ALERT # 149 September 9, 2014 MBHP FISCAL YEAR 2015 PROVIDER RATE INCREASES AND INCENTIVES The following information should be noted immediately by your chief executive officer, chief medical officer, chief operating officer, chief financial officer, program director, quality management director, compliance officer, billing director, and staff. The Massachusetts Behavioral Health Partnership (MBHP) is pleased to announce provider rate increases for most covered services, effective July 1, 2014. In addition to outlining the details of these rate increases, this Alert provides updates regarding MBHP s provider rate incentive programs. The one exception to the effective date of provider rate increases is the CHIA rate increase for Intensive Care Coordination (ICC), which is effective August 1, 2014. 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 MBHP Members, while seeking to provide fair and equitable reimbursement rates to its network providers. MBHP expects providers to utilize these funding enhancements to support investments in their programs aimed at improving access, quality of care including continuity of care and integration of physical and behavioral health care, and efficient utilization management. FY 2015 Rate Increase Overview MBHP will issue provider rate increases that will result in an expenditure of $9 million. The average rate increase of selected covered services is 2 percent. FY 2015 Rate Increase Specifications Inpatient Services MBHP Rate Increases for Selected Behavioral Health Covered Services Covered Service % Increase *increase determined by pay-for-performance methodology described in Alert Inpatient Mental Health 1.5%; 2.25%; 3% Based on P4P Inpatient Eating Disorder 2.25% Inpatient Mental Health for ID/PDD 2.25% Inpatient Level IV Detox 2.25% Observation/Holding Bed 2.25% Provider Alert #149 1
Covered Service % Increase Administratively Necessary (AN) Days 0% 24-Hour Diversionary Services Acute Treatment Services (ATS) 1% Clinical Stabilization Services (CSS) 1% Community-Based Acute Treatment (CBAT) and 3% Intensive CBAT (ICBAT) *increase determined by pay-for-performance methodology described in Alert 2.25; 3% Based on P4P Community Crisis Stabilization (CCS) 2.25% Enhanced Acute Treatment Services (E-ATS) Adult and Adolescent 3% Transitional Care Unit (TCU) 2.25% Non-24-Hour Diversionary Services Community Support Program (CSP) inclusive of CSPECH 2.25% Enhanced Psychiatric Day Treatment 2.25% Enhanced Structured Outpatient Addiction Program 2.25% Intensive Outpatient Program (IOP) 2.25% Partial Hospitalization Program (PHP) and PHP for Eating Disorders 2.25% Program of Assertive Community Treatment (PACT) 2.25% Psychiatric Day Treatment 2.25% Recovery Support Navigator (RSN) 2.25% Structured Outpatient Addiction Program (SOAP) and SOAP with Motivational Interviewing 2.25% Emergency Services Emergency Services Program (ESP) 2.25% Mobile Crisis Intervention (MCI) 1% ESP Psychopharm 2.25% ESP Risk Management 2.25% Outpatient Services Outpatient Services (diagnostic evaluation, individual/group/couples/family treatment/counseling, 2.25% acupuncture, ambulatory detox, assessment for safe and appropriate placement (ASAP), bridge visit, case/family consultation, collateral contact, dialectical behavioral therapy (DBT), developmental/psychological testing, medication management, OP electroconvulsive therapy (ECT), transition visit) Methadone Counseling Services 1% Urgent Outpatient 2.25% CBHI Services Family Support and Training (FS&T) 1% In-Home Behavioral Services (IHBS) 1% In-Home Therapy (IHT) 1% Intensive Care Coordination (ICC) 1% Therapeutic Mentoring (TM) 1% Average % Increase of Selected Covered Services 2.0% Covered Services That Will Not Receive a Rate Increase The following covered services will not receive the base rate increase. Methadone Dosing Specialing Administratively Necessary Days Provider Alert #149 2
