From the Kansas Health Institute:
Blue Cross and Blue Shield of Kansas won’t require customers who need outpatient mental health services to get prior authorization going forward, but it can recoup payments from providers if their treatment is significantly different from that of their peers.
Mary Beth Chambers, spokeswoman for Blue Cross and Blue Shield of Kansas, said the change brings the insurer’s mental health policies in line with its policies for other types of medical care and with mental health parity laws. Eliminating prior authorization also will reduce paperwork for providers, she said.
Blue Cross and Blue Shield of Kansas contracts with New Directions Behavioral Health to administer its mental health and substance abuse benefits, and New Directions will analyze “practice patterns” to determine how mental health providers generally treat a given diagnosis, Chambers said. If they find outliers, they then will ask for documentation to show the treatment was medically necessary, she said.
“Maybe the documentation they’ll provide shows there’s medical necessity … and maybe it won’t,” she said.
Chambers said she wasn’t sure how much variation would be significant enough for a practice to be considered an outlier, but the emphasis will be on educating providers in the early stages. Eventually, however, Blue Cross and Blue Shield of Kansas could recoup payments from providers if care isn’t determined to be medically necessary, she said.
“We want to make sure people are receiving all of the services that are medically necessary while holding down costs,” she said. “If we overpay … that just adds to the cost of health care and the future costs of our members.”
Vishal Adma, president of the Kansas Psychiatric Society, said its members are in favor of ending prior authorizations, which will allow them to begin treating patients sooner. Reviewing outlier practices also could help ensure that patients get quality care, he said, though they aren’t in favor of insurers recouping payments for services that already were provided.
“Prior authorization is a labor-intensive process,” he said. “It makes sense for them to focus on the outliers.”
Sky Westerlund, executive director of the Kansas chapter of the National Association of Social Workers, said the principle behind reviewing coverage to determine if it is medically necessary is fine, but it could prevent people from getting needed care.
“The problem that occurs in mental health is it’s (medical necessity) basically used as a tool to deny services and deny payment,” she said.
Insurers have varying criteria to determine if a mental health service is necessary. For the Blue Cross and Blue Shield affiliates, outpatient treatment is approved when the patient has a diagnosed mood or behavior disturbance that is likely to improve with treatment and “demonstrates motivation for treatment.” More specific criteria are used to determine whether a patient should have sessions as infrequently as once per month or as often as multiple times per week.
Part of the concern is that New Directions will compare people with the same diagnosis but won’t take into account differences in the extent of their needs, Westerlund said. One person with depression might feel better in four sessions, while another might need as much as a year to recover, she said.
“It’s not like a broken arm, it takes four weeks to heal,” she said. “It’s individualized.”
Westerlund also raised privacy concerns related to documentation that New Directions had told providers it would require. A letter to providers dated Nov. 30 said documentation should include objective and subjective descriptions of the patient’s “presentation” in each face-to-face interaction; the patient’s specific diagnosis; any changes to treatment goals; start and stop times; and any follow-up appointments scheduled.
“They just don’t need to know deep information, sensitive information, for authorization or payment purposes,” she said.
Chambers said insurers always have been able to collect that information and aren’t seeking therapy notes. Presentation information in a mental health context could include whether a person was intoxicated, appeared to be tired or well-rested, was crying or was calm, she said.
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