# Presentation: 922716

## 
MAKING HIPAA HAPPEN
 A State Viewpoint

CMHS/CSAT TA Initiative

December 12, 2001

**MAKING HIPAA HAPPEN**
** ****A State Viewpoint**
**CMHS/CSAT TA Initiative**
**December 12, 2001**

**Notes:**
 Text of presentation is provided in this section of each slide.

## Slide 2

**Notes:**
First of all, you need to know that I’m an old guy and that my view of the world is somewhat dated. 

- Other Unimportant Places

**Notes:**
Second, you should know that I have a unique view of the country based on being a New Englander.

Truth is that if you’re from Rhode Island, you even consider Connecticut as being one of those “southern border states” that doesn’t even rate a name on the map.

## 1987 Medicaid Coverage

1989 PASRR

1998 HIPAA

“...and other duties to be assigned by the director.”

- 1989 PASRR
- 1998 HIPAA
- “...and other duties to be assigned by the director.”

**A Personal History**

**Notes:**
With that said, my experience with HIPAA is not likely a whole lot different from that of many of you sitting out there.  Going back a few years, I went to a NASMHPD conference in 1987 and came back saying “Did you know that some states bill Medicaid for mental health services?” and heard “That’s great. You’re in charge.”

And then in 1989 I went to a NASMHPD conference and came back saying “Did you hear about this PASRR stuff?” and heard “That’s great. You’re in charge.”

Then I got smart and shut up for 10 years.  About 3 years ago I was at a MHSIP meeting and Ron Manderscheid started talking about this thing called HIPAA that was looming on the horizon and I went back and opened my mouth about it and heard the familiar refrain.

But neither Medicaid nor PASRR went away, so HIPAA became one of those “...other duties as assigned by the Director” in my job description.

I’m guessing that many of you are NOT working full-time on HIPAA; you don’t have a large staff to help out; and are likely faced with the same problems that I am.  And to top it off no one else seems to want to hear about it. 

But I actually think that we all have some opportunities hidden in there also which we’ll get to in a while

## MHRH and Medicaid sound the alarm
GACH concludes WIDESPREAD impact
IMMEDIATELY establish top level statewide office to oversee all
Bring players together, supply money, get consultants, get it DONE!
YES!!

- GACH concludes WIDESPREAD impact
- IMMEDIATELY establish top level statewide office to oversee all
- Bring players together, supply money, get consultants, get it DONE!
- YES!!

**HIPAA**

**Notes:**
So, how did HIPAA implementation go in Rhode Island?  Let’s take a look.

## State effort on hold
Medicaid agency has money but consumed with their own interests
Other state agencies waiting for state level action while fervently praying that HIPAA goes away
MHRH trying to cobble something together but still searching for answers.

- Medicaid agency has money but consumed with their own interests
- Other state agencies waiting for state level action while fervently praying that HIPAA goes away
- MHRH trying to cobble something together but still searching for answers.

**Well, Actually “NO”**

## And the simple fact, as you’ve heard over the last day or so, is that in many cases there ARE no answers to be found.

**And the simple fact, as you’ve heard over the last day or so, is that in many cases there ARE no answers to be found.**

## At your service......but no one wants to hear about it!!

**Notes:**
With that said, let’s look at some of the issues that we have to deal with, and then take a look at what I see as a couple of opportunities.

**Notes:**
This is kind of what my environment is like.  I’m the little squished thing in the middle.  And HIPAA is just ONE of the pressures that I have to deal with on a daily basis.

## 
REGISTERED NURSE

Assessment (minimum 1 1/2 hours)
	X0117  $ 119 per assessment

Individual minimum 40-50 minute X0118  $   60 per visit

Individual minimum 15-20 minute X0119 $   24 per visit

Group minimum 40-50 minute 
	X0120  $   24  per client per visit

Medication Group 90 min. 
	X0345  $   24  per client per visit

**REGISTERED NURSE**
**  **
**Assessment (minimum 1 1/2 hours)**
**	****X0117  $ 119 per assessment**
**Individual minimum 40-50 minute X0118  $   60 per visit**
**Individual minimum 15-20 minute X0119 $   24 per visit**
**Group minimum 40-50 minute **
**	****X0120  $   24  per client per visit**
**Medication Group 90 min. **
**	****X0345  $   24  per client per visit**
** **

**RN-CNS w/PRESCRIBING PRIVILEGES**** **
** **
**Assessment (minimum 1 1/2 hours)**
**	****X0416  $ 198 per assessment**
**Individual minimum 40-50 minute X0417  $   99 per visit**
**Individual minimum 15-20 minute X0418 $   38 per visit**
**Group minimum 40-50 minute **
**	****X0419  $   39  per client per visit**
**Medication Group 90 min. **
**	****X0421  $   39  per client per visit**
** **

**Notes:**
Let’s take a very concrete look at what I’m faced with. 

Say my Commissioner wants to look at our utilization of Registered Nurses as opposed to RN’s with Prescribing Privileges and see how much Medicaid we’re paying for each. 

In our current system, I just spend maybe 20 min. looking at codes X0117 – X0120 as compared with X0141 – X0144 and I’m done.

But we know that the new system is going to take away all of my local codes and substitute some generic national codes. So, as things stand at this point, at  BEST I’ll need to combine a code for the type of service with some indication of service duration and hopefully add some data from the provider registry which is all smoke and mirrors at this point.

## Duhhhhhhhh...

**Notes:**
And then hope I don’t end up looking like this guy. 

But I can’t let it consume me as I don’t have any control.  I’ll just have to do the best with what I have and hope that it works.

