06/25/2010
Utilization management and cost-containment in a post-parity world
The federal Mental Health Parity and Substance Abuse Equity Act, signed into law on Oct. 3, 2008, requires that group health insurers treat mental health and substance abuse benefits the same as medical benefits. The act removes any visit limits, day limits and dollar maximums for those services if they're more restrictive than medical and surgical benefits.
Utilization management, however, is still permitted. Our parent company is experienced in managing parity benefits in Oregon, which has had parity since 2007, and in all its service areas (Idaho, Oregon, Utah and parts of Washington) for the Federal Employee program.
Although limits or financial maximums have been removed for impacted groups, utilization management activities are an effective way to manage the quality and cost of behavioral health and chemical dependency care. Our behavioral health department reviews services when utilization reaches specific thresholds, at which point clinical information, such as a treatment plan, may be required. The threshold for most outpatient services is 20 visits. Most residential or inpatient services will be reviewed after two days.
Asuris supports the use of practice guidelines to assist in determinations of clinical appropriateness of treatment services provided for mental health and chemical dependency disorders and conditions. The practice guidelines describe generally accepted practices developed by nationally recognized organizations and are based on the most recent medical evidence. We adopt guidelines to help practitioners and members make decisions about the appropriate care for specific conditions.
Estimated cost avoidance for behavioral health utilization management in 2010 is $7 million, and we expect to save an additional $4 million in behavioral health network management.
« Back to Communications
|
