1 David Lisonbee President/ CEO Twin Town Treatment Centers Succeeding in the World of Managed Care 8GG Managed Care Contracting and Service Delivery
2 Managed Care: Contracting and Service Delivery Ho\tv to ider1tify and pursue I CO busir1ess opportunities \IVhat does your organization G r1eed so as to cor1trt1ct ar1d service :... - _... rr1ar1aged care: creder1tials, utilizatior1 revievv 1\!lanaged care processes: intake/ triage; au thoriza tior1, uti I iza tior1 revie'jv/ case rr1ar1agerrlent; billir g, follo\tv-up ar1d appeal.
3 Behavioral Managed Care The role of managed care is to control cost, quality and risk. Screen and qualify providers Manage size and scope of provider network Control pricing/ costs of services Control access, level of care and length of stay Evaluate performance
7 Identifying and Contracting with Managed Care Identify managed care companies which provide a large number of benefit plans/ members in your market. Your intake department knows which ones are common for your current calls and clientele The State's department of managed care or insurance often provides demographic listings of managed care/ insurance companies in your market(s) Assess managed care company's geographic and service needs
8 Identifying and Contracting with Managed Care Inquire about the number of "lives" for which the company manages care in your market Inquire about the number of competing service providers on their roster for this service area. Ask for a preferred/ network provider application
9 Negotiate Managed Care Contract From your managed care company prospects, ask for and complete credentialing and service agreement applications and send with your credential documents (see next page). Negotiate rates based upon the managed care current range.
10 Negotiate Managed Care Use your break-even and retail rate as your boundaries. Contract Continually follow-up with the contracting and credentialing process. The provider relations/ network development departments rarely benefit from your participation. The ball is in your court!
15 Managed Care Contractin Credentialin ui rements Current State license or certification for each service site or satellite office. If a license or certification applies to more than one site, the license or certification must identify all covered sites or a letter from the issuing State must be submitted that indicates the addresses of all covered sites and that they are licensed or certified. Current accreditation certificate (Joint Commission, AOA, AAAHC, COA or CARF). Please send a copy of the accreditation notification letter identif ing. all service sites or satellite offices covered by the accreditation. A copy of the most recent State site visit and Continuous Quality Improvement Plan if your organization is not accredited by the Joint Commission, AOA, AAAHC, COA or CARF. A current copy of the organization's (a) medical malpractice, (b) errors and omissions, and (c) comprehensive general and/ or umbrella liability insurance certificates of coverage, including the limits of liability and policy period. If your organization is a governmental entity, a signed statement that the organization is covered under a Tort Claims Liability Act or similar legislation is required. Completed Lawsuit Claims Questionnaire and/ or claims. Clinical staff roster with name, credential, credential number, title.
16 Managed Care Processes and Servicing Tips for Coordination of Care-Utilization Review Never ask for a program dictated" levels of care, lengths of stay or sess1ons Create the case for level of care/ utilization before making the caremanagement call- use the level of care criteria for tips Ensure that you know where the patient stands in their individualized treatment program. Are they making progress and if not, what are you going to do differently? Avoid uthey're doing pretty good... " Prepare to answer why the patient an't be ade uatel served in a lower
18 Don't fill residential beds simply for plentiful income Most treatment should be provided on an outpatient basis Little evidence demonstrates that residential has better outcomes than outpatient treatment Provide only the most cost-effective, evidence-based treatment Ensure that every service (to be) billed has been authorized for payment All patients and family members must be treated respectfully Understand which party holds the financial and clinical risk on each case- get authorization from the payor Develop strong communications and relations with managed care provider relations and care-management
20 Thanks To the Following Managed Care ProviCier Relations Representatives for tllei I ---- \ I
21 Appeal Panel: Sample Appeal Letter _is appealing the_/_/_ medical necessity denial of the_ dates of_ service noted above. The clinical rationale for this denial is based upon,"_. Due to this, you will not likely benefit from_. You can also benefit from_". Following are patient signs and symptoms, which overtly qualify the patient for _ level of care, pursuant to_ criteria: 1. The patient established a_ pattern of_._ started problematic_ abuse at age_. Frequent_ is needed to curtail drug use while new behavioral and cognitive skills are being exercised. 2. Despite numerous attempts and treatment episodes to achieve and maintain abstinence/ sobriety, he has only been able to establish_ of continuous sobriety throughout _I ife. _ appears to lack adequate _for which this episode of treatment was designed to help establish. 3. The patient has a long-term history of_of which his physician is currently treating. His dependence on _coupled with his_ creates a life-threatening situation._ physicians have been coordinating their treatment with this treatment staff given this critical condition. Frequent monitoring is necessary to ensure that the patient curtails_ use given his_ condition. 4. The patient has a history of_ disease/ disorder. The ASAM placement criteria consider co-occurring medical (psychiatric) conditions to indicate a need for much higher levels of care. 5. The patient has an extensive history of relapse and currently presents an inability to avoid drug use beyond_. He is able to_. He appears to lack_ skills for which this episode of treatment was prepared to train. 6. The patient has_ stages of change. The client acknowledges that his drug dependence has harmed_. This treatment episode was to be focused on_. 7. Included in negative consequences of which the patient continues to use despite of are:_; ; _. New_ skills were to be additional foci of treatment. 8. The patient's initial_presented_.subsequently, the patient_.asam level of care criteria specify_are indications for the need for higher levels of care.
22 Cc MD 9 Pursuant to_ decision to deny this episode of care, the patient lost his primary motivator for change and hope for recovery. His current_ coupled with_ dependence persists as a life-threatening and unresolved threat. 10 The treatment team intervened successfully with the patient's_through the administration of_. 11 The patient started to_. The patient began to _leading to relapse and continued substance dependence. 12 Due to the_ denial, unmet treatment goals will include the_. The patient has also not had a complete opportunity to_. These _Substance Abuse_ Rehabilitation level of care criteria clearly indicate this patient need for continued _treatment::_;_;_... The following ASAM Level of Care Criteria clearly indicate this patient need for continued intensive outpatient treatment:_;_;_... I hope you'll agree that providing the _level of care has been in the patient's best interest and safety, and agree to authorize_ sessions of treatment at the _ level of care and authorize a resumption of treatment, given the high potential of morbidity and/ or lethality of this situation. Most Sincerely, X