Early Health System Experiences with Collaborative Care (CoCM) Billing Codes: a Qualitative Study of Leadership and Support Staff

Abstract

BACKGROUND: Although collaborative care (CoCM) is an evidence-based and widely adopted model, reimbursement challenges have limited implementation efforts nationwide. In recent years, Medicare and other payers have activated CoCM-specific codes with the primary aim of facilitating financial sustainability. OBJECTIVE: To investigate and describe the experiences of early adopters and explorers of Medicare's CoCM codes. DESIGN AND PARTICIPANTS: Fifteen interviews were conducted between October 2017 and May 2018 with 25 respondents representing 12 health care organizations and 2 payers. Respondents included dually boarded medicine/psychiatry physicians, psychiatrists, primary care physicians (PCPs), psychologists, a registered nurse, administrative staff, and billing staff. APPROACH: A semi-structured interview guide was used to address health care organization characteristics, CoCM services, patient consent, CoCM operational components, and CoCM billing processes. All interviews were recorded, transcribed, coded, and analyzed using a content analysis approach conducted jointly by the research team. KEY RESULTS: Successful billing required buy-in from key, interdisciplinary stakeholders. In planning for CoCM billing implementation, several organizations hired licensed clinical social workers (LICSWs) as behavioral health care managers to maximize billing flexibility. Respondents reported a number of consent-related difficulties, but these were not primary barriers. Workflow changes required for billing the CoCM codes (e.g., tracking cumulative treatment minutes, once-monthly code entry) were described as arduous, but also stimulated creative solutions. Since CoCM codes incorporate the work of the psychiatric consultant into one payment to primary care, organizations employed strategies such as inter-departmental ledger transfers. When challenges arose from variations in the local payer mix, some organizations billed CoCM codes exclusively, while others elected to use a mixture of CoCM and traditional fee-for-service (FFS) codes. For most organizations, it was important to demonstrate financial sustainability from the CoCM codes.CONCLUSIONS: With deliberate planning, persistence, and widespread organizational buy-in, successful utilization of newly available FFS CoCM billing codes is achievable.

Use of Medicare’s Behavioral Health Integration Service Codes in the First Two Years: an Observational Study

“…Indeed, early adopters of BHI codes have struggled to implement feasible and sustainable staffing, care delivery, and billing practices. 3 Other codes for similar enhanced coordination services (e.g., Chronic Care Management) also experienced low initial take-up, though not to the same extent. 4 This suggests that the structural investments required for BHI services may be particularly challenging.…”

“…Organizationally, practices with low or uncertain BHI service volumes could explore sharing personnel and contract structures with other local practices, and consider how to utilize staff that can deliver and bill for both behavioral health and other types of care management. 3 Use of BHI codes in the first two years was low, but grew steadily. Identifying the characteristics of participating provider organizations, and the clinical utilization patterns of BHI service users, will help inform payment policy and organizational implementation strategies that can support BHI as part of more comprehensive care management infrastructure.…”

Translating economic evaluations into financing strategies for implementing evidence-based practices

“…Moreover, it is important to consider patients’ active roles in financing care: to what extent is it feasible, equitable, and ethical to use co-pays or other patient payments to fund EBPs? To the extent possible, financing strategies should be straightforward and target the level(s) or system(s) that produce the largest improvements in implementation outcomes; complex strategies may require their own implementation support, as considerable challenges to execution have been observed [ 69 , 70 ].…”

Uptake of Medicare Behavioral Health Integration Billing Codes in 2017 and 2018

“…Qualitative research has identified barriers to using the CoCM codes and a recent study based on a random sample of Medicare beneficiaries found that 0.1% of those with behavioral health conditions received services through either type of code in 2017 and 2018. 3 We expanded on that study to examine the uptake of these codes among a different group of beneficiaries-those with behavioral health conditions attributed to primary care practices, as those with primary care providers are most likely to benefit from these codes. We also examined whether the types of diagnoses and providers differed between CoCM and BHI claims, and if claims were concentrated within practices and states.…”