MBHP FISCAL YEAR 2011 MID-YEAR PROVIDER RATE INCREASES AND INCENTIVES

ALERT # 98 February 10, 2011 MBHP FISCAL YEAR 2011 MID-YEAR PROVIDER RATE INCREASES AND INCENTIVES 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 various provider reimbursement rate increases and incentives which will be effective for the period of February 1, 2011 through June 30, 2011. At this time, MBHP is not able to commit to the continuation of these provider reimbursement rate increases and incentives beyond the end of Fiscal Year 2011. With the implementation of these provider rate increases and incentives, MBHP continues its long-standing practice of using innovative payment strategies to ensure access to the highest quality of behavioral health services for Members of the MassHealth PCC Plan, while seeking to provide fair and equitable reimbursement rates to its network providers. The following table provides a summary of the provider reimbursement rates increases and incentives that became effective on February 1, 2011. SUMMARY OF FY 2011 MID-YEAR RATE INCREASES AND INCENTIVES Service Category Incentive/Nature of Increase Inpatient Mental Health and ICBAT Rate increase: Pay for Performance (P4P) Program Inpatient MH, ICBAT, Level IV ATS Incentive: Rapid Admission of MBHP Members Outpatient (MH OP providers) Rate increase: Medication Management provided by adult credentialed psychiatrists who bill with adult psychiatry modifier U6 and credentialed psychiatric nurse mental health clinical specialists (PNMHCS) Outpatient (Mental Health and Incentive: Timely Outpatient Services post discharge substance use providers) from Inpatient MH and ICBAT Outpatient (CSPs operated by Mental Incentive: Community Support Program (CSP) visits at Health and substance use Outpatient Inpatient MH, ATS, E-ATS, and Level IV ATS providers providers) prior to discharge ATS, E-ATS, and Level IV ATS Incentive: ATS, E-ATS, and Level IV ATS provider arranges CSP visits at their program prior to discharge Emergency Services Programs (ESP) Rate Increase: Adult community-based ESP Encounters (non-ed mobile & ESP community-based location for MBHP Insured Members only) 1

As in past years, MBHP is tying rate increases to provider compliance with certain measures of performance in the areas of access, quality and continuity of care, and utilization management. This year, we are particularly placing emphasis in the rate increase and incentive methodology on the following: Access - Ensuring timely access to all covered services for our Members 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. Continuity of Care - Providers at all levels of care share the responsibility for ensuring cooperation and accountability in order to enable Members to transition among behavioral health and physical health services while receiving consistent, comprehensive, and uninterrupted quality care. This is particularly important during transitions from mental health and substance use 24-hour levels of care to outpatient services. Additionally, as in past years and 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. 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. FY 2011 MID YEAR RATE INCREASE SPECIFICATIONS The following details the FY 2011 mid-year increases that MBHP is making to rates paid for selected levels of care. Outpatient and Diversionary Mental Health and Substance Use Services Effective February 1, 2011, providers of the following outpatient and diversionary mental health and substance use services who are participating in the MBHP Outcomes Management Initiative will be eligible to receive rate increases as specified below. Rate increases are being applied to these selected service types in an effort to sustain specific services that are critical to supporting MBHP Members in the community, as well as to respond to the concerns expressed by providers about the viability of rates for these particular services. Service: Outpatient medication management o Eligible service types: 90801, 90805, 90807, 90882, 99404, 99404 with Modifier EP, 90862, and 90862 with Modifier TG, 90857, 96372 o Eligible providers and related claim modifiers: Credentialed adult MD/DO Claim modifier U6 Credentialed adult PNMHCS Claim modifier SA Credentialed child/adolescent PNMHCS Claim modifier UF o Rate increase amount: 12 percent Service: Adult ESP community-based encounters o Eligible service types: S9485 HE SE Adult ESP community-based ages 21+ S9485 U1 SE Adult ESP mobile non-ed ages 21+ o Rate increase amount: 5 percent o Please note: This rate increase applies to services provided to MBHP Members only. Providers will continue to bill the above codes for these services for MBHP Members. However, because this rate increase does not apply to uninsured individuals for whom these codes (S9485 HE SE 2

