CalAIM is a California statewide multi-year initiative to transform and strengthen existing Medi-Cal, the statewide Medicaid health insurance system. Medi-Cal is run by the California Department of Health Care Services (DHCS) and covers numerous things including, but not limited to, adult health, dental, managed care, children’s medical care, mental health, and substance abuse treatment. The first changes of the CalAIM initiative were rolled out in January 2022 and additional reforms will be phased in through 2027. The goals for the program are: (1) identify and manage comprehensive needs through “whole person care,” (2) improve quality outcomes and reduce health disparities, and (3) make Medi-Cal more navigable for enrollees.
CalAIM is designed to significantly transform the treatment of mental health and substance use disorders and requires service provider organizations serving Medi-Cal members to adhere to new rules and regulations. The current system Medi-Cal system depends on county-based plans that manage adults with severe mental illness (SMI) and youth with serious emotional disturbance (SED). The mild-to-moderate population is managed via a carve-out model through the state’s health plans under Medi-CAL. Under the CalAIM plan, Medi-CAL is being redesigned to create incentives for coordination and integration. One of the biggest changes is that Medi-CAL’s managed care organizations (MCOs) will now be included in the SMI/SED service delivery system. Eventually, the role of the MCOs and the counties will shift to support the goals of whole person care and fully integrated care for all Medi-CAL recipients.
As the implementation of CalAIM proceeds, service providers will see a diminished role for the counties and an increased involvement of the MCOs in the role of managing whole person care. This can present challenges for providers who are used to complying with county-based rules. These providers will be responsible for ensuring adherence with the MCO administrative rules, particularly during the transition phase, regardless of who manages or acts as the payer.
Traditionally, the focus of the typical electronic health record (EHR) has been on service delivery workflows, but now service provider organizations face the necessity of incorporating a comprehensive view of the whole person, including social determinants of health (SDoH), physical health reporting requirements, and social service needs. For service providers in California, an EHR is required for the billing and reimbursement complexity of CalAIM. Besides the standard operational support offered by an EHR, there is a need for new and enhanced functionalities. Three specific areas of increased focus include client experience, documentation flexibility, and revenue cycle management.
Consumer Experience Factors for Clinical Success
The increase of newer models of care such as hybrid service delivery with telehealth and in-home care delivery coupled with an enhanced focus on consumer choice, will increase provider dependance on EHR to support client engagement. The increased role of the MCOs and the decreased roles of the counties creates additional choices for clients as they are selecting their treatment providers. Therefore, technology is required to satisfy the mission critical functions of client engagement, mobile tools, virtual care capabilities.
Consumer experience in health care has not, in the past, received the attention that it has in other marketplaces. However, we know that engagement in behavioral health care is an important factor for clinical success. Once clients have choices about where they want to get their care, the type of care they want, and how they want to access the care, provider organizations will need to embrace the client experience. Technology plays a strong part in client engagement, and providers will now have to consider how clients or families might interact by pre-screening on a website, scheduling appointments using a mobile device, being able to see health status via the web, etc.
Other areas that require the use of technology, and that will be required as consumers embrace their choices in treatment organizations, are outcomes reporting and management. Being able to see the performance of an organization before you select them as your care provider is a significant differentiator under CalAIM. As outcomes reporting becomes increasingly widespread and reliable, more and more potential clients will use them as a factor in selecting a care provider.
The increased focus on the human experience is generally changing communications with individuals receiving behavioral health care services and their families. As providers concentrate on whole person care and integrated care, other facets of interaction and support for those receiving services are evolving.
Key needs and solutions to support client engagement include:
- Mobile Service Delivery: EHR solutions with integrated mobile capabilities are becoming increasingly important as CalAIM
- Virtual Care Solutions: Clients are seeking out providers that have virtual appointment options available as they are selecting their treatment providers.
- Client engagement tools: Patient portals, appointment reminders, and secure messaging align with increased attention to outcomes and quality measures. Assessments and screens that can be shared through a portal bring efficiency and ease of use for clients and providers
Documentation Flexibility Need to Support CalAIM
As California, the counties, and the MCOs modify their requirements, including moving from treatment plan to problem lists, one of the areas of EHR functionality that is especially important is the ability to add and modify existing documents to comply with CalAIM rules. The ability to configure documentation without requiring computer programming, and with minimal disruption for the clinical staff, will be required for success.
