Topic: Billing and Funding of SUD Services in Health Care Settings

California SUD/Health Care Integration Learning

SUMMARY REPORT MEETING 3

Date: Wednesday, June 22, 2011 Time: 11AM – 12:00PM Hosts: UCLA Integrated Substance Abuse Programs (ISAP) & CA Dept. of Alcohol and Drug Programs (ADP) Topic: Billing and Funding of SUD Services in Health Care Settings

Guest Facilitators: - Allison Clinton – DHCS Audits Manager, Audit Review and Analysis Section - Ralph Zavala – DHCS Audit Manager, Financial Audits Branch - Rob Maus – ADP Program and Fiscal Policy Branch - Gladys Mitchell – ADP Licensing and Certification Division/Policy and Program Support - Mike Hori – ADP Audits Branch

Review of ILC Meeting 2: Valerie Pearce, UCLA ISAP

. The second ILC meeting on Data Privacy and Health Homes occurred in-person at the May CADPAAC Quarterly in Sacramento, on May 25, 2011. A total of 109 participants including county administrators and provider organization representatives attended. . Expert speaker Paul Samuels (Legal Action Center) presented on “Applying the Substance Abuse Confidentiality Regulations to Health Information Exchange (HIE),” reviewing main points from the Data Privacy Forum conducted on 5/24/11 and holding a Q&A session on county-specific issues. . Expert speaker Mady Chalk (Treatment Research Institute) presented on both the data privacy topic as well as on “Coordinated Care and Health Home,” highlighting the relevance of Health Homes in the delivery of AOD services within the broader health care system. . A summary from this meeting has been distributed and posted on the UCLA ILC webpage: http://www.uclaisap.org/Affordable-Care-Act/html/learning- collaborative/index.html

Logistics . Summary and materials discussed from the previous ILC meetings are available at http://www.uclaisap.org/Affordable-Care-Act/html/learning- collaborative/index.html. Subsequent meeting materials will continue to be posted on this site. . All further meetings will be held 11:00AM (PT) on the 4th Wednesday of every month, unless otherwise noted. . The next ILC meeting will be held via conference call on July 27, 2011 at 11AM. Thank you to Dan Peters and Mark Stanford for volunteering to present on their County’s initiatives around the integration of SUD/Health care services.

ILC Meeting 3 Topic: Billing and Funding of SUD Services in Health Care Settings Topic Introduction – Valerie Pearce, UCLA ISAP

. The topic for today’s learning collaborative surfaced as a result of the discussion that took place during the May CADPAAC Integration committee meeting (led by Karen Kane and Gary Atkins). It was clearly established that there was further need for ongoing discussion around billing-related issues for SUD services as counties began integrating SUD services outside of the AOD system. Many administrators desired clarification on how to adhere to current policies and regulations when attempting to start new SUD initiatives in non-AOD settings (mental health, primary care, FQHCs). Questions circulated around the required licensing and certifications for organizations as well as staff in order to bill drug medical, SAPT block grant dollars; how FQHC billing works; what types of services are eligible for billing in non-AOD settings (screening, brief intervention, brief treatments, etc.)?

Discussion Rob Maus – ADP Program and Fiscal Policy Branch:

 Findings from the 2010 California County SUD Primary Care Integration Survey (UCLA) revealed that 92% of respondents perceive financing as one of the main barriers to integrated care (compared to lower-rated barriers of shared documentation and developing partnerships with PCPs).  FQHCs are a logical place to pursue integration for SUD providers but not everyone is knowledgeable about appropriate billing and interface with Federally Qualified Health Centers (FQHCs). This places limitations on financing for services which can hinder partnerships from developing.

Allison Clinton – DHCS Audits Manager, Audit Review and Analysis Section: The FQHC Process and How to Reimburse for Services

 Perspective Payment System (PPS) Reimbursement o FQHCs & Rural health clinics (RHCs) are reimbursed on the PPS methodology which is calculated as an all-inclusive rate for all services incurred at the clinic. o All of the FQHC’s reimbursable costs are divided by the total number of visits to determine the PPS rate (or cost per visit). Fee-for-service is no longer billed. o Any FQHC reimbursable service is included and billed at this rate. Medi- Cal will only reimburse for a provider visit given that the provider is a physician, physician assistant, nurse practitioner, certified nurse midwife, clinical psychologist, or LCSW. o ‘Incident To’ services (e.g.: lab tests, immunizations, re-fills on birth control pills) are services included in the PPS rate when a billable service is applied but are services that are by themselves NOT billable. o Drug counselors are NOT a practitioner type that is billable under the FQHC program; however, the costs of the counseling services provided by drug counselors are reimbursed through the PPS rate as an ‘Incident To’ service. Given that the services are drug-counseling/Drug Medi-Cal, ADP- approved program counselor services are indirectly reimbursed every time the FQHC rate is billed by being included in the PPS rate.

Question & Answer with Allison Clinton

Q: How often can you re-compute your PPS rate?

