Name: Documentation in the Value-Based Care Era: A Compliance Roadmap for Behavioral Health Providers
Uploaded: 2026-04-21T17:46:08.078Z
Duration: 27 min 44 s
Description: Documentation in the Value-Based Care Era: A Compliance Roadmap for Behavioral Health Providers

Transcript for "Documentation in the Value-Based Care Era: A Compliance Roadmap for Behavioral Health Providers": Hello, everybody. Let me give everyone a couple minutes to come on in. I'm Susanna Vogel. I'm lead content here at Brelium. Thanks for joining us. So as we wait for people to come on in, I'm just gonna give you a tour around the platform. We're on Goldcast. So to the right of your screen, you're gonna see a chat functionality. If you wanna introduce yourself here, you can say hi and let people know where you're calling in from. This is also a spot where you can, type in questions as we go and as we get started, and we'll save some time at the end to field those. K. So we are gonna get started. If you're new here, I wanna welcome you to Brilliant's April webinar. We offer continuing education every month to help leaders in behavioral health, ABA, and hospice navigate challenges in their industry. This month, I have the absolute pleasure of being joined by Caitlin O'Connor, cofounder of Elevar Law, to discuss a topic that's gotten a lot of attention recently, the shift to value based care in behavioral health. Caitlin is an absolute expert on this topic, and she's here to help us break down the hype, dissect what, value based care actually looks like in practice, and discuss how it can impact your day to day. So let's bring her onto the stage now. Caitlin, Hello. welcome. Thank you for having me. Excited to be here. So great to have you. So let's start. If you could tell the audience a bit about yourself, your background, starting your practice, and how you came to know so much about value based care. Sure. Yeah. So, hi, everyone. As Susanna mentioned, I'm Caitlin O'Connor. I'm cofounder at Elevare Law. Elevare Law is a digital health law firm. So we work with all different types of health care innovators from tech enabled providers that are really transforming the way that care is delivered to patients every day to, technology companies that are building technology to help providers in their practices also deliver care more efficiently, better, with better quality, etcetera. I have been working in this space for eight years now. So my entire career has been spent in healthcare innovation as a lawyer. I have worked with some clients that are very, very early stage all the way up to public companies that are sort of out there, changing the way from a very public perspective, changing the way that care is delivered. So, definitely a big topic that has come up a lot recently is this sort of transition to value based care. It's something that I think for my entire career, we've been hearing about and we have been sort of waiting and wondering if and when that transition from traditional fee for service care to value based care would actually take place. And I think we're in a moment now where, I think it's a little bit of an inception point where we may actually see some real movement, real shift in the industry across provider types, not just in primary care or hospitals anymore, but across behavioral health, physical therapy, etcetera. So, really excited to talk about this today. Definitely something that has come up a lot, and I have lots of thoughts to share about it. Yeah. I'm really interested to hear why you think we're we're at this pivotal moment for behavioral health. But before we do that, let's define our terms because I think value based care can seem like sort of a hype buzzword. What does it actually mean? So in the context of behavioral health, what is this? What is the shift from fee to first service to value based care? Yeah. It's a great question, and I agree. It's one of those sort of buzzwords that we hear a lot, but everybody sort of uses it in a different way. So the way that I like to think about it is I actually like to separate value based care into sort of three discrete categories. Three three discrete components of value based care. One is care delivery. Right? So prioritizing value over volume, no longer just trying to, as a provider, you know, spend as many minutes as possible to achieve your RVUs that you need to achieve, but actually prioritizing is this care actually driving the outcomes we want it to drive? In behavioral health, are patients less impacted day to day by their anxiety or their depression or substance use disorder, whatever they may be, dealing with? How are we what are we focused on in that care? And and again, it's prioritizing value over volume. And I I wanna be clear that I think for a long time providers, especially in the behavioral health space, have already been doing this. I think that the way they have been incentivized by payers has made it challenging to truly focus on outcomes over volume. And so the second piece of this, right, is payment. Value based payment, I think is a sort of second component of what we think of as value based care. And it is how payers, insurance companies can now are now incentivizing providers in a more real way to prioritize value over volume. So, no longer just paying for, again, minutes spent in a visit with a patient, but actually asking providers to track outcomes. Our patients PHQ nine scores improving? Are their GAD seven scores improving? And what is the provider doing that has helped them improve those scores? Is it medication? Is it maybe increasing medication adherence or changing medication to a more effective medication regimen? All of those little things that drive those outcomes. So so, you know, like I said, historically, I think payers have in a traditional fee for service environment really focused on paying for volume, which has made it hard for behavioral health providers to deliver care in a way that prioritizes value. But now, I think more and more payers are starting to actually incentivize providers through different forms of payment models to prioritize. value. And I won't spend too much time on the nitty gritty here because there are a lot of different forms of value based payment. There are a couple that are most common in behavioral health. But generally speaking, I think there's sort of a subcategory in that value based payment category as well or sort of two components. Right? There's the payment side of it. How are you