IROC Treatment Provider FAQ

Transcription

1 FAQ Version Summary ew Questions Added Answers Revised * Answers Archived 5/17/ , 15, 22-29, 40-42, 4, 11 12, 14, , 59, /25/ thru 42 n/a n/a ew questions are identified with * Revised Answers are identified with * Quick avigation 1. Acronyms 2. BPA Health etwork Process 3. Prescriber Agreements 4. Funding 5. Medications 6. Screening / Eligibility 7. SUD or General Referral/Authorization/Service 8. MAT Services Referral/Authorization/Service 9. Documentation 10. Claim Submission 11. SUD Treatment Provider Auditing 12. Contact Information Page 1 of 14

2 A cronyms CARF Commission on Accreditation of Rehabilitation Facilities IROC Idaho Response to Opioid Crisis MAT Medication Assisted Treatment OTA Opioid Treatment Addendum BPA Health etwork Process Question 1: Where can I find the "Opioid Treatment Addendum" (OTA)? Answer: Please contact BPA Health Provider etwork Management. Question 2: What will be required of the SUD Treatment Provider regarding the claims withhold and related performance measures? Answer: The 5% withhold amount will be applied to the IROC funded clients. The current measure to have "encounters notes entered within 5 days" will apply to SUD Treatment claims. It will not be applied to bundled rate for the MAT Services. If the client is enrolled in MAT Services and is authorized MAT Bundled Services and MAT Management Fee, the "encounter notes entered within 5 days" will not be measured for encounters entered against these two authorized services. Prescriber Agreements Question 3: Are there requirements for providers to partner with a non-profit? Answer: o. There are no requirements to work with non-profit or for profit. There is a requirement for the Prescriber to be an approved Data Waiver 2000 Prescriber. *Question 4: Who is the contact person for prescribers about being on the list of available Data Waiver 2000 providers? Answer: Prescribers may contact Rachel Gillett with Idaho Department of Health and Welfare at Rachel.Gillett@dhw.idaho.gov or (208) Question 5: I am a SUD Treatment Provider interested in engaging and contracting with a prescriber in my area. Does BPA Health have a sample contract I could use to do this? Answer: Yes. Please contact BPA Health Provider etwork Management. Question 6: Can SUD Treatment Providers contract with more than one prescriber? Answer Yes. SUD Treatment Providers may enter into a contract or agreement with one or more Prescriber(s). Question 7: Can Prescribers contract with more than one SUD Treatment Provider? Answer: Yes. Prescribers may enter into a contract or agreement with one or more SUD Treatment Provider(s). Page 2 of 14

3 Question 8: Where is the process of getting an IROC prescriber on the list? Answer: A prescriber must be a DATA 2000 Waivered prescriber and have an arrangement with an IROC SUD treatment provider to be eligible to receive IROC funding. BPA Health does not keep a list of IROC prescribers; however, the Division of Behavioral Health is calling all DATA 2000 Waivered prescribers listed on SAMHSA's website to let them know of IROC and see if they would like to be notified contacted by an SUD treatment provider to enter into an agreement. BPA Health sends an updated list of those prescribers who have agreed to learn more approximately once a month, or as prescribers are identified. Question 9: Where is the MAT provider list located? Answer: The list of SUD treatment providers who are contracted to serve IROC funded clients and have arrangements with MAT prescribers can be found on BPA Health's website. Use the search criteria for MAT Coordination to search for these SUD Treatment Providers. The provider list is located on BPA Health's website. Question 10: Is there a way to see who has arrangements for MAT services with prescribers? Answer: The list of SUD treatment providers who are contracted to serve IROC funded clients and have arrangements with MAT prescribers can be found on BPA Health's website. Use the search criteria for MAT Coordination to search for these SUD Treatment Providers. Funding *Question 11: What is the length of the IROC grant? Answer: The IROC grant began Mary 1, 2017 and is currently funded thru April 30, Medications Question 12: What types of medications are available to clients through IROC funding? Answer: IROC funding will reimburse for Methadone, Suboxone or Buprenorphine medications. It will not reimburse for altrexone (brand name Vivitrol). Question 13: Does Medicaid reimburse for the prescription cost for the 3 medications under MAT Services for Medicaid covered clients? (Methadone, Suboxone, or Buprenorphine) Page 3 of 14

