Utilization Management in 2016 - Check Yourself Before You Wreck Yourself by John Raymond CAC. Presented at NCAD 2016.

2. WELCOME

3. Utilization ManagementUtilization Management
In 2016In 2016
Check Yourself Before You Wreck Yourself

4. Presented By

5. John Raymond
Director of Client Services, Utilization Management and
Development
PRRS, Inc.
John@PRRSinc.com

6. 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.

7. Session Objectives
a. Redefining Utilization Management
b. Working with private health insurance companies
• Outline changes in documentation requirements
• Understanding how these changes effect you and
your clients
a. How will these changes impact your revenue cycle

8. 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.

9.  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.

10.  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

11.  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

12.  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?

13.  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

14.  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

15.  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

16.  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

17.  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

18.  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

19. The Don’ts of Documentation

20. The Don’ts of Documentation

21.  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?!?

22.  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

23.  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?!?!?!

24.  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?

25. 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.

26. 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

27. 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.

28. Continuing Education Certificate and Evaluation Process
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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.

29. THANK YOU