Psychiatric collaborative care management may improve outcomes, boost revenue

Although Kristine McVea, MD is an internist at OneWorld Community Health Centers Inc. in Omaha, Neb., she’s also often a “surrogate psychiatrist,” titrating and prescribing psychiatric medications for patients with anxiety, depression, and other mental health problems daily. These patients need access to psychiatric services. However, it’s not uncommon for them to wait months or longer to see a psychiatrist. 

The good news is that, as of Jan. 1, 2018, financial incentives exist for physicians and psychiatrists to collaborate when caring for patients with behavioral health disorders. In its 2018 Medicare Physician Fee Schedule, CMS created a new Psychiatric Collaborative Care Model that enables physicians to generate revenue when they co-manage patients with a psychiatrist or some other professionals trained in behavioral health and provide ongoing care management support. 

With psychiatric collaborative care management, the primary care physician bills Medicare monthly when the care team delivers services that meet or exceed a time threshold defined under the billing code. The internist then pays the behavioral healthcare manager (usually employed by the practice) and psychiatric consultant directly. 

Collaborating for better outcomes

The collaborative care model is important because it underscores the connection between physical and mental health, says Seth Bernstein, Ph.D., executive director of the Institute for Behavioral Health Integration in Corvallis, Ore. Bernstein cites the example of depression that fuels diabetes. By addressing the underlying mental health issue, physicians may improve physical health outcomes as well. Internists and primary care physicians are well-positioned to address these concerns because of their long-standing relationships with patients, he adds. 

Thomas Weida, MD, a primary care physician at University Medical Center in Tuscaloosa, Ala., says primary care physicians are among those most qualified to spot the mental health conditions that drive some  physical health symptoms. He provides the example of sleep disturbances that may be related to anxiety-a problem he often treats in his practice.

In a collaborative care model, Weida, who plans to bill psychiatric collaborative care management this year, says he can work with a psychiatrist to identify the most appropriate medication without requiring patients to see an additional provider, and get paid for doing so. 

Weida says the new collaborative care model will take some of the burden off physicians trying to care for patients with behavioral health conditions. “We see a huge number of the walking wounded-those with depression and anxiety. Having some additional expertise is helpful,” he says.

Addressing operational challenges

Although psychiatric collaborative care may improve outcomes, it may create operational challenges-specifically, the need for practices to create a care team that includes a behavioral healthcare manager and psychiatric consultant.

According to CPT guidelines, the behavioral healthcare manager must have a masters or doctoral degree-level education or specialized training in behavioral health. The psychiatric consultant must be a medical professional who is trained in psychiatry or behavioral health and qualified to prescribe the full range of medications. 

Neither are required to be practice employees, but it might be most cost-effective for small practices to hire someone to serve as a full- or part-time behavioral healthcare manager if that individual can also perform chronic care management (CCM), transitional care management (TCM) and other clinical services, says Charlie Hutchinson, CPA, chief financial officer at InSync Healthcare Solutions LLC in Tampa, Fla.

Likely candidates include social workers as well as physician assistants or nurse practitioners with specialized training in behavioral health techniques (e.g., motivational interviewing and behavioral activation). 

Weida says his practice employs a full-time social worker to serve as the behavioral healthcare manager. Another option is for practices to jointly hire a behavioral healthcare manager and share his or her time, he adds.

McVea’s practice hired a licensed marriage and family therapist to serve as the behavioral healthcare manager. Though the clinic hasn’t yet billed for psychiatric collaborative care management, McVea says OneWorld essentially began performing the service a year and a half ago, most frequently for patients with depression, anxiety, and schizophrenia. 

“In terms of increasing access to psychiatric care, the program has been amazing,” says McVea. Since implementing the program, she says, the clinic has reduced the waiting list for psychiatric care from 300 patients to zero.

Weida’s practice plans to contract with a psychiatrist on an hourly basis. He suspects that the psychiatrist’s time will be minimal because the behavioral healthcare manager will do the majority of the work assessing patients and following up with them. Practices that employ the behavioral healthcare manager directly would therefore retain most of the revenue that the program generates, he adds.

Another option for the psychiatrist’s contract is to simply split the total revenue, says Mike Strong, MBA, CPC, bill review technical specialist at SFM, a worker’s compensation consulting firm in Bloomington, Minn. A 70/30 split in favor of the internist or primary care physician makes the most sense. 

“Ultimately, it’s the [primary care physician’s] license on the line because they’re the ones prescribing the medication,” he says. “They’ll be the ones held accountable if it’s prescribed inappropriately.”

Designing a workflow

Once the behavioral healthcare manager and consultant psychiatrist are identified, practices need to determine how they’ll integrate them into the practice’s workflow. 

Here’s how it works under OneWorld’s current collaborative care model: When McVea suspects a patient might have a behavioral health problem, she asks the clinic’s behavioral healthcare manager to enter the exam room to perform an initial assessment and brief intervention. If the patient does have a problem-and consents to treatment-the primary care team and patient jointly develop a care plan that could include psychotherapy, medications, or a combination of the two.

