Showing posts with label health policy. Show all posts
Showing posts with label health policy. Show all posts

Tuesday, January 18, 2022

Leveraging digital and policy tools to address the COVID-19 Behavioral Health Crisis

Even before the emergence and spread of COVID-19, the US was experiencing a behavioral health treatment crisis: 2018 data showed that only 43 percent of adults with mental health needs, 10 percent of individuals with substance use disorder (SUD), and seven percent of individuals with co-occurring conditions were able to receive services for their conditions.

The treatment gap is staggering, and COVID-19 is making it worse: an estimated 56 percent of adults report the pandemic has negatively impacted their mental health. Worse yet, the crisis is felt most acutely by the same health delivery systems that must deal with COVID-19 itself. Hospitals, health systems, and clinical practices—together with other first responders—are the front line. They bear the burden of their own stress and must also cope with the many patients who present with a range of mental illnesses and substance use disorders.

Digitally-enabled care models enable health systems and health plans to meet their most urgent needs in the era of COVID-19. Some solutions also help systems take advantage of favorable, albeit time-sensitive conditions, enabling them to lay the foundation for permanently expanding behavioral health services in the post-pandemic period.



Focus Area 1: Health System Employees


A pressing need for health system leaders is keeping their workforce healthy, focused, and productive during this period of extreme stress, anxiety, and trauma. The need for ongoing, easily accessible behavioral health resources for the healthcare workforce will only grow as the pandemic continues.

Solutions: Consider providing immediate, free access to behavioral health solutions for employees and their families. Also consider extending access to first responders, other healthcare workers, and other essential services workers in the community.



Many digital solutions are granting temporary access to these services and are expanding their offerings to include new, COVID-19-specific modules, resources, and/or guidance at no cost.

The following are a few digital solutions to consider:
  • Recovery management tools for individuals with SUD.
  • Text-based peer support groups. Organizations are using these to address loneliness and social isolation in group-based chat settings, one-on-one interactions between individuals and peer staff, and broader community applications.
  • Online cognitive behavioral therapy (CBT) solutions. These tools are being used to expand access to lower-acuity behavioral health services, targeting both frontline workers and the general population.


Focus Area 2: Individuals with Acute Behavioral Health Conditions


During surge periods, the overwhelming focus is on containing and treating COVID-19; this disrupts services that are essential for individuals with severe mental illness and SUD. Maintaining continuity of care will be critical to preventing decompensation of these patients, which could drive increased rates of ED visits and admissions.



Solutions: Many digital companies are hosting virtual recovery meetings and providing access to virtual peer support groups. Additionally, shifts in federal and state policies are easing restrictions around critical services, including medication-assisted treatment (e.g., buprenorphine can now be prescribed via telephone), that can mitigate risky behavior and ensure ongoing access to treatment. The following are several solutions to consider:
  • Medication-assisted therapy (MAT) via telemedicine. These solutions provide access to professionals who can prescribe and administer MAT medications, provide addiction counseling, and conduct behavioral therapy (e.g., CBT, motivational interviewing) digitally.
  • Behavioral health integration. Providing screening, therapy, and psychiatric consultations across settings of care—especially primary care—will help with the increased demand.


Focus Area 3: New funding opportunities


Healthcare organizations should also look to new funding opportunities to develop digital infrastructure that expands access to critical services. Specifically, as part of the CARES Act, the FCC launched the COVID-19 Telehealth Program and extended the Connected Care Pilot Program to provide avenues for immediate funding for such implementations. Additional telehealth opportunities, including reimbursement for audio-only services and temporarily eased provider licensure requirements, have further paved the way for expansion of tele-behavioral health capabilities.

COVID-19 has brought the behavioral health crisis to the foreground and the marketplace is brimming with innovative solutions. The moment to act is now: health systems that double down on behavioral health today will emerge from the pandemic response well-positioned, having built healthier, stronger communities and workforces along the way.


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Thursday, August 27, 2020

Notable recent HIPAA and coding events

A recent Department of Health and Human Services (HHS) HIPAA settlement and new guidance related to COVID-19 payments shed light on the government’s enforcement priorities.

Richard Heckert, retired chairman of DuPont, once said, “[i]f you always tell the truth, you won’t have to remember what you said.” This applies in every aspect of life, including compliance with the HIPAA Security Rule and documenting the requisite medical necessity to substantiate a particular diagnosis or treatment code. Two recent items reinforce the importance of being honest.

On July 23, 2020, the HHS Office for Civil Rights (OCR) issued a statement that it had reached a settlement with a rural healthcare provider in North Carolina for repeated failures to comply with multiple aspects of the HIPAA Security Rule. Over nine (9) years ago, the entity filed a breach report regarding the impermissible disclosure of approximately 1,263 patients’ protected health information (PHI) to an unknown email account. As OCR delved deeper into its investigation, the following longstanding and systemic issues came to light:
the failure to conduct a risk analysis;
  • the failure to implement policies and procedures; and
  • the failure to provide any HIPAA training to workforce members until 2016.

As OCR Director, Roger Severino stated, “[h]ealthcare providers owe it to their patients to comply with the HIPAA Rules. When informed of potential HIPAA violations, providers owe it to their patients to quickly address problem areas to safeguard individuals’ health information.” Lying or shall I say, being less than truthful about compliance with the technical, administrative, and physical safeguard requirements of the Security Rule, as well as separate requirements of the Privacy Rule, is something that is material to government investigations. The next worse thing to lying directly to a government agent, is falsifying an annual risk analysis or failing to conduct a comprehensive one at all.

