In this segment of the report, we address the type of information that is addressed during UR. Due to the implications this process has for privacy, this is an area of enormous concern. There is tremendous variability in the type and extent of information MCOs collect, ranging from the best practice of examining only diagnosis, objectives, and treatment plan, to the worst practice of reviewing the full medical record, including psychotherapy session notes.

NMHA was greatly disturbed to discover that every MCO policy we reviewed maintains the right to access the full medical record (including detailed psychotherapy notes) of any consumer covered under its benefit plan at its whim. We strongly encourage legislation, regulations, standards and any other advocacy effort that would eliminate this highly unacceptable worst practice.

Of note, the American Managed Behavioral Healthcare Association (AMBHA) recommends the following in their Statement on Clinically Appropriate Access to Medical Records:

"Disclosure of information should be limited to the minimum amount of information necessary to accomplish the purpose for which the information is used…The sharing of actual detailed clinical notes is usually not necessary to this process." (NMHA would consider this a best practice if "usually" were deleted from the last line.)

In preparing this report, NMHA observed that variability in the extent of information collected and reviewed by MCOs coincides with their differing philosophies about the ownership of mental health records. There are three distinct views:

1. The consumer owns his or her own medical records. NMHA and most other consumer-centric advocacy groups consider this to be a best practice for effectively and appropriately assuring privacy is protected. This is a stated position of at least one MCO that we were able to identify. This particular organization stated in its policies the importance of ensuring that member records contain only information which is essential to the UR process.

2. Medical records are the property of clinicians, but they may be "borrowed" by health plans. This is the stated position of several MCOs that we identified in this study.

3. Consumer records are the property of the health plan and are governed by the plan's policies. This also is the stated position of at least one major MCO, and we consider this to be a worst practice.

Beyond UR, many MCOs have reported that they need to review full medical records, including full session notes, for a random portion of cases, in order to obtain or maintain accreditation from the National Committee for Quality Assurance (NCQA). In fact, we have heard numerous anecdotes from clinicians where a sufficient number of records for the given health or mental health plan were not available, so the MCO requested records for consumers covered by other plans (an extreme worst practice). Most importantly, NCQA has confirmed that this is not a requirement for their accreditation process. Mock records demonstrating that appropriate information is collected in an effective and efficient format will suffice. As a result, NMHA strongly encourages providers to allow access only to mock records for purposes of MCO accreditation reviews.

"Top 10" Key Findings and Recommendations

Methodology

NMHA Standards for Responsible Management of Consumer Information (Position Statement P-34)

Maintenance of Consumer Information

Medical Records and Session Notes

Managed Care Staff Policies

Protocols For Clinicians and Their Staff

Special Populations and Circumstances