they have it.
3 more evals/day = 15/week= $750/week $750 x 50 weeks = $37,500/year

13. Adding IOP/MAT Service
OPBH Work Redesign
ARC
14-hour MD contract
Unfreeze 20-hour admin. vacancy for sustaining Damariscotta Expansion Project

14. Analysis of Barriers/Threats for Diminishing Returns: Business Case for ARC Damariscotta Office
Physician Services
Jeff’s overall schedule is not working: 5 different services, 5 different locations.
Physician direct services is only 2-3 hours per week for 4 hours paid.
Potential caseload of 100 MAT clients can not be realized w/ this model.
Every new Suboxone pt. represents 3 additional IOP units per week.

15. Analysis of Barriers/Threats for Diminishing Returns: Business Case for ARC Damariscotta Office
Administrative Support
Inconsistent admin. support renders poor capacity flow.
Internal customers (MD, Therapist, RN, Billing and Registration)
External customers (welcoming, scheduling, pt. access)
Safety: One staff on 2nd shift means no supervision of waiting area and parking lots.
Currently pulling from Brunswick admin. staff to have skeleton crew coverage; creates problems with infrastructure at Brunswick site.

16. Damariscotta Office Growth Cost and Replication
Current Cost and Volumes
4 hr. MD (employed) $20,800
20 Hr. Counselor $33,250
Total $54,050
Capacity = 30 MAT customers. Capacity reached w/in 4 months
Effectively shuts down revenue model and bottlenecks access queue
Proposed Model and Volumes
14 hr. MD (Contract) $72,000
20 hr. Counselor $33,250
20 hr. Admin. Support $22,000
Total $127,250
Capacity = 100 MAT customers
Based upon Brunswick model, this will sustain growth throughout the year.

17. Damariscotta Office Growth Cost and Replication
Assumptions
Getting clients access to IOP in Lincoln Co. will increase the average daily census.
Implement Access Project: 150% increase
Implement Suboxone: 20% increase
Access to MAT and psychiatry will increase program(s’) census and retention.

18. Damariscotta Office Growth Cost and Replication
Assumptions
Access project will lower barriers and improve customer service as in Brunswick.
Admin. Support on site will increase direct services productivity through improved internal and external customer service/responsiveness.
Possibility of working with Crisis & Counseling for referrals from LiSA Two Bridges Jail will result in a solid (un-ending) referral source.

19. Staying on the Growth Curve in Damariscotta
New Projected Revenue
IOP Formula: [ADC*3(sessions per wk)*52 (wks/yr) *225(charge)] * .45 (Medicaid contractual)
ADC of 8 in IOP renders net revenue of $126,360 or remains budget neutral
ADC of 10 in IOP renders net revenue of: $157,950
Additional Revenue Associated with Dama Growth
Increased 90801’s: 100*115*.45= $ Increased aftercare groups: 3 groups/wk ADC-(8*75*3*52) * $42,120
Physician Billing: Medication Management groups: 4 groups/wk ADC (4*8*52*100) * $74,880

20. Staying on the Growth Curve in Damariscotta
Total Revenue $280,125
Total Cost $127,250
Total Net Revenue $152,875

21. Key Business Case Ideas
Improved performance can lead to an improved bottom line and/or improved stewardship.
Staff retention and morale seem to improve in organizations where staff are excited and involved.
Business principles are a good communication tool and provide us a way to advocate for our work and therefore, our clients.

22. Assignment #1
What challenges will you have as you try to illustrate the business case?
How might you change the membership of your change team to meet these challenges?

23. An Example – Improving Show Rates
Maximum Group size = 12, and the no-show rate is 50%
Average reimbursement/person = $20.00
So, if 6 people show up, then the agency recoups 6 x $20.00 = $120.00/group.
What happens if one more person comes to each group and you run 10 groups/week?

24. YOUR Data How will you make the business case for your change?
Average reimbursement = total reimbursement/units of svc billed

25. Walk-through Instructions
September 2018 – MeHAF Opioid MAT Expansion Project
Instructions: During October, please do a walk-through of your current MAT service line for the patient described below. As part of our November coaching call we’ll report out on what we learned and discuss how this might shape your service line in the future

26. Patient- Walk Through Case
Childless adult, 35 years old
Discloses that he/she has OUD and is seeking some kind of help
He/she is a daily user of opioids, but not via injection
No chronic pain and no co-morbidities
Has funding of some kind. Insurance, not Medicaid

27. How does this person get him/herself admitted to the MAT service line?
What are the steps?
Who does each of those steps?
What is the time frame?
Where are the billing opportunities?