being paid as a provider? How are the payers paying you as a provider? But then the second component is risk. How much risk are you taking on as a provider? And what happens if you don't achieve the outcomes you are supposed to achieve? Or if you are, you know, getting paid a capitated payment, what happens if you spend more than you get paid in that capitated payment? Are you do you have to come out of pocket for that or can will the payer subsidize that additional spend? So, sort of again, two components ranging from very, very low risk, which would be your traditional fee for service payment model. Mhmm. Doesn't matter if you achieve outcomes or not, you're going to get paid for the minutes that you spend. That's it. All the way up to full risk models where you as the provider are responsible for 100100% of any sort of downside risk. So again, going back to that capitation example, you're gonna get a PMPM, a flat rate per month for all of the patients that you treat maybe in a particular population, maybe across your entire practice. If you spend more than that payment that you get, that's on you. You have to come out of pocket, hope you have some extra cash in the bank because you're going to have to pay for whatever additional treatment you provide that cost beyond that capitated payment. Just to run through it really quickly, again, ranging from low risk to full risk, there's fee for service and then there are more traditional pay for performance or performance based models like MIPS or the CMS access model, which I know we'll talk about in a second. Mhmm. There are bundled payment structures, which is a slightly different type of value based payment model, where it is very episode based. So think of like a surgical procedure. There's usually a ninety day window that the provider gets paid for and anything they do within that ninety day window, that's all the the, reimbursement that they get for that is that bundled payment. Shared savings and shared risk models. There are, for example, the CMSSP, the Medicare Shared Savings Program ACOs, where they get paid a certain amount. There's a benchmark set. They bill fee for service throughout the year. If they bill more than that benchmark, they share in that downside risk, so maybe CMS will cover 50% of the losses or in some models, CMS will cover 0% of it. But if you spend less, if you bill less on a fee for service basis, then that benchmark, you also get to share in the savings. You might get 50% of that upside. Mhmm. Then there are less common in behavioral health, partial capitation models, full capitation models, and global models. But in behavioral health, we really see most commonly that payment for performance, again, like CMS access, Yeah. shared savings where you're sort of managing an episode of care, or a particular patient population with a particular diagnosis, and you are sharing in the savings if you spend less than whatever benchmark is set, and then that bundled payment. Again, that's that very Mhmm. all very episode based, but that's more of an upfront payment, and you have that to spend and you get to control what you spend on that on that episode. Okay. So. Okay. so. you know a lot of it I just broke out a lot of ways that we could slice and dice this. dice this. Yeah. But how do providers you provide? even assess whether, a value based care model is right for their practice at this time? What sort of factors should they be weighing when thinking about should we switch over from key for service to an arrangement like this? Yeah. So that's where that third component that I didn't mention yet, I think is really important. Mhmm. And that third component of value based care is contracting. Right? So what does your actual contract say? And in order to understand whether you should sign a particular value based contract, should you participate in a shared savings model or a performance based model, There are a couple of things that are really, really important that I see providers miss a lot. The first is, and this is the most important one from my perspective, what is your data infrastructure look like? Do you actually know what your current patient population looks like from an outcomes perspective. Do you know what outcomes you have achieved thus far in caring for a particular patient population? And do you know what outcomes you can actually drive going forward? And if you don't have the data infrastructure to be able to drill down and say, okay, what percentage of our patients are have anxiety and depression diagnoses? And what percentage of our patients have spent time in an inpatient facility recently because they had an exacerbation or they had some, whatever reason it might be. And so that data infrastructure is really, really important. If you don't have that, I recommend setting up a data infrastructure first, looking at your data, figuring out what your population looks like before you ever consider a value based model because you will. What I see a lot is you run the risk of signing a contract that requires you to achieve arbitrary metrics that you may or may not be able to achieve. And then you end up losing money on the back end because you didn't have that data ahead of time to be able to know what you could actually drive and what your population looks like. A couple of others, payer mix. There are some payers that are very actively contracting in value based models. Medicare, we all probably have heard of CMMI. Medicaid is probably the largest value based payer in the country. It's a little bit fragmented because it's state by state. Medicare Advantage is a big one, and then some commercial payers as well. Particularly in the behavioral health space, I do see a good amount of commercial payers, offering value based payment structures. Okay. Okay. So now let's imagine that provider said yes. We're in. We're wanna make the jump. What is changes in their day to day? How do they have to update their documentation practices, what their training staff to include in notes to make the jump to value based care? Yeah. So I I think that, overall, the structure of your notes doesn't necessarily change. But the information that you include in that structure right? Like, I think, Susanna, you and I talked previously about a traditional SOAP note. I don't think the SOAP note itself changes that much, but I think within each category of that soap note, there are different things that you wanna be documenting that you may not be right