As with much of the healthcare industry, Behavioral Health and Chemical Dependency treatment facilities and providers face ongoing challenges in the areas of reimbursement, quality care delivery and medical/legal risks.
From a reimbursement perspective, most behavioral health facilities and providers continue to receive per diem/per unit payment. That means every day counts and is scrutinized by payers for medical necessity based on documentation provided. Admissions may be denied outright or the full and appropriate length of stay may not be approved.
Practitioners strive to deliver quality care. At times, gaps in care may occur or, more often, the documentation of the care delivered is lacking. Quality Assurance efforts often lag far behind care delivery such that discovery of a gap may be well after a patient is discharged and the opportunity to address the gap has gone. And always lurking is the risk of an accusation of malpractice due to a perceived gap in care delivery.
At the end of the day, behavioral health facility administrators want to:
- Secure appropriate reimbursement from payers by including critical clinical elements in medical necessity documentation and ensuring that the required length of stay is approved and reimbursed
- Mitigate denials by appropriately documenting medical necessity before patient discharge and claims submission
- Assure quality by proactively identifying and addressing gaps in diagnostic care delivery and mitigating malpractice risk by assuring quality care delivery
Even with these objectives, BH providers often do not address critical clinical elements, in practice or documentation, that could achieve them. Clinical documentation is a key indicator of a facility’s capacity to deliver quality care and ensure appropriate and medically necessary reimbursement.
Certainly, not all cases are created equal. Not all suffer from shortcomings in treatment practice or medical necessity and clinical documentation. It stands to reason that a review model that focuses on the low hanging fruit—high cost cases with suboptimal reimbursement and correctable documentation issues—and provides real-time review from a payer’s perspective would foster opportunities for care delivery and documentation improvement while a patient is still in a behavioral health facility.
Let’s look a little more closely at what that model may look like.
Physician-Directed Clinical Documentation Improvement Model
There would be four structured elements to drive near and long-term benefits:
- Proactive analytics
- Real-time review of documentation
- Payer-oriented case review technology
- Ongoing provider education & coaching
As noted previously, not all behavioral health and chemical dependency cases would necessitate review. Lower risk cases where there would not be much bang for the buck could be excluded. Of course, facilities also handle most cases and document the care delivered appropriately. Proactive analysis of hospital/provider claims data would tell us where the suboptimal payer determinations are and enable targeting of such cases accordingly. The data would be segmented in myriad ways including by: payer, line of business, diagnosis, procedure code, individual practitioner and even individual patient or patient profile. An example may be claims denials by a certain payer for a certain treatment due to insufficient documentation.
Armed with this information, a behavioral health facility can then set out to capitalize on the opportunity.
Real-time Review of Documentation
To be most impactful, there are two key criteria: (1) being able to review the case while the patient is still in the facility; and (2) for the review to be conducted by a physician who is experienced in health plan behavioral health criteria-based utilization management. Importantly, all behavioral health/SUD patient records would be reviewed by board-certified psychiatric and addiction medicine physicians from the managed care environment. They would be adept at using medical necessity criteria from CMS, Interqual, MCG, ASAM, etc. This would be a proactive process that begins upon admission when the case review is first triggered and concludes prior to the submission of a claim with the intent to deliver real-time feedback to providers, thereby fostering timely corrections.
Payer-Oriented Case Review Technology
An enabling, secure, HIPAA-compliant technology platform would be employed to easily identify and display gaps in medical necessity documentation, potential quality of care concerns and coding opportunities. This tool would be structured with elements and process flows that mirror a criteria-based medical necessity review by a payer. Interfacing with EMR systems, the platform would standalone and would not automatically trigger changes in the patient record. While it would be a system to help providers identify potential documentation or care delivery short comings, importantly, it would be at arm’s length and ultimately be up to the treating provider/facility to take action and enhance documentation accordingly.
Ongoing Provider Education & Coaching
An important aspect of this model is to foster continuous improvement and enduring change. In addition to the “in the moment” case by case feedback, providers would also have the opportunity for peer to peer coaching with reviewers, training (including optional CME credit), and targeted instruction based on analytical findings.
At the end of the day, it is all about the patient. This model, deployed as a technology-enabled service, helps to ensure that quality care is delivered and that practitioners are accurately conveying medical necessity and disease burden, ultimately leading to correct payment for their services and reducing malpractice risk. At the same time, it assures payers that they are compensating providers appropriately. A win-win-win for all.
Register for our free webinar on February 28 to hear more about this model, how it can be applied and specific examples of the impact it can have in the behavioral health environment.