28. Who else needs this information?
Who Does What Chart
Step in the Process
Who is assigned?
When is this task done?
Who is it handed off to?
Who else needs this information?
Verify Coverage
Request prior authorization
Document authorization
Limits
Provide services
Document service provided
Bill for appropriate amount
Collections: bill paid or
Denied
Monitor receivables
Make corrections and
Resubmit
Monitor cash flow

29. Resources/Additional Background
How to Perform a Walk-through
Billing Guide (see pages 5 and 14)
How to Flowchart

30. Maximizing Reimbursement for MAT/R: tools for success
Mary Jean Mork, LCSW

31. Official Disclaimer
Consultant makes no warranty regarding the manner in which any payer, governmental or private, will accept or deny any claim for reimbursement relating to integrated mental health services.
In publishing or otherwise disseminating any Work Product this author makes no representation or warranty regarding the manner in which any payor, governmental or private, will accept or deny any claim for reimbursement relating to integrated mental health services; that the provided is not intended to replace the information contained in the ICD-9-CM and CPT-4 manuals or specific coding, reporting, or reimbursement information that may be disseminated by third-party or government payers; and that providers should seek advice for their own consultants with respect to submission of particular claims or categories of claims for reimbursement by payors.

32. Typical billing scenario
Medical billing for physician
Medical billing for labs
Behavioral health billing for assessments
Behavioral health billing for groups
Other?
What is your present arrangement for billing?

33. Methods of Billing for Behavioral Health within a Medical Practice
Level of Collaboration
BHC covers all expenses
Practice offers space
Practice offers space and scheduling
Practice employs
Co-located Practice
Level 3 and 4
BHC bills
BHC schedules
Separate records
Separate service
Some communication with releases
Streamlined referral and scheduling process
Communication with releases
Practice bills
Same record
Shared responsibility for schedule
Streamlined processes
Communication without need for releases
Partially Integrated
Level 5
Separate record
Coordinated care
Releases part of routine
Connected to primary care team
Shared responsibility
Improved coordination and communication
Working toward becoming part of primary care team
Fully Integrated
Level 6
Solid communication and coordination
Part of primary care team

34. Types of Billing Codes for Substance Use Treatment in Primary Care
Mental Health Codes also used for Substance Use Treatment
Assessment (Paid by all)
Individual and Family Treatment (Paid separately or connected to E/M code – allowed by all)
Group Treatment (not allowed by Medicare in FQHC’s or RHC’s but could be delivered and billed by co-located clinician)
E/M codes
Used by medical providers and psychiatric providers

35. Behavioral Health Codes
LCSW (or LCPC) or Psychologist
90791: Initial Assessment
90832, 90834, 90837: Individual Therapy
90846, 90847:Family Therapy
90853: Group Therapy
Psych NP/PA
Use E&M codes for new patients or for ongoing patients
Services must be medically necessary
Practitioner must be practicing within their scope of practice
Used in conjunction with a medical or psychiatric diagnosis

36. From: Haram Consulting: MAT Toolkit – Billing 2017

37. Billing and coding for Group Visits
Currently - no nationally accepted standards for coding and billing for group visits.
Several years ago the American Academy of Family Practitioners (AAFP) sought to clarify Medicare billing requirements and received the following response from the Western regional Medicare contractor:
“...under existing CPT codes and Medicare rules, a physician could furnish a medically necessary face-to-face E&M visit (CPT code or similar code depending on level of complexity) to a patient that is observed by other patients. From a payment perspective, there is no prohibition on group members observing while a physician provides a service to another beneficiary.”
American Academy of Family Physicians (AAFP). Coding for Group Visits. Retrieved on July 9, 2014 from

38. Ways to bill for groups in primary care
Medical before or after behavioral portion of the group:
Behavioral health delivers group services - bills
Medical provider bills for the shared medical visit
For example: a 90 minute group may have a for the “shared medical visit” portion and 60 minutes for the behavioral group treatment
Medical “pull out” of group:
Medical provider “pulls out” patients throughout group session – bills for medical visit
Behavioral health bills for group, minus time away with provider
Medical provider bills for the group (and behavioral health doesn’t bill)
Ensure that payer allows two services on the same day

