Sustainability Strategies for Services Integration Programs

A key component of sustainability planning for rural services integration programs is identifying a specific funding strategy. The Rural Community Health Toolkit provides information about general Sustainability Strategies.

Reimbursement for Care Coordination Services

To pay for services, many rural programs seek reimbursement opportunities. One reimbursement opportunity is to use Current Procedural Terminology (CPT) codes to bill insurers for care coordination services provided. Each insurer may respond to the codes differently. Rural programs should identify which codes are covered and by which insurers, how much money is offered, and how to properly use the codes.

There are several CPT codes for transitional care management (TCM), complex chronic care coordination, and chronic care management (CCM). CMS provides specific guidelines for using these codes for care coordination. Examples of these codes include:

CPT Code 99495 – Transitional care management services with moderate medical decision complexity (face-to-face visit within 14 days of discharge)
CPT Code 99496 – Transitional care management services with high medical decision complexity (face-to-face visit within 7 days of discharge)
CPT Code 99490 – Chronic care management for a patient with multiple chronic conditions (at least 20 minutes of time spent with patient per month)
CPT Code 99487 – Complex chronic care management for a patient with multiple chronic conditions (60 minutes of time spent with patient per month)
CPT Code 99489 – Each additional 30 minutes of time spent per month with patient on complex chronic care management services

For additional information on billing codes and reimbursement strategies, see Care Management Medicare Reimbursement Strategies for Rural Providers.

Partners

One rural services integration program stressed the importance of having conversations with partners about the vision for program sustainability. The sustainability plan may alter the original implementation approach. For example, a school-linked health program in the Delta worked to transfer ownership of the program over to the schools at the conclusion of the program. Since the teachers were already trained to implement the program, operation costs are minimal.

Value-Based Care and Alternative Payment Models

Value-based care emphasizes the need to increase the quality of care and patient experience, often focusing on coordinating and integrating multiple types of care and services to achieve better outcomes. Rural providers can participate in a range of alternative payment models that incentivize value and quality through services integration. For example, the Integrated Care for Kids (InCK) Model is seeking to address the fragmentation of health and social services for children with substantial physical and behavioral health issues. In rural Illinois, the Egyptian Public & Mental Health Department is leveraging the payment structure of the InCK Model to help cover the work of their integrated services team called "i-Hub."

Resources to Learn More

Chronic Care Management Services
Document
Provides information on CPT codes for CCM services, eligible CCM patients and billing practitioners, and Medicare Physician Fee Schedule billing requirements.
Organization(s): Centers for Medicare & Medicaid Services

Integrated Care Sustainability: National Trends and Best Practices
Slide Presentation
Discusses the economic impact of integrated care and how to make it more sustainable by addressing regulatory barriers and through different payment options.
Author(s): Klowden, M.
Organization(s): National Council for Behavioral Health
Date: 12/2018