Presentation on theme: "Definition and Application of Rