Clinical Supervision of Behavioral Health Providers

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How do you handle clinical supervision of your behavioral health providers?

  • Typically licensed providers meet every other week for one hour for individual consultation (if the provider is full time) with the behavioral health director, because technically they do not require supervision as they are independently licensed. We also have weekly team meetings where we discuss cases. We try to be available for on the spot questions. Unlicensed therapists (and sometimes new providers) will need to meet more often per school or licensure board’s requirements, which is typically one hour of individual supervision and one hour group/team supervision.
  • Our clinic is small, with only 4 BH providers, including the BH Director and one Psychiatric NP and an LPN. As all of our providers are independently licensed, clinical supervision is not required for their licensure/insurance reimbursement. However, quarterly chart reviews are completed by the BH Director for all providers and feedback regarding documentation is provided at that time.

How many hours a month does each clinician meet individually with their clinical supervisor (does it differ by years of experience? If so, how?)?

  • 1-4 hours per month depending on developmental and training needs of the provider, and also depending on whether they are full or part-time. Years of experience are considered, but also if a provider is new to the clinic culture or if there’s a learning or coaching goal (especially disciplinary) to monitor and train for.
  • Each provider has a 1:1 scheduled with the BH Director to discuss clinical concerns, work flows, morale, etc. every month.
  • We have a monthly Peer Supervision meeting that is 1-2 hours. One hour a week with newest team member (SW/IBH). Times with other MH team members varies. (This question confirms we need to make that more solid and consistent). Some are contracted and received clinical supervision elsewhere.

How often does the entire group of clinicians meet for clinical supervision?

  • Behavioral health team meets weekly, but not all part-time providers can attend that frequently who work away from the main site.  The off-site provider comes once per month. We also have a monthly team education where we discuss a learning topic or watch a webinar or invite an outside speaker on a topic such as how does diabetes impact mental health, etc. Our agency also has a biweekly all-provider meeting that meets across disciplines.
  • The team meets weekly for one hour with our Psychiatric NP and her staff to consult on cases. We have a great team and work together well in doing “curbside consultations” as needed throughout the day to support one another.
  • We have a monthly meeting for the whole team to handle content like how to do crisis assessments and response and other topics; but it’s not direct clinical supervision.

 

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Coding Auditor Recommendations

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  • Jeanne Chapdelaine at Wipfli is my recommendation.
  • Debra Walsh, RHIA at Debwalsh1515@yahoo.com (recommended 2x)
  • I met this vendor at a recent conference and she works with FQHCs.
    • MRS – Medical Reimbursement Specialists
    • Robin Ingalls Fitzgerald
    • 1-866-991-4819
    • robin@mrsnh.com

After Hours Call Vendors

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  • We are using Citra Health. Great after-hours service.
  • We use Fairview After Hours. They do not integrate now send reports.  I would love to hear the results to see if anyone has found a better solution. We also have to contract with an interpreter service for them to use after hours for our patients. I am curious about cost too.
  • Essentia Health

Artificial Nail Policies

  1. The dress code portion of our employee handbook contains the phrase, “Clinical staff may not wear artificial nails.”
  2. Almost without exception nail extensions and artificial/acrylic nails are banned for all persons doing direct patient care due to infection risk.
  3. Natural and Artificial Nails:   Natural nail tip length should not exceed ¼ inch and, if nails are polished, they must be well maintained and must not be chipped.  Artificial nails are not permitted.

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

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.

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