MBHP PROVIDER REIMBURSEMENT RATE INCREASES

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1 ALERT #40 September 15, 2008 MBHP PROVIDER REIMBURSEMENT RATE INCREASES THE FOLLOWING INFORMATION SHOULD BE NOTED AND COMMUNICATED IMMEDIATELY TO YOUR CHIEF EXECUTIVE OFFICERS, CHIEF FINANCIAL OFFICERS, MEDICAL DIRECTORS, MANAGERS, AND BILLING STAFF. The Massachusetts Behavioral Health Partnership (MBHP) is pleased to announce a reimbursement rate increase for most covered services in its network effective August 1, This will mark the fifth consecutive year in which MBHP has increased rates to most providers in the network. MBHP s efforts to continually strive to provide fair and equitable rates to its network providers is reflective of MBHP s commitment to ensuring the highest quality of behavioral health services for Members of the MassHealth PCC Plan as well as a recognition of the support providers need to continue to do this important work. As in the past four fiscal years, MBHP is tying rate increases to provider compliance with certain measures of performance and quality. As required by MBHP s policy on outcomes management, only those providers who are participating in the MBHP Outcomes Management Initiative will be eligible for rate increases. Additionally, rate increases for some levels of care are contingent upon the performance measures specified below. Please be reminded that, by accepting this rate increase and signing a revised Exhibit A Agreement, the provider agrees to the contingencies delineated throughout this Alert. NETWORK MANAGEMENT PRIORITIES The following are values and practices that MBHP expects of itself and its provider network, many of which are incorporated into the performance indicators on which provider rate increases are based this year for various levels of care. MBHP recognizes that many providers exemplify some or all of these values and practices, and appreciates providers willingness to continue to identify opportunities to better realize them in their work with PCC Plan Members. Resilience, Rehabilitation, and Recovery - MBHP is committed to the integration of resiliency, rehabilitation, and recovery principles, practices, and programs throughout the continuum of care. MBHP encourages providers to educate their staff about rehabilitation and recovery principles and resources available to them in their work and to 1

2 consumers in their communities. Providers should work with staff and consumers in developing recovery-oriented practices and programs within the services they offer and appropriate to the populations they serve. MBHP especially values the integration of peer and family specialist services and recognize providers who have worked to introduce this innovative resource into their programs. In FY09, MBHP encourages providers to become familiar with the Transformation Center, a consumer and provider resource, and the new Recovery Learning Communities (RLC) in each region, funded by the Department of Mental Health, and to develop working relationships with the RLC staff and programs that can provide resources and supports to provider organizations and the people they serve. Cultural Competence - MBHP has been studying gaps in services to culturally and linguistically diverse groups across the state and appreciates providers efforts to partner with us in recent years to develop programs to specifically meet the needs of underserved populations, such as Community Support Programs (CSP), which were designed to be responsive to specific diverse communities. MBHP continues to encourage providers to assess the needs in their communities and agencies and make efforts to partner with those communities and with MBHP to find ways to better meet behavioral health needs. MBHP held focus groups with providers during the past two years to identify needs and strategies to improve culturally and linguistically appropriate services and service delivery across the state. In FY09, MBHP expects to develop additional opportunities to partner with providers and other key stakeholders to improve behavioral health services to diverse communities. Access Ensuring timely access to all covered services for our Members across the Commonwealth is a priority for MBHP. Access to inpatient mental health services is particularly critical given the acute needs of individuals requiring that level of care as well as the well publicized impact on Members and the system of care when access is not readily available. The Office of Medicaid and MBHP require that all inpatient acute mental health providers agree, subject to available beds and age appropriateness, to admit persons who require inpatient acute mental health services upon referral to their facility by an Emergency Services Program (ESP), regardless of a person s clinical profile, cultural and/or linguistic background, or ability to pay. MBHP continues to adhere to this no reject policy and expects the full compliance of the inpatient mental health provider network. MBHP acknowledges the contribution of the providers who continue to participate in the statewide MBHP Access to Care Workgroup and continues to seek the involvement of all ESP, inpatient, and other providers in implementing new strategies for facilitating more timely access to acute behavioral health services in the coming year. In particular, inpatient providers will be asked to develop facility-specific plans for improving access to their services, including the implementation of best practices to streamline the admission process. MBHP also looks forward to partnering with the Massachusetts Association of Behavioral Health Systems to offer training and support to inpatient providers in their efforts to improve access. As reflected in the Rate Increase Specifications section below, MBHP has incorporated four indicators related to access into this year s pay-for-performance rate methodology for inpatient providers. They involve access for uninsured individuals and state agency- 2