4 Answer Buprenorphine containing prescriptions (includes Suboxone film (buprenorphine/naloxone), generic buprenorphine/naloxone tablets, and generic buprenorphine tablets) must be from an authorized prescriber for treatment of documented opioid dependence or opioid abuse. Oral buprenorphine/naloxone combination products are preferred except in pregnant women to minimize the possibility of diversion of buprenorphine single entity via the injection route. Methadone can only be dispensed through on opioid treatment program certified by SAMSHA (Substance Abuse and Mental Health Services Administration). Refer to medicaidpharmacy.idaho.gov for more information on the Preferred Drug List (PDL). Question 14: Is altrexone an allowable medication? Answer: o. altrexone is not a medication that IDHW IROC funding will reimburse. Methadone, Suboxone or Buprenorphine are the approved medications under IROC Funding. Question 15: Are clients being told they have the option to choose between all of the FDA approved medications for opioid addiction? Answer: BPA Health does not tell patients what kinds of medications are approved under IROC MAT funding. It is up to the prescriber and the patient to determine the best course of treatment. That said, IROC funding will only pay for Buprenorphine, Suboxone and Methadone. Should the prescriber and patient determine another medication is best suited to the patient's needs, the patient will need to utilize a different funding source to cover the cost of that medication. Screening / Eligibility Question 17: Can a SUD Treatment Provider limit the number of clients under IROC funding and MAT Services? Answer Yes. SUD Treatment Providers may limit the number of clients for whom they coordinate MAT Services. Question 19: I know that the population for the PWWC and IVDU is higher in the hierarchy than IROC. Does that mean that those populations do not get IROC funding? Answer: Yes. If a client qualifies for another population (such as PWWC and IVDU) they will be placed in that population for their SUD Treatment. Through the course of treatment, if the client would benefit from the service of Medication Assisted Treatment, the provider can ask to have the client transferred to IROC (the population that would cover for that service). The client would still need to meet the eligibility criteria for IROC to be transferred by BPA Health. Page 4 of 14

5 Question 20: Who determines if a client qualifies for IROC funding? Answer: BPA Health completes the eligibility determination with individuals seeking SUD Treatment and funding. To be eligible for MAT Services an individual must be 18 years of age or older, not be on probation or parole, and have an opiate as their primary drug of choice. An authorization is created for "Alcohol and Drug Assessment" to a SUD Treatment Provider. Question 21: Who determines if a client qualifies for Medication Assisted Treatment (MAT) Services? Answer: The SUD Treatment provider and the client will assess if MAT Services are a treatment approach that would be beneficial for the client. The Prescriber would evaluate the client for MAT Services. Question 22: Does the MAT prescriber have to be approved by BPA Health? Is there a way to know if the doctor that is contacted, is approved by BPA Health? Answer: The prescriber (including physicians) do not have to be approved by BPA Health; however, they must be a DATA 2000 Waivered prescriber, or a licensed Methadone Clinic, who is willing to provide services utilizing the funding available and through the funding mechanism established. It is up to the SUD treatment provider to determine the qualified prescriber they would like to enter into an agreement with, and then ensure they that individual/organization continues to be able to prescribe MAT under the DATA 2000 Waivered policies or Methadone Clinic policies. Question 23: In the beginning of IROC there were some criminal justice components that made some people ineligible. Is the criminal justice criteria no longer reviewed? Answer: Certain individuals involved with the criminal justice system are ineligible for IROC. Should we have additional funding availability in the future, thiscriteria may be revisited. Always encourage clients to call BPA Health to verify eligibility for IROC. Question 24: Can someone that is already in MAT services apply, and qualify, to get IROC funding? Answer: Yes, anyone who has an opiate use disorder can contact BPA Health and determine if they are eligible for IROC funding. Should the individual be found eligible for IROC, they can choose to engage in SUD treatment only or to receive assistance for payment of their MAT in addition to SUD treatment. Should an individual already be receiving MAT, the prescriber and SUD treatment provider may not bill for a second MAT evaluation as that would have been completed prior to IROC funding. Question 25: If a patient arrives at 5am to do an intake, however, BPA Health doesn t open until 8am, would you recommend having the patient leave and return later to make the phone call? Page 5 of 14

