Mental Health Billing and RCM: Succeeding in Value-Based Care Models

The mental and behavioral health care landscape is shifting. As payers and providers increasingly recognize the importance of delivering coordinated, whole-person care, organizations are actively transitioning to value-based care models that prioritize service outcomes over volumes.

And so far, it’s working: One study found that more than 75% of New York-based practices that adopted value-based care saw fewer hospital readmissions and higher post-discharge follow-up rates. The initiative also generated $204 million in cost savings.

It’s clear that shifting to a value-based approach is not just important — it’s urgent; however, the transition presents significant challenges for mental health billing and revenue cycle management (RCM) processes. With the movement already underway, organizations must act now to prepare for the rapidly approaching future of mental health billing and RCM.

What Is Behavioral Health Value-Based Care?

Value-based care is both a care delivery and a payment model designed to improve health outcomes. For behavioral health clients, this can translate to lower readmission rates, fewer barriers to care access, better treatment adherence rates, and more. In these models, providers focus on improving outcomes, and mental health billing processes are set up to hold organizations accountable for driving those outcomes.

There are several key principles behind behavioral health value-based care models:

• Outcomes, not volume: In a fee-for-service model, organizations are paid or reimbursed for services delivered. In contrast, a value-based care approach rewards providers based on measurable improvements in patient outcomes. If a client shows improvement on the GAD-7 anxiety assessment, for example, the provider is paid for that outcome.

• Holistic, individualized care: As the Centers for Medicare & Medicaid Services (CMS) notes, “In value-based care, health care providers recognize that each person is unique and can experience improved health outcomes through person-centered, coordinated care.” By valuing each client’s unique needs, reducing barriers to access, individualizing treatment plans, and focusing on delivering high-quality care, providers center their clients at every step.

• Care coordination: Since whole-person care is essential to behavioral health value-based care models, providers are required to coordinate with clinicians in other specialties. A psychologist, for example, might collaborate on care plans with a client’s primary care physician, speech-language pathologist, or school counselor. This integration helps reduce emergency situations and acknowledges the intertwining nature of clients’ physical and mental health needs. At the same time, clients take a more active role, partnering with their providers to achieve desired outcomes.

• Long-term outcomes and incentives: With a greater emphasis on outcomes, value-based care models take more of a long-term approach to client care. Organizations are required to submit data on key factors like emergency room visits related to mental health crises over time to demonstrate how they’re helping drive measurable improvements in client health.

Behavioral health organizations most often enter value-based contracts through Medicaid managed care, certified community behavioral health clinic (CCBHC) demonstration programs, and shared savings models with integrated primary care networks. These contracts often focus on reducing psychiatric hospitalizations, improving follow-up after emergency visits, and increasing access to evidence-based therapy.

Meeting Value-Based Care Requirements: Roadblocks and Solutions

Although billing and reimbursement in value-based care models are tied to the quality of care a provider delivers, most payer claims systems and mental health billing processes are still built around the fee-for-service model.

On top of that, behavioral health care is comparatively more complex, meaning organizations are facing challenges with both the current billing model and a possibly daunting transition. Behavioral health organizations often have limited IT infrastructure and workforce shortages, which makes transitioning to outcome-based contracts uniquely challenging.

That’s not where the difficulties end, but fortunately there is help. Below are four common areas where providers often run into obstacles in mental health billing and RCM for behavioral health value-based care, along with solutions to overcome them.

1. Tracking Outcome Data Within Complex Care Dynamics

Behavioral health is a particularly complicated specialty, with clients often requiring multiple visits over a long period of time, coordination with other providers, and connections with services like care homes, inpatient and outpatient facilities, and sometimes home health aides.

With so many factors to juggle, tracking outcome data — rather than service delivery data — can be difficult. In fact, the National Committee for Quality Assurance (NCQA) found that in programs designed to provide whole-person health, behavioral health providers had far more required mental health metrics to assess (85%) compared to general medical programs (19%). Many Medicaid programs, for example, require behavioral health providers to report on Healthcare Effectiveness Data and Information Set (HEDIS) measures such as seven-day follow-up after hospitalization for a mental illness, which requires coordination across inpatient, outpatient, and community-based providers.

Measuring outcomes requires not only the right data, but consistent reporting across all providers, and managing the sheer volume of metrics can strain administrative teams. But an advanced electronic health record (EHR) takes much of that manual work off of those teams.

A top behavioral health EHR, like Core Solutions’ Cx360 platform, should offer:

• A comprehensive repository of clinically validated assessments to help providers measure relevant outcomes data

• Advanced analytics that rapidly review datasets to track real-time outcomes across clients

• Intelligent dashboards with easily accessible and intuitive data reports — along with permissions-based access for coordinated providers

2. Adjusting to Outcome-Based Clinical Documentation

Value-based care requires both quantitative mental health metrics and qualitative documentation — both of which help governing organizations, insurers, and states assess the efficacy of behavioral health services.

But documentation is notoriously time-consuming and difficult to maintain with accuracy in mental health. According to some studies, behavioral health providers spend up to 13.5 hours per week on documentation alone. They also need to continually reassess patient-reported outcome measures, which adds to the administrative burden. As organizations shift to value-based care models, they’ll need to adjust documentation practices to focus on outcomes, which poses even bigger challenges for overburdened staff.

A top EHR can help with this transition by offering:

• Cross-team collaboration tools that help providers across the care continuum align on outcome-based documentation

• Artificial intelligence (AI)-powered solutions that automate and streamline documentation processes

• Evidence-based, outcome-focused workflows that aid providers in documenting client notes accurately

3. Using the Right Mental Health Billing Codes

Mental health organizations must juggle multiple billing coding standards, including ICD-10 medical codes, Current Procedural Terminology (CPT) codes, and Healthcare Common Procedure Coding System (HCPCS) codes.

Yet, these coding systems currently align with diagnoses and services delivered to clients. When adopting a value-based care model, organizations will need to shift to coding practices that reflect outcome-driven services.

A strong EHR assists in this process with:

• Customizable and rule-based coding checklists that ensure providers align codes with outcomes

• Notifications and alerts of incorrect billing codes to prevent time-consuming or costly errors

• Automation solutions for streamlining coding, saving providers and staff time

4. Ensuring Accurate Claim Submissions

With timely, accurate claim submissions, organizations are reimbursed appropriately and quickly in any care model. But in behavioral health value-based care models, linking claims to measurable client outcomes adds new complexity to the submission process. For example, organizations report longer payer review timelines and higher denial rates when outcome documentation is incomplete or inconsistent, making claim tracking tools essential.

EHRs set the foundation for accurate, outcome-focused claim submissions by:

• Formatting and cleaning claims in alignment with customizable templates

• Tracking claim status and flagging denials to enable teams to immediately address issues

• Offering administrative checklists for regular claim audits so organizations can fix overarching errors

Setting the Right Foundation

Adjusting to mental health billing and RCM in a value-based care model will be just that: an adjustment. But it doesn’t have to come with the growing pains many organizations anticipate. By shifting workflows, data collection procedures, and billing processes to focus on whole-person, outcome-oriented care, organizations can set the foundation for long-term success. And by training staff regularly on what it takes to make value-based care work effectively, organizations can secure staff buy-in and minimize hiccups.

An advanced solution like the Cx360 Enterprise platform can support all of these goals and more. With embedded AI-powered solutions and robust revenue cycle management capabilities, the platform can help ensure organizations don’t lose time, money, or resources as they shift to a new model of care.

Reach out today to discover how Core Solutions’ advanced technology can help you navigate this complicated transition.