Can LMFTs be reimbursed for IBH/BH services at FQHCs?

1) LMFTs are eligible mental health providers for Minnesota Health Care Programs (MHCPs include Medical Assistance [MA], MinnesotaCare, MN Family Planning Program).

 
2) LMFTs are NOT eligible mental health providers for Medicare.

 
“But most FQHC Medicare patients are Dual Eligible (i.e., enrolled in both MA & MC). Therefore FQHCs must first bill CMS as a Medicare “billed to deny.” Once the claim is denied by Medicare, the claims should then be submitted to DHS as a Medicaid service. Medicaid will pay the claim at the Medicaid Fee for Service level. DHS will not pay the FQHC rate on claims such as these. 

Important Clarification– Medicare mental health services require a doctorate degree (with the exception of MSW licensed clinical social workers, such as LICSWs and LCSWs). So, when any other mental health professional provider (LMFT, LPCC, etc.) with a master’s degree treats a Medicare enrollee that also has Medicaid coverage, the claim follows the process described above.”

**This clarification applies to all non-Medicare eligible BH providers

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Can anyone share policies, processes, documentation requirements, etc. for supervising PAs? We are considering adding them to our team. 

  • Contact the Health Plans because as a part of credentialing they can tell you the requirements of a sponsoring MD.
  • We have a physician supervise the PA and a “ Physician- Physician Assistant Delegation Agreement” needs to be completed.  You can go on line and get the MN version for current year.   We have this updated each year for the PA and supervising physician.  This is required for insurance credentialing as well.  Also attached is a policy regarding clinical privileges as well as the form used for initial and reappointment of clinical privileges.  This is updated every 2 years.
  • I have one Physician Assistant on staff; no real difference in supervision from NPs, except that they need a physician delegation agreement (which NPs don’t).  otherwise, we’ve kept all privileging/credentialing the same.
  • All PAs are required to fill out a delegation agreement and they are privileged and credentialed just the same as an MD- except verifying their different licensure of course. Then one Physician is usually in charge of the supervision portion of the arrangement- we have our associate medical directors fill that role.

This form pretty much defines who can be a supervising physician:

Physician Supervision Minn. Stat. § 147A.01, Subd. 23 defines Supervising physician as “a Minnesota licensed physician who accepts full medical responsibility for the performance, practice, and activities of a physician assistant under agreement as described in § 147A.20. Minn. Stat. § 147A.01, Subd. 24 defines Supervision as “overseeing the activities of, and accepting responsibility for, the medical services rendered by a physician assistant. The constant physical presence of the supervising physician is not required so long as the supervising physician and physician assistant are or can be easily in contact with one another by radio, telephone, or other telecommunication device. The scope and nature of the supervision shall be defined by the individual physician-physician assistant delegation agreement.”

Nominal Fees

  • Medical-$20
  • Medical-$15, Behavioral Health-$10, Dental-$50  (we also have set fees for some non-covered dental services)
  • Medical/BH-$0 at 100% of FPG, Dental-$20 at 100% FPG. The nominal fees move up as one’s % of FPG increases up to 100% of charges at 200% of FPG.
  • Medical/BH-$10, Dental-$25

Behavioral health clients transferring care from one agency to another- do we need to redo the Diagnostic Assessment (DA)?

We have a new therapist with an established caseload starting next month. Most of the provider’s existing clients will be following the therapist to the health center:

Since these existing clients already have a Diagnostic Assessment completed by the therapist do they need to charge for a new diagnostic session at the health center? (This assumes the DA is current and doesn’t need updating)

OR

Can the therapist charge a regular 90834 session and just scan the existing DA into the chart?

Responses:

  • It does not matter where the DA came from as long as it is within 3 years.  Just put a note in the progress note about where the DA is in the electronic health chart, the date of it and who did it.
  • The answer may vary depending on clinic policy.  DHS does not require a brand new DA per agency as long as the existing one is up to date.  Diagnostic information should be transferable in much the same way we refer to external agencies for other mental health services such as case management, ARMHS, or even a different mode of therapy.

    Technically, you can go ahead and bill for a 90834 for the first session at a new agency.  I’d write in the progress note to refer to the DA that is scanned in the chart.  I’d probably also give a fresh PHQ9 so that the agency can track this depression screen.