3 involved youth and adults, as well as compliance with reporting bed availability to MBHP. Integration of behavioral and physical health - As required in the Provider Manual, MBHP has always expected network providers to obtain consent to communicate with a Member s Primary Care Clinician (PCC) and provide appropriate information to the PCC about diagnosis and treatment. In FY08, MBHP increased its rates for case consultation provided by psychiatrists and APRNs to encourage them to provide telephonic consultation to PCCs regarding both Members whom they have seen as well as potential new referrals about whom the PCC has questions. To further integrate care, MBHP now encourages all network providers to ascertain whether Members to whom they are providing services either have not seen their PCC for preventive care or have a chronic illness, such as diabetes, for which they are having trouble following their physical health care plan. Often the root cause of a Member not following their physical health care plan is a mental health or substance use condition, which MBHP expects its network providers to be able to assist the Member in addressing. MBHP reminds providers that they may make a referral to MBHP s Targeted Outreach care management program for Community Support Program (CSP) assistance for physical as well as behavioral health concerns. To do so, call the MBHP Assessment Unit at , ext Outcomes Management - The core elements of MBHP s Comprehensive Outcomes Management Program will continue in FY2009 as they have in previous fiscal years. With the implementation of the Children s Behavioral Health Initiative, the Child- Adolescents Needs and Strengths (CANS) tool will be a required assessment instrument for all Members under the age of 21. MBHP will offer provider training in interpreting the results of CANS assessments and incorporating these results into Members service plans. MBHP will also offer training on the use of other assessment instruments for adults. Please see Alert 39 for further information about the use of the CANS. Utilization Management: Length of Stay MBHP seeks to provide its Members with clinically appropriate, least restrictive services in the intensity and duration necessary to meet their behavioral health needs. In doing so, MBHP partners with its provider network to plan and manage care, and to manage utilization at all levels of care. MBHP will continue to work with several levels of care around specific utilization management data and goals. In FY08, MBHP began utilizing profiling data with various substance use levels of care, similar to that used with outpatient and ESP providers, in an effort to work more closely with substance use service providers in examining and improving how the continuum of care is being used to meet the needs of individuals with substance use and co-occurring disorders. MBHP will also continue to work closely with inpatient mental health and Intensive Community Based Acute Treatment (ICBAT) providers to manage utilization in these acute levels of care in FY09. MBHP will continue to use data to monitor length of stay and engage in collaborative efforts to implement strategies to improve provider performance related to this performance measure. As reflected in the Rate Increase Specifications section below, MBHP has continued to incorporate two indicators related 3

