Examples of Sustainable IBH Financial Strategies

Practice: Burlington Pediatrics/Mebane Pediatrics^1,2

Practice Type: Independent Pediatric Practice, Family-Centered Medical Home

Payer Mix: Medicaid/Children’s Health Insurance Program, Private Payers

Funding Sources: Grants, FFS payments

Financing Strategies:

• Used grant funds to hire a master's-level psychologist and a family navigator, implement Triple P (Positive Parenting Program), and systematize behavioral health screening.
• Increased utilization of two developmental and behavioral health screening codes: 96110 and 96127.
• Conducted shadow billing during the grant period to accurately project costs and ensure a seamless transition to self-funded operations.
• Hired a consulting firm to produce benchmarks for contract negotiations with private payers and negotiated with payers for specific codes.
• Embedded behavioral health screenings into electronic health record workflows to ensure billing requirements were documented.
• Optimized coding management processes through systematic quarterly reviews of billing code utilization.

Results: In a 12-month period, this pediatric practice was able to generate over $110,000 from codes 96110 and 96127.

Source: American Medical Association Behavioral Health Integration Collaborative

Link: https://www.ama-assn.org/member-benefits/events/behavioral-health-integration-strategies-independent-practices

Practice: Mountain Family Health Centers³

Practice Type: Federally Qualified Health Center (FQHC), Patient-Centered Medical Home (PCMH)

Payer Mix: Medicare, Medicaid/Children’s Health Insurance Program, Private Payers, Local Hospitals

Funding Sources: Grants, pay-for-performance incentives, per-member-per-month (PMPM) payments, shared savings

Financing Strategies:

• Negotiated with a Medicaid managed care plan for a value-based contract with PMPM payments and a Community Integration Agreement with $75K–$1M annually in grants and other funds to hire new behavioral health staff and support care transitions.
• Participated in the state’s Payment Reform Initiative for Medicaid Enrollees for shared savings.
• Partnered with 3 local hospitals to receive PMPM payments for serving uninsured patients.
• Earned National Committee for Quality Assurance PCMH designation, which qualified the practices for Tier 1 status and associated PMPM payments used to support integrated care.
• Invested in a risk-assessment tool, another Tier 1 requirement, to support care planning and unlock PMPM payments for advanced primary care.

Results: In 10 years, this FQHC was able to go from having only one part-time behavioral health provider to having 2 psychiatric nurse practitioners, as well as one behavioral health provider (mostly licensed clinical social workers) for every 2 medical providers.

Source: The Commonwealth Fund

Link: https://www.commonwealthfund.org/publications/case-study/2022/dec/integrating-behavioral-health-services-primary-care

Practice: ACCESS Family Care Medical & Dental Clinics (Access)⁴

Practice Type: Federally Qualified Health Center, Patient-Centered Medical Home

Payer Mix: Medicaid/Children’s Health Insurance Program, Private Payers, and Medicare

Funding Sources: Grants, PPS payments

Financing Strategies:

• Created a reciprocal billing model where the Certified Community Behavioral Health Clinic (CCBHC) invoices Access for contracted staff time and Access recoups costs via grant funding or insurance reimbursements, and where Access and the CCBHC use fee-for-service billing codes for clinical services based on the location of service.
• Used grant funding to cover start-up costs, staffing, medications, and care for uninsured patients.
• Leveraged mental health billing codes to receive maximum reimbursement.

Results: The partnership expanded MOUD to 8 Access clinics and a mobile outreach unit, and increased psychiatry visits (by 66%) and therapy visits (by 55%) over a 4-month period. Thanks in part to Medicaid expansion, Access was able to stretch its grant dollars to serve more uninsured patients.

Source: Center for Health Care Strategies

Link: https://www.chcs.org/resource/a-federally-qualified-health-center-and-certified-community-behavioral-health-clinic-partnership-in-rural-missouri/

Practice: Marathon Health^5,6

Type: Direct Primary Care Practice

Payer Mix: Employers, Unions

Funding Source: PMPM payments

Financing Strategies:

• Incorporated costs for integrated behavioral health services, in-person or virtually, by licensed mental health specialists into PMPM fees.

Results: Unions and employers that are members of Marathon Health have achieved 45% PMPM savings (an average of $6,148) for members who use both primary care and behavioral health services.

Source: Marathon Health

Link: https://marathon.health/mental-health/