6 Answer: If a prescriber's hours are different from BPA Health's hours, the prescriber's office may instruct the client to contact BPA Health prior to the intake appointment. The prescriber's office can then work with BPA Health and the SUD treatment provider they have arrangements with to determine the authorization was entered into WITS. Alternatively, the prescriber's office could choose to schedule the individual for later in the day when BPA Health is open so they know if the services are authorized at the time of the call. There is no guarantee that a client will qualify for funding prior to screening. Prescriber assumes the risk if they provide services prior to qualification. Question 26: If the doctor is not able to make the call for authorization, can someone in his office do it? Answer: The call does not have to be made in the presence of the prescriber, anyone in the prescriber's office, with authority to receive information on an authorization and who knows the names of the SUD treatment providers the prescriber has arrangements with, can someone in his office do it? Question 27: Some patients are under the assumption that they will automatically qualify for MAT, but sometimes they don t and there is a wait. Can that be relayed to clients? Answer: Yes, BPA Health will notify callers at the time of screening that, while the service has been authorized, the chosen prescriber may not be able to get them in for the initial appointment right away. Question 28: If a patient is referred to BPA Health to screen for IROC funding and are approved for this new process, will the prescribing agency be given something in writing indicating start date? Some agencies not affiliated with WITS may not be aware of the TEDS OMS date. Answer: The prescriber s office will receive verbal confirmation (with client approval) of the authorization from BPA Health at the end of the screening/eligibility call. The prescriber will need to contact the SUD treatment provider to ask for a physical copy of the authorization for their records. Additionally, prescriber s offices will not be required to collect TEDS/OMS data this will be the responsibility of BPA Health or the SUD treatment provider depending on where the individual is located at the time of the screening call. Question 29: If the client attends the program and then drops out of services for over 30 days and then returns; are they still eligible for services? Answer: Yes, an individual can qualify for IROC funding more than once. They will need to contact BPA Health and complete the eligibility screening. Page 6 of 14

7 SUD or General Referral / Authorization / Service Question 30: Can a client go to one SUD Treatment Provider for treatment and another SUD Treatment Provider for MAT Services management/coordination? Answer: o. A client must go to the same SUD Treatment Provider for treatment and coordination of MAT Services. Question 31: Can an existing client transfer into IROC funding from another IDHW funding source? Answer: Yes. If it is appropriate for a client to transfer into IROC population/funding because exploring MAT Services would benefit the client, the SUD Treatment Provider may request the client be transferred. As with other population/funding transfers, the provider must explicitly ask in their request to move the client to another population/funding source and identify which one (when possible). An updated ASAM or other clinical information may be requested to support the request. Question 32: Do clients covered under IROC funding have access to Residential services? Answer: o. IROC funded clients are not covered for Halfway House, Residential, or Medically Monitored Residential. IROC funded clients do have access to Adult Social Detox. Question 33: Since Residential is not a covered service under IROC funding, can the client be transferred to another funding source to receive Residential Treatment? Answer: Similar to the processes in place today, if the client is in a funding source that does not cover for Residential, the client case may be reviewed for transfer to another funding source (if client meets eligibility for another population). Important to understand is the client will lose the funding for MAT Services when a transfer from IROC funding occurs. Question 34: Is Case Management separate from the monthly $50 management fee? Answer: Yes. Case Management is a separate authorization. SUD Treatment Providers should ensure that they have an authorization that meets the case needs and is within the authorization maximums. Question 35: Is Outpatient or Intensive Outpatient also limited to 6 months of treatment? Answer: o. Other SUD Treatment is not limited to 6 months. Current processes for clinical review will be used for SUD Treatment and RSS. Question 36: If clients are not participating in their SUD Treatment (Outpatient or Intensive Outpatient) can they continue to receive MAT Services? Page 7 of 14