     BUT, since new patients need to develop charts in the EHR, and we all track data on clinical outcomes, your agency might determine that a new DA might be important.  For example, it’s useful to share biographical data with other providers in the agency in way that doesn’t require poring through scanned documents.

    At our clinics we have encouraged new therapists who are bringing a lot of patients (10+) with them to scan old DAs into the EHR so that they can get jump started with new patients immediately.  After all, it is difficult to complete time-consuming DAs on existing patients PLUS additional new DAs on new patients…. Which slows down their building a caseload.  But I have also asked therapists to matriculate new DAs on existing patients within 3 to 6 months (with long term patients).  If the therapist is only bringing 1-3 patients with them, I’d likely advise just writing the new DA vs. scanning.

 

How many chart reviews do you have your Providers perform on each other per year? Do you give them any administrative time to accomplish these chart reviews?

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  • Approximately 1 per month peer reviews and 5 per month mid-level reviews and all physicians have 4 hours of administrative time per week. 
  • 5 per quarter. They are currently completed during no-shows. 
  • 3-4 per quarter, total up to 16 per year. No, but sometimes I feel like we should. 
  • 1 per month, 12 total. No admin time to do them, they will usually complete during no shows or at the end of the day. Very manageable. 
  • For medical provider peer reviews, our providers review 10 charts apiece, twice per year. Dental providers review seven charts apiece, also biannually. The medical records department also completes chart audits on 25 charts quarterly. 
  • Our Providers review 5 charts per quarter.  No extra administrative time is given. 
  • Our CMO is responsible for Peer Reviewing 10 patient charts per provider each quarter. We have a contract physician peer review our CMO’s charts. We do not give any additional admin time to complete these reviews. 
  • We do Peer Reviews 3 times a year. Adult providers review 8 charts and we block their schedules to complete. Pediatric providers review 10 charts and we do not block their schedules to complete. 
  • 15 per quarter which equates to 60 per year. 
  • We do not give them admin time for peer review specifically.  They have admin time to complete all non-clinical tasks.  We ask each provider to review 3 charts four times per year.

E-Visits

As an FQHC, can we perform e-visits? Is anyone doing these? Do you happen to know any specifics regarding e-visits and FQHCs?

  1. We are NOT doing e-visits. As far as I know, these would not be reimbursable because they are not face-to-face encounters.  But maybe there are recent changes to the rules to allow this?
  2. We are contemplating very seriously using telehealth.  I am sending along California’s guide for FQHC telehealth reimbursement.
  3. We are actively pursuing this. Not sure yet on payment. Worst case scenario, fee-for-service.

What are you using for your lab accreditation? What has been your experience with this accreditation body?

  1. We have been accredited by Joint Commission for the last 15+ years.  We have overall had good experiences with Joint Commission standards keeping us current with best practices.  We have not considered switching to another accreditation body.
  2. CLIA, Great – easy – inexpensive – non-cumbersome
  3. We have CLIA waivers for our clinic sites with minimal lab needs such as INR’s, urine dip sticks, etc.  Our primary lab services are performed through our associated critical access laboratories which require no credentialing or accreditation on our part.
  4. We use Junell Peterson from JMP Laboratory Consulting for our accreditation.  She does a great job, is very thorough and works very well with myself and the lab supervisor.  I have cc’d Junell on this email so if you have additional questions you can reach out to her directly. jmplaboratoryconsulting@gmail.com

If we know that a client is a sex offender, murdered someone, or has served prison time due to a felony and include this in our visit note how do we ensure others within the clinic do not have open access to this chart?

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  • The BH visit itself can be designated confidential and only those with proper authorization will be able to access it
  • Do not put the information on the problem list- only in the BH notes.
  • All EHRs have confidential, secure, signature noted access that should be used for this information.
  • All EHRs have security/permission levels set by the individual. Any information that a person accesses will be traceable by their sign-on/fingerprint.
  • Epic has an application called “Break the Glass” that requires users to document their reasons for any apparently unauthorized attempt to access an EMR. It displays a security screen that requests a reason you need to look at the record before access is granted.

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