The behavioral healthcare manager stays in contact with the patient and regularly reviews the patient’s care plan with the psychiatric consultant, who may recommend medication or refer the patient to behavioral health specialty care.

It works similarly in Weida’s practice. During the hand-off to the social worker, Weida tells patients he is referring them to a care manager. This helps remove the stigma associated with a mental health diagnosis, he adds. When obtaining patient consent, he tries to explain that a monthly copayment is ultimately less expensive than having weekly visits with a psychologist or psychiatrist. The program also significantly reduces the time it takes for patients to see results, he adds.

Weida’s practice rolled out the program with Medicare patients who have been diagnosed with anxiety, depression, and substance abuse. He hopes to expand it if and when other insurers start paying for services.

“A lot of times, when Medicare says, ‘This is an official code, and we pay for it,’  the
other insurers fall in line,” says Weida. “That’s what we’re hoping will happen, and then we can make it more available to many of our patients.”

Billing for services rendered

When billing psychiatric collaborative care management, physicians must carefully document the time they spend rendering these services, says Jaci Kipreos, CPC, president of Practice Integrity LLC, a coding education and consulting company in Henrico, Va. This includes describing the specific tasks that the behavioral healthcare manager and psychiatrist perform, such as consultation, patient outreach and patient follow-up. The total time the care manager spends consulting with the psychiatrist should match the total time the psychiatrist reports for his or her services, she adds.

Strong says documentation should also include a confirmed diagnosis, the names and credentials of the behavioral healthcare manager and psychiatrist, goals of treatment, and overall progression toward those goals. Also document the patient’s achievement of the goal. This helps identify the end of the episode of care, he adds. A new episode of care also begins after a break of six calendar months or more. 

Legal considerations

Practices need to consider HIPAA when sharing protected health information with the psychiatric consultant, says Chris Apgar, CISSP, chief executive officer of Apgar and Associates, a HIPAA and regulatory compliance consulting company in Portland, Ore. More specifically, physicians, behavioral healthcare managers, and other covered entities can’t disclose psychotherapy notes without patient authorization.

The psychiatrist doesn’t need to sign a business associate agreement unless he or she is working solely as an adviser (i.e., not seeing his or her own patients independently), says Apgar. If the psychiatrist does see patients independently-and transmits HIPAA-covered transactions-he or she is considered a covered entity. Most psychiatrists with whom physicians contract for psychiatric collaborative care management will be covered entities, he adds.

There’s also a legal angle to consider, says Apgar. Federal Stark laws prohibit physicians from referring patients to other providers with whom they have a financial relationship. Physicians contracting with a psychiatric consultant should therefore avoid advertising the psychiatrist’s services other than those provided for the psychiatric collaborative care. Physicians also shouldn’t provide no-cost or below-market rates for rental space within the practice so the psychiatrist can see his or her own patients.

“The key is not providing what would be considered ‘financial benefit’ to the psychiatrist,” says Apgar. If a patient wants to see the psychiatrist involved in psychiatric collaborative care management outside of the care model, this won’t violate Stark law either, provided the physician doesn’t advertise the psychiatrist’s services, he adds.

Running the numbers

The psychiatric collaborative care model  likely will work well in practices that have a large number of Medicare beneficiaries with depression, says McVea. However, even if the volume of patients who use psychiatric services is low, physicians need to think about the severity of the patients’ health conditions, she says. 

“When you look at the people who are in the [emergency department] every single month, these are people who have a lot of behavioral health issues and who aren’t connected to care,” she says. “These could be patients who take a lot of time to treat. To be able to treat those high-cost patients and manage them more effectively, it will be the right thing to do,”

Medicare payment reform is another angle to consider. Containing costs and improving health outcomes may boost physician scores under the Merit-based Incentive Payment System, says Hutchinson. Psychiatric collaborative care management, for example, may help physicians meet quality measures such as anti-depressant medication management, screening for clinical depression, and screening for unhealthy
alcohol use.

When evaluating financial viability, physicians also need to think about psychiatric collaborative care in the context of TCM and CCM, says Hutchinson. Practices that find a way to marry each of these services from an operational standpoint, including hiring one individual to oversee all efforts, will reap the financial benefits, he says. 

“Once practices say they’re going to structure their practices around these enhanced reimbursement models from Medicare-and the practice is focused on that and they staff and coordinate it correctly-I think you could definitely make a business model out of that,” he adds.

If a practice hasn’t yet ventured into care management services, it should consider doing so, says Weida. Even small practices have the CCM and TCM volume necessary to sustain a profit, he adds. 

Psychiatric collaborative care management presents practices with an opportunity to improve outcomes while generating additional reimbursement, says Hutchinson. They’ll need to redesign the workflow, but he says it will be a win-win for most practices. “They have to make a business decision,” he adds. “Are they going to leave the reimbursement on the table or are they going to try and get the dollars?”