8 Answer: o. Clients must be actively participating and engaged in SUD Treatment in order receive MAT Services. The SUD Treatment Provider would follow discharge processes if the client has not engaged in at least the last 30 days. The SUD Treatment Provider must inform the Prescriber the client is not participating in treatment and will be discharged. BPA Health will not monitor or fund services after discharge. Question 37: Is there any limitation on how much Case Management is allowed per month for clients with IROC funding? Answer: Yes. The existing frequency of Case Management services apply to the IROC funded clients. The existing allowable frequency is up to 4 hours of Case Management per week. Question 38: Is there any limitation on how much Recovery Coaching is allowed per month for clients with IROC funding? Answer: Yes. The existing frequency of Recovery Coaching apply to the IROC funded clients. The existing allowable frequency is up to 192 units (48 hours) of Recovery Coaching for 6 months. Question 39: How will Treatment, RSS, and MAT Services be authorized? Will they be separate authorizations? Answer: The MAT Services will always be a separate authorization from RSS and SUD Treatment. There will be two services on one authorization: MAT Bundled Services (the services performed by the prescriber, visits and medication) and MAT Management fee (the services performed by the SUD Treatment Provider to coordinate the MAT service). SUD Treatment and RSS may be on the same authorization depending on who is providing the service and if the services were requested at the same time or a different time. These will be authorized together or independently as they are today under all funding. Question 40: If the client doesn t show up for the GAI, or the GAI assessment indicates treatment isn t warranted and/or a client declines outpatient, who discusses with them how to taper off medications if they don t have funds for private pay? Answer: It is up to the SUD treatment provider and the prescriber to determine how best to handle this situation. Question 41: How will BPA Health know who to refer clients to? Answer: The provider chosen is the client choice so BPA Health will give options based on client need and the IROC contracted providers in the area. Question 42: Can treatment facilities consult with PCP s to encourage a successful referral for treatment? Page 8 of 14

9 Answer: Yes, consulting between agencies will increase the likelihood of successful engagement in both MAT and traditional SUD treatment services. MAT Services Referral / Authorization / Service Question 43: What is the maximum amount of MAT Services a client may have? What are the readmission rules? Answer: A client may only have 180 days ( 6 months) of MAT Services in the project year. If a client admits to MAT Services for 30 days ( 1 month) and leaves MAT Services, they can return in the same project year and receive the remaining 150 days ( 5 months). If a client admits to MAT Services and utilizes 180 days ( 6 months), they cannot access MAT Services in the same project year. Question 44: Why is the initial authorization for MAT Services only 14 days long? What if I need more time? Answer: It is preferred that the client receives the "MAT Evaluation" with a prescriber within 14 days of being referred by the SUD Treatment Provider for the evaluation. We understand that not all evaluations can happen in 14 days. Simply call BPA Health to inform them of the scheduled date of the prescriber appointment and to get an extension of the authorization. The initial authorization cannot exceed 30-days from start date. Question 45: Are MAT Services available under other funding sources/populations? Answer: o. MAT Services are only available for clients who are funded under IROC funding. Question 46: What if the client needs continued MAT Services after the conclusion of the 6 months of state funding? Answer: The client, SUD Treatment Provider, and Prescriber may discuss the best course of action for continued MAT Services. For example, the client may stay in SUD Treatment Services and arrange to self-pay the Prescriber for the MAT Services. Question 47: If client doesn t come to the SUD provider, how does the MAT provider get paid for services rendered? Answer: When a client calls from the prescriber s office, BPA Health will collect the required TEDS information for the Admission record data and send it to the provider. Should the client not present for the GAI, the SUD treatment provider will use those data points to populate the admission record and then continue with billing for the authorized MAT services. When a client calls from the prescriber s office, BPA Health will collect the required TEDS information for the Admission record data and send it to the provider. Should the client not present for the GAI, the SUD treatment provider will use those data points to populate the admission record and then continue with billing for the authorized MAT services. Page 9 of 14

