Managing Utilization Review in Light of Parity (MHPAEA)

Transcription

1 Managing Utilization Review in Light of Parity (MHPAEA) The Healthcare Association of New York State Conference SAE & Associates Parity Compliance Team October 4, 2017

2 SAE & Associates Parity Compliance Team Steven A. Estrine, PhD Project Director Frank McCorry, PhD Team Leader Brian Baldwin, LCSW UM/UR, Network Adequacy Maria Messina, PhD Consumer Communications/Appeals Alex Hutchinson, MBA Benefit Design/Data Metrics

3 Objectives Lower the possibility of a denial based on the interpretation of the medical necessity criteria (MNC). Review the elements of a denial letter and determine if the MNC are appropriately applied and communicated. Review the essential elements of a properly constructed appeal. Identify the data requirements to monitor and manage denials/appeals. Discuss how to organize and analyze the data on a payer-specific basis to target improvement opportunities that yield more revenue or lower internal administrative costs.

4 UTILIZATION MANAGEMENT UTILIZATION REVIEW

5 CASE EXAMPLE CASE EXAMPLE A 30-year old male seeking admission to a partial hospital program (PHP) after discharge from an IP Psychiatric Unit where he had been treated for 6 days after a suicide attempt. His diagnosis is MDD with a co-occurring disorder of alcohol use disorder (AUD). The MNC are as follows for PHP services: The patient demonstrates symptomatology consistent with the most current version of the DSM diagnosis that requires and can reasonably be expected to respond to therapeutic intervention. Evaluation needs to include an assessment of substance abuse issues. There is evidence of patient s capacity and support for reliable attendance at the partial hospital program. An adequate support system is available to provide the stability necessary for maintenance in the program or the patient demonstrates willingness to assume responsibility for his/her own safety outside program hours.

6 CASE EXAMPLE (Cont.) The MNC are as follows for PHP services (cont.): There may be a risk to self, others, or property (e.g.. inadequate ADL; mood, thought or behavioral disorder interfering significantly with activities of daily living; suicidal ideation or non-intentional threats or gestures; risk-taking or other self-endangering behavior) which is not so serious as to require 24-hour medical/nursing supervision, but does require structure and supervision for a significant portion of the day and family/community support when away from the partial hospital program. The patient s condition requires a comprehensive, multi-disciplinary, multi-modal course of treatment, including routine medical observation/supervision to effect significant regulation of medication and/or routine nursing observation and behavioral intervention to maximize functioning and minimize risks to self, others and property. The treatment plan must clearly state what benefits the patient can reasonably expect to receive in the program; the goals of treatment cannot be based solely on need for structure and lack of supports.

7 Case Disposition: The MCO/Provider Interaction What are the important points to be made by the UR staff speaking to the MCO? What must be documented in the case record? How must suicidality be handled? How must the co-occurring disorder be factored and demonstrated as relevant to the admission?

8 APPEALS PROCESS

9 What You Need to Know About the Appeals Process More time spent on Appeals means less time spent on patient care. Providers fall into distinct categories: Providers Those who appeal Those who do not appeal Successful Unsuccessful Common reasons why providers choose not to appeal: Lack of staff/resources Revenue loss does not outweigh cost to file appeal Feel probability of success is low Managed care organizations understand these issues and more importantly have a good idea of what bucket you fall into.

10 Denial Letter Case Study We have decided to deny coverage of the following medical services that you or your provider asked for: Partial Hospitalization Treatment, revenue code XYZ, from 9/21/17 and beyond. We have determined that the services are not medically necessary. You are a 30-year old male who was admitted to partial hospitalization treatment on 9/21/17, after being discharged from inpatient psychiatric treatment. You had been in inpatient mental health treatment from 9/15/17 to 9/21/17, because of trying to end your life. You were treated with therapy and the medications: Prozac Seroquel, and Trazodone. You were no longer expressing thoughts that you wanted to end your life. As of 9/21/17, it was not medically necessary for your symptoms to be managed in partial hospitalization treatment. You have a supportive environment at home. Your treatment could have been safely addressed in a less restrictive level of care, such as an outpatient mental health level of care. What opportunities does this denial letter offer for an appeal?

11 What opportunities does this denial letter offer for an appeal? Diagnosis not identified COD not addressed Incomplete Clinical rationale o No documentation of specific MNC used o Questionable and vague characterization of home environment

12 Important Components of a Successful Appeal Cover Letter Executive Summary, which addresses MCO s MNC specifically and contradicts points in the Denial Letter. Assessments, Treatment Plan and Progress Notes attached, which support a positive Level of Care Determination. All must provide evidence of functional deficits resulting from the episode of illness.

13 DATA METRICS

14 Data Inventory Assessment Questions to ask yourself: Can you report on authorization denial activity (including continued stay reviews) by: Level of care requested? Reason for denial? Payer? Can you report on appeal activity by: Outcome (upheld or reversal)? Reason for reversal? Outcomes by payer? Do you have the ability to calculate revenue lost or gained related to denials or reversals?

15 Data Inventory Assessment (Cont.) Examples of key metrics to track: # of denials as percent of number of requests for authorizations Reasons for denial Disposition following denial (e.g., if request for inpatient admit is denied, what LOC was approved) Average # of days/visits approved per authorization Metrics need to be developed for both behavioral health and medical/surgical services.

16 Data Inventory Assessment (Cont.) If you answered yes to these questions, then you have the ingredients needed to measure, manage and improve your authorization process. If you answered no to one or more of these questions, then you are disadvantaged in your ability to improve your authorization process.

17 Getting the Most from Your Data Profile your key payers they are profiling you. Understand how authorization decisions/denials are distributed by reason code. Review denials with clinicians to assess validity of the reasons used. Monitor denial activity or authorization process requirements to identify changes in trends. Compare results for BH with M/S where appropriate to highlight NQTL practices that might be parity violations. Compare results across payers.

18 You can t manage what you don t measure done correctly, good data is a by-product of well-managed processes.

19 Data Metric Examples Denial rates for behavioral health services requiring authorization versus that for medical/surgical services requiring authorization. The frequency of continued stay reviews for inpatient admissions and the average # of days approved per review. Reversal rates for appealed denials for behavioral health services versus that for medical/surgical services.

20 Getting the Biggest Bang for Your Buck The authorization process, by necessity, must be driven by clinical information Level of care required to effectively treat the patient Intensity/duration of services to stabilize/improve the health status of the patient Environmental factors (home environment, support from family/friends, etc.) Where you focus your attention needs to take into account the cost/benefit to your institution and the patient Level of effort/resources required to appeal a denial Consequences to patient well-being if care is not provided in requested level of care Revenue/profit margin at stake related to denials of services

21 Getting the Biggest Bang for Your Buck (Cont.) Financial data must be aligned with authorization denial activity data so that responsible decisions can be made as to where/when you should pursue appeals. This means that you must be able to link data from different systems to get a comprehensive view of the impact denials are having on your organization. Billing Authorizations Medical Record Denials

22 Thank you! For more information about SAE s Parity Compliance work, contact: Steve Estrine, PhD (212) sestrine@saeassociates.com