4 to length of stay into this year s pay-for-performance rate methodology for inpatient providers. Continuity of Care: Aftercare and Readmission Rates Providers at all levels of care share the goal of enabling Members to successfully live in the community. The vision is for Members to transition within and among behavioral health and medical care services while receiving consistent, comprehensive, and uninterrupted quality care. Integrated coordination of care within and among all levels of care and service types, particularly as Members transition from inpatient to outpatient services, requires cooperation, shared responsibility, and accountability among providers as well as between providers and the Member and his/her family. As reflected in the Rate Increase Specifications section below, MBHP has continued to incorporate an indicator related to readmission rates into this year s pay-for-performance rate methodology for inpatient providers. MBHP is available, through all of our departments, to provide consultation and technical assistance on these network management priorities. Please refer to the MBHP contact information at the end of this Alert. FY09 RATE INCREASE SPECIFICATIONS MBHP appreciates the commitment of network providers to provide quality services to its Members and the effort made to achieve these rate increases through the performance measures reviewed in this section. Inpatient Mental Health Services Effective August 1, 2008, inpatient and ICBAT providers who are participating in the MBHP Outcomes Management Initiative will be eligible to receive an increase to each facility s individually set rate for inpatient mental health services. Each facility s rate increase will be based on its performance on the measures delineated below, with percentage points assigned to each. In order to provide timely information as close as possible to the August 1 st effective date, the MBHP regional director will communicate the rate increase amount to inpatient and ICBAT providers by phone. MBHP regional network management staff will then meet with each inpatient and ICBAT provider as soon as possible thereafter to review this rate methodology, the provider s performance on the measures, and the provider s resulting rate increase. The inpatient and ICBAT rate increases will apply not only to acute mental health services but also to administratively necessary days. Pay-for-Performance Indicators As referenced above, the following measures will comprise each inpatient and ICBAT provider s rate increase. A percentage increase will be attached to each indicator based on the provider s performance. All indicators apply to both adult and child/adolescent units, unless otherwise specified. Utilization Management: Length of Stay (LOS) o LOS Difference This indicator measures the difference between the facility s risk adjusted Projected LOS and the Actual LOS over a 12-month period. Providers 4

5 achieve a level of rate increase dependent upon the amount of the difference between ALOS and PLOS. o LOS Improvement This indicator measures the improvement in the facility s risk adjusted Projected LOS and the Actual LOS over a 12-month period. Providers achieve a level of rate increase dependent upon the statistical significance of the improvement achieved from FY07 to FY08. Continuity of Care: Readmission o 7-Day Readmission Rate Difference This indicator measures the difference between the facility s risk adjusted projected 7-day readmission rate and actual 7-day readmission rate over a 12-month period. Providers achieve a level of rate increase dependent upon the amount of the difference between the actual and projected rates. Access: No Reject Policy/Uninsured Admissions o The adult inpatient provider must have met the minimum threshold, between April 15, 2007 and April 14, 2008, of adult uninsured admissions equal to 3 percent of the facility s total MBHP admissions in the previous fiscal year. This indicator does not apply to child and adolescent providers. One hundred percent of inpatient providers achieved this indicator in FY08. The provider agrees to a minimum threshold, between April 15, 2008 and April 14, 2009, of uninsured adult admissions equal to 3 percent of the facility s total MBHP admissions in the previous fiscal year. Providers will be given their thresholds in August, noting that a given provider s threshold typically does not vary significantly from year to year. Providers will continue to be expected to report uninsured admissions to the MBHP Access Line. Access/Continuity of Care: State Agency Transitions In addition to several factors already incorporated into the risk adjustment methodology in COGNOS, MBHP s utilization database, MBHP introduced the following indicator as part of FY08 s pay-for-performance methodology. This is an effort to recognize the efforts providers make to provide services to consumers of state agencies. MBHP recognizes that some of these admissions impact length of stay and otherwise require a significant commitment of services at these facilities. o Child and adolescent: Providers achieve a level of rate increase dependent upon the percent of the facility s MBHP child/adolescent admissions that were state agency-involved at the time of admission (DCF-involved youth based on X RID number, DYS-involved youth based on Y RID number, and DMHinvolved youth based on MassHealth eligibility categories.) o Adult: Providers achieve a level of rate increase dependent upon the percent of the facility s MBHP adult admissions placed on authorization status A4 Administratively Necessary Days - Awaiting DMH Hospital during the current admission. Access/Continuity of Care: Daily Bed Reporting 5

