Behavioral Health
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Medicaid is the single largest payer for mental health services in the United States and is playing an increasingly larger role in the reimbursement of substance use disorder services and in developing effective strategies to combat the current opioid epidemic. We support our clients’ policy, reimbursement, auditing, and program integrity needs with a variety of mental health providers, including: individual professionals, such as psychiatrists, clinical psychologists, and clinical social workers; outpatient psychiatric hospital services, such as those provided by community mental health centers (CMHCs) and certified community behavioral health clinics (CCBHC); and inpatient psychiatric hospital services, such as services provided by psychiatric residential treatment facilities (PRTFs). Our firm supports states’ efforts to further expand and enhance behavioral health access, services, and integration.

Myers and Stauffer has extensive experience in assisting state Medicaid agencies with effectively designing, reimbursing, and overseeing medical, behavioral health, and long term services and supports to vulnerable populations with mental health or substance use disorders. Our key competencies include: reimbursement system modeling, development and process design; rate setting, analysis, and reporting; cost gathering, review and audit; provider appeals; stakeholder training; waiver consulting; and regulatory and state plan development and technical support.

We provide the following services:

Audit and Attest

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Bob Hicks, CPA
Member
bhicks@mslc.com

816.945.5321

Many behavioral health programs are relatively new and have not traditionally been included in the cost reporting structures developed by Medicare and Medicaid. However, we have assisted states in developing appropriate cost gathering tools and providing validation services to assure the states and providers that costs are being reported consistently and in accordance with program criteria. Our firm has experience supporting our clients’ audit and attest needs for CMHCs, PRTFs, CCBHCs, and other behavioral health providers. Our services include:

  • Develop cost reporting tools.
  • Cost report collection.
  • Web-based data exchanges for cost reports, supporting documentation, and related information.
  • Cost report database management, analytic, and reporting systems.
  • Audit and attest work programs and standardized work papers.
  • Attest protocols compliant with state and federal definitions.
  • Risk assessments to target audit work.
  • Training programs for clients, providers, and other stakeholders.
  • Claims management and audit systems.

Rate Setting and Reimbursement

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Tim Guerrant, CPA
Member
tguerrant@mslc.com

317.846.9521

Behavioral health providers can have complex structures, lines, and actual service offerings. Myers and Stauffer brings an in-depth understanding of the goals and objectives of both providers and state agencies when we establish rates for behavioral health services. Our team works from the premise that rate setting must be accurate, transparent, and predictable, while simultaneously demonstrating that payments are sufficient to support the delivery of high quality, cost-effective services, and promote good health outcomes. As with all public programs, as change occurs, innovative approaches are necessary. We put our experience to work for our clients, as evidenced by our work in assisting our state clients with applying for and securing grants to establish CCBHC providers. We provide services such as:

  • Cost report design.
  • Web-based submission and communication system design (web-based portal) for cost report and documentation.
  • Cost reporting tools development for state specific criteria.
  • Cost report collection, database management, and analytics.
  • Cost report monitoring.
  • Develop cost-based rates.
  • Develop fee schedule rates.
  • Cost settlement calculations and notice of program reimbursement.
  • State plan amendment and administrative code consulting.

Medicaid Financing and Reporting

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Jared Duzan, CFE
Principal
jduzan@mslc.com

317.846.9521

Medicaid financing and reporting processes such as the upper payment limit (UPL), intergovernmental transfers, certified public expenditures (CPE), provider assessment fees, and other approaches should be aligned with funding with policy objectives. These programs may create opportunities to leverage federal funding or to maximize state funding to better address behavioral health challenges. Our team, which includes former Centers for Medicare & Medicaid Services (CMS) analysts, has many years of experience and a variety of skillsets that we have used to address federal reporting needs for many state clients. For example, we have helped states resolve issues impacting outstanding grant award finalizations. Our ultimate goal is to provide our clients with the training, knowledge, tools, and skills necessary for state agency staff to fully manage the federal reporting process. Our services include:

  • Demonstrate federal UPL.
  • Compliance for institutions for mental disease (IMD) and PRTFs.
  • CPE calculations.
  • Assist states with identifying and applying for grants to supplement Medicaid financing.

