State can’t track behavioral health programs, legislators told

by Steve Brawner ([email protected]) 129 views 

Twenty-three percent of all Arkansas Medicaid claims for three types of behavioral health services involve multiple claims on the same day, raising questions the program can’t answer regarding how many of those claims are legitimate.

That was one of the findings discussed Wednesday by The Stephen Group, a health care consultant advising the Health Reform Legislative Task Force, which is a group of legislators considering health care reform.

Lead consultant John Stephen told legislators that the state spent $464 million on behavioral health programs in 2014 but lacks the outcome metrics that would enable the program to assess the value of the services provided.

The Stephen Group looked at three types of claims – individual psychotherapy, rehabilitative day service, and intervention by a mental health professional – and found that 23% of the claims in those three areas occurred on days when there were second and third claims in one or more of the groups.

Sometimes claims were made for the same medical code on the same day, with no way to know if the additional billings were clinically supported. For example, 7% of claims for counseling and therapy sessions involved multiple claims on the same day. The 56,268 multiple claims, with an average claim of $97.72, cost the state $5.4 million.

Eliminating all the multiple claims for those three services would save the state $40 million a year. However, Stephen emphasized that the findings do not necessarily reflect widespread fraud. It’s possible that the multiple claims improve patient outcomes. The bigger issue is that the state’s Medicaid program lacks the ability to determine if that’s the case.

The consultants advised the Department of Human Services to immediately implement changes to begin managing behavioral health costs. Among the specific recommendations was to require advance approval for multiple uses of the same code or of certain codes such as those three that are often used together. DHS should create measurable outcome metrics for the various types of services. Master treatment plans should be audited, and penalties created.

Stephen told legislators that part of the problem lies with constitutional and legal issues that prevent the Medicaid program from having the flexibility it needs to make evidence-based changes. Those issues make Arkansas one of the most difficult states for a program to make reforms.

In 2014, voters approved a constitutional amendment giving legislators the ability to approve all rules changes. John Selig, DHS director, said this has created a cumbersome process that at times can overwhelm legislative committees.

“It just creates a huge opportunity,” he said, “if we’re trying to make a significant change in a program, and there could be a hundred pieces of that change, of that package, that’s a hundred opportunities for some stakeholder group to say, ‘We don’t like that, and so … could you hold that up until the next committee?’ And each of those changes actually goes through at least three committees. … It is a very burdensome process for us to make changes, and we’ve often found that when we try something significant, it looks like we’re only going to do some small pieces of it through, and so we back off.”

Meanwhile, Arkansas’ Medicaid Fairness Act places a high burden of proof for the Medicaid program to deny payment for unnecessary services. Selig said there’s nothing like it anywhere else. Stephen agreed that the act needs to be changed, saying, “It’s going to be a real problem if you don’t change that particular area to get any savings out of behavioral health.”

Dawne Stehle, director of DHS’ Division of Medical Services, told legislators that DHS did attempt to make changes to the program in a process that occurred in 2014. The program ran into a roadblock during the public comment period with stakeholders worried about the proposed changes. Meanwhile, the state was changing gubernatorial administrations and then the task force was created, all of which caused the process to stop.