Boosting Your Bottom Line

Boosting Your Bottom Line Making More Money for Clinics Lisa Clark, MBA NYS Office of Mental Health 7/26/16

Partners in CTAC and MCTAC include:

Agenda Introduction Review of Revenue Maximization Basics Strategies Fiscal Impact Show Me the $$ Quick Tips Identify Specific Areas of Need for Fall 2016 CTAC Series Questions

1 5 9 13 17 21 25 29 33 37 41 45 49 53 57 61 65 69 73 77 81 85 89 93 97 101 105 109 113 117 121 125 129 133 137 141 145 149 153 157 161 165 169 173 Fiscal Viability of Article 31 Clinic Providers 100% % SURPLUS/(LOSS) OF TOTAL EXPENSES (n= 175) 80% 60% 44% 40% 30% 20% 26% 0% -20% -40% -60% -80% Data Source: 2013 CFR; Adjusted for Outliers

WHAT S YOUR ISSUE?

Challenges to Fiscal Viability Discontinuation of Comprehensive Outpatient Services (COPS) Funding Clinic rate supplements that offset the uninsured and underinsured 30 Providers with COPS rates >$130 Conversion to Ambulatory Patient Groups (APGs) 4 year transition to 100% APG rates Old System: 3 rate codes, 6 clinic services New System: 8 rate codes, 40 CPT codes Modifiers Insufficient Commercial Rates Payer Mix (% Medicaid vs Other)

Challenges to Fiscal Viability Productivity No Show Rates High Expenses: Rents, Staff Salaries, Fringe Benefits Claim Denials Inconsistencies amongst plans Day-to-Day Operations Transition of other BH Services to Medicaid Managed Care Not a Clinic thing or is it?

Revenue Maximization Review

Revenue Maximization Collecting the most money for the services that you re already providing OR Picking up the bags of money left on the floor!

What you Need to Know

Where s the $$? Pre-Admission Visits Initial Assessments Modifiers Physician Add-Ons Crisis Intervention Complex Care Management

Pre-Admission Visits OMH allows (but does not require) 3 pre-admission procedures prior to admission Pre-Admission = Screening Status Individual has not officially been admitted to the clinic 30 day clock for Treatment Plan has not started Benefits Provides reimbursement while evaluating the need for further treatment Provides revenue for services to individuals who may not want further treatment Common Pre-Admission Procedures Crisis Intervention (Brief) Initial Assessments

Initial Assessments Face-to-face interaction of at least 45 min, in order to: Evaluate for admission Determine MH diagnosis Develop a Treatment Plan Can be provided during Pre-Admission/screening and/or after admission NOTE: An Assessment is a procedure and Pre-Admission is a status The terms are NOT interchangeable

Initial Assessments OMH allows up to 3 Initial Assessments during an episode of service 2 Types of Assessments: 90791 Initial Assessment Diagnostic & Treatment Plan (45 min+) 90792 Initial Assessment Diagnostic & Treatment Plan with Medical Services (45 min+) Managed Care Plans don t have to pay for 3 They commonly pay 1 @ 90791 and 1 @ 90792 Know how many each plan covers

90792 Initial Assessment with Medical Services Can only be performed by a Psychiatrist, Physician, or Psychiatric Nurse Practitioner Using the 90792 code alone won t pay the correct rate! You MUST add a Physician Modifier to the 90792 to be paid correctly Psychiatrist = AF Physician = AG Nurse Practitioner = SA Using the modifier code adds 45% to the rate 2015: 52% of providers did NOT add the modifier $$ TIP: Have MD & NPP use 90792 rather than 90791 & program billing software to add modifier

How much more can you make? Adding the AF/SA modifier to 90791/90792 pays:

Maximize Revenue thru Initial Assessments Initial Assessment Diagnostic & Treatment Plan 90791 1.0344 $ 163.02 $ 236.38 Amt w/physician mod Initial Assessment Diagnostic & Treatment Plan with Medical Services (Must Add Modifier AF or SA to get 45% rate increase) 90792 1.0344 $ 163.02 $ 236.38 Amt w/physician mod Psychiatric Assessment - 45-50 mins 99201-99205 New 0.6620 99212-99215 Est $ 104.33 $ 195.63 Amt w/add ON Psychiatric Assessment - 45-50 mins - ADD ON 90836 0.5793 $ 91.30 Psychotherapy - Indiv 45 mins 90834 0.8275 $ 130.41 $ 189.10 Amt w/physician mod Example: 1st Visit MSW for Intake & Psychosocial (90791) 2 nd Visit MSW completes Psychosocial &/or Tx Plan (90791) 3 rd Visit Psychiatrist (45min+) for Initial Assessment w/medical (90792) + Modifier

