Mental Health Clinic Restructuring Update · PDF file1 Mental Health Clinic Restructuring...
Transcript of Mental Health Clinic Restructuring Update · PDF file1 Mental Health Clinic Restructuring...
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Mental Health Clinic Restructuring Update
April 2010
Gary WeiskopfNew York State Office of Mental Health
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Purpose of Presentation
General Overview of Clinic Restructuring– http://www.omh.state.ny.us/omhweb/clinic_restructuring/
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Key Objectives of Clinic Restructuring
1. More responsive set of clinic treatment services and greater accountability for outcomes
Clinic is defined as a level of care with specific services
2. Redesign Medicaid clinic rates and phase out of COPSRelate payments to services and policy objectives
Modifiers and payment weights to reflect variations in cost
3. HIPAA compliant procedure-based payment system
4. Provisions for indigent care
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Clinic Program
Required Services– Outreach & Engagement– Initial Assessment (including Health Screening)
Health screening is the gathering and assessing of information concerning the recipient’s medical history and current physical health status (including physical examination) to determine potential impact on the recipient’s mental health diagnosis and treatment, and the need for additional health services or referral.
– Psychiatric Assessment– Crisis Intervention– Psychotropic Medication Administration (Injectables - clinics
serving adults)– Psychotropic Medication Treatment– Psychotherapy (including individual/group/family/collaterals)– Complex Care Management
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Clinic Program
Optional Services– Psychotropic Medication Administration
Optional for clinics only serving children– Developmental and Psychological Testing– Health Physicals– Health Monitoring
The continued measuring of specific health indicators associated with increased risk of medical illness and early death.
– Psychiatric Consultation - offsite
Staffing – Within Scope of Practice
– Psychiatrist– Physician (MD)– LMSW– LCSW – Psychologist– RN/LPN– NPP – LCAT– LMFT – LMHC
– Licensed Psychoanalyst– Licensed Psychologist– Physician’s Assistant –
Physical Health Only– Permitted staff– Students within approved
SED programs– Qualified non-licensed staff
including qualified peers and family advocates
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Staffing
Depending on the extension of the social work licensing law exemption, – Transition period to the new clinician standards
that mirrors the financial phase in.By the end of year 1 uncompensated care pool clinic services (except outreach and engagement) must be provided by appropriately licensed staffBy the end of year 3 all clinic services (except outreach and engagement) must be provided by appropriately licensed staff
– Commissioner has staffing waiver authority as permitted by law.
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Elements of Reimbursement System
Services Billed using Ambulatory Patient Groups (APGs)– based on CPT/HCPC CodesNon Face-to-Face: Bill for non face-to-face time spent coordinating care for complex patients
– Time spent must be medically necessary and documented in the consumer’s chart
Multiple Same Day Services: – Reduce the need for consumers to make multiple trips – Minimize missed appointments – Some limits will be establishedPhysician Billing: For some services the physician component will be billed using the physician fee schedule
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Elements of Reimbursement System
Payment adjustments for:– Visits in a language other than English – CPT – Visits delivered outside of normal business hours - CPT– Visits provided in off-site non-licensed locations – Rate
Code Restricted to services for children up to and including age 18 and for homebound adultsOutreach and engagement will always be done offsite
Medicaid/Medicare cross-over clients will be reimbursed the same as Medicaid fee-for-service clients
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APGs Replace “Threshold Visit”
Uses CPT codes to consolidate related procedures Establishes procedure weights based on factors affecting resource use
– service duration, location, practitioner qualificationsOMH procedure weights will be based on the minimum qualifications for staff permitted under OMH regulations to deliver a particular procedurePayments are the service weights (discounted as appropriate)
times a base rate. – No bundling for mental health
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Base Rates
Base rate is dependent on peer groupEach peer group will have a common base rate Peer groups:
Upstate DownstateLGUUpstate HospitalUpstate D&TCDownstate Hospital/Downstate D&TC
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Modifier Chart – Draft
OMH Service Name
Offsite After Hours
Language other than
English
Physician/NPP
Complex Care Management x x xCrisis Intervention Service - Per 15 minutes x x x
Crisis Intervention Service - Per Hour x x
Crisis Intervention Service - Per Diem x x
Developmental and Psychological Testing x x
Psychotropic Medication Administration x x MD payment Included in rates
Psychotropic Medication Treatment - No Time Limit
x x MD payment Included in rates
Initial Mental Health Assessment, Diagnostic Interview, and Treatment Plan Development
x x x x
Psychiatric Assessment - Minimum of 30 Minutes
x x MD payment Included in rates
Psychiatric Assessment - Minimum of 45 Minutes
x x MD payment Included in rates
Individual Psychotherapy - Minimum of 30 Minutes
x x x x
Individual Psychotherapy - Minimum of 45 Minutes
x x x x
Group and Multifamily/Collateral Group Psychotherapy - Minimum of 60 Minutes
x x x
Family Therapy/Collateral w/o patient -Minimum of 30 minutes
x x x x
Family Therapy/Collateral with patient -Minimum of 60 minutes
x x x x
Outreach and Engagement (outside visit) x x x
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General Billing Rules
Multiple off-site procedures - may only bill one off-site modifier for:
– Multiple procedures for 1 client in a day– Procedures provided to more than 1 recipient in the same
location in the same day.– Procedures provided to recipients and their collaterals in the
same visit.
