Secure Financial Support for Behavioral Health Services

Public payers, like Medicaid and Medicare, and many private payers, offer specific reimbursement guidelines and programs for integrated behavioral health services, and it's crucial for practices to understand the specific billing codes, coverage policies, and any state-specific regulations associated with these programs to ensure proper reimbursement for integrated behavioral health care services provided to their beneficiaries. Navigating these reimbursement options, from traditional fee-for-service to innovative value-based payment approaches and exploring supplemental funding avenues, are crucial for the financial sustainability of integrated services.

The traditional fee-for-service billing method is based on individual services rendered, requiring understanding of specific Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System HCPCS) codes for integrated care functions like behavioral health screenings, assessments, and brief interventions. These codes are the fundamental language used to describe the services provided to patients.

Each code has specific documentation and service delivery requirements for accurate reimbursement. Engage with public and private payers directly to understand the specific payment methodologies, covered services, coding and billing requirements, and any state-specific nuances that apply to their operations and the provision of integrated behavioral health services.

Value-based payment models, while shifting away from pure fee-for-service, still rely on these codes to identify the services that contribute to the overall cost and quality of care for a patient or a population. Examples of value-based care payment model include:

• Bundled Payments: Bundled payments are single payments covering all services for a defined condition or episode of care. Instead of paying separately for each individual test, procedure, or visit, a lump sum is allocated to cover the entire "episode of care," which can span from the initial treatment through recovery. This approach incentivizes providers — including hospitals, physicians, and post-acute care facilities — to collaborate and deliver efficient, coordinated care, as they are collectively responsible for managing costs within the bundled amount. If the total cost of care falls below the bundled payment, providers may share in the savings, while exceeding the target price can lead to financial risk, thus promoting a focus on quality and cost-effectiveness throughout the entire care continuum.
• Prospective Capitated Payments: In this payment model, a provider or healthcare organization receives a fixed amount of money per patient enrolled in their care over a specific period (usually per member per month or PMPM), regardless of how many times that patient seeks care or the types of services they utilize. The provider receives a set payment for each "covered life" for a defined period, shifting the financial risk from the payer to the provider. This incentivizes providers to keep their patient panel healthy and manage resources efficiently, as their revenue is tied to the number of enrolled patients rather than the volume of services they provide.
• Pay-for-Performance: In the pay for performance (P4P) model providers are incentivized to achieve predefined quality or efficiency benchmarks. Instead of solely compensating based on the volume of services provided (as in fee-for-service models), P4P links a portion of the payment to the achievement of specific performance metrics. These metrics can encompass various aspects of care, including clinical outcomes, patient safety, patient satisfaction, adherence to evidence-based guidelines, and cost-effectiveness. Successful implementation of P4P requires careful tracking and reporting of these metrics to demonstrate achievement and receive the associated financial rewards.

Payers use historical claims data, which is based on CPT and HCPCS codes, to establish benchmarks for cost and utilization within value-based arrangements like bundled or prospective capitated payments. Understanding the typical services (and their associated codes) for a specific patient population or episode of care is essential for setting budgets and evaluating performance against those benchmarks. For example, in bundled payment models, CPT and HCPCS codes help define the scope of services included in the "bundle" for a particular condition or procedure. The total payment for the bundle covers all the services identified by these codes within a specific timeframe.

The CPT and HCPCS codes listed above are essential for demonstrating the delivery of these integrated services. By accurately coding for counseling, psychotherapy, behavioral health assessments, and care management activities, you can:

• Bill for these services: Even within value-based models that have a population-based payment component, there's often still a fee-for-service element or specific payments for care management and other integrated services.
• Track utilization and outcomes: Consistent use of these codes will allow your practice or system to monitor how often behavioral health services are being used and, when linked with outcome data, assess your impact.
• Demonstrate value to payers: Reporting these codes, especially in conjunction with improved physical health outcomes and patient satisfaction, can help justify the investment in integrated behavioral health and potentially lead to increased reimbursement or shared savings under value-based contracts.
• Meet quality metrics: As value-based payment increasingly incorporates behavioral health measures, the ability to accurately code and report these services will be crucial for achieving quality targets and maximizing payments.