On the bright side, we know that there are problems with local Medicaid codes and that people that understand the issues are working at the national level to get them squared away. We can only hope that they are successful!

## XIX agency does enterprise assessment and plans for remediation.....for THEMSELVES.
No locks on anything, fax machines in public places, clients wandering around
My secret password:  repmert

- No locks on anything, fax machines in public places, clients wandering around
- My secret password:  repmert

**Security**

**Notes:**
So, let’s look at what RI has done in the area of security.  Well, we know that the final regs aren’t out yet but we also know basically what they’ll deal with.  Our Medicaid agency has finished their enterprise assessment, checking out everything internally and out to the point that they touch another agency.  And they had Federal reimbursement for doing it.  And they’re even making plans for remediation.

To their credit, they DID sit with mental health for a few hours and ask a bazillion questions.  Do we get data electronically from the community.  Do we have paper records around.  Do we do any Medicaid billing?  Do all of our computers automatically log the user off if there’s no activity for a while?

So, now I KNOW that our building is not secure; that none of the offices have doors that lock; that virtually no one has working locks on file cabinets; that our fax lines are in public places; that inmates from the State prison deliver supplies and move furniture; and that there are clients free to roam around.  

Wonderful.

And of course we need ways to protect our computer systems from the bad guys on the outside.  Do I even want to think about the people who use their name spelled backwards as their password?  Or even better the ones that create a REAL tough password and tape then end up taping it to their monitor ‘cause they can’t remember it?

## The Bad News
You’ve got some problems.

The Worse News
You’re on your own!!

- You’ve got some problems.
- The Worse News
- You’re on your own!!

**Notes:**
So thank you very much Medicaid.

In another area, after fighting the battle of the unique individual ID across programs and agencies for years without much success, I was glad to hear that HIPAA was finally going to give us one.  AT LAST a way to tie everything together! 

Of course, as you’ve already heard it’s on hold and I will definitely be REtired and perhaps even EXpired before the hold is lifted!

## The HIPAA Hippo

**Notes:**
Hey! Look at this cute little guy!

Doubtless created by some industrious Federal worker trying to add a bit of fun to our lives!

## Still Not TOO bad.....

**Notes:**
But in real life the guy would look a bit more like this, which still isn’t TOO bad.

## Think “Titanic”

**Notes:**
But here’s the real truth!

Way big!  Way scary!

And a much more accurate a representation than the little smiley guy in the car.

## HIPAA is NOT going away, although it has been pushed back a bit.
It carries some REAL negative consequences if you don’t play ball.
And THAT is where there’s some hope.

- It carries some REAL negative consequences if you don’t play ball.
- And THAT is where there’s some hope.

**Hope to be found**

**Notes:**
But HIPAA is not going away and it carries some REAL negative consequences if we don’t comply.

I admit that it’s slow; that the process is cumbersome and hard to understand.

And it’s not driven by people with any great understanding of how state government and management information systems work.

And I wouldn’t be holding my breath waiting for them to put someone who knows how Behavioral Health works in a key position!

- And someday THIS guy...

**Notes:**
but eventually THIS guy .....

- Is going to turn into this guy!

**Notes:**
.....will turn into THIS guy and we’ll be moving down the road at a million miles an hour.

And those higher up than I will have to find resources somewhere as the consequences of not doing so are too big.

## Simple answers to tough questions like: “Are we covered entities or aren’t we?” Or at least a way to GET simple answers.
Tools: Checklists like those in the notebooks.
Validation. How do we make the $ people believe?
A way to tap Federal $ like XIX can.

- Tools: Checklists like those in the notebooks.
- Validation. How do we make the $ people believe?
- A way to tap Federal $ like XIX can.

**What Do States Need From The Feds?**

**Notes:**
So, I’ve finally managed to get to my topic for the day!

Try to think of it in terms of some of the “soft” information system enhancements that we KNOW we should all have, stuff like security checks, privacy guidelines, disaster recovery.  Think of your office where a bill for a service provided to a client comes in to the central fax, gets ferried over to a processing person who logs onto a terminal and does some magic and sends the bill in the out tray for the secretary to file.  Now stick in a brand new processing person and a brand new secretary.  Do they sit down at their desks, pull out their procedure manuals, and put in a days work?  Not real likely.  I think that HIPAA actually gives us a way to get some of this stuff taken care of and will even put some urgency behind it in another year or so.

And this might also be a good way to work in changes to your databases that you’ve wanted to make for years.  Dress it in HIPPA garb and off you go.

It’s not neat.  It’s not clean.  It’s not necessarily “today”.  But it IS an opportunity.

So how am I dealing with the new standards?  Plugging along.  Doing what I can with what I have.  And looking for HIPAA leverage to find new resources to take larger steps.

## 	CMHS, CSAT, CSAP, DS200+, Block Grants, Infrastructure Process, TEDS, MHSIP, HIPAA  need
Clarity
Coordination
Cooperation

- Clarity
- Coordination
- Cooperation

**Notes:**
Whoa! Look at all of those Federal initiatives and agencies dealing with management information systems and performance partnership grants and measurement systems and funding. 

Dare we hope for the “three c’s” of Clarity, CoORdination and CoOPeration?

Life would be MUCH easier. 

And God forbid that the Medicaid guys ask CMHS for some input in the mental health area. After all, they’re just under the same umbrella agency!

**Notes:**
And my closing thought l is that YOU all should be taking a proactive approach also, else you will surely end up like the hotdog in this picture.

## 

Questions?

Ron Tremper
RI Dept MHRH
rtremper@mhrh.state.ri.us

**Questions?**
**Ron Tremper**
**RI Dept MHRH**
**rtremper@mhrh.state.ri.us**