One of the reasons that documentation flexibility is growing in importance is that California is committed to integrated and coordinated care. Therefore, data sharing is part of the overall strategy for success in CalAIM. Standardization of documentation and the ability to collect information as discrete data is a requirement for these expectations.
An additional functionality that is integral to care transformation is the use of measurement-based care. This type of care requires flexibility in data collection and data capture during the treatment process. This means that it is either dependent on, or supported by, ease in creating and implementing clinical documents/data collection instruments. The ability to connect to reporting outcomes, and to those required for fidelity reporting, mandates that the documentation that occurs during treatment interactions is able to support these models.
Perhaps one of the most important uses of data collected via documentation customization is pulling those data through to various dashboards used to demonstrate progress. Dashboards are more than just static performance indicators. They are also benchmarks of performance indicators, so that they can be improved before the reporting period ends. These dashboards enable timely insights into client health and progress aligning with quality improvement initiatives, measurement-based care, and whole person views of a specific client.
Documentation needs for organizations to succeed in CalAIM are likely to include:
- Integrated treatment plans: Flexible and adaptable treatment plans across the continuum of care that can be self-managed by agencies to add and change programs, services and workflows as Cal-AIM continues to evolve will support provider agencies through this transformation.
- Reporting and Compliance: Clinical documentation integrated with analytics and outcomes supports data gathering for reporting requirements and measurement-based care within workflows at the convenience of staff without interruptions for providers or clients
- Analytics and Outcome Metrics: Visibility and transparency into clinical outcomes with dashboards and ease of use supports clients and providers by making clear where programs and services are succeeding and where additional focus is needed.
- Business Intelligence (BI): Dynamic and customizable BI dashboards enable real-time data insights so agencies can evaluate service delivery costs and identify performance improvement opportunities.
Revenue Cycle Management for Medi-CAL
Revenue Cycle Management (RCM) is one of the most important functions of any behavioral health care provider organization. Often thought of as “simply billing,” RCM is instead one of the primary sources of reliable data for an organization. In addition to assuring reimbursement for services rendered, RCM can be seen as integral to organizational strategy. An operational approach to RCM can provide behavioral health agencies with numerous benefits, including the ability to understand workflow, measure standards of care, determine the cost of providing a service, and provide a basis for all quality, and other required reporting.
At its core, RCM processes and systems should ensure that encounters and claims submitted are accepted by the payer/manager of care. In a fee-for-service world, unless the claims are accepted, they cannot be paid. This results in lost revenue, or increased days in accounts receivable, or even the need to write off services completely.
Beyond that, once expanding into value-based contracting or alternative payment models, RCM takes on a new level of importance. Because of use of encounter data (meaning CPT (Current Procedure Terminology) codes, DSM-5 diagnosis codes, other service codes, ICD (International Classification of Disease) codes, etc.), and other reporting, even in a fully risk value-based payment (VBP) model providers still must be able to report individual services delivered. Encounter data is mission critical for assuring access to the information needed to calculate performance.
The functionality needs for a service provider organization to succeed in CalAIM is likely to include:
- Cal-AIM payment rules and changes required for programs and services are complex and detailed. EHR solutions with configurable billing systems that allow for easy updates will best support California providers in managing these changes.
- Fully integrated billing processes to support accelerated payments and uninterrupted revenue.
- Automated data transfer from service delivery to the billing system to enable timely and efficient clinical data correction. This aspect of the system can cut the time between service delivery and claim completion.
- Claims validation and claims scrubbing, to increase accuracy and reduce denials.
- Processes to optimize configuration, conduct payor testing, provide thorough training, and guide customers through the full financial process quickly.
- Streamlined authorization handling for multiple visits, facilitating the creation, and support, of realistic and comprehensive treatment plans.
- Alignment with Los Angeles County’s Integrated Behavioral Health Information System (IBHIS), for providers located there, with full integration into the EHR, to work efficiently, optimize revenue, and demonstrate high performance.
In summary, the importance of fully integrated RCM with the larger EHR system cannot be overstated. Success in both fee-for-service and value-based payment models is dependent on the type of sophisticated functionality that assures that all services are captured and can be reported. Reporting of service data is required for success in all payment models, all quality measures, and all performance management. For large and small service provider organizations, to succeed in CalAIM, an excellent RCM is key for success.
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