Physician Add-Ons Psychotropic Medication Treatment 99201-99205 New 0.6620 99212-99215 Est $ 104.33 Psychiatric Assessment - 30 mins 99201-99205 New 0.6620 99212-99215 Est $ 104.33 Psychiatric Assessment - 30 mins - ADD ON 90833 0.3724 $ 58.69 Psychiatric Assessment - 45-50 mins 99201-99205 New 0.6620 99212-99215 Est $ 104.33 Psychiatric Assessment - 45-50 mins - ADD ON 90836 0.5793 $ 91.30 $ $ 163.02 195.63 Amt w/add ON Amt w/add ON 90833 Psychiatric Assessment 30 minutes ADD-ON 90836 Psychiatric Assessment 45 minutes ADD-ON Psychotherapy - therapeutic communication and interaction for the purpose of alleviating symptoms or dysfunction associated with an individual s diagnosed mental illness or emotional disturbance, reversing or changing maladaptive patterns of behavior, encouraging personal growth and development, and supporting the individual s capacity to achieve age-appropriate developmental milestones.

Medicaid Physician Add-Ons Medicaid vs Medicare 90833: Total time spent >= 30 mins, incl E&M 90836: Total time spent >= 45 mins, incl E&M E&M codes = 99201-99205, 99212-99215 Medicare rules are different! Time for E&M service is in addition to the time spent for psychotherapy Example: If you bill 99212 and 90833 and the total time of visit = 30 minutes this = an overpayment

TIP for New Patients 99201 99205: E&M codes for the Psychiatric Assessment of a new patient If your psychiatrist or NPP is: Spending a minimum of 45 minutes on this initial appt (they often do), Providing a basic review of health information, Determining the appropriateness for treatment, MH diagnosis, treatment planning, and medication therapy Code these visits as 90792 and have your billing system automatically add the AF/SA modifier Look at your reports and see how often 99201-99205 are being used

How Much $ are you Leaving?

Crisis Intervention Crisis Intervention Brief (H2011) Pays $56 - $79 15 minute units, up to a max of 6 units Face-to-face or by phone Individuals don t have to have previously received services at the clinic Can be provided off-site (pays 50% more) Crisis Intervention Complex (S9484) Minimum of 1 hr of FTF contact by 2 or more staff Individual must have been in service at the clinic within 2 yrs Crisis Intervention Per Diem (S9485) 3 or more hrs of FTF time by 2 or more staff Individual must have been in service at the clinic within 2 yrs

Complex Care Management An ancillary service to psychotherapy, psychotropic medication treatment or crisis intervention services Must take place within 14 days of eligible service Billable in 5 minute units, 4 units max Provided in person or by phone, with or without the client Provided in order to prevent a change in community status or as a response to a complex condition NOT routine care or referrals Must be medically necessary The need for follow-up must be documented Pays $14 - $19/unit Underutilized

Offsite Services for Children School-based satellite clinics Must be written in Treatment Plan Home Visits after school School vacations - Home Visits - Provide services at alternate locations: e.g. Library, Boys & Girls Club, etc. Benefits Family engagement Continuity of care Increases revenue by 50% Example: Psychotherapy Family & Client 1 hr (90847) $195.63 in clinic = $293.45 at home = $97.82 more $$ TIP: Use 90847 whenever psychotherapy is 60 mins and family is present for > 29 mins and child for 30 mins

Show me the Quick Tips: 1. Check MD claims for 99201-99205. Can they be billed as 90792 with AF/SA modifier? 2. How many Initial Assessments are you doing per individual? Should have at least 1 @ 90791 and 1 @ 90792 3. Are there 90833 and 90836 s for MD time? 4. How many Crisis-Brief visits (H2011) were done? 5. How often is Complex Care Mgmt (90882) being used? 6. If your clinic or satellites are open before 8 AM, after 6PM, or on the weekends, are you billing for After Hours (99051)? 7. If you have bi-lingual staff, are they submitting for Language other than English (U4) when translation is provided?

What else can you do?

