Any provider who participates in the Medicaid program knows that it risks committing fraud if it bills twice for the same service. Unfortunately, Certified Community Behavioral Health Clinics (CCBHCs) that are also Federally Qualified Health Centers (FQHCs) have been incorrectly advised by the Centers for Medicare & Medicaid & Services (CMS) to do just that.
CCBHCs are entities that were created by a Substance Abuse and Mental Health Services Administration (SAMHSA) demonstration project to improve the availability and quality of services provided in community mental health centers. Once certified, the CCBHC is required to offer a specific range of services and meet standards for service. The model is intended to ensure access to coordinated comprehensive behavioral health care. CCBHCs are paid similar to FQHCs using a Prospective Payment System (PPS) rate that is based on certain costs to provide CCBHC services.
In 2016, CMS issued detailed guidance to CCBHCs concerning the PPS rate that unfortunately included some incorrect guidance directed to those CCBHCs that were also FQHCs. In that guidance (which can still be found on SAMHSA’s website here), CMS strongly implied that CCBHCs could bill the same encounter twice – once using its CCBHC rate and once using its FQHC rate. The guidance stated as follows:
A clinic that participates in the Medicaid program as both a FQHC and CCBHC should receive the CCBHC PPS rate whenever it provides any of the services covered by this demonstration, even if there is an overlap with services included in the clinic’s FQHC PPS rate. The state should continue to pay the health center its established FQHC PPS rate and does not need to modify the payment amount. If a clinic user received a CCBHC service and FQHC service during one encounter/visit the provider is eligible to receive both the CCBHC PPS and the FQHC PPS.
This gave the wrong impression that a CCBHC could get paid twice for the same service if it was also an FQHC. At the very least, it is unclear because it seems to assume without stating that a “CCBHC service” will never overlap with an “FQHC service,” which is simply not the case. Many FQHCs provide services that are included in the costs used to establish their PPS rates that are also services that would be used to establish their PPS rate if they were certified as a CCBHC.
Fortunately, in 2021, the federal Government Accountability Office (GAO) issued a report highlighting this problem. When GAO sought comment from CMS, CMS indicated that it intended to state that CCBHCs are only eligible for both payments if nonoverlapping services are provided. See page 30 of Medicaid Behavioral Health CMS Guidance Needed to Better Align Demonstration Payment Rates with Costs and Prevent Duplication (Sept. 2021). CMS explained, for example, that “a CCBHC also certified as an FQHC may provide mental health counseling and a dental cleaning for the same client on the same day” and two payments would be appropriate. But “a client with mental health counseling and a primary care screening service on the same day should not trigger both types of payments, because both of these services are already included in CCBHC prospective payment rates. In this case, CMS officials told us states should pay only the CCBHC rate.” Id.
CCBHCs relying on the 2016 guidance and billing twice for the same encounter should consider whether they have identified an overpayment that must be reported and returned to the state Medicaid agency. 42 C.F.R. § 401.305. Failure to report and return an overpayment within sixty (60) days of identification can result in an ordinary overpayment being treated as a false claim potentially subject to penalties of up to triple the amount of the overpayment plus $12,000 to $25,000 per claim. One would hope that under these circumstances the state Medicaid agency would take into account the unclear CMS guidance provided when determining how to resolve such a self-report.