Utilization Management in 2016

WELCOME

Utilization ManagementUtilization ManagementIn 2016In 2016

Check Yourself Before You Wreck Yourself

Presented By

John RaymondDirector of Client Services, Utilization Management and

DevelopmentPRRS, Inc.

John@PRRSinc.com

Session Description

During the course of this session, we will discuss and learn about the changes and challenges in Utilization Management for 2016, and how they impact the mental health and substance abuse industries.

Session Objectives

① Redefining Utilization Management② Working with private health insurance companies

• Outline changes in documentation requirements• Understanding how these changes effect you and

your clients③ How will these changes impact your revenue cycle

UM…What? Redefining utilization management

Utilization management (UM) is the evaluation of the medical necessity, appropriateness, efficacy and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable health benefits plan.

Medical Necessity- Medical necessity is defined as accepted health care services provided by

health care entities, appropriate to the evaluation and treatment of a disease, condition, illness or injury and consistent with the applicable standard of care.

- the behavioral health medical necessity criteria (MNC) are guidelines used by utilization review and care management staff (licensed registered nurses or licensed independent behavioral. health practitioners, and physicians) to determine when services are medically necessary

- Parity is putting the MEDICAL back in MNC

Let’s break it down.

Efficacy - the ability to produce a desired or intended result.

Primary health insurance providers are now studying the efficacy of treatment modalities.- Increase in chart audits- Cigna partners with ASAM

Let’s break it down

How quickly can we manage this issue? How quickly can we titrate to a lower LOC? Is the client being treated at the level of care truly

needed to manage crisis symptomology? Is the client being treated at the LOC authorized?

Efficiency and Appropriateness

Parity- Mental health parity describes

the equal treatment of mental health conditions and substance use disorders in insurance plans.

- parity requires equal coverage, not necessarily "good" coverage

Fraud- UA Fraud- Fee Forgiving- Enticement to

Treatment- Service Hour Fraud- Etc.

Why change now?

Changes in Documentation Changes in Appeals

Processes Changes in Policy

Reimbursements Changes in MNC Changes in Claims

Processing

Cigna Aetna UHC/Optum BCBS

2016 A Paradigm Shift in UR

Group Notes Biggest Impact Focus on putting the medical

back in MNC Must tie in to a treatment plan. Documentation must reflect

accurately the provided care.

IF YOU DON’T DOCUMENT IT DIDN’T HAPPEN.

Documentation

Must Reflect Acuity- Challenges and plans- Barriers to treatment and plans to overcome- NEVER PROGRESS ONLY- Oreo Cookie- Must tie into the treatment plan- Never present a problem without the therapeutic

interventions to work towards a resolution

Individual Notes

Are a must for some payers or strong documentation to support why they are not happening

Follow the same guidelines as individual Family challenges must be met with family

interventions and documented

Family Sessions

Document any physical symptoms Emotional symptoms

Behaviors outside the norm, positive or negative (Mostly negative)

If you don’t document it didn’t happen

NOTHING IS IRRELEVANT

Must include the title of the group and length Must include a group description

The group must be tied into the treatment plan Each note must be a minimum of 1 paragraph (4

sentences) Specific to the client

Group Notes – Yes, This Means More Work

The Don’ts of Documentation

The Don’ts of Documentation

MMSE Participation

Impact of the group on the client or why not Problems /Challenges Presented

Intervention / Solutions to Challenges

NEVER PRESENT A PROBLEM W/O AN INTERVENTION

Wait What?!?

Document any physical symptoms Emotional symptoms

Behaviors outside the norm, positive or negative (Mostly negative)

If you don’t document it didn’t happen

NOTHING IS IRRELEVANT

Efficacy Are you providing a recognized therapeutic service that has a direct impact on the recovery of your client?

Is your therapeutic service cost beneficial to the payer?

WHY?!?!?!

Poorly Documented Services Hours or Failure to Document Service Can Cause a Denial

For the WHOLE Day/Claim

Audits Slower Revenue Revenue Stoppage Recoupments

Do I Really Have To?

Let’s Talk About MNC Varies by Payer ASAM is a factor but not as heavily as previously Diagnosing using the DSM-V properly New focus on “Medical” in MNC Most payers provide their criteria online Understanding and interpreting the in’s and outs of

each payer and their MNC is the role of the UM Department.

NO CERT POLICIES 50 % of policies that did not require auth. in 2015 do

NOW. 80% of all no cert policies will deny on the back end

and require submission of the medical record for review.

THESE ARE NOT EASY CATCHES

Take-Aways If you don’t document it didn’t happen What you do must be considered of value not only to

the client but the payer Utilization Management has had significant changes in

2016 and it is the role of the UM Department to stay ahead of the changes and work with the payer to improve LOS and reimbursement.

Continuing Education Certificate and Evaluation ProcessTo receive Continuing Education (CE) credits for approved educational sessions, you must:

•Have your attendee badge scanned at the beginning AND at the end of each session.•Attend each session in full.•Complete the CE process within 45 days of the end of the event.•Ensure you are able to receive messages from support@ce-go.com.•Login to the CE-Go website using the personal email you received from CE-Go.•Verify all of the sessions you attended.•Complete the evaluation form for each session you attended.•Download your Continuing Education Certificate for your records.

If you have any questions regarding this process, please contact CE-Go at 877.248.6789 or support@ce-go.com.

THANK YOU