A: (AC) Providers can re-compute their PPS rate through a Change-in-Scope-of- Service Request. This requires the provider to demonstrate a designated “qualifying event” i.e. relocation, remodeling, an addition or a deletion of a service, etc. that meet a certain threshold in cost changes

Q: Can the addition of an AOD service be considered a “qualifying event?”

A: The addition of AOD services is considered a qualifying event only if these services were never offered prior AND adding these services meet the “threshold”-cost increase of 1.75% to recalculate the PPS rate.

Q: What is the benefit for an FQHC to add counseling services into their PPS rate calculation if they can’t bill for it?

A: (AC) When you add an ‘Incident To’ service, you are adding a cost which increases the numerator of your PPS rate calculation. For example, if the PPS rate is $150 and the addition of Drug Medi-Cal services increase this rate by $5, every billable service is reimbursed an extra $5 to cover the cost of the ‘Incident To’ service. Although counselor visits are not directly billable, their costs are included in the numerator and therefore incorporated in the PPS rate to cover those costs.

Q: Can this regulation be altered so as to include MFTs and licensed counselors as a billable provider?

A: (AC) The classification of a billable provider is a federal law that is not easy to change. A: (RZ) If a state wishes to change any regulation, a state plan amendment must be submitted to the federal government, which must then be approved. CMS must support this amendment and may make revisions to the draft prior to submission. The DHCS policy department should also provide feedback. While the overall process can take up to one year or longer, it is required and encouraged to make any change in regulations that are in favor of the department or provider.

Q: So to clarify, is the prohibition for FQHCs to bill for MFT services in the federal Medicaid law or a state plan issue?

A: (AC) MFTs are not considered a billable provider in the federal law and state plan amendment. The definition of what is a billable visit, and who is a practitioner, is in the code section of the federal Medicaid law. The state plan “piggybacks” on this federal code. States who wish to change these regulations must go through a waiver process. DHCS does not actively participate in legal regulation changes of this sort but the DHCS Policy Division should have further information about this process.

Q: Does the FQHC have to be Drug Medi-Cal-certified? If so, does the county need to contract with the FQHC?

A: (AC) It’s my understanding that they must be an “ADP-approved” program, following ADP’s guidelines of Medi-Cal to bill Medi-Cal. ADP and DHCS must further discuss to see how FQHCs will handle existing confusion (e.g. the words “approved” and “certified” are interchangeably used and can be confusing).

Q: If the costs of the alcohol and drug services are folded into the PPS rate, then we should not be billing Drug Medi-Cal. If we’re not billing Drug Medi-Cal, why would we need to be certified? Is there another way to satisfy DHCS’s concern that we are “approved” by ADP?

A: (??) Certainly, Drug Medi-Cal doesn’t allow for the kind of brief interventions we see in primary care. We’d be certifying for standards that aren’t applicable and are not evidence-based practices.

Q: My FQHC performs SBIRT, and we have two MFTs who work there. Can we get this site certified and get the MFTs AOD-certified so that they can be an outpatient provider?

A: (Victor Kogler of ADPI) I have a board member who works in a FQHC. They have a drug Medical-certified women’s program, and they bill Drug Medi-Cal for those services. It is not billed within the FQHC’s PPS rate. When we’re talking about certification, I believe we’re discussing program certification. I don’t know if they’re restricted to Drug Medi-Cal services only. A: (ADP Licensing) There ARE FQHCs that are Drug Medi-Cal certified. We do not pre-determine if they are Drug Medi-Cal certified.

A: (AC) I don’t want to say “yes” or “no” (that our department will require FQHCs to be Drug Medi-Cal-certified); it is something Ralph and I must take back to our management before we say that they MUST be required to be Drug Medi-Cal certified. We will get back to you. We need to revisit the actual term of “certified” prior to giving counties and providers a definite answer on that.

A: (VK) I think the answer we WANT to hear is that if they want to bill Drug Medi- Cal they should be certified, but if they simply fold the AOD services into their PPS rate and don’t bill Drug Medi-Cal, then they don’t have to be certified.

A: (AC) The problem herein is this: with FQHCs, we really don’t have services that we allow an FQHC to carve out of their PPS rate, and then bill another program. The ONLY service that is allowed for providers to carve out of the rate and bill Medi-Cal fee-for-service is pharmacy. The provider won’t be able to take the ADP Drug Medi-Cal services out of their PPS rate, and then bill Drug Medi- Cal. The PPS methodology is not set up this way due to tracking purposes. It is difficult to keep track of providers because the systems are not linked for carved- out services. Providers, therefore, cannot do this.

Q: Why can’t we just blend the ADS funding with the FQHC Medical funding? It would make the most sense for the services to be carved INTO, rather than out. If an SUD is like diabetes, why is it being treated like a completely different matter?

A: (Lanis Clark, ADP Audits Branch) Our concern is tracking in terms of funding, certain services, and certain costs. It’s key to not bill two systems for a similar service. Blending the two systems creates concerns, b/c we are billing two systems for a similar cost. A single funding system is simply not the way it’s structured.