10 Question 48: Once a client has been approved for the MAT bundle, how do the medications get paid for? Answer: The authorization bundle includes the MAT medication. It is up to the SUD treatment provider to determine how they will disperse funding to cover costs for prescriber visits and prescription costs. Question 49: How long should a provider wait if a client it not getting to appointments? Answer: SUD treatment providers and prescribers will want to work closely together to ensure the individual makes it to the GAI appointment. It is not suggested there should be any wait time to begin making contact with a client should they miss their GAI appointment. Question 50: When can I bill for the MAT management fee? Answer: The MAT management fee is billable from the time the SUD treatment provider begins client specific coordination with the prescriber. Question 51: Will the SUD provider have the $50 coordination fee from the beginning of the MAT authorizations? Answer: Yes, the MAT management fee is billable from the time the SUD treatment provider begins client specific coordination with the prescriber. Question 52: The MAT authorization closes sometimes due to no activity for 30 days depending on how the client utilizes it. How can providers prevent the authorization from closing due to inactivity? Answer: Unfortunately, closure of an authorization after 30 days of no activity is WITS functionality that cannot be turned off. One suggestion (that may or may not work for your agency), is to bill the MAT Management Fee every 30 calendar days. That will allow for the billing from the prescribers to be a little more sporadic, but since there is activity on the authorization, the authorization can remain open in WITS. Question 53: There are a lot of times when the pharmacy doesn t have the medication on hand, so several trips to the pharmacy are needed. How can this be prevented? Answer: SUD treatment providers should work closely with the pharmacy to set up billing practices and ensure the pharmacies medication supplies will meet the demand for their clients. Question 54: How will the MAT prescriber get an authorization if they don t have a SUD relationship? Answer: All MAT bundled services are authorized to the SUD treatment provider and, therefore, it is up to the SUD treatment provider to determine who they have arrangements with for MAT. Question 55: Is the monthly MAT management fee a rolling month from date of authorization start date? Page 10 of 14

11 Answer: The MAT management fee and MAT bundled services will start as is a 30- day authorization. Thus if the An authorization started on January 22nd it would end 30 days later on February 21st. and a new authorization will be started on the 31st day. The next 30-day authorization would start on February 22nd. Question 56: If the client doesn t show up for the GAI, how can the prescription get paid for? Answer: The MAT bundled services (which includes prescriptions) is payable through the first 30 days before an individual receives the GAI. Should they not present for the GAI in the first 30 days, the SUD treatment provider can bill for the authorized services and medications paid for in that first 30 days. The SUD treatment provider will need to enter an Admission record into WITS and complete the Admission record using as much known information as possible and not leaving any yellow fields blank. Question 57: If a client struggles to get an appointment with the prescriber, how long should the SUD provider wait? Answer: SUD treatment providers and prescribers will want to work closely together to ensure the individual makes it to the GAI appointment. It is not suggested there should be any wait time to begin making contact with a client should they miss their GAI appointment. Documentation in WITS Question 58: Will the SUD Treatment Provider be required to document the treatment and progress, including the MAT Services, in the ASAM for reviews? Answer: Yes. The client's progress and engagement in the MAT Services is important to clinical reviews. Please include it in ASAM Reviews. Question 59: How does a provider document the purchase of medication? Answer: In the encounter note document the medication purchased and maintain the receipt/invoice for your records as a backup. Claim Submission Question 60: May I bill for the management fee if the client is found not eligible for MAT Services? Answer: Yes. A SUD Treatment Provider may enter an encounter and bill for the $50 MAT Management Fee for the first 30 days even if the client is found to not be eligible for continued MAT Services after prescriber determination. Question 61: I am a SUD Treatment Provider and I have contracts or agreements with a Prescriber for the office visits with Prescriber, and a contract or agreement with a Pharmacy for the medication. How much is the reimbursement for me as the coordinator of the service, the prescriber, and the medications? Page 11 of 14