While recent Medicare and Medicaid changes have expanded billing codes for integrated behavioral health services, including for substance use disorder (SUD) treatment, the current fee-for-service reimbursement rates may not cover the full cost of providing comprehensive care. Practices and systems should explore using practice/system operating funds, graduate medical education funds, and/or grant funds to supplement their financial sustainability or to cover the cost of transitioning to an integrated behavioral health model. Federal grant opportunities may be available to offer support for specific integration models and approaches, integration-related workforce education and training, and value-based payment models for integrating behavioral health and primary care. State or local health departments may offer funding to support behavioral health integration initiatives within their jurisdictions. Additionally, private funders may also offer grants for practices and health systems that serve their specific areas of interest, geographic regions, or target populations. Grants for integrating behavioral health and primary care sometimes include opportunities to participate in practice facilitation and learning collaboratives. These grants often have specific eligibility criteria and application requirements that must be carefully reviewed.

Unlike traditional primary care practices, Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) operate under unique payment structures. The same is true for Certified Community Behavioral Health Clinics (CCBHCs). All three entity types meet specific eligibility criteria and serve underserved populations with a focus on comprehensive, integrated care, which influences their reimbursement methodologies and coding practices.

FQHCs and RHCs typically operate under a prospective payment system (PPS) or an all-inclusive rate (AIR) for most primary care and behavioral health services delivered during a qualifying integrated care visit. These bundled payment approaches encourage the efficient provision of a comprehensive suite of integrated services within a single patient encounter. While a general encounter code is the primary billing mechanism, utilizing specific CPT and HCPCS codes to document the behavioral health services provided remains important for cost reporting, quality measurement, and potentially for supplemental payments or specific program requirements.

While Medicare has a standardized PPS and AIR for FQHCs and RHCs, Medicaid offers states considerable flexibility. States can implement Alternative Payment Methodologies as long as they ensure payments are no less than the federal PPS rate. This leads to variations in reimbursement models, PPS rates, covered services, and the role of Medicaid Managed Care Organizations (MCOs) and Medicaid Accountable Care Organizations (ACOs). State-specific billing guidelines, telehealth policies, and other factors further contribute to a diverse payment landscape.

Similarly, CCBHCs often employ a PPS based on the anticipated costs of delivering a wide array of services, spanning mental health, substance use, primary care screening, and robust care coordination. Billing for CCBHCs involves using specific HCPCS codes that correspond to the defined service categories within their PPS framework, directly aligning reimbursement with the provision of integrated, whole-person care rather than individual services. Medicaid offers States significant control in designing these PPS rates, determining covered service categories, and implementing quality bonus payments.

FQHCs, RHCs, and CCBHCs must directly engage with their state Medicaid agencies to understand the specific payment methodologies, covered services, billing requirements, and any state-specific nuances that apply to their operations and the provision of integrated behavioral health services.

A thorough understanding of the financial implications of behavioral health integration necessitates a careful accounting of both the immediate and less obvious costs associated with implementation. By proactively identifying these expenses, primary care practices can develop realistic budgets and financial projections to ensure the long-term viability of their integrated care programs.

The costs of integrating behavioral health can be broadly categorized as follows:

• Direct Costs: These costs are the tangible and easily quantifiable expenses directly related to establishing and operating the integrated program and include salaries and benefits for newly hired providers and staff, training for all staff, new or upgraded digital health equipment or technology, and modifications or renovations to the physical space.
• Indirect Costs: These costs are less immediately apparent but equally important expenses that arise from the changes in practice operational systems, workflows, protocols due to integration and include administrative overhead for billing and coordination, time spent on care coordination activities, and potential impacts on primary care provider productivity during the initial integration phase.

Look at your payer mix and target patient population by each payer. As you start implementation, your target population for the first iteration of integration may be selected based on which patients' care is reimbursed by which payer. The rules for how behavioral health services are reimbursed in medical settings vary from state to state and payer to payer, so it is important to understand the rules for your setting as you begin to work on integration.

To bill for services, the behavioral health provider must be credentialed with the health plans that serve your patient population. Credentialing must be done separately for each plan. This process can take from a few weeks to months. Some plans allow retroactive billing once credentialing is complete. Check with each plan about this.

Health systems and other large health care organizations might enter into a joint dialogue with payers about how they can support integrated care programs and provide the reimbursement necessary to provide behavioral health care for their members. This dialogue will help them understand that the behavioral health provider is part of the care team, not a specialist operating in a referral mode from a distant site. Emphasize that integrated workflows can help improve outcomes for complex patients, and work with payers to determine billing procedures.