Documentation falsification in relation to medical necessity and coding, has emerged in another area – COVID-19 admissions in hospitals. On August 17, 2020, the Centers for Medicare and Medicaid Services (CMS) released an update, which addresses the implementation of Section 3710 of the CARES Act for Inpatient Prospective Payment System (IPPS) hospitals “to address potential Medicare program integrity risks.” This section enabled the HHS Secretary “to increase the weighting factor of the assigned Diagnosis-Related Group (DRG) by 20 percent for an individual diagnosed with COVID-19 discharged during the COVID-19 Public Health Emergency.”

So, what does this mean? Basically, failure to do what the guidance says can open a person up to either an HHS-OIG investigation and/or a False Claims Act lawsuit. As the update states,

To address potential Medicare program integrity risks, effective with admissions occurring on or after September 1, 2020, claims eligible for the 20 percent increase in the MS-DRG weighting factor will also be required to have a positive COVID-19 laboratory test documented in the patient’s medical record. Positive tests must be demonstrated using only the results of viral testing (i.e., molecular or antigen), consistent with CDC guidelines. The test may be performed either during the hospital admission or prior to the hospital admission.

In other words, be certain to have all of the medical necessity and testing documented before submitting a claim utilizing a code, which provides an extra 20 percent reimbursement.

As was stated at the beginning, when you tell the truth, you never have to remember what you said. Whether it is HIPAA compliance or submitting a claim, be accurate and honest. It can save a lot of “heartburn” in the long run.

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Monday, August 24, 2020

2021 E/M guideline and leveling changes

Providers need a mechanism to be accurately reimbursed for the time and effort that they expend in providing care. Evaluation and Management (E/M) leveling has been the standard method in which to provide appropriate, defensible payments for services.

However, it has been successfully argued that the 1995 and 1997 E/M guidelines in place today are overly complex and incentivize or reward the quantity of documentation over the quality. AMA CPT® has issued a new set of guidelines for 2021 intending to help simplify E/M leveling for office and other outpatient services.

For 2021, CMS will move from a points-based system for history, exam and medical decision making, to a medical necessity-based system. Broadly stated, under ‘95/’97 rules, for each service provided, there is an assigned point value: the more points, the better the level. Medical decision making has always been the arbiter, though; a great exam and history input will not get top reimbursement for a simple case of postnasal drip. For 2021, the leveling methodology will change; the new rules require that documentation be appropriate to support the patient’s diagnosis, and CMS will move from a points-based system to a medical necessity-based system.

According to HealthCare.gov, medically necessary services are defined as “health care services or supplies that are needed to diagnose or treat an illness, injury, condition, disease, or its symptoms—and that meet accepted standards of medicine.”

It is essential that providers understand that the new rules do not constitute a diminution in documentation or a reduction of supporting facts for a given diagnosis. In fact, AMA CPT® and CMS are raising the bar on the quality of documentation for a given diagnosis. This can result in reduced documentation needs and more focus on supporting the medical necessity of the diagnosis.

When you look at best practices for E/M leveling and compliance, it’s crucial to understand that your E/M documentation is being reviewed by many different tools and interpretations of the current (CPT®, 95, 97) guidelines. What might be acceptable for a private payer will not pass a Medicare review. At this time, most healthcare systems have adopted the CMS guidelines and rules as outlined by their Medicare Administrative Contractor (MAC). The importance of following the MAC guidance is that each MAC has developed education and tools based on their interpretation of the guidance provided by CMS. It is important to provide physicians, non-physician providers, and coding staff with E/M education specific to the MAC rules during the onboarding process and to have a process in place to provide any updates or changes to guidelines via live training or internal communiques.

Due to evolving technology and the use of EHRs, E/M templates should be reviewed on a regular basis. Many over-coding issues can be traced to the poor design of templates that auto-populate or pull information from previous visits without having the provider validate that it is pertinent to the service.

Routine reviews of E/M documentation are essential. Every compliance plan should have a program outlined to review provider documentation on a regular schedule to evaluate the effectiveness of training and ensure templates are being used and edited correctly. Annual reviews are recommended with more frequent inspections of the outliers.

There is help on the horizon. The 2021 E/M changes to office and other outpatient services were meant to ease the documentation burden on providers. When you compare the changes side by side, the new focus is clearly on medical decision making.


AMA CPT® 2020 AMA CPT® 2021

99214 - Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family. 99214 - Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter.


First noticeable change: there will no longer be a requirement for a specific level of history and exam. Providers have often felt forced into documenting items of history and/or exam they felt were not pertinent to a visit in order to support the E/M level that was medically necessary and appropriate. Now, history and exam need only be relevant and pertinent based on the reason for the visit. Their efforts will now focus the level on medical decision or time as defined by the code description.

On November 1, 2019, the AMA CPT® published an article regarding the changes that provided the CPT® Evaluation and Management (E/M) Office or Other Outpatient, Prolonged Services Code and Guideline Changes and E/M Office Revisions Level of Medical Decision Making (MDM) table that will be included in the 2021 CPT® book. These new guidelines and table will standardize and level the playing field for all payers by providing clear guidance and clear definitions for the elements listed in the new medical decision-making table:
  1. Time
  2. Services reported separately
  3. Number and complexity of problems addressed at the encounter

With the proper planning, education and implementation, this change will have a positive impact on both the physician workload and quality of patient care.


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