Substance Use Disorder

RCPA has become aware that there have been higher than normal claims denials by both Medicare and Medicaid related to certain diagnoses. Those diagnoses are Schizophrenia and Post Traumatic Stress Disorder (PTSD) as defined by the DSM-V and ICD-10.

The DSM-V only identifies Schizophrenia Not Otherwise Specified (NOS) and PTSD NOS, versus the ICD-10 which offers eight schizophrenia diagnoses and three PTSD diagnoses. As a result, our practitioners are likely choosing Schizophrenia or PTSD NOS, since they are mostly using the DSM-V. Billing staff have options of eight or three diagnoses respectively, but will use what the practitioner has selected, the only DSM-V diagnosis available. It is highly probable that the individual being evaluated meets something other than NOS. There are very specific criteria for the NOS diagnosis which can certainly be used as the criteria is met, but when the criteria is not met, the claims are accurately denied. RCPA wants to hear from you about how this is affecting your business.

The second billing issue is related to electronic health records (EHR) that have not yet loaded the ICD-10 codes for billing. It is our understanding that there are at least two vendors doing business in Pennsylvania who have not loaded the ICD-10 billing codes into the EHR. RCPA wants to hear from members about how they are billing in the absence of the EHR, not having the ICD codes, and other universal billing concerns.

Please find more information about claims rejections here. Send comments to Sarah Eyster by Friday, April 15.

In recent years, the Office of Mental Health and Substance Abuse Services (OMHSAS) had received concerns regarding the Bureau of Children’s Behavioral Health Services (Children’s Bureau). Four major themes emerged from this feedback relating to communication, regulations and policy, operational consistency, and system partner engagement. Last spring, OMHSAS engaged Mercer Consulting to conduct a study of the Children’s Bureau that included three two-hour focus groups with OMHSAS system partners, including representatives from RCPA. The primary goal of the review was to identify ways in which OMHSAS can improve internal operations as well as communication and collaboration.

On Tuesday, Deputy Secretary Dennis Marion shared both an executive summary of the Mercer Independent Study as well as his description of the steps forward that OMHSAS has initiated in response to the concerns and findings. The action items outlined by Deputy Secretary Marion are:

  • Review and consolidation of regulations related to Behavioral Health Rehabilitation Services (BHRS). OMHSAS will engage with stakeholders to draft regulatory changes with the expectation that proposed BHRS regulations will be released for public comment in mid-2017.
  • Strategic reorganization of OMHSAS leadership. On March 7, Shannon Fagan joined OMHSAS as Children’s Bureau director, and Sherry Peters became director of the Bureau of Policy, Planning, and Program Development.
  • Organization-wide effort to improve consistency and quality. Moving forward, OMHSAS senior staff will focus on identifying areas of potential improvement, developing strategies to strengthen internal and external processes, promoting an organizational culture of collaboration, coordination, communication, and cohesiveness, and monitoring progress towards addressing the concerns voiced by OMHSAS stakeholders.
  • Emphasis on family and stakeholder engagement. The involvement of PACA, RCPA, BH-MCOs, and their contractors, played an integral role in working to identify issues of concern.
  • A redefining of “customer service.” To address concerns relating to responsiveness and professionalism, internal meetings have been held to stress the importance of holding OMHSAS staff to high standards of customer service.
  • Renewed focus on communications. In response to concerns regarding effectiveness of internal and external communications, Shanna Klucar was appointed as executive assistant to the deputy secretary on January 30.

OMHSAS invites RCPA members and other stakeholders to share comments and concerns regarding Children’s Behavioral Health Services to Shannon Fagan, bureau director, as well as the RCPA Children’s Division. In addition, members may contact OMHSAS leadership Sherry Peters and Shanna Klucar with more general comments and concerns.

The Department of Human Services (DHS) Medical Assistance Online Provider Enrollment Application information is now electronic, online, and available to provider organizations. The improvements and modernization of the PROMISe system have been strongly encouraged by RCPA and a significant goal of DHS. Some of the benefits of online enrollment application submissions are:

  • Allowing documents that previously had to be mailed or faxed to be uploaded directly to the portal;
  • Permitting providers see the status of their submissions; and
  • Decreasing wait time to review applications.

The information you will need to submit an application for enrollment:

  • Access the online enrollment application
  • Review the training guide
  • Review the frequently asked questions document for important clarifications
  • A “Help” feature is available at any time during the completion of an application
  • Supplemental Services require the Behavioral Health Managed Care Organization to attest that a provider is credentialed

RCPA has been advocating for years for significant changes to the Mental Health Outpatient regulations to help to protect and strengthen mental health outpatient services in Pennsylvania. In 2010, RCPA developed a position paper outlining the major problems in this area. In response to this crisis, the Office of Mental Health and Substance Abuse Services (OMHSAS) developed a task force to work on regulation changes. The task force was a broad range of stakeholders which included consumers, counties, providers, and behavioral health managed care organizations. The task force worked for several years to develop a new set of regulations intended to protect and strengthen mental health outpatient services. The job of the task force was complete in 2014 and OMHSAS submitted the revised regulations to internal sources for approval. From beginning to now, it has been six years since we requested help. OMHSAS responded with strong support but the regulations have been held up in various areas of the department and the administration.

We received the following email today from Jean Rush, who has been the lead at OMHSAS since the beginning of the project:

“I wanted to share the current status of the OP regulation package since we drafted the revisions. With the expansion of Medicaid, the department has made changes to our State Plan Amendments for compliance with ACA which have been approved by CMS. This will require some minimal changes to the OP regulation package which were not an issue during our work.

OMHSAS will be making the minimal changes to the regulation package in conjunction with the Office of Medical Assistance Programs (OMAP) as the Medicaid Authority for the Commonwealth, as well as our Office of Legal Counsel.

The changes will not impact your recommendations but are necessary for compliance and the ability to complete the IRRC review. We will share the changes with you via email and if there are any areas where input is needed, I will be contacting you to schedule a call to discuss.

We appreciate all of the time and dedication to this project and will continue to work on making the changes to move this regulation package to completion. It is still a priority for the department.”

RCPA is hopeful that a resolution is forthcoming and will keep you all posted.

Time is running out; the deadline for revalidating is Thursday, March 24, 2016. Numerous RCPA members have already gone through this process, but it appears that large numbers of providers have not yet done so. A special provider revalidation webinar will be held by RCPA on Wednesday, January 6 at 10:00 am. Jamie Buchenauer, from the Department of Human Services, will be presenting the webcast.

This article from Capitolwire is a good and extensive overview of what is going on with the budget here in Harrisburg. Health and Human service budget line items are still fluid until the House and Senate negotiate a final budget deal. RCPA will provide updates on any budget deal, and RCPA encourages members to continue to contact the governor and state legislators to inform them why it’s necessary for them to pass a state budget sooner rather than later. Questions, contact Jack Phillips.