Best and Worst Practices In Private Sector Managed Mental Healthcare

Best (& Worst) Practices In Private Sector
Managed Mental Healthcare

Part I: Level-Of-Care Criteria
May 1999

Denial notification and appeal processes

Denial letters

Our panel spent considerable time reviewing the model letters vendors use to inform providers that the treatment plans they have proposed for their clients have been denied authorization. The best practice letters included clear language in the following areas:

The maximum time frame for responding to the denial. In the best example, this started from the date the provider received the denial letter, as opposed to the worst example that started from the date the letter was mailed (regardless of whether the letter was received).
A simple description of how to file an appeal (to whom they are sent, what information needs to be included, and in what format it should be provided).
Recommendation of an alternative treatment plan to the one that was denied authorization.
The clinical rationale for denying the authorization (as a worst practice example, one vendor simply noted that the provider can contact the vendor if s/he wants to inquire about the clinical rationale for the denial decision).
Notice of the availability of an independent appeal option (as a worst practice example, one vendor noted that "we have an independent appeal available, but we don't advertise it").

Appeals

Our examination of appeal procedures were generally favorable. However, there was considerable discussion that the policies described on paper did not echo the panelists' experiences with them. This is an area where follow-up study about the implementation of protocols is greatly needed.

Given that caveat, we were pleased that all of the vendors reported that they follow or exceed the requirements for authorization and appeal timelines developed by the National Committee for Quality Assurance (NCQA). In addition, most of the vendors offer independent appeals and do not require authorizations for initial evaluations. The only exceptions to these last two policies were in situations where their clients had requested otherwise (a worst practice among private sector purchasers). The main variance was found in the following area:

Number of levels
of appeal available Best practice Worst practice

4 2

One troubling finding across the companies, however, was that appeals by consumers and providers are rare. Several of the vendors we spoke with were concerned that providers and consumers must have more complaints than they are actually lodging. In addition, many vendors reported that they are rarely denying care due to current political pressures-instead they negotiate reductions in care plans, which are not as conducive to formal appeal procedures.

Introduction

Key findings

"Report card" on information sharing

Child and family issues

Substance abuse and co-occurring disorders

Cultural competence

Provider autonomy

Coordination/ consultation among providers

Denial notification and appeal processes

More observations, recommendations and areas for further study

Acknowledgments