Transcript handout

PRACTICAL IMPLICATIONS FOR
TRANSFORMING YOUR WORKFORCE IN
PREPARATION FOR BEHAVIORAL HEALTH
REDESIGN
OHIO ASSOCIATION OF CHILD CARING AGENCIES
MAY 23, 2016
Daphne K. Saneholtz, Partner
Brennan, Manna & Diamond, LLC
2
Agenda
• Introduction
• Charge/Focus of Today’s Conversation
• Health Care Policy Environment
• Big picture – payment and service delivery reform
• Factors impacting the behavioral health workforce
• Ohio initiatives
• Behavioral Health Redesign in Ohio
• Coding and billing
• Services, practitioners, and reimbursement
• Practical considerations
• Credentialing
3
Introduction
• Who am I?
• What is BMD?
• Why am I qualified to lead you through this exercise?
• Who are you?
4
Charge/Focus of Today’s Conversation
• Help you to understand the current health care policy
environment (specifically, behavioral health redesign),
how it is changing, and how this will affect your business,
particularly your workforce
• This is NOT a general update on redesign
5
Health Care Policy Environment
6
Health Care Policy Environment
• The health care policy environment provides a
backdrop against which we can better
understand what is going on in Ohio,
specifically as it relates to behavioral health
redesign
• It is against this backdrop that policymakers
decide how to advance initiatives that are in
line with health care trends nationally and in
the states
7
Service Delivery and Payment Reform
• All signs point to value, not volume, and true
reform at the national and state levels
• Payment reform (e.g., volume to value, more
risk sharing, pay for quality, etc.)
• Service delivery reform (e.g., ACOs;
emphasis on care coordination; increased
collaboration; integration of physical health,
behavioral health, long-term services and
supports; etc.)
8
Factors Impacting the BH Workforce
• Impact of ACA and MHPAEA
• More people covered by Medicaid and private insurance
• Parity technically means access to more services
• Emphasis on integrating physical and behavioral health care; more
people will be identified as needing services
• More practitioners needed
• Use of SBIRT
• Many individuals who are identified will receive brief interventions
or brief treatment, often conducted by health educators, recovery
specialists, or other types of staff in primary care system
• Focus on increasing size of workforce and recruiting a
younger and more diverse workforce
9
Factors Impacting the BH Workforce
• Recovery-oriented practices; incorporating peers into the
workforce
• Demand for outcomes and quality improvement
• Moving to a chronic care, public health model to define
needed services
• Importance of prevention, long-term recovery, lived experience of
recovery
• BH workforce is complex, comprising professionals
ranging from psychiatrists to non-degreed workers and
para-professionals
10
Ohio Initiatives
• Managed care
• Currently, nearly all populations and services in managed care
• BH carved into managed care 1/1/18
• Children in the child welfare system mandatorily enrolled in
managed care 1/1/17
• Bundled payments
• Patient centered medical homes
• MyCare Ohio
• BH redesign (see next slides)
11
Behavioral Health Redesign In Ohio
12
What does BH redesign include?
• An infusion of $35+ million by ODM for new
services
• Disaggregation of existing services
• New billing and coding requirements for new and
existing services
• “Recoding all Medicaid behavioral health services to
achieve alignment with national coding standards”
• Practitioners must enroll as individual providers; providers
must have NPIs 1/1/17
• Rendering provider must be on claim 1/1/17
• BH providers must transition to new code set between
1/1/17 and 6/30/17
• Different reimbursement for services
13
Brief Interlude on Billing and NCCI
• ODM has emphasized that one of the motivators
for BH redesign is aligning billing and coding of
BH services in Ohio with (1) billing and coding
practices for physical health care and (2) national
billing and coding standards
• Why?
