February 15, 2019

The National Association of Community Health Centers (NACHC), working with PCSS, launched a pilot study on how to best address intake, billing and coding procedures in community healthcare centers, critical aspects in positive patient outcomes.

Shellie Sulzberger, LPN, CPC, ICDCT-CM and Patrick Sulzberger, CPA, CHC, of Coding & Compliance Initiatives Inc. and Gervean Williams, Director of Financial and Business Practices, ,NACHC, conducted the study for NACHC and PCSS and recently issued the “MAT Documentation and Charge Capture Process: Medication Assisted Treatment (MAT)” report. The purpose of the study was to review all aspects of care outside of treatment—compliance and process improvement—which can be critical to patient care. “Creating procedures for everything from intake to billing and coding leads to better patient care,” Mr. Sulzberger says. The result of the study was defining a model that outlines each department’s responsibility toward a patient’s care. “Lack of accountability and lack of communication in even a small healthcare center can ultimately affect patient outcomes,” Mr. Sulzberger says.

The project focused on three healthcare centers: PCC Community Wellness Center in Chicago, IL; Cherokee Health Center in Knoxville, TN; and United Community & Family Services in Norwich, CT. NACHC chose the health centers because they were all treating OUD with medications and they represented both urban and rural regions. Between the centers, they are treating more than 7,000 OUD patients among 205 providers.

“They all had MAT programs in place. Our role was to study what they were doing, what was working, what wasn’t, and create a blueprint for other facilities,” Mr. Sulzberger said. “The major takeaway from this is that you need a leadership team.” No matter what the size of the center or where it is located, the greatest predictor of success is buy-in from leadership.
A strong leadership team will focus on successful execution operationally, as well as thinking strategically about the MAT program and its role within the health center overall, the report states.

“The patients treated in this program have difficult underlying issues, so the drain on physicians and clinicians can be higher than average,” Mr. Sulzberger says. “It is important to have physician leadership to educate the primary care providers and the behavioral health professionals as part of the team in an effort to provide a more holistic approach to treating patients with any substance use condition.”

This report breaks treatment into three aspects:

1) Upstream functions

  • Case management
  • Scheduling and pre-registration
  • Patient check-in

2) Delivery Functions

  • Initial assessment
  • MAT induction
  • Follow-up visits and MAT provider
  • Group and/or individual therapy sessions
  • Medication counts (as applicable)
  • Patient outreach

3) Downstream functions

  • CPT coding
  • Diagnosis coding
  • Billing
  • Claims follow-up
  • Review-re-work rejections and denials
  • Communication with upstream and delivery

Another key aspect defined to having a successful MAT program is creating a peer support network. The center that had a recovery coach on staff saw better referrals and outcomes, Ms. Williams says. “Someone who’s been there, having that advocate to speak the language is crucial,” she says.

The report addresses all aspects of patient care, including prevention, noting primary care services can play a critical role by: 1) screening patients, 2) conducting brief intervention, 3) referral for treatment, and 4) creating a process flow from primary care to MAT programs.

“Additionally, each state involved in the study had different Medicaid reimbursements,” noted Ms. Williams. In Illinois, for example, Medicaid typically goes bankrupt six months into the fiscal year. Therefore their center has to account for this temporary shortfall in reimbursement in its yearly budget. On the other hand, Connecticut’s Medicaid program is robust and provides timely reimbursement throughout the year. Tennessee’s program performs somewhere in the middle.

“Another important factor to consider is when the billing and payment posting team is experiencing rejections, denials and other barriers to payment, it is important for this information to be communicated to providers in a timely manner since they are the entry point for capturing diagnosis and CPT coding information,” Mr. Sulzberger notes.

As a result of the study and report, NACHC is planning a series of webinars to educate health centers across the country and may have an in-person training at the NACHC’s National CHI conference and other venues. PCSS will have more on the webinar series in the future.

View full report