By: Amber Knouff and Lisa English Hinkle

As the predominant primary care providers in medically under served areas, Rural Health Clinics (RHCs) are on the front lines of the opioid epidemic, treating patients in the areas that have the highest incidences of opioid related problems and the fewest healthcare services.

RHCs care for Kentucky’s most medically complex and neediest patients in areas designated as medically underserved or health manpower shortage areas. Many of these areas have high poverty rates with high numbers of Medicaid beneficiaries.

Because rural occupations tend to be physical ones including farming, mining and industrial/factory work, these populations experience higher rates of disability and complicated long-term problems that historically have been treated with opioids for long term pain relief.

RHCs not only deal with these medically complex problems but now must deal with addiction issues caused by long-term prescribing.

At one time, these opioid medications were represented by pharmaceutical companies to be tamper proof and non-addictive. RHCs are an important part of the answer to addressing Kentucky’s opioid epidemic. With the right resources, RHCs have the tools to incorporate behavioral health services and substance use disorder treatment that can be paid for under the current prospective payment system.

Integrate Behavioral Health Services

Behavioral health services are in severe shortage. As with any other primary care practice, RHC patients present with not only primary care problems but also with behavioral health issues that contribute to the underlying medical issue.

According to CMS, between 2010 and 2013, among adult Medicaid beneficiaries treated for a behavioral health disorder, 75 percent of spending for these individuals was for treatment of comorbid conditions as opposed to their behavioral health conditions.

By integrating behavioral health services as a component of primary care and adding behavioral health providers, RHCs can treat patients in a coordinated manner with comprehensive care plans. Providing behavioral health services in the RHC setting can lessen the stigma patients often experience when seeking treatment and increase patient compliance and follow-up. These behavioral health services, including substance use disorder treatments, can generate additional revenue for the RHC.

Additional Revenue

Additional revenue is the key – the market for behavioral health services is vast. A report from the National Institute of Mental Health estimates that around nine percent of the population of the United States suffers from a personality disorder and major depressive disorder is the leading cause of disability in the US for individuals ages 15-44 according to the World Health Organization.

In one survey, the Federal Substance Abuse and Mental Health Services Administration estimated the number of Americans over the age of 12 who were addicted to or abused drugs or alcohol in that year at 23.9 million.

According to CMS, Medicaid beneficiaries comprise about 25 percent of patients with opioid use disorders, but only 32 percent of those Medicaid patients received treatment for their substance use disorder. Meanwhile, the supply of behavioral health providers is failing to meet the demand, especially in rural and underserved areas.

The Basics

Behavioral health services in RHCs, including treatment for mental health disorders, substance use disorders and co-occurring mental health and substance use disorders, are covered by Medicaid per regulation 907 KAR 1:082. These services include everything from screening and assessments through intensive outpatient programs and therapeutic rehabilitation program services.

A wide variety of provider types are eligible to provide reimbursable services, such as physicians, psychiatrists, advanced practice registered nurses, and a host of counselors, social workers and therapists who are licensed or working under the supervision of a specified licensed practitioner. Medicare has a more limited list of reimbursable behavioral health providers, but also includes physician assistants and nurse practitioners with proper training.

The Medicare Benefit Policy Manual defines a behavioral health RHC visit as a face-to-face one-on-one encounter between the provider and the patient, but certain Medicaid-reimbursable behavioral health visits can occur in a group setting, such as in family or group outpatient therapy.

Where to Begin

Integrating behavioral health services within an RHC is not impossible. RHCs should focus on understanding reimbursement policies and procedures and covered services. Extra costs incurred to implement these services can increase a RHC’s payment rate.

Under 907 KAR 1:055 – Section 10, an RHC can submit a change in scope request to Kentucky’s Department of Medicaid Services whenever adding a covered service that would result in a minimum of five percent change in the existing final payment rate, which would be likely with the addition of behavioral health services. In addition, compliance activities should be implemented as a check to maintain consistency with Medicare and Medicaid rules for RHCs.

Mind the Regulations

Once behavioral health services have been integrated, RHCs will have to adjust for additional compliance issues. Substance use disorder patient records are protected by an even stricter privacy regime under 42 C.F.R. Part 2, also known as “Part 2.” Part 2 regulations have recently been revised for the first time in twenty-plus years to create somewhat more permissible disclosures when accomplished in a manner consistent with regulations. These regulations have more specific release requirements than other patient privacy laws such as HIPAA or HITECH.

Also, opioid-based medication-assisted therapies for opioid substance use disorder treatments are subject to strict standards promulgated by the Kentucky Board of Medical Licensure and the Kentucky Board of Nursing, so RHCs may have to adjust prescribing policies and train staff to meet these guidelines as well as assure that all policies and procedures capture these regulations. Also, some of these services may be provided through telehealth if organized and provided in a manner consistent with regulatory requirements, which may overcome some of the problems created by a shortage of providers.

Two Birds with One Program

RHCs are front and center in the opioid crisis, so it’s time to bolster the services necessary to fight it while getting an additional revenue stream. More behavioral health services are reimbursed by federal healthcare programs than ever before, so RHCs may be leaving money on the table by overlooking the inclusion of these services.

Both RHCs have a strong incentive to add behavioral health services that can be provided under Medicaid and Medicare per visit payment rates when performed in accordance with regulatory requirements. And, with such high incidence of problems, these services are very important to comprehensively address the needs of rural patients.

-Lisa English Hinkle is a member of McBrayer and concentrates her practice area in healthcare law. Amber Knouff is an associate with McBrayer and focuses her practice on healthcare law and professional liability defense.