• Recognition of the importance of integration
• Interest in reducing improper payments by Medicaid
14
Brief Interlude on Medicaid Billing for
BH Services
• Medicaid is the single largest payer for mental health services
in the US and is increasingly playing a larger role in the
reimbursement of substance use disorders
• Improper payments occur when Medicaid funds are used to
pay the wrong entity, the wrong amount, for services not
received, or for services not supported by documentation
• Providers who receive Medicaid overpayments (whether selfidentified or identified by the State after any appropriate
reconciliation and opportunity for a hearing) must return those
funds to the State within 60 days of identifying the overpayment
• Also, providers that improperly bill for services can be removed
from Medicaid participation and may face criminal and civil
monetary penalties
Source: Billing Properly for Behavioral Health Services: Be Part of the Solution. CMS.
15
Brief Interlude on Medicaid Billing for
BH Services
• According to the 2013 Payment Error Rate Measurement
(“PERM) report, nearly 89% of Medicaid FFS improper
payments resulted from documentation errors, number of
units billed errors, and policy violations
• A 3-year summary of similar data also revealed that
mistakes in the number of units billed accounted for the
highest dollar errors among mental health services claims
• Federal and State entities expect providers to know the
policies that govern the services they furnish to Medicaid
beneficiaries
• This includes documentation rules and proper coding
procedures, what services are covered, and who is
eligible for those services
Source: Billing Properly for Behavioral Health Services: Be Part of the Solution. CMS.
16
Brief Interlude on Medicaid Billing for
BH Services
• Example: practitioners should not report multiple HCPCS/CPT
codes if a single HCPCS/CPT code exists that describes the
services performed (e.g., do not bill for family and individual
therapies separately when the therapy was provided to the
individual with family present)
• Example: some behavioral health treatment plans include
medication therapy. Medicaid regulations require that
pharmacies offer beneficiaries counseling on the medications
they dispense. Medicaid denied a pharmacy’s claims because
the pharmacy could not offer documentation that the required
counseling was offered to beneficiaries.
• Example: state law requires that providers record progress
notes the same day they provide the services. A Medicaid
provider submitted progress notes to support an inpatient claim
dated 1 month after the date the provider performed the service
Source: Billing Properly for Behavioral Health Services: Be Part of the Solution. CMS.
17
Brief Interlude on Medicaid Billing for
BH Services
• A number of units error represents a miscalculation of the
time or quantity of a service, item, or medication.
• Examples: using a 1-hour code for a 15-minute procedure; billing
for three units of service when only two are in the documentation;
billing a prescription for 30-days when the pharmacy dispensed
only a 14-day supply
• Example: psychiatrist’s office mistakenly billed 90837
Psychotherapy, 60 minutes with patient instead of 90832
Psychotherapy, 30 minutes with patient for a 30-minute visit
Source: Billing Properly for Behavioral Health Services: Be Part of the Solution. CMS.
18
Brief Interlude on NCCI
• The National Correct Coding Initiative (“NCCI”) is a
program developed by CMS that uses methodologies to
reduce overpayments to providers due to incorrect coding
on claims
• Section 6507 of the Affordable Care Act directs state use
of NCCI methodologies
• NCCI has two types of edits:
• Procedure-to-procedure edits that define pairs of HCPCS/CPT
codes that should not be reported together for a variety of reasons
• Medically Unlikely Edits define for each HCPCS/CPT code the
maximum units of service that a provider would report under most
circumstances for a single beneficiary on a single date of service
19
Brief Interlude on NCCI
• At least the PTP edit appears on the ODM coding chart
20
According to OHT, BH redesign is…
21
What does BH redesign mean for you?
• A lot of things! These things do not fit into nice, neat
little boxes. They bleed over into one another and
have far-reaching implications. Even still, we are
going to focus on a few…
• The ways in which BH redesign will impact your
business operations and workforce are tied to:
• Services (the way services will be transformed),
• Practitioners (who can do them), and
• Reimbursement (how much practitioners will be paid)
• The question is, how can you prepare to meet the
challenges head-on and turn them into
opportunities?