Impact of Payer Mix Know your payer mix and understand how this impacts your bottom line!

Impact of Productivity *Normalized Weighted Productivity when 55% of total staff hours are billable * Normalized Weighted Productivity = conversion of CPT units of service to a standardized 45 minute unit

Impact of Productivity Normalized Weighted Productivity when 45% of total staff hours are billable Approximately 13% decrease in Revenue

Denial Rates 78% Medicaid/MMC & 2% Denial Rate Input Parameters - Revenue Revenue Per billable Rev per CPT Payer Mix Medicaid $ 138.97 33% Medicaid Managed $ 138.97 45% Medicare $ 45.00 5% 3rd Party $ 72.54 10% Uncompensated $ 69.49 5% No Payment (denials, voids, etc.) 2% Avg Revenue per CPT $ 121.38 100% Collection Rate 98% 72% Medicaid/MMC & 8% Denial Rate Input Parameters - Revenue Revenue Per billable Rev per CPT Payer Mix Medicaid $ 138.97 30% Medicaid Managed $ 138.97 42% Medicare $ 45.00 5% 3rd Party $ 72.54 10% Uncompensated $ 69.49 5% No Payment (denials, voids, etc.) 8% Avg Revenue per CPT $ 113.04 100% Collection Rate 92% What s your denial rate? Set goals for denials and track them!

Do you get denials from MC Plans that don t seem right?

OMH Can Help! Please send copies of your remittance issues along with any additional information to: OMH-Managed-Care@omh.ny.gov

Dashboard Reports Staff Productivity Report % billable Billable hr. billable hours goal hrs. CPT Unit show rate John Jones 327.00 400 81.75% 390 85.96 % Jun-15 36.50 50 73.00% 43 87.30 % Jul-15 39.25 50 78.50% 47 83.75 % Aug-15 50.25 50 100.50% 60 85.86 % Sep-15 54.25 50 108.50% 64 84.62 % Oct-15 45.50 50 91.00% 55 86.96 % Nov-15 35.75 50 71.50% 43 77.33 % Dec-15 30.50 50 61.00% 37 92.73 % Jan-16 35.00 50 70.00% 42 92.42 % Year to Date 327.00 400 81.75% 390 85.96 % Clinic Performance to Budget Oak St MH Clinic YTD 6/30/2016 Budget Actual Variance Gross 856,213 850,125 (6,088) Total Rev 856,213 842,361 (13,852) Operating Surplus/(Deficit) 0 (7,764) (7,764) Units of Service 6,586 6,415 (171) Gross Cost per Unit 130.00 132.52 2.52 Net Revenue per Unit 130.00 131.31 1.31 Net Surplus/(Loss) per unit 0 (1.21) (1.21) Medicaid Participation 80.00% 82.31% 2.31% Revenue cycle performance to Benchmarks RCM Performance Benchmark Actual Variance Avg days AR Outstanding: 45 61 16 Denial rate all sources: 5.00% 4.20% -0.008 Denial rate Medicaid: 2.50% 2.10% -0.004 % claims submitted on time: 100.00% 93.00% -0.07

Revenue Maximization Results 2016 Survey of Clinic Providers who received in-person Revenue Maximization Training

1 5 9 13 17 21 25 29 33 37 41 45 49 53 57 61 65 69 73 77 81 85 89 93 97 101 105 109 113 117 121 125 129 133 137 141 145 149 153 157 161 165 169 173 Fiscal Viability of Article 31 Clinic Providers 100% % SURPLUS/(LOSS) OF TOTAL EXPENSES (n= 175) 80% 60% 44% 40% 30% 20% 26% 0% -20% -40% -60% -80% Data Source: 2013 CFR; Adjusted for Outliers

Revised Fiscal Viability with 15% Revenue Increase SURPLUS / (LOSS) OF TOTAL EXPENSES (n= 175) 120% 100% 80% 60% 40% 17% 18% 65% 20% 0% -20% 1 5 9 13 17 21 25 29 33 37 41 45 49 53 57 61 65 69 73 77 81 85 89 93 97 101105109113117121125129133137141145149153157161165169173-40% -60% -80% Data Source: 2013 CFR; Adjusted for Outliers

Questions?

THANK YOU FOR ATTENDING TODAY S WEBINAR! Check out our new website: www.ctacny.org CTAC email: ctac.info@nyu.edu