39. Behavioral Health Group Billing - 90853
Effective and efficient form of treatment
Requires - Initial Psychiatric Assessment to determine the diagnosis for each group member
Treatment Plan required and includes group as method of treatment
Each Group Treatment note includes:
General statement about the group session and
Paragraph specific to that patient’s involvement/progress in that session.
All other Progress Note expectations apply

40. Billing for Groups FQHC’s and RHC’s -
Medicare does not allow - but some practices are delivering services and not billing Medicare
MaineCare does appear to reimburse for group services
Provider based practices (non-FQHC or RHC).
Medicare and MaineCare both allow
Medicare requires LCSW or Psychologist for any billing

41. Keep in mind…
•Document clearly – individual services provided to each patient as well as the services provided to the group as a whole
•Emphasize the medical management component
•Use medical E/M code (rarely 99214)
•If more than one clinician billing (i.e., a physician and psychologist) differentiate services provided to avoid duplicate billing
•Patient education is not directly reimbursed under current system, except in specific cases such as diabetes self management education (DSME) by a certified diabetes educator (CDE)
References:
Putting Group Visits into Practice in the Patient Centered Medical Home. Stephanie Eisenstat MD, Karen Carlson MD and Kathleen Ulman PhD. Massachusetts General Hospital 2014
Putting Group Visits into Practice: A Practical Overview to Preparation, Implementation and Maintenance of Group Visits at Massachusetts General Hospital. 2012, Eisenstat, Lipps Siegel, Carson and Ulman

42. What to do for the uninsured? OHH
Opioid Health Homes are an option
OHH factors to consider:
Need to have a mix of MaineCare and uninsured
May be able to partner with pharmacy or other parts of the team (e.g. peer recovery)
OHH will pay for medication for uninsured
Financially viable for MaineCare patients in induction phase due to need for multiple medical visits vs. those in maintenance phase?
DHHS is in process of gathering information about present OHH regulations and barriers to implementation

43. One additional barrier: Interpreting 42 CFR part 2 in relation to MAT/R services in the primary care setting

44. Confidentiality and 42 CFR part 2 – general guidelines
You must follow 42 CFR part 2 Confidentiality Rules if you are:
An identified unit within a general medical facility that holds itself out as providing, and does provide drug/alcohol diagnosis, treatment, or referral for treatment….
Individual or entity other than a general medical facility that holds itself out as providing, and does provide, drug/alcohol diagnosis, treatment, or referral for treatment….
Medical personnel or other staff in a general medical care facility whose primary function is the provision of drug/alcohol diagnosis, treatment, or referral for treatment
You do NOT fall under these rules if:
This is just a piece that is delivered as part of general medical care
This is just a piece that the behavioral health clinician offers as part of their overall integrated practice
You need to get clarity from your legal counsel
For more information: Legal Action Center

45. Potential steps to take if expecting barriers
If setting up groups that include both medical provider and behavioral health clinician: Contact payers to determine if the behavioral portion of the group visit can be directly billed by the BHC
Contact Medical Director of the Medicare carrier : Paul Hughes –
Inform each insurer in advance of your intent to begin furnishing group visits and how you plan to bill for them. American College of Physicians.

46. References for Group Visits
1. Shared Medical Appointments: A Recipe for Success (Cleveland Clinic) 2.Group Visit Coding (American Academy of Family Physicians) • 3.Specific Payment Codes for the Federally Qualified Health Center Prospective Payment System (CMS) • or search for FQHC PPS Medicare Benefit Policy Manual , Chapter 13 - Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Services (CMS) • or search for Medicare Benefit Policy Manual, Chapter 13,

47. Reimbursement Resources
Medicare Links
Medicare Documentation Guidelines for Evaluation and Managements Services 95 & 97
NHIC
CMS National Correct Coding Initiative
Evaluation and Management Service Guide -
CMS. Local Coverage Determination (LCD): Psychiatry and Psychology Services (L26895)
for provider based services and medical necessity that can be applied to services billed under Part B by individual providers
Other
– the National Council for Community Behavioral Healthcare
– Integrated Behavioral Health Project

48. Contacts Eric Haram, LADC eharam@gmail.com
Mary Jean Mork, LCSW