New Evaluation and Management (E&M) codes: 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, and 99215 Inpatient Mental Health Services and ICBAT Pay-for-Performance Measures MBHP regional directors will communicate specific rate increase amounts to inpatient 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 the payfor-performance measures, and the provider s resulting individualized rate increase. The following measures comprise the pay-for-performance methodology used to determine this component of the FY 2015 rate increase for each inpatient and ICBAT provider. 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. Points were awarded based on the provider s performance in each of the measures below. The points accumulated for each applicable measure were totaled, earning the provider a hospital- specific rate increase. Utilization Management: Length of Stay (LOS) LOS Difference This indicator measures the difference between the facility s Risk Adjusted Mean Length of Stay (AdjMean) and its Actual Length of Stay (Actual). Points were awarded based on the difference between the facility s AdjMean and Actual. The measurement period was a 12-month period run on August 6, 2014. LOS Difference Improvement This indicator measures the improvement in the facility s LOS Difference over the preceding year. The two compared measurement periods were 12-month periods run on August 11, 2013 and August 6, 2014. Access: Risk Adjusted Mean This indicator measures the case mix of each facility. Points were awarded based on the risk factors of the Members admitted to the facility during the measurement period. The measurement period was a 12-month period run on August 6, 2014. Continuity of Care: 7-Day Readmission Rate Difference This indicator measures the difference between the facility s risk adjusted 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 risk adjusted 7-day readmission rates. The measurement period was a 12-month period run on August 6, 2014. Access/Continuity of Care: State Agency-Involved Members Inpatient child and adolescent and ICBAT facilities: Points were awarded based on the percentage of MBHP Members admitted to the facility during the measurement period who were state agency-involved (i.e., DCF, DYS, DDS and/or DMH) at the time of their admission. Inpatient adult facilities: Points were awarded based on the percentage of MBHP Members admitted to the facility during the measurement period who were involved with DMH at the time of their admission. The measurement period was a 12-month period run on August 6, 2014. Access/Continuity of Care: Massachusetts Behavioral Health Access (MABHA) Reporting Points were awarded based on the facility s performance in updating the bed availability website three times daily during the 12-month measurement period, July 2013 June 2014. Provider Alert #149 3
Provider Incentive Programs In Provider Alert #138 issued on January 6, 2014, MBHP indicated that we would consider modifications to the provider incentive program. Upon review, the following revisions to the provider incentive program will be made. Effective October 1, 2014, MBHP will discontinue the provider incentives below: SUMMARY OF DISCONTINUED PROVIDER RATE INCENTIVES Service Category Incentive/Nature of Increase Outpatient (mental health OP providers) Incentive: A therapy visit within 7 days of discharge A medication visit within 14 days of discharge A second therapy visit within 30 days of discharge If all three of the above outpatient services were provided within the applicable timelines to a Member post-discharge, additional units of incentive payments were issued. MBHP will continue the following provider incentives: SUMMARY OF CONTINUED PROVIDER RATE INCENTIVES Service Category Incentive/Nature of Increase Outpatient (CSPs operated by mental health and substance use disorder outpatient providers) ATS, E-ATS, and Level IV ATS Incentive: Community Support Program (CSP) visits at Inpatient MH, ATS, E-ATS, and Level IV ATS providers prior to discharge Incentive: ATS, E-ATS, and Level IV ATS provider arranges CSP visits at its program prior to discharge *Please refer to Provider Alert #101 for billing instructions for the continued incentives for outpatient, ATS, E- ATS, and Level IV ATS. For the continued incentive for outpatient, Community Support Program (CSP) visits at Inpatient MH, ATS, E-ATS, and Level IV ATS providers prior to discharge, please continue to submit claims with billing code T2025, modifier HE, and Place-Of-Service code 99. Effective September 1, 2014, MBHP will institute the new provider incentive and opportunity for outpatient providers described below: SUMMARY OF NEW PROVIDER RATE INCENTIVE AND OPPORTUNITY Service Category Incentive/Nature of Increase Incentive: Community Support Program (CSP) visits within 7 calendar days after discharge from an Inpatient Mental Health episode Outpatient (CSPs operated by mental health and substance use disorder outpatient providers) Outpatient (mental health and substance use disorder outpatient providers) Opportunity: Transition visit conducted within 7 calendar days after discharge from an Inpatient Mental Health episode *For the new CSP incentive, CSP visits conducted within 7 calendar days after discharge from an Inpatient Mental Health episode, claims must be submitted with billing code T2025, modifier HE, and Place-Of-Service code 11. Provider Alert #149 4