6 Although daily bed reporting has been part of MBHP policies and procedures for several years, it was introduced as a pay-for-performance indicator for the first time in FY08. Providers will receive the rate increase if they have demonstrated 90 percent compliance with reporting their daily bed availability from September 4, 2007 to April 14, Outpatient and Diversionary Mental Health and Substance Use Services, and Inpatient Substance Use Services Effective August 1, 2008, outpatient mental health and substance use service providers, diversionary mental health and substance use service providers, and inpatient substance use service providers (including EATS, ATS, and Level 4 Detox) who are participating in the MBHP Outcomes Management Initiative will be eligible to receive a rate increase. Compliance was determined by the submission of the Outcomes Compliance Update Form, by April 30, 2008, documenting the use of a standardized assessment instrument. Again this year, providers who offer medication management services and psychological testing will receive the rate increase without participating in the MBHP Outcomes Management Initiative in relation to those services only. A rate increase of 3 percent will be available to the following providers of outpatient and diversionary services: Mental health and substance use outpatient services providers, including facility and hospital-based clinics, hospital and non hospital-based group practices, and individual providers Mental health and substance use diversionary services providers Substance use inpatient services providers In addition to this standard rate increase of 3 percent, rates for some outpatient and diversionary services will be further augmented, as specified below. These additional rate increases aim to sustain particular diversionary services that are critical to supporting MBHP Members in the community as well as to respond to the concerns expressed by providers about the rates for these particular services. These increases are also effective on August 1, Child Partial Hospitalization Program For partial hospitalization for children up to age 12, there will be a floor rate established with the standard rate increase of 3 percent applied in addition. The resulting rate will be paid for PHP claims based on the age of the Member served. MBHP network management staff will communicate specific rates to child PHP providers. Adolescent Partial Hospitalization Program For partial hospitalization for adolescents age 13 18, there will be a floor rate established with the standard rate increase of 3 percent applied in addition. The resulting rate will be paid for PHP claims based on the age of the Member served. MBHP network management staff will communicate specific rates to adolescent PHP providers. Family consultation and case consultation (CPT codes and 90882) provided by the following licensure levels will be increased commensurate with diagnostic services provided by these licensure levels: MD, Child Psychiatrist, APRN, and Child APRN. Furthermore, the following services will receive the standard rate increase of 3 percent, in addition to rate increases provided to these levels of care in recent months: 6

7 Enhanced SOAP for Adolescents Adolescent SOAP providers were subject to a rate increase in April 2008, and they will also receive the standard rate increase of 3 percent as of August 1, CBAT Community Based Acute Treatment (CBAT) providers also received a rate increase in April 2008, and they will also receive a rate increase as described below, as of August 1, Of note, this is the first year in which CBAT providers were subject to the pay-for-performance methodology listed below: o Access: Daily Bed Reporting: CBAT providers were expected to demonstrate 90 percent compliance with reporting their daily bed availability, per existing MBHP policies and procedures, between September 4, 2007 and April 14, For CBAT providers who met this goal, the rate increase will be 4 percent. For those who did not, the rate increase will be 3 percent. Levels of Care Not Eligible for Rate Increase The following levels of care will not receive rate increases at this time, due to the specific funding mechanisms for these services. Emergency Service Programs (ESP) Coordinated Family Focused Care (CFFC) Additionally, Clinical Support Services (CSS) will not be eligible for a rate increase at this time as there are recently established rates in place for this newly contracted service. Compliance with the MBHP Outcomes Management Initiative Relative to Rates In FY09, MBHP will continue the following policy and procedure for reducing provider rates if MBHP determines providers are noncompliant with the Outcomes Management Initiative. Noncompliance is defined as: a. the provider is not routinely administering a standardized assessment instrument to Members with whom treatment has been initiated after July 1, 2004; and b. the provider is not incorporating outcome data into treatment planning for Members with whom treatment has been initiated after July 1, Consistent with current policy, these measures of compliance with the Outcomes Management Initiative will be verified through periodic medical record reviews. Verification of documentation of the use of outcomes is included in the health record review assessment. If it is determined that a provider is not in compliance with the outcomes policy, a corrective action plan will be issued. If compliance with outcomes is not resolved in accordance with the corrective action plan timelines, the provider will be lowered to the noncompliant rates, effective for future claims. Providers who are found to be noncompliant with outcomes will be returned to outcomes compliant status by MBHP on a quarterly basis. Additional information will be forthcoming from MBHP relative to the MBHP Outcomes Management Initiative and compliance monitoring. 7