12 Answer: The MAT Services is a bundled rate established to pay the Prescriber for all MAT Services and include the necessary visits at their clinic and the medications. Because this is a bundled amount, the SUD Treatment Provider and the Prescriber are encouraged to outline the costs and reimbursement expectations in their contract or agreement. Question 62: Is there a screening process to determine if the client has ability to pay 50% of the MAT Services cost in the final 3 months? Answer: o. There is not a formal screening process established to determine the clients ability to pay. There is a 50% copay in the final 3 months to be paid directly to the Prescriber for the MAT Services. SUD Treatment Providers and the Prescriber are both encouraged to work with clients in the first 3 months of the MAT Services to prepare the client for their 50% cost-share in the final 3 months. OTE: The 50% client cost-share applies to the MAT Services; it does not apply to other SUD Treatment services. Question 63: I am a SUD Treatment Provider who is coordinating MAT Services for a client. How do I bill BPA Health for the MAT Services? Answer: The SUD Treatment Provider may use their current business processes to bill BPA Health for the MAT Services. There are few general rules to consider: All claims must be entered and billed in WITS by the SUD Treatment Provider The SUD Treatment Provider may submit the claim for the $50.00 Management Fee one time in a 30-day period. The SUD Treatment Provider may submit a claim for one MAT Services Evaluation up to $ in the first 30-day period. The SUD Treatment Provider should require and receive invoices from the Prescriber(s) for their services and submit the claim in WITS for the appropriate bundled rate for each 30-day period. It is recommended that the SUD Treatment Provider submit the claim(s) in WITS at least every 30 days (to prevent authorization closure by the WITS system) The SUD Treatment Provider will need to manage the 30-day period cost and could be responsible for costs over the 30-day allowable. Question 64: For MAT Bundled Services, what does the rate cover? Answer: The bundled rate per 30 days includes reimbursement for all of the Prescribers services. The following definitions apply to services delivered by the prescriber under MAT Services: 1. Initial MAT Evaluation. Office visit to evaluation if the client is a candidate for MAT Services. Includes patient history, medical exam, establish as a new patient with prescriber, etc. Page 12 of 14

13 2. Monthly Bundle for MAT Services. Medication checks, medication, drug tests, on call services in emergencies, interface with the SUD Treatment Provider, and case management to ensure client compliance. Question 65: Are SUD Treatment Services separate from MAT Services? Answer: Yes. SUD Treatment services and the related costs are separate from MAT Services and paid under the appropriate bundled rate. Question 66: Can the MAT management fee and MAT bundled service fee be billed in the same month? Answer: The MAT bundled services and MAT management fee can be billed at the same time. The MAT management fee is billable from the time the SUD treatment provider begins working client specific coordination with the prescriber on the authorization and payment of MAT services through the MAT bundled authorization. Question 67: How long do providers have to bill MAT services? The prescriber doesn t always bill in a timely manner. Answer: The SUD treatment provider center should submit billing as quickly as they can after they receive the invoice from the prescriber. The SUD treatment provider may have to contact BPA Health to request the authorization be re-opened to allow them to for billing. It is understood billing may take a little longer than the typical 30 day window and BPA Health will work with providers to re-open the authorization. SUD Treatment Provider Auditing Question 68: If a SUD Treatment Provider is CARF certified, will an annual audit now be required based on the addition of the MAT Services? Answer: o. Established BPA Health audit schedules and requirements will not change as a result of a SUD Treatment Provider participating in IROC funding. Should IDHW request any information regarding services or payment with a CARF certified provider organizations, the Regional Coordinator will work with the organization directly on the requested information. Question 69: I am a SUD Treatment Provider who is audited by BPA Health. What documentation do I need to be prepared to have about prescribers visits and medication for clients receiving MAT Services? Answer: BPA Health will include IROC specific clients in the annual audit processes. Audit items will include documentation to support the MAT Services claims for Prescriber services. It will also include documentation supporting Evidence Based Programs included in treatment (Matrix Model, Cognitive Behavioral Therapy (CBT)). Page 13 of 14

14 Question 70: What is the SUD Treatment Provider required to have in their records to ensure back-up document is available for the claims submitted in WITS? Answer: The invoice(s) from the Prescribers that report the dates of service for the MAT Services evaluation; and the invoice(s) for the bundled services that report medication type and the 30-day time period covered by the bundled rate. Contact Information Idaho Department of Health and Welfare Program Specialist Denise Jensen , State Opioid Treatment Authority (SOTA) Rachel Gillett , WITS WITS Help Desk , Toll-Free: , BPA Health Call Center , Toll Free: Provider Services , Toll Free: Regional Coordinators o Region 1 ancy Irvin , ancy.irvin@bpahealth.com o Region 2 Dean Allen , Dean.Allen@bpahealth.com o Region 3 & 4 LaDessa Foster , LaDessa.Foster@bpahealth.com o Region 5 & 6 Lisa Bell , Lisa.Bell@bpahealth.com o Region 7 Doug Hulett , Doug.Hulett@bpahealth.com Page 14 of 14