now. For example, many value based models are very objective, very, again, back to the data, very algorithmic in nature. So payers are purely looking at in a lot of cases, numbers on the paper in terms of what was the PHQ nine score, for example, on day one, and then what is it six months later, and then what is it twelve months later, and has that improved, and if so, by how much. And so making sure that one, as a provider, you know what needs to be documented in order to achieve whatever outcomes or at least track toward whatever outcomes you are supposed to be delivering and making sure you're actually documenting it. And then also understanding what is the downside risk. So I usually frame this in depending on how, you know, big your organization is. You're very small independent provider group. I actually don't recommend taking any downside risk at all. I would focus purely on like a pay per performance. And so if you're looking at that, right, what are the outcomes that you can actually drive? And making sure you talk about them with the patient and integrate it into every conversation that you have with them. So if you're having a traditional visit, talk to them about it. If you're interacting with them in between visits, check-in like, hey, how has your anxiety been this week? And that may not be super different from how you're working with patients now, but the documentation of how you describe that conversation maybe. Right? Because if you are trying to improve a GAD seven score, then you don't wanna necessarily just write in a narrative sense, spoke to the patient about how their anxiety is impacting their day. You wanna actually have them fill out a complete a GAD seven right there and say, spoke to the patient about how their anxiety is impacting their day to day, and this was their GAD seven score today. Mhmm. So. adding those objective measures throughout the care journey in your note, I think is what is what is most important. And then, again, operationally, just making sure you're actually actively having those conversations with patients every time you interact with them. Yeah. What new audit risks do you see, and what new requirements do you see payers looking for, under value based care models? So so when it comes to audit risk, there are sort of two components of that. Right? One is, like, what is the risk that you get audited? And. then secondly, if you do get audited, what is the risk that you have to pay money back to the payer or they uncover some sort of issue in your documentation? I don't think the risk of being audited on its face changes. Payers do random audits all the time. You shouldn't be scared if you sign a value based contract and you're getting audited one year in, that is normal. Just like fee for service, that risk is sort of stays the same. But what changes is sort of what we just talked about. What does the documentation say? Because the payer is going to look at, usually if you're in a value based model, you need to report to the payer proactively on a regular cadence what your outcomes are in an ongoing basis. The cadence varies. What you have to report varies, but usually you're making regular reports. So the payer is going to look at, okay, you told us every quarter this year that you improved GAD seven scores for fifty percent of your patients or eighty percent of your patients. When they audit you, they're going to look at what we just talked about. Not did you write did you show specifically in the note on a time stamped day that you've measured the GAD seven? You took the GAD seven, you got the score, and you put it in the medical record. You put it in the the record. So again, not just saying patient has anxiety, we talked about it, it's not impacting their day. But the payer is now also going to be looking for, okay, if you say you improved GOT7 scores for fifty percent of your patients, show me those specific patients and show me the records and the specific dates on which you measured their GOT7 score and what those scores were. And so, you know, that again, I don't think conceptually that's different. Right? As a provider, you should always be documenting in as much detail as possible what you talk to the patient about, what the payers want to see. But I think that that piece of adding that objective data as often as possible is what what really changes. And if you get that wrong, that's where you can have risk. of clawbacks from payers. Because if you can't prove to them that you took that CAD seven on a regular basis and and not just that you took it, but how you as the provider actually change those scores. Like, if you talk to a patient on January. 1 and then you never talk to them again until May 31 and their yeah. Seven score improves. That's great. But did you do that, or did they go see another provider who prescribed them medication and who was actually in control of that care? So you need to show those regular touch points. The payers need to be able to show that not only did the outcomes happen, but that you are the one that drove those outcomes. What are two or three strategies that you would recommend to compliance or quality assurance teams to begin to review their documentation and make sure they're consistently building that case? So that what the circumstance you just described, you see a patient in January, not again until May, doesn't happen. Yeah. So I think a couple of things. I mean, I I have worked with a ton of remote monitoring companies in my career, so I'm a very big proponent of remote therapeutic monitoring or some form of remote monitoring that doesn't necessarily require you as the provider to be the one constantly checking in with the patient. But your assistant in the practice or a RN with training and behavioral health or an LPN or something can do that for you. But regular touch points in between visits, getting the getting the patient set up with even just a mobile app on their phone that reminds them once a week to respond to a short assessment and tell you how they're feeling. Having someone on your team review actually review that data regularly so so you can identify sooner if the patient needs a change in medication or needs to come in for a visit or needs to hop on a telehealth visit, whatever it may be. So number one, I I really do recommend remote monitoring. It just makes those in between touch points a little bit more automated and a lot easier. But the flip side to that or the second step that is also