Q: Can drug counseling services be included as part of the PPS rate?

A: (AC) Drug counseling services can be included as part of the PPS rate as an ‘Incident To’ service. These services, like all ‘Incident To’ services, are not directly billable. If a clinic has included drug counseling services in their PPS rate they will have a higher PPS rate than if they did not. That rate is billed every time clients have any type of a medical visit which covers these Drug Medi-Cal costs. For example, immunizations are considered an ‘Incident To’ service. When a patient comes in to receive an immunization shot, the FQHC does not bill for this service. Instead, the costs of the shot are included in the PPS rate that is paid whenever a billable service occurs. As a result, the costs of the shot are indirectly paid for. Note: PPS rates are extremely high. The average PPS rate is $160 per visit, so it’s key to realize we ARE covering their costs, even if it appears that we are not.

If an FQHC has Drug Medi-Cal services included in the PPS rate as an ‘Incident To’ Service but also reports to ADP and bills fee-for-service for Drug Medi-Cal services, then we are paying TWICE for the same services. This is what we’re trying to avoid; this is why ADP and DHCS have to work together to ensure this doesn’t happen. We must ensure duplicates aren’t taking place.

Q: Do you think Substance Abuse counseling will be considered what is known as a valid billable visit with HCR?

A: (AC) I don’t know yet. When a patient comes into a clinic, they will see a physician first, and then be referred to a counselor for counseling services if they have an addiction issue. With this order of events, substance abuse counseling is an ‘Incident To’ Service because it is secondary to the physician visit. I don’t know if this will change later down the road with HCR, but we haven’t heard anything.

Q: Are AOD counseling services billable if it’s provided by an LCSW or psychologist? And do I have to call it mental health or substance abuse counseling?

A: (AC) Yes, AOD counseling services are billable by an LCSW or psychologist because they are billable providers. I am unsure, however, as to whether you have to call it mental health or substance abuse counseling. If it falls under a specific practitioner’s scope of practice and they’re seeing patients for a drug and alcohol issue, then it’s billable.

Q. What other kinds of alcohol and drug services, outside of outpatient counseling, can be folded into the PPS rate (in other words, can one fold in medication-assisted treatment or residential treatment/detox)?

A: (AC) We don’t have a list of items, per se, although we have some clinics that provide methadone treatment. I don’t know much about Drug Medi-Cal because that is a separate program. Residential treatment would not be an FQHC service so it would not be covered. For medication-assisted treatment, if patients see a physician, that physician visit is billable. Very few clinics have pharmacies included in their PPS rate; typically pharmacies are separate from clinics and they bill Medi-Cal on a fee-for-service basis.

Q. If you wanted to add SUD services into an FQHC and recalculate the PPS rate, how do you prove that you’re reaching the 1.75% threshold?

A: (AC) DHCS’s Audits and Investigation website has a forms page that includes a Change- in-Scope of Service Request form. The provider needs to fill it out completely. The percentage calculation is made automatically to indicate whether or not the threshold is met and the PPS can be recalculated.

Q. FQHCs that provide homeless services are federally required to provide SUD services. Are these the only FQHCs that are required to provide SUD services? What are those required services under HRSA?

A: (AC) I’m not sure because HRSA, which is part of CMS, is an entity that tells the FQHCs what qualifies as a required service or not. We will check with HRSA to see what those qualifications and requirements are.

Closing Remarks – Valerie Pearce, UCLA ISAP

. Although we still have a lot of questions unanswered, this discussion has been crucial for ADP and DHCS to understand what internal discussions are needed to provide ongoing guidance to the counties around billing and funding policies and regulations. Integration as we know remains challenging and continuing to ask questions will help identify the several barriers and facilitate the resolution process. . Please send any additional questions to Valerie Pearce at [email protected]). COUNTY PARTICIPANTS

MBA  Lassen (Anita Harsh) SMALL  Kings (Brenda Randle) MEDIUM  Kern (Lily Alvarez)  Santa Cruz (Bill Manov)  Solano (Andrew Williamson)  Stanislaus (Madelyn Schlaepfer) LARGE  Fresno (Dennis Koch)  Los Angeles (Wayne Sugita & John Viernes)  Orange County (Brett O’Brien)  Riverside (Karen Kane)  San Bernardino (Dan Peters)  San Diego (Susan Bower) ORGANIZATION PARTICIPANTS  ADPI (Victor Kogler)  CADPAAC (Tom Renfree)  CTC (Rich Bradway)  COMP (Steve Maulhardt)

ADP PARTICIPANTS  Craig Chaffee  Lanis Clark  Mary Dodson  Christopher Lewis  Robert Maus  Gladys Mitchell  Michael Hori  Vishaal Pegany  Alice Trujillo  Marcia Yamamoto  Angela Zamora

DHCS PARTICIPANTS  Allison Clinton  Ralph Zavala  David Phippen UCLA PARTICIPANTS  Rick Rawson  Beth Rutkowski  Valerie Pearce  Darren Urada  Liz Nelson  Stella Lee  Grace Kim