and S9485 U1 SE) have also been billed in the past, the following NEW CODES will replace them: NEW CODE: S9485 HW SE (Adult ESP community-based ages 21+ Uninsured Person) will replace S9485 HE SE; and NEW CODE: S9485 HK SE (Adult ESP mobile non-ed ages 21+ Uninsured Person) will replace S9485 U1 SE. Claims for Uninsured Persons for dates of service on and after February 1, 2011 with either S9485 HE SE or S9485 U1 SE will be denied. Inpatient Mental Health Services Effective February 1, 2011, 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 or ICBAT services. Each facility s performance on measures delineated below have determined if the facility is to receive a standard inpatient rate increase of 2 percent or if it has achieved a level of performance that will result in a 3 percent rate increase. Approximately one-third of the inpatient facilities in the MBHP provider network achieved a level of performance that earned a 3 percent increase to their rates. MBHP regional directors will communicate specific rate increase amounts to inpatient and ICBAT providers soon after this Alert is disseminated. They will then schedule meetings with each inpatient and ICBAT provider as soon as possible to engage in a more detailed review of the rate methodology, the provider s performance on each measure, and the provider s resulting rate increase. Pay-for-Performance Measures The following measures comprise the formula used to determine the FY 2011 mid-year rate increase for each Inpatient and ICBAT provider. Points were awarded based on the provider s performance in each of these measures. All seven measures were used in the formula for adult inpatient units, and six of the seven measures were used in the formula for child/adolescent inpatient units and ICBAT programs. The points accumulated for each applicable measure were totaled, earning the provider a rate increase of 2 percent or 3 percent. Utilization Management: Length of Stay (LOS) o LOS Difference This indicator measures the difference between the facility s risk adjusted Predicted Length of Stay (PLOS) and its Actual Length of Stay (ALOS) over a 12-month period. Points were awarded based on the difference between the facility s PLOS and ALOS. The measurement period was a 12-month period ending November 28, 2010. o LOS Improvement This indicator measures the improvement in the facility s risk adjusted ALOS over the prior measurement period. Points were awarded based on the net change in the facility s ALOS. The measurement period was a 12-month period ending November 28, 2010, as compared to the prior year. Continuity of Care: 7-Day Readmission Rate Difference o This indicator measures the difference between the facility s risk adjusted predicted 7-day readmission rate and actual 7-day readmission rate over a 12-month period. Points were awarded based on the difference between the facility s actual and predicted 7-day readmission rates. The measurement period was a 12-month period ending November 28, 2010. Access: No Reject Policy/Uninsured Admissions o Points were awarded if the adult inpatient facility met its minimum threshold of adult uninsured admissions from April 15, 2009 to April 14, 2010. The minimum threshold was equal to 3 percent of the facility s total MBHP adult admissions in the previous fiscal year. This indicator 3

applies only to adult inpatient mental health rates, and it does not apply to child and adolescent inpatient mental health or ICBAT rates. Access/Continuity of Care: State Agency Involved Members o Inpatient child/adolescent and ICBAT facilities: Points were awarded based on the percentage of MBHP Members admitted to the facility during FY 2010 who were state agency-involved (i.e., DCF, DYS, and/or DMH) at the time of their admission. o Inpatient adult inpatient facilities: Points were awarded based on the percentage of MBHP Members admitted to a facility during FY 2010 who were placed on authorization status A4 Administratively Necessary Days - Awaiting DMH Hospital during the current admission. Access/Continuity of Care: Massachusetts Behavioral Health Access (MABHA) Reporting o Points were awarded based on the facility s performance in updating the bed availability website during FY 2010. Continuity of Care: Discharge Forms o Points were awarded based on the facility s performance in providing MBHP with discharge information (by phone or fax) within one business day of discharge for all inpatient and ICBAT admissions in FY 2010. Other Inpatient Mental Health Rate Increases The following A code services shall be paid at each facility s individualized inpatient rate as of February 1, 2011: A1, A5, and A6 The following A code services shall be paid at the current standard rates for all inpatient providers plus a 2 percent increase as of February 1, 2011: A2, A4, and AN Compliance with the MBHP Outcomes Management Initiative Relative to Rates As noted above, only those providers who are participating in the MBHP Outcomes Management Initiative will be eligible for rate increases. In FY 2011, MBHP will continue the 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, 2004. FY 2011 MID-YEAR PROVIDER INCENTIVE SPECIFICATIONS Effective February 1, 2011 and continuing through June 30, 2011, providers of the following services will be eligible to receive incentive payments as specified below. Incentives will be paid in units. The number of units to be paid for each incentive is indicated below. Outpatient and Diversionary Mental Health and Substance Use Services Incentive description: MBHP will make incentive payments to mental health and substance use outpatient providers for timely outpatient services following a discharge from an inpatient mental health or ICBAT facility. o Eligible discharges: discharges of MBHP Members of all ages from inpatient mental health and ICBAT facilities o Eligible providers to receive the incentive payment: outpatient mental health and substance use providers 4