To get started:

1. Create a table that lists the number of patients by payer source and conduct basic analytics to see if there are significant differences in patient characteristics and payment adequacy considering case mix. A simple approach to case mix is to create a 2-by-2 matrix of age group (i.e., adult or youth) and disability status (i.e., disabled or non-disabled) by payer.
2. Identify the primary insurance types (commercial, Medicaid, Medicare, etc.) held by your patient population.
3. Review existing contracts with these payers to understand current reimbursement rates for medical services and identify potential opportunities or barriers related to behavioral health integration.
4. Proactively engage with payers to inquire about specific policies, value-based care arrangements, or supplemental payment options relevant to integrated behavioral health care.
5. Ensure patient records accurately reflect the services provided and meet the detailed requirements for each billing code.
6. Initiate and manage the credentialing process for each behavioral health provider with all relevant health plans serving your patient population.
7. Verify that all healthcare professionals delivering and billing for services possess the necessary credentials, licenses, and certifications recognized by payers.
8. Adhere to any supervision guidelines that may apply to specific behavioral health services or provider types to ensure compliant billing.

Some States and some other payers still use "carve-out" strategies in which payment for behavioral health care is administered by an independent behavioral health management vendor, separately from payments for general health care, for at least some defined groups of people. A variant on this is the "carve-in" in which a separate unit within the managed care organization addresses behavioral health care under a budget for behavioral health services only. Either "carved-in" or "carved-out" approaches can make it difficult to provide integrated care because they create obstacles to coordination and whole-person approaches.

Develop your plans with awareness that "carve-in" and "carve-out" payment makes it more challenging to provide integrated, whole-person care. To the extent your organization—or membership organizations to which you belong—has influence, encourage payers to move toward single combined budgets that pay for all medical and behavioral health services. At the same time, strive to ensure that the quality measures to which you are held accountable include behavioral health outcomes as well as medical outcomes. An environment that includes combined budgets and balanced outcome measures makes it easier to develop and sustain behavioral health integration.

Regardless of the particular payment models used, a number of factors can influence the financing of integration, including:

• Whether enough patients are being referred to the integrated behavioral health provider;
  • This includes both reaching into the target population to make a difference in population health outcomes and ensuring that the behavioral health provider is busy enough to make a difference in billings or global revenue.
    1. Routine screening for behavioral health conditions (using validated tools like the Patient Health Questionnaire-9 or Generalized Anxiety Disorder Scale-7) can identify patients who need referrals and having established referral workflow can ensure that a member of the care team offers a referral to patients who screen positive for mental health issues or substance use.
    2. Tracking and reporting clinician-specific referral data and combining that with a friendly, incentive-based competition can motivate providers to increase behavioral health referrals by fostering awareness of their own performance and encouraging them to meet or exceed other care team members' referral rates.
• Whether enough patients are arriving for scheduled visits;
  • This requires sufficient enrollment and a low no-show rate.
    1. Adapting workflows and setting up schedules to allow for warm hand-offs can ensure that patients are seen for behavioral health symptomology during primary care visits, instead of having to have a separate appointment.
    2. Understanding patients' barriers to scheduling and attending visits and working with the care team, practice staff, and community partners to address those barriers can support patient attendance at appointments.
• Whether the organization is being paid for billed services;
  • This requires reimbursement rates that are adequate for funding integrated behavioral health.
    1. Negotiating with payers can help ensure adequate payment rates, as can optimizing coding and billing practices.
    2. Exploring opportunities to be paid in more global ways other than traditional fee-for-service billing can also increase payments.

Monitoring these processes is vital so you can identify threats to sustainability early and adjust processes to deal with them.

Savings achieved by integrating behavioral health and primary care are likely to come from reduced expenditures for institutional care in settings such as hospitals, emergency departments, and nursing homes. In general, expenditures for primary care and behavioral health outpatient care are likely to increase moderately even as total health care spending decreases because of reduced institutional care expenditures.

If your organization does not provide expensive institutional services and is not responsible for paying for them, you probably don't have the data to know whether your interventions result in savings. Therefore, you should negotiate with payers who carry that responsibility to obtain data or reports about those services. Some payers will give you the data and help you develop the capability to use it. Others may keep the data but provide reports. In some way, you'll need data to determine what effect your interventions have on costs and other outcomes.