8 FY10 RATE INCREASE SPECIFICATIONS During FY09, providers should be mindful of the following in anticipation of potential rate increases that may become effective in FY10. MBHP anticipates that potential provider rate increases for all levels of care would continue to be contingent upon participation in the MBHP Outcomes Management Initiative. Inpatient Mental Health Services and ICBAT: Pay-for-Performance Indicators for FY10 For FY10, MBHP anticipates that potential provider rate increases for inpatient and ICBAT levels of care will be contingent upon similar indicators of utilization management, continuity of care, and access. Specifically, these indicators will likely include, but not be limited, to the following: Utilization Management - Length of Stay Difference Utilization Management - Length of Stay Improvement Continuity of Care - Readmission Rate Difference Access/Continuity of Care - State Agency Transitions Access: No Reject Policy/Uninsured Admissions: Providers will admit a minimum threshold, between April 15, 2008 and April 14, 2009, of uninsured adult admissions equal to 3 percent of the facility s total MBHP admissions in the previous year and will report these admissions to the MBHP Access Line before the end date. The MBHP network management staff will communicate each facility s specific uninsured admission target to them. Access: Daily Bed Reporting: Providers will demonstrate 90 percent compliance with reporting their daily bed availability, per existing MBHP policies and procedures, between April 15, 2008 and April 14, Continuity of Care: Discharge Forms: Providers will demonstrate 90 percent compliance with providing discharge information (by phone or fax) to MBHP within one business day of discharge for all inpatient admissions between November 1, 2008 and April 14, Please note that the coming year is the first in which the last item measure is being introduced. MBHP will distribute specific policies and procedures to inpatient providers about the submission of discharge forms before the measurement period begins on October 1, Outpatient and Diversionary Levels of Care: Pay-for-Performance Indicators for FY10 For FY10, CBAT provider rate increases will continue to be based upon the following pay-forperformance indicator: Access: Daily Bed Reporting: CBAT provider will demonstrate 90 percent compliance with reporting their daily bed availability, per existing MBHP policies and procedures, between April 15, 2008 and April 14,

9 Substance abuse levels of care: Planning for potential rate increases for FY10 MBHP is mindful that providers of services to our Members with substance use disorders have asked us to consider developing a specific approach to rates for those levels of care. During FY09, MBHP will pursue the development of a pay-for-performance approach to be applied to rate increases for some substance use levels of care in FY10. Provider Action Required Contracting Beginning in September, those providers who receive a rate increase will receive, under separate cover, a revised Exhibit A Agreement and an outpatient fee schedule, if contracted for outpatient services. Providers will be required to sign and return the Exhibit A to MBHP. Please be reminded that, by accepting this rate increase and signing a revised Exhibit A Agreement, the provider agrees to the contingencies delineated throughout this Alert, including continued participation in the MBHP Outcomes Management Initiative and, for inpatient mental health providers, adherence to the No Reject Policy. Claims All claims submissions will continue to be subject to MBHP billing policies and procedures. Given that the rate increases described herein will be effective on August 1, 2008, before most providers receive this Alert, MBHP will automatically adjust any claims for dates of services on or after the effective date, if providers already submitted them at the previous rates. Questions If you have questions regarding this Alert, please contact our Community Relations department at (press 1 for the English menu, 2 for the Spanish menu, then #3 then #1 to skip prompts), Monday through Thursday, 8 a.m. to 5 p.m., and on Fridays from 9:30 a.m. to 5 p.m. You may also contact your MBHP regional director with questions or to request assistance relative to the network management priorities delineated at the beginning of this Alert. Region Director Telephone Metro Boston Jim Kaufman Northeast Moira Muir Southeast Joanne Waithaka Central Elizabeth O Brien Western Linda Trott

10 Finally, if you have questions regarding your compliance status with the MBHP Outcomes Management Initiative, please contact Tori Brower, outcomes project manager at or 10