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 Methodology
NMHA initially contacted 20 of our nation's largest health maintenance organizations (HMOs) and mental health care carve-outs that serve clients in the private sector. Unfortunately, many HMOs from the original list were eliminated, as they subcontract mental health utilization review and other services to the carve-out vendors already identified for the study. In addition, some companies were eliminated because they were unresponsive to our requests (please see the Report Card section on the previous page) or because they were merging or had recently merged with a larger entity. As a result of these factors, NMHA based this project on the content of the level-of-care criteria sets obtained from five of the major mental health carve-out companies and two of the largest HMOs in the nation. We also reached six of these seven vendors for a series of follow-up questions on the following topics: How the documents were developed; How frequently they are updated; How they are implemented; and How the decisions on which they are based may be appealed. Finally, we collected several sample "denial" letters that are used to inform providers that the care plan they proposed was not authorized, as well as two sets of the training materials the vendors use to teach their own internal utilization review staff how to apply their level-of-care criteria. These materials were supplemented by numerous other sample denial letters we had received from consumers, family members and clinicians in the field. An expert panel was next assembled to discuss the content of all materials, which were distributed in advance to allow for a thorough review (a full listing of the panel members, including their brief biographies, is contained in the inner cover of this publication). Please note that the names of the respective vendors were "stripped" from all papers prior to the panel review process to ensure objectivity. It is important to note that this was a qualitative, rather than a quantitative, review process. The panel first agreed upon a list of the most important substantive areas for comparing the level-of-care criteria and subsequent materials, which is reflected in the chapter headings that follow. All of these areas were thoroughly discussed during a panel meeting, subsequent phone calls, and through ongoing correspondence. This report is the resulting summary of all of these deliberations.		Introduction Key findings "Report card" on information sharing Methodology Development process Comprehensiveness Corporate philosophy Access issues Compliance 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