o Eligible outpatient services for which units of incentive payment will be paid: A therapy visit within 7 days of discharge (i.e., day of discharge plus 6 days) from an inpatient mental health or ICBAT facility 3 units of incentive payment Eligible service types: diagnostic evaluation - 90801 individual therapy - 90804, 90804 with modifier TH, 90806, 90806 with modifier TH family therapy - 90847, 90847 with modifier TH group therapy - 90853, 90853 with modifier TH A medication visit within 14 days of discharge (i.e., day of discharge plus 13 days) from an inpatient mental health or ICBAT facility 3 units of incentive payment Eligible service types: diagnostic evaluation - 90801 medication management - 90805, 90807, 90857, 96372, 99404, 99404 with modifier EP, 90862, 90862 with modifier TG A second therapy visit within 30 days of discharge (i.e., day of discharge plus 29 days) from an inpatient mental health or ICBAT facility 3 units of incentive payment Eligible service types: diagnostic evaluation -90801 individual therapy - 90804, 90804 with modifier TH, 90806, 90806 with modifier TH family therapy - 90847, 90847 with modifier TH group therapy - 90853, 90853 with modifier TH If all three of the above listed outpatient services are provided within the applicable timelines to a Member who has been discharged from an inpatient mental health or ICBAT facility, additional units of incentive payment will be paid to the outpatient provider(s) who delivered one or more of the three services. One unit of incentive payment will be paid to the provider who delivered each of the three listed outpatient services, whether there are one, two, or three providers involved in that service delivery. Incentive description: MBHP will make incentive payments to Community Service Programs (CSPs), operated by both mental health and substance use providers, to conduct visits on site at inpatient mental health, ATS, E-ATS, and Level IV ATS programs prior to a Member s discharge from one of those levels of care. o Eligible discharges: discharges of MBHP Members of all ages from inpatient mental health, ATS, E-ATS, and Level IV ATS facilities o Eligible providers to receive the incentive payment: Community Service Programs (CSPs) operated by both mental health and substance use providers o Eligible CSP services for which one unit of incentive payment will be paid: Face-to-face CSP services conducted on site at an inpatient mental health, ATS, E-ATS, or Level IV ATS program with a Member on or before the day of discharge from one of these levels of care. If more than one CSP visit is conducted with a given Member on-site before discharge, only the first CSP billed service will be eligible for an incentive payment. CPT Code: H2015 Incentive Description: MBHP will make incentive payments to ATS, E-ATS, and Level IV ATS providers who arrange CSP visits on site at the ATS, E-ATS, or Level IV ATS prior to a Member s discharge. o Eligible discharges: discharges of MBHP Members of all ages from ATS, E-ATS, and Level IV ATS programs 5

o Eligible providers to receive the incentive payment: ATS, E-ATS (both adult and adolescent E-ATS), and Level IV ATS providers o Eligible diversionary services for which one unit of incentive payment will be paid: ATS, E- ATS, or Level IV ATS program arranges for a CSP to visit Member on site prior to his/her discharge from ATS, E-ATS, or Level IV ATS program, and the face-to-face, on-site CSP service is conducted with the Member on or before the day of discharge. CPT Code: T2025 Claims Submission All incentives will be paid based on claims that reflect services provided to MBHP Members. Incentives will not be paid for arranged or scheduled appointments that do not result in actual provision of the specified service. MBHP will provide reports to providers on a monthly basis containing Member information and dates of service that meet the criteria for each of the incentive programs described above. Providers shall use these lists to then submit claims for the incentive programs. The reports will have all the necessary information for the provider to bill, including a new code, T2025 (no modifier) being used for these incentive claims. For the incentive payments to be paid to Community Service Programs (CSPs) as described above, CSP providers will be expected to review the dates of service contained in the MBHP report and submit an incentive claim only for those that reflect a face to face visit. Inpatient Mental Health and Substance Use Services MBHP is initiating an Inpatient Rapid Admission Incentive in an effort to improve Member access to inpatient mental health, ICBAT, and Level IV ATS levels of care, support ESPs in their efforts to secure admission for Members to these levels of care, incentivize inpatient providers to improve compliance with the no reject policy and streamline their admission processes, and decrease Member wait times in hospital emergency departments and elsewhere. Incentive Description: MBHP will make incentive payments to inpatient mental health, ICBAT, and Level IV ATS providers for rapid acceptance of Members for admission without delay. o Eligible admissions: MBHP Members of all ages referred by ESPs, provided that the Member is accepted by the inpatient mental health, ICBAT, and Level IV ATS program within established time parameters. o Additional criteria: This incentive will apply to every MBHP inpatient admission that meets the above criteria whenever the Rapid Admission Incentive is active statewide. This incentive will not be paid when the incentive is deactivated due to Members awaiting admission for an extended period of time. o Providers eligible to receive the incentive payment: inpatient mental health, ICBAT, and Level IV ATS providers o Eligible inpatient services for which one unit of incentive payment will be paid: inpatient mental health services, ICBAT, and Level IV ATS when accepting Members for admission within established time parameters, provided that the Rapid Admission Incentive is active statewide T2025 with a CG modifier More detailed policies and procedures for operationalizing this incentive will be provided to inpatient mental health, ICBAT, and Level IV ATS providers, as well as ESPs, via separate correspondence. Additionally, MBHP regional network management staff will review these protocols with involved providers in various 6

