Behavioral Health Network
Chair: Brenda Goldstein-LifeLong Medical Care
CPCA's 2013 Behavioral Health Meeting Schedule
(Materials and conference call information will be sent our prior to each call)
**Note: all meetings will take place at CPCA and will inlude a working lunch
Thursday, June 20 (10 am - 2 pm)
Thursday, September 12 (10 am - 2 pm)
Thursday, December 5 (10 am - 2 pm)
In May 2012, the California Primary Care Association’s Behavioral Health Network surveyed community clinics and health centers (CCHCs) about the broad scope of behavioral health services provided to their patients. Staff from 40 CCHCs, the majority of whom were the behavioral health directors, responded to the survey. One survey was completed per health center even if they had multiple sites. Of the respondents, 88% were FQHCs and 10% were lookalikes. A series of fact sheets were developed to summarize the results.
- Integration of Physical and Behavioral Health Services
- Substance Abuse
Chronic Pain Management
CPCA offered a webinar that reviewed data on prevalence and current recommendations of management of Chronic Pain patients and emphasizes the importance of having a Pain Management Program to alleviate stress from the practice. The speaker outlined patient risk types and recommended treatment for those identified with Chronic Pain. Recommendations include: establishing contract agreements, frequency of office visits, incorporating additional educational sessions, and monitoring urine toxicology. Real-life scenarios of Chronic Pain Patients were also shared as an interactive component to provide hands-on demonstration of ways to improve the overall patient experience.
Golden Valley Health Centers has graciously offered to share with their peers some of the protocols and materials that they have created for their chronic pain program. It is hoped that these will be helpful tools as other health centers embark on developing chronic pain programs to serve the needs of their patients.
- Pain Management Intake Assesment
- Addiction Education Patient Handout
- Patient Care Agreement
- Revised Chronic Pain Instructions
- Opiod Risk Tool
- Chronic Pain Summary
Psychology Services at FQHCs
CPCA expressed their concern with DHCS over the recent audit findings where psychology visits exceeding two per month were disallowed. DHCS observed that no TAR process exists for FQHCs, but suggested that, when billing for visits in excess of the two-per-month limit, providers document the medical necessity for the visits.
CPCA asserted that Medi-Cal utilization controls such as the two-visit limit do not apply to FQHCs in the first place and that there is no basis for requiring additional documentation, noting that the HRSA Bureau of Primary Care Services October 31, 2003, Program Information Notice (doc. No. 2004-05) states that state Medicaid agencies are “required to reimburse FQHCs and RHCs for behavioral health services provided by [clinical psychologists and clinical social workers] whether or not those services are included in the State Medicaid plan.” We also informed them that California Welfare and Institutions Code sections allow psychology services and state that FQHCs shall be paid PPS.
A & I staff acknowledged that the state was sued and lost at the trial court in the issue of limiting psychology services to 2 visits but that they were directed to continue this practice until the appeal is resolved. DHCS indicated once the appeal is concluded, CPCA will have the needed clarity on this issue.
Unfavorable Apellate Court Decision on 2-Visit Limit for Psychology Services in FQHCs
On May 2, the California Court of Appeal 3rd District (Sacramento) rendered an opinion in Mendocino Community Health Clinic v. Department of Health Care Services that is unfavorable to FQHCs. The key issue in the case is whether the Medi-Cal program may apply the two-visit per month visit limitation per beneficiary on psychology services when these services are provided by FQHCs. The plaintiff argued that the utilization control on psychology services does not apply to FQHC services because under federal law the State is required to reimburse FQHCs based on 100% of their reasonable costs and on a per visit basis for FQHC core services and because the California Code section that established FQHC services as a Medi-Cal covered benefit does not impose utilization controls on FQHC services. The Court of Appeal decision overturns the lower court’s finding that the utilization controls on psychology services does not apply to FQHCs because these are core FQHC services that must be fully reimbursed.
The Court of Appeal reasoned that the Medi-Cal program’s utilization controls on psychology services applies to FQHCs because 1) there is nothing in federal law that prevents the State from imposing utilization controls on FQHC services and 2) state law imposes utilization controls on outpatient psychology services.
In its decision, the Court criticized the plaintiff for reading too much into the statutes to support its case, yet the court wasted no effort in doing precisely the same thing to come to its conclusion. The Court said "The norm is that states can impose utilization controls to manage Medicaid funds, so we will not impute to Congress an intent to have the states pay for unlimited psychology services rendered to Medicaid patients by FQHC’s without evidence that Congress so intended." The Court also found no significance to the fact that the California statute does not explicitly impose utilization controls on FQHC services. The Court said: "… the absence of reference to utilization controls in the statute concerning FQHCs could just as easily result from the Legislature’s view that because the FQHCs are rendering outpatient services, they are subject to the already existing statutes and regulations concerning utilization controls applicable to outpatient clinics." Ultimately, the court found that because the California Code section that provides for FQHC reimbursement is found in the same chapter of the Code that imposes utilization controls on "outpatient clinic" psychology services, the utilization controls apply to psychology services provided by FQHCs. With this faulty reasoning, the Court basically deferred to the Medi-Cal agency’s interpretation of the law.
The final disposition of the case is pending. It is unknown at this time whether the plaintiff will appeal.
The decision affects all FQHCs that provide psychology services. (The court did not address limits on psychiatry services, but based on the court’s reasoning about limitations on psychology services it would follow that, had the issue been before the Court, the regulatory limit on psychiatry services would also apply to FQHC services.)
Pending final resolution of this case, CPCA continues to caution FQHCs not to bill for psychology and psychiatry visits that exceed the regulatory limits per beneficiary, as the Medi-Cal program will most likely disallow these excess visits unless there is an approved Treatment Authorization Request (TAR). The catch is that the Department of Health Care Services has repeatedly maintained that there is no administrative process in place for FQHCs to seek TARs. If you have specific questions about the case or how this decision will specifically impact your operations, CPCA advises you to contact your legal counsel.
CPCA Staff Contact
For questions please contact our Assistant Director of Clinical Affairs, Petra Stanton at email@example.com or 916.440.8170.