22
Existing Medicaid BH Services
Existing Medicaid SUD
Services
Existing Medicaid MH
Services
23
Service Transformation
24
And Another New “Service”
Beginning July 2016
25
26
Service Transformation
• Let’s review the last three slides…
• 11 existing ODM-identified distinct SUD services and 11
existing ODM-identified distinct MH services (some
staying, some going, some transforming) + 4 ODMidentified new BH services + SRS
• This framework will go away and be replaced by one
driven by recognition of 50+ HCPCS and CPT procedure
codes and corresponding descriptions, built upon a
primary care foundation
27
Discuss: Services and Practitioners
• Does the addition of new services mean you will add
different practitioners to your workforce? What kinds of
practitioners? What skill sets? What level of education,
licensure, supervision, etc.?
• Differentiate between truly new services and procedure codes that
may look new but really result from the disaggregation of existing
services.
• Will you continue to do “old” services? Will you replace
old services with new services? Can the practitioners who
were doing the old services do the new services? Is their
level of education, licensure, supervision, etc.
acceptable? What are the reimbursement implications?
28
Discuss: Services and Practitioners
• How were you using, and who was doing, CPST before?
What will become of the programs for which you used
CPST? What will become of the people who were doing
those services? Will you use them? The same?
Differently?
29
Discuss: Practitioners and
Reimbursement
• What does the composition of your existing workforce
look like? What does it need to look like going forward,
given the transformation of services?
• How does reimbursement impact these questions?
• Consider…
• Licensed v. non-licensed BH practitioners
• Independent BH professionals v. those who require supervision
• Paraprofessionals
• Medical professionals performing BH functions
• Community v. office based
30
Practitioners
• Current ODM rate chart is almost obsolete as a lot of work
has been done over the past few weeks
• The “provider types” are still evolving
• Peer Support Specialists will be a “new” category
• Case Management Specialists not exactly “new”; exist
under ODADAS standards and have same requirements
as QMHS
• For SUD services, most unlicensed practitioners will get the CDCA
credential so there are not very many CMSes on the SUD side
• QMHS staff will be divided into subcategories based on
level of education (high school, Associate, Bachelor,
Masters); reimbursement differentiated by education level
31
Practitioners
• I noticed that these provider
types appear in the existing
ODMHAS rule, but not on the
new ODM coding chart. So I
asked “does this mean they will
not be allowed to provide
services?”
• I learned that many of them are
only providing prevention
services, and prevention is NOT
included under the “scope” of
BH redesign (right now)
32
Practitioners
• Psychology assistant, fellow, trainee,
•
•
•
•
•
and intern are covered and can bill all
codes
School psychs have been added
Pharmacists are being added
The “provisional” license for counselors
doesn’t really exist any longer since the
CSWMFT Board changed its licensing
practices a few years ago
So the only professional groups that
will NOT be included are OTs and
Psychology Aides
Art Therapists and Music Therapists do
not have separate licensure in the state
of Ohio; they are generally licensed by
the CSWMFT Board and then declare
a scope of practice in Art Therapy of
Music Therapy
33
Practical Considerations
• Will the new reimbursement generally impact your decision to
keep practitioners? Will you have them do the same or different
job? Will you have to train them differently?
• What can you get reimbursed by Medicaid v. what are you
paying for the practitioner (e.g., salary, benefits, CE, liability
insurance)?
• Can you offer the same service and have a lower level practitioner
deliver it for the same or similar reimbursement? Do you really need
the higher level practitioner? (Example: MD/DO v. CNS, CNP)
• Employed practitioners v. contracted practitioners
• If employ, greater control, liability; if contract, contractor/organization
receives reimbursement for services and contractor signs professional
services agreement to get paid
• Opportunities to diversify service delivery (within BH, in
addition to BH) using existing or new staff
34
Practical Considerations
• Opportunities for sharing, centralizing functions
• Of primary importance: credentialing, billing
• Also, HR, IT, marketing, etc.
• Merger/consolidation, acquisition, joint operating
agreement, shared or administrative services
organization, independent practice association
35
Credentialing
36
What is credentialing?
• Credentialing is a process used to evaluate the
qualifications of a practitioner
• This includes a review of completed education, training,
and licenses. It also includes any certifications issued by a
specialty board.
• This will become increasingly important to you as you
begin to engage with managed care plans
37
Why is credentialing important?
