Fall is here in Ohio, and we all continue our march towards a redesigned behavioral health system in Ohio. The amount of training, and opportunity to understand what is changing and how it will impact service delivery models and funding is significant, though definiative conclusions and clear operational direction is harder to come by right now. That being said, I did walk away from a couple of trainings recently with some pieces of information that I believe are relative for some of you who have not “got the memo” yet.
Dual Eligibility and Social Workers
Having been trained as a Counselor vs a Social Worker, I always enjoyed the ribbing our two professions gave each other. And yes, I usually start it. Regardless, one thing that Social Workers (LISW) have always been able to do over Counselors, is to provide therapy services to people who have Medicare. What was less clear was exactly how an operation addresses the fundamentally understood rule that Medicaid is the payor of last resort, when a person comes into your clinic dually eligible for Medicaid and Medicare. Mind you, what I am going to tell you is not necessarily different to how things have always functioned, but it was not really expressed as policy. Operationally, if a client comes in to your clinic with dual eligibility, but you do not have an LISW available to start treatment, an agency can instead provide the necessary credentialed professional that meets Medicaid requirements, and access Medicaid for the purposes of paying for treatment services. In other words, if an agency does not have the properly credentialed person necessary to trigger payment from the Medicare system, they may instead, assuming dual eligibility, use professionals that meet Medicaid regulations and bill Medicaid directly. What the state is adding, during the re-design of our behavioral health system, is a method that prevents billing Medicare first, in order to receive a denial of service and then accessing Medicaid payment.
While this may not come as a surprise to everyone, from the questions at the different meetings I have attended, the ability to by-pass Medicare for Medicaid is not known to all. I liken it to the ability to access an out of network provider in your own health insurance plan, without penalty. Basically – that is not allowed to happen, so this idea does not fit within the confines of our own experiences easily. None the less, operations should be quick to understand this and realize that, for the dual eligible populations at least, an LPC or LPCC (we got our “L” back in all the confusion) is able to treat and be productive for this part of your clinic.
I will make this topic short and sweet. There are no service limits associated with treatment to children. To say it in a different way, there are no prior authorization requirements for treatment to children. My belief is that less people knew that, than the ability to bill Medicaid instead of Medicare if there is only a Counselor available to provide treatment. What is important to understand, however, is that even though there are no prior authorization requirements for children receiving mental health treatment, the state of Ohio will still issue advisement letters when you go past the service limits defined for adults. Many of us understood these limits as a firm line in the sand, vs a suggestion. I interpret an advisement letter as a reminder that the state is taking seriously the management of its behavioral health resources, and wants to make sure that, as an agency, you have clear, medically necessary, documentation to support the service level.
Behavioral Health Redesign
TIL Consulting will continue to monitor the progress of rules and training materials as well as be available to provide technical assistance on operational challenges the re-design will have on your agency.