The two continued incentives that support CSP for Members who are in a 24-hour level of care, as well as the new CSP incentive for Members discharged from a 24-hour level of care, demonstrate MBHP s continued commitment to ensuring this valuable service is available to Members who are at risk for admission to a 24- hour behavioral health inpatient/diversionary treatment setting. MBHP is replacing the previous outpatient provider incentive aimed at providing timely access post-discharge with the Transition Visit. In order to better meet Healthcare Effectiveness Data and Information Set (HEDIS ) measures related to follow-up after hospitalization, MBHP has developed the Transition Visit. The Transition Visit aims to improve PCC Plan/MBHP Members connectedness to aftercare services upon discharge from inpatient facilities by promoting adherence to discharge, medication, and risk management plans(s). The purpose of the Transition Visit is to reduce readmission to an inpatient facility and increase community tenure by providing aftercare supports and resources within 7 calendar days after discharge. Visit Purpose Review discharge plan, barriers, medication, support system, follow-up appointment, etc. Improve quality of discharge planning and aftercare compliance Visit Operating Procedures Must be conducted by a master s-level clinician Must be conducted within 7 calendar days of discharge from an inpatient mental health facility Conducted by the Member s OP behavioral health provider or by an OP behavioral health provider who is accepting a Member as a new referral and intends to provide ongoing OP services Duration of visit: 30 minutes Providers bill visit using code 0513 The Transition Visit form should be completed fully and can be found on the MBHP website in the For BH Providers section, on the Reports and Support Materials web page, under Provider Reports and Publications. Primary and secondary diagnosis should be indicated on the form. MBHP will conduct medical record audits to ensure quality assurance. Transition Visits have been available and will continue to be available to inpatient providers who have staff able to provide this service to Members post-discharge. Future Rate Increase Specifications MBHP anticipates that any potential provider rate adjustment for all levels of care will be contingent upon providers performance under various measures that will likely include but not be limited to: Utilization management Length of Stay difference and Length of Stay improvement Continuity of care Readmission rate difference Access/continuity of care State agency-involved Members Access: Massachusetts Behavioral Health Access (MABHA) reporting Child and Adolescent Needs and Strengths (CANS) compliance Provider Alert #149 5
HEDIS measures related to continuity of care Initiation and Engagement in Treatment for Alcohol and other Drug Dependence (IET) Follow-Up After Hospitalization for Mental Illness (FUH) Provider Action Required Contracting Providers who are contracted by MBHP for services that are subject to a rate increase will receive a revised Exhibit A (contract) effective retroactively to July 1, 2014. Providers will be required to sign and return the Exhibit A (contract) to MBHP. For contracted outpatient providers, an updated Outpatient Fee Schedule will also be sent. MBHP requests that providers waive MBHP s obligation to provide a 30-day notice in order to implement the rate increases effective July 1, 2014. Claims Providers should begin billing services at the new rates for dates of service July 1, 2014. All claims submissions will continue to be subject to MBHP billing policies and procedures. All paid claims for services that are subject to a rate increase with a date-of-service back to July 1, 2014 will be reprocessed with the new rate by MBHP. Providers will not have to resubmit any prior paid claims. 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 Donna Frates, interim (978) 716-3370 Northeast Eric Adelman (617) 350-1948 Southeast Steve Etkind (508) 217-3233 Central Elizabeth O Brien (508) 890-6406 Western Linda Trott (413) 858-8602 Provider Alert #149 6