Financing Strategies

Context: The tobacco treatment program treats roughly 6,000 outpatients and 1,500 inpatients each year. The program serves a significant proportion of Black or African American patients.

Intervention: The program uses a “medical model” in which medical providers (mostly PAs and NPs) provide medical treatment and bill insurance for services through standard medical billing (E+M codes). This is intensive treatment with multiple visits. It occurs inpatient in 2 hospitals and outpatient in 13 sites and through telehealth. The medical providers work in a team-based approach with behavioral providers to manage patients with psychiatric illness and comorbid substance abuse. Medical billing makes the model financially sustainable and supports free treatment for financially disadvantaged patients. Opt-out referral systems are in place in several areas of the health system. Other areas use direct outreach or provider referral.

Funding: The program is supported through third party billing through Medicare, Medicaid, and private insurance. Program startup and growth costs, prior to the breakeven point, were supported by the Duke Cancer Institute with temporary funding through an NCI grant.

Which Providers Bill?: MDs, NPs, PAs, and LCSWs all bill insurance for services.  Inpatient and outpatient medical providers bill using E+M codes (not 99406-7), and behavioral providers bill using psychotherapy codes.

For Which Services?: E+M based billing is categorized as “Medical Management” and requires that medication use is considered for the patient and discussion of medication use is documented in the progress note. Psychotherapy codes bill for psychotherapy and require a psychiatric diagnosis (e.g., depression, anxiety, adjustment disorder).

Billing Codes Used: E+M Codes (inpatient and outpatient) (not 99406-7) and Psychotherapy

Administrative Costs: The Duke Cancer Institute has a billing department that manages billing.  The Institute supports management and scheduling staff.

Reimbursement and Sustainability: The medical model is financially sustainable, except for temporary infusions of capital required for start-up and growth. Because  the model is financially sustainable, the program does not have financial limits on growth; they currently employ 11 billing clinicians and plan to continue growing to meet the needs of their large health system.

The program has a mission to provide high-quality intensive treatment the underserved and have a large population of uninsured or underinsured patients. The program also has a large number of patients with psychiatric illness, who require move intensive team-based treatment.  Financial sustainability has allowed the program to provide free services for disadvantaged populations and intensive treatment for people who need it.

Context: The tobacco treatment program treats approximately 5,500 patients annually. All adult tobacco users are eligible for treatment. Most patients are insured; however, a small subset of uninsured patients receive financial assistance for treatment.

Intervention: The program utilizes a standardized tobacco use screener and opt-out model of referral for tobacco treatment for all patients. Nurses and physicians assess inpatients’ and ambulatory outpatients’ tobacco use status, provide quitting advice, and document their status in the medical record, which automatically generates an opt-out referral to the program (Bates-Papas et al., 2024; Kotsen et al., 2021). All patients referred are offered tobacco treatment by a clinical coordinator. Inpatients receive bedside or phone-based cessation counseling. Outpatients are evaluated during initial consultation and receive recommendations for individual or group telehealth treatment. All patients are recommended to use, and prescribed when needed, pharmacotherapy based on shared decision making and patient preference, following NCCN guidelines. Patient education materials tailored for cancer care are also provided.

The overall philosophy of the program, embedded in the psychiatry department, is to treat the whole person. Therefore, clinicians provide comprehensive psychotherapy, which not only treats tobacco dependence, but also addresses other psychosocial issues and comorbidities, particularly co-existing behavioral health conditions pre-dating cancer diagnosis and post-diagnosis psychological distress (NCI Monograph 23; Park et al., 2020).

Funding: The program is funded by institutional support. Like all other psychiatry services at the center, tobacco treatment services are billed to health insurance for outpatient ambulatory care.

Which Providers Bill?: Psychologists and psychiatric advanced practice nurses (APNs) bill health insurance for tobacco treatment services. All program clinicians are tobacco treatment specialists (TTSs).

For Which Services?: All outpatient services are billed, including diagnostic psychiatric evaluations and follow-up visits for psychotherapy.

Billing Codes Used: Psychologists bill CPT code 90791 for evaluation. Follow-up psychotherapy is time-based: a 30-minute visit is billed as 90832, a 45-minute visit is billed as 90834, and 60-minute group psychotherapy is billed as 90853. Psychiatric APNs who perform 15-minute medication management visits bill using code 99407.