Delivery System and Payment Transformation

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Jerry Dubberly, PharmD
Principal
jdubberly@mslc.com

404.524.9519

Myers and Stauffer is an innovator in assisting government-sponsored health care programs with the development of delivery system and payment transformation initiatives. We aim to help our clients improve access to behavioral health services and supports and improve health outcomes. Our behavioral health delivery system and payment transformation services include but are not limited to:

  • Stakeholder engagement.
  • Pursuit of federal authorities to accomplish programmatic objectives.
  • Integration of behavioral health and physical health.
  • IMD and substance use disorder (SUD) strategies.
  • Value-based contracting and alternative payment models.
  • Selection and use of quality measures.
  • Medicaid health homes for individuals with behavioral health needs.
  • CCBHC establishment, expansion, and improvement.
  • Data analytics and dashboards: performance measures, improvement target goals, provider attribution, and key performance indicators.

Benefit/Program Integrity

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Ryan Farrell, CFE
Principal
rfarrell@mslc.com

512.342.0800

Through our benefit/program integrity services, we review behavioral health programs, including services to children with severe emotional disturbance and adults with chronic mental illness. Behavioral health services reimbursed by a state Medicaid program can cover a broad range of services, such as clinical and rehabilitation services provided in a variety of settings like community mental health centers, residential treatment centers, and schools or other community locations. Our approach uses computerized analyses to aid in the detection of improper provider billing practices including: services not rendered, services in excess of policy limits, duplicate services, and unreasonable service duration.

In addition to claims data analysis, Myers and Stauffer conducts reviews of provider service records focused on assessing the accuracy and completeness of the documentation for services billed to Medicaid with specific emphasis placed on the provider’s adherence to state Medicaid statutes, regulations, and policies. Our reviews of applicable documentation includes: intake assessments, results of psychological testing, treatment plans, status reviews, service authorization records, time sheets and other service notes, and any other applicable documents. Services include:

  • Claims analysis.
  • Post-pay claims audits – clinical and financial.
  • Pre-pay claims audits – clinical and financial.
  • Medicaid recovery audit contractor (RAC) services.
  • Software modules for surveillance and utilization review subsystem (SURS), fraud and abuse detection services (FADS), and case tracking.
  • Provider compliance.
  • Payment system processing accuracy.
  • Fraud, waste, and abuse detection (FWAD) litigation support.

Managed Care Oversight and Compliance

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Mike Johnson, CPA, CFE
Member
mjohnson@mslc.com

404.524.0775

Behavioral health services delivered in a managed care environment can sometimes create unique challenges. This service delivery model typically requires an additional layer of oversight due to the manner in which most managed care plans delegate behavioral health services to a third party vendor. Analyzing the administrative and medical loss payments can be challenging, to ensuring that the appropriate safeguards are in place for network adequacy and access to services.

Myers and Stauffer’s managed care team has experienced these issues firsthand. We have successfully on-boarded managed care plans and conducted on-going operational reviews. Myers and Stauffer offers a comprehensive portfolio of managed care oversight and compliance services, which can be applied generally to all provider categories, but also to behavioral health. These services include:

  • Encounter data reconciliation and validation.
  • Financial audits, performance audits, and program effectiveness audits.
  • Network adequacy assessments and member access compliance.
  • Readiness reviews.
  • Claims payment and denial assessments, accuracy, and timeliness.
  • Medical record review.
  • Grievance and appeals analysis.
  • Contract compliance.
  • Other provider-specific issue review and resolution activities.

Waivers

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Jerry Dubberly, PharmD
Principal
jdubberly@mslc.com

404.524.9519

Our expertise in delivery system and payment transformation, strategic planning, financial analysis, rate setting, and project management enables us to help our clients evaluate their needs and identify the appropriate federal authorities necessary to achieve their objectives. We have worked closely with states and CMS to gain approval for the design and implementation of a variety of state initiatives. Myers and Stauffer’s waiver services include, but are not limited to:

  • Strategic planning, stakeholder engagement, and CMS negotiation support.
  • Designing, implementing, and evaluating 1115, 1915(b), and 1915(c) waivers.
  • Cost effectiveness, cost neutrality, and budget neutrality calculations.
  • Waiver compliance and quality oversight reporting.
  • Reimbursement and rate setting.
  • Program integrity.