regularly scheduled meetings. Preparations for the implementation of this incentive began on February 1, 2011, with partial implementation of the Rapid Admission Incentive planned on February 22, 2011 and full implementation planned on March 22, 2011. Claims Submission The Rapid Admission Incentive will be paid based on claims that reflect services provided to MBHP Members. Incentives will not be paid for accepted admissions that do not result in an actual admission and the provision of inpatient, ICBAT or Level IV ATS services. MBHP will provide reports to providers on a monthly basis containing Member information and dates of service that meet the criteria for the Inpatient Rapid Admission Incentive. Providers shall use this data for the submission of claims under this incentive. Providers shall then use these lists to then to submit claims using a new code, T2025 with a CG modifier. Alternatively, providers can access eligible claims before the reports come out using ProviderConnect. An authorization will be built for eligible claims and those can be viewed in ProviderConnect. Authorized claims can be billed before the reports are sent using information obtained from ProviderConnect. For more information on finding these authorizations in ProviderConnect, please contact MBHP Community Relations at 1-800-495-0086. FY 2012 RATE ADJUSTMENT SPECIFICATIONS MBHP anticipates that any potential provider rate adjustments for all levels of care in FY 2012 and beyond will continue to be contingent upon participation in the MBHP Outcomes Management Initiative. In addition, we expect potential rate adjustments for any and all levels of care to be contingent upon providers performance under various measures. One such measure that will likely apply to provider rate increases at multiple levels of care going forward is reporting their access and availability on the MABHA website. Inpatient Mental Health Services and ICBAT: Pay-for-Performance Indicators FY 2012 For FY 2012, MBHP anticipates that potential provider rate adjustments for inpatient and ICBAT levels of care will be based upon a facility s performance on the following measures, using a revised risk adjustment methodology: Utilization Management - Length of Stay Difference Utilization Management - Length of Stay Improvement Continuity of Care - Readmission Rate Difference Access/Continuity of Care - State Agency Involved-Members Access: No Reject Policy/Uninsured Admissions: Between April 15, 2010 and April 14, 2011, providers will admit a minimum threshold of uninsured adult admissions equal to 2 percent of the facility s total MBHP admissions in the previous fiscal year and will report these admissions to the MBHP Clinical Access Line by April 14, 2011. Access: MAHBA Reporting: Providers will demonstrate compliance with reporting their daily bed availability, per existing MBHP policies and procedures, during FY 2011. The current expectation for 24-hour levels of care is that providers will enter bed availability a minimum of three times per day (i.e., once per shift), seven days per week. Additionally, providers are encouraged to update the website whenever their bed availability changes due to an admission or discharge. Continuity of Care - Discharge Forms: Providers will demonstrate compliance with providing discharge information (by phone or fax) to MBHP within one business day of discharge for all inpatient and ICBAT admissions during FY 2011. 7

PROVIDER ACTION REQUIRED Contracting Beginning in February 2011, those providers who are contracted by MBHP for services that are subject to 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 Agreement to MBHP. Please be reminded that, by accepting these rate increases 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 February 1, 2011, before providers receive this Alert, MBHP will automatically adjust any claims for dates of services on or after the effective date, for services billed at previous rates. Questions If you have questions regarding this Alert, please contact our Community Relations department at 1-800-495-0086 (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 or regional network manager with questions regarding the matters delineated in this Alert. Region Director Telephone Metro Boston Jim Kaufman (617) 350-1940 Northeast Moira Muir (617) 350-1913 Southeast Joanne Waithaka (617) 350-1912 Central Elizabeth O Brien (508) 890-6406 Western Linda Trott (413) 322-1802 8