Administrative Costs: Clinical documentation needs to be thorough, describing symptoms and co-occurring medical and psychological conditions. Along with comprehensive biopsychosocial assessment and treatment of tobacco use disorder, clinicians complete a full and ongoing mental status exam, including screening and/or detailed assessment (e.g., distress thermometer and PHQ 2, GAD 2) of co-existing psychological and distress symptoms (e.g., depression and anxiety). Psychiatric history is ascertained through clinical interviewing, and a detailed substance use history is conducted to assess for common tobacco-related comorbidities. Treatment plans summarize personalized behavioral and pharmacologic interventions. The program developed standardized workflows, EHR template notes, and billing templates which assist clinicians with this assessment and treatment documentation.

These administrative costs can be especially challenging in certain scenarios. At times, patients decline, no show, or drop out of treatment due to smoking-related stigma or concerns about out-of-pocket costs.  In addition, many private health insurance companies have behavioral health “carve outs” and deem the psychiatry department “out of network” despite providing medical coverage for patients’ cancer care at the center.  In some of these cases, the patient financial services department will waive fees for tobacco treatment services.

Reimbursement and Sustainability: This free-standing cancer center has a large clinical volume, and growing demand for tobacco treatment, attributable to program maturity, oncology care provider awareness, ongoing quality improvement efforts, and accessibility of telehealth treatment. Several years ago, the hospital administration decided that all ambulatory tobacco treatment services should be billed fee-for-service to health insurance. In addition, billing for brief tobacco treatment delivered by other oncology care providers has increased over the last five years. This business plan provides significant billing revenue supporting program sustainability. In addition, as part of the Medicare Merit-based Incentive Payment System (MIPS) initiative, the center receives significant annual monies from bonuses due to strong adherence in providing assessment, documentation, brief tobacco treatment and referral, and sharing patient registry data on measures under #226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention.

Context: The program treats roughly 1240 patients each year. The program operates across four clinic locations where patient demographics vary substantially. Most of the patients served are insured and about half are referred from other clinical providers.

Intervention: The program offers individual in-person and telehealth counseling and referrals to the state Quitline, using an automated EHR and eReferral system. A TTS connects referred patients with care. A reimbursement model for counseling services helps fund the program.

Funding: In addition to reimbursement, the program is supported through institutional and grant funding.

Which Providers Bill?: MDs and CRNPs bill insurance for services.

For Which Services?: Providers bill for evaluation and management of tobacco use.

Billing Codes Used: The program bills for Toxic Effect of Tobacco (initial or subsequent encounter) T65.291; Tobacco Use Disorder F17.2, and other diagnostic codes as appropriate.

Administrative Costs: There are specific documentations requirements necessary to justify billing the evaluation and management services provided, and up-front resources were allocated to put documentation templates and procedures in place.

Reimbursement and Sustainability: While the reimbursement rate is appropriate for the level of service provided, billing reimbursement does not cover the operational costs of the program and must be supplemented with other sources of funding.

Define the program goals. Include broad impacts as well as measurable goals (e.g., increased reach and effectiveness).

Demonstrate that your aims align with health system priorities and funding requirements (e.g., Cancer Center Support Grant (CCSG) Community Outreach and Engagement (COE); Commission on Cancer (CoC) or National Accreditation Program for Breast Centers (NAPBC); health equity initiatives, etc.).

Describe the gap in cancer care the TTP is filling. Refer to the Surgeon General’s Reports on Smoking and Tobacco Use and the National Cancer Institute Tobacco Control Monograph 23, Treating Smoking in Cancer Patients: An Essential Component of Cancer Care, for evidence to support establishing tobacco treatment as a pillar of cancer care. This infographic from the report and this infographic from the monograph summarize the essential need for health systems to address tobacco use.

Share key assessment measures to demonstrate the impact of the program thus far.

Describe the services offered, clinical settings, and workflows. Include any plans to expand to new settings. Refer to the Program Planning Tool to define your program design.

Include a budget with operations costs to inform requested funds. Be sure to account for any anticipated revenue. Adapt this example to your own needs. The link will prompt the download of an Excel budget template.

Provide the bottom-line requested funds to sustain your program.

Solicit letters of support from engaged health system partners and external interested parties to strengthen this request for institutional funding.