Modifiers for off-site and language other than English cannot be billed together for the same procedure.
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General Billing Rules
Multiple Service Limits– 2 different procedures per client per day - excludes crisis,
medication, physical health visitsLimit 2 outreach & engagement unless
– Clinical staff documents necessity of more
Up to 3 Pre–Admission Assessments– Psychiatric assessment may be included
First visit for an adult can be off-site to– Determine homebound status for adult – medical or physical
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General Billing Rules
Complex Care Management– Provided within 5 working days of a
psychotherapy (face-to-face) or crisis service– Must be performed by a licensed professional– Provided with or without the recipient – Provided in person or by phone– Not to be used for routine follow-up – Requires a minimum of 15 minutes clinician time
doing complex care
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Proposed Weights and Rates
Rates and Weights
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Indigent Care
Uncompensated Care Pool proposed for:– D&TCs licensed by DOH and approved for the pool by
DOH– Free-standing Article 31 mental health clinics
Hospital operated clinics are not eligible for this poolThis does not include any OMH supplemental reimbursement – to be determined
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For participation in the 2010 pool, 2009 data from Article 31 agencies must be provided by March 31st 2010.
Agencies that do not submit annual data by dates to be established by OMH will be excluded from the pool for that year.
Partial payments from the pool will be made monthly.
Indigent Care
Indigent Care Reimbursement
Eligible indigent care visits must equal to 5% of visit volume to qualify. Reimbursement is calculated according to the following schedule.
– First 15% of visits reimbursed 50% of the value of the peer group average Medicaid rate.
– Second 15% are reimbursed at 75% – Visits >30% are reimbursed at 100%
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Indigent Care Pool Covered Services
For APG and indigent care purposes, a visit is defined as all procedures provided to an individual in a day.OMH anticipates that visits can be counted toward indigent care volume if they meet the following conditions:
– Self pay, including partial pay or no pay visits– Required or optional mental health clinic procedures provided but NOT
covered under a clinic’s agreement with an insurer. The service must be provided by a practitioner qualified to deliver the service under state regulations.
– Unreimbursed clinic visits/procedures appropriately provided to an insured recipient by a clinic staff member not “empanelled” by the third party payer in contract with the clinic.
The provider must document that the clinic or recipient received a denial of payment.
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Indigent Care Pool Covered Services
Unreimbursed clinic visits/procedures provided to an insured recipient by a clinic staff member when the procedure is not reimbursed by a third party payer NOT in contract with the clinic.
Clinic must received a denial of payment from the insurer or an attestation from the client Documentation must be retained by the clinicSubject to an audit by the New York State Office of the Medicaid Inspector General.
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Indigent Care Pool Non-Covered Services
Visits will not be counted if they meet the following conditions: – Visits paid in whole or part by a third party payer (including
Medicaid Managed Care).– Visits not authorized (considered not medically necessary)
by an insurer/managed care plan.– Visits provided to a recipient who has coverage from a third
party payer not in contract with the clinic when an insurer does reimburse the insured for the visit.
– Visits delivered by persons unqualified to deliver the services under state regulations.
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Transition
Phased-in over time to enable transition– 1st year – 75% old, 25% new – 2nd year – 50% old, 50% new, etc.
Clinics to submit APG claim only except for COPs OnlyCOPs only claims will phase out over 3 years
– Continue with the current billing process.
Current Status
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Draft regulations ublished March 17thFinalizing ratesProviding ongoing training on clinic restructuring
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