essential is making sure that you understand what that data means. So not just tracking the data, but making sure that if you are using a mobile app or you're doing the monitoring on your own, making sure you have actual insight into what data is changing and why it is changing. And so I think, you know, building a very detailed operational plan around how to drive outcomes is sort of the umbrella recommendation. And I think the sort of two things that can be really helpful are remote monitoring and then also whether it's training for your staff or a really powerful analytics platform, some way to make sure that you have real insights into the data that is being collected and how you can impact changes in that data over time. Yeah. I have to do a quick plug for Brelium here. One great thing about our platform is that we can look and see how documentation quality is changing over time. So say you begin to require, you know, you document a symptom. Did you or yeah. It's talking about a symptom. Did you do the equivalent test, or do you have that data to go alongside it? If you see that providers are missing that, you can send automated feedback within the platform to make sure that they're really showing those points of quality, to back up the documentation, and you have that all within the same brilliant feedback loop. So we are kind of getting close on time here. I'm wondering as we wrap up, you know, there are some providers who are still a little bit worried about shifting over to value based care. Can you talk about what it means in terms of staying competitive, in terms of staying current, to to really embrace this? So do you see it as optional? Do you see it as the future? Where where are you on this? I am probably look. I have some clients that I think are really, really great candidates for value based for participation in value based models. I'm a but I'm a little bit more conservative overall. I don't actually think that it's right for every type of provider. I don't think it's right for every practice. I don't think it's right for every health system. So, you know, not to sort of sound like a broken record, but, like, I think it is only right if you have the data to that that you can use to decide what outcomes and metrics you can actually drive. Right? So, like, an example is CMS access. Great model, really exciting. There's a specific behavioral health track, which to me is a really important, important signal that payers are starting to focus more on value based models and behavioral health, which historically have primarily been focused on, like, primary care and hospitals. So that's great. I think it's also a good signal that payers are starting to better understand behavioral health, but there are a lot of details that we need to pay close attention to. Number one is the actual payment amounts. The actual payment amounts for the behavioral health track and CMS access are, like, $6 upfront. And if you don't improve GAD seven or PHQ nine scores, then you don't get the additional $6 at the end of the year. But if you do, you get an additional $6 per patient per month. So that's $12 per patient per month, and you can't bill any fee for service codes for those patients that are participating in access. So number one, I think it's only right if you can afford it. If you can afford to only get paid $12 per patient per month, which may require a lot of scale, may require a lot of AI. Providers can determine whether it's whether it's right. So, you know, yeah, I think it's I think like I said, I think it's a really important signal, but I don't think it's right for everyone. And and then the the last thing I'll say about that is just to reiterate, like, pay attention to what you can actually control. I I think a really good example of this is weight loss. A lot of payers are very much incentivizing providers to drive weight loss among patients. That's great. And as a behavioral health provider, you can play an important part in driving weight loss. But if you are not the primary care provider that is prescribing a GLP one or managing the patient's diabetes or other comorbidities, you should not sign a contract where you are accountable for driving weight loss among your patient population. You can agree to other things, right? You can agree to drive behavioral change in patients. Maybe you can monitor their activity levels and you can help them learn how to be more active and you can track that. But that's important. If you're going to do a value based contract, you should agree to improve activity levels, not to increase weight loss because there are a lot of things outside of your control. So, again, I think it's only right if you know what you can control and you're confident that you can actually drive the outcomes that you agree to. And then lastly, I think right now in this moment, you've got to have scale because value based payments are so much lower than fee for service in a lot of cases. I think it's really only a good fit right now for for practices with a lot of scale, large health systems, etcetera. Okay. Well, this has been a really fantastic conversation. As we wrap up, can you let the audience know where to find you if they wanna hear more insights from you and your team? Yeah. Sure. So you're welcome to connect with me on LinkedIn. It's just Caitlin O'Connor. My name is on the screen. You can also visit our firm's website, which is just elevarelaw.com, elevarelaw.com. We've got lots of great blogs on there. I actually wrote recently a pretty detailed article on value based safe harbors to anti kickback statute and other really strict fraud and abuse laws that a lot of providers are concerned about. So if you're sort of wondering, you know, how do I manage care coordination when the anti kickback statute exists, that article may help. And yeah, I think that's probably it. Website, LinkedIn, those are probably the best two places to connect. Fantastic. And Bralium is here to help you navigate, changing compliance standards. So if you want to start recording different things in your notes and seeing how you would track that and make sure your staff is aligning with your new frameworks, we can show you how. So we'll follow-up after this webinar with additional resources on that. Thanks for joining us, and we will announce our webinar for next month on LinkedIn. Really appreciate everyone spending the lunch hour with us, and have a great rest of your day. Thanks, Susanna. Bye, Thank. you.