• It protects patients from incompetent providers
• It protects providers from potential liability claims
• Periodic re-credentialing ensures that providers
continue to have necessary skills and expertise
• State laws require that certain providers be
licensed, registered, or certified
• Payors have credentialing and privileging
requirements for reimbursement
38
Why is credentialing important?
• MCPs must credential/re-credential providers per OAC
5160-26-05 (Managed Care Agreement between ODM and MCPs,
Appendix H, Provider Panel Specifications)
• When initially credentialing and re-credentialing providers, the MCP
must utilize the standardized credentialing form and process as
prescribed by ODI under ORC 3963.05 and 3963.06
• The MCP must ensure that the provider has met all
applicable credentialing criteria before the provider can be
listed as a panel provider
• At the direction of ODM, the MCPs must submit
documentation verifying that all necessary contract
documents have been appropriately completed
39
Poor credentialing means…
• Exposure to costly and time consuming litigation
• Financial losses
• Increased administrative expenses (e.g., time spent on a
protracted credentialing process)
• Decreased revenue (e.g., payor unwilling to pay for services
delivered before credentialing was completed; delays in getting
provider in a position to bill for services)
40
Credentialing Policies
• You should have in place documented
credentialing policies that describe a formal
program that ensures verification of the
qualifications and competency of every job
applicant who is a licensed or certified health
care practitioner
• The better your policies, the better the
program
• This results in a greater ability to avoid the problems
described on the previous slide
41
How can you avoid problems?
• Draft and implement clear, written credentialing policies
• Document compliance
• Document primary and secondary source verification
• Periodically audit the credentialing and privileging processes
• Draft and implement confidentiality policies
• Board members and other individuals or committees involved in
these processes should share personal information about
practitioners only with each other to determine whether or not to
hire, terminate and/or privilege the particular person at issue.
• Information in personnel files relating to credentials and privileging
should be kept in secure, locked files with restricted access
42
How can you avoid problems?
• Contract out the credentialing/privileging process
to a credentials verification organization (CVO)
• Use of a CVO does not relieve you of the duty of securing
complete and accurate information. If a CVO is negligent in
verifying or providing credentialing information, you are still
responsible for the consequences of that negligence, unless you
included an appropriate indemnification provision in your
agreement with the CVO.
• CVOs and specialized credentialing software can make
your life easier (for a fee). They can auto-generate
applications and forms, centralize and organize the
collection of documents, send reminders, etc.
43
Delegated Credentialing
• Delegated credentialing is the process by which a health
plan (or any other entity responsible for credentialing)
agrees to turn over a portion of their credentialing review
process to a qualified entity and must provide oversight
over the delegate for ongoing adherence to program
requirements
• Once delegated, the provider is now responsible for
credentialing and re-credentialing each provider for each
plan
• Can delegate to a provider, ASO, SSO, etc.
44
Delegated Credentialing
• Under traditional credentialing, the MCP receives a provider’s
application, reviews the credentialing documents, and verifies
data on the application related to training, work history,
licensure, etc. using primary sources. Once reviewed and
verified, the file is brought to the MCP’s credentialing
committee.
• This process can take 3-6 months or longer depending on the
MCP’s workload, motivation to add new providers to their
network, etc.
• Delays can occur from credentialing documents expiring in the
process and lost or neglected applications
• If clarification is needed for any aspect of the application and a
response is not received in a timely manner, an application can
be rejected or returned
45
Delegated Credentialing
• Under delegated credentialing, the provider collects all
credentialing information and documentation upon hire (or at
the start of the program), all information is reviewed and
primary source verifications are conducted. The practitioner is
presented to the credentialing committee and once approved,
is entered on the MCP rosters for the next monthly submission.
• Depending upon the individual plan (and the delegation
agreement), following receipt of the roster, your new hire can
potentially be considered participating as early as the effective
date approved by committee.
• Requesting information once for enrollment in all MCPs makes
onboarding your new hire easier. The earlier the practitioner is
onboarded, the sooner he/she can start providing and billing for
services.
46
Questions?
Daphne Kackloudis Saneholtz, Esq.
(614) 246-7508
[email protected]
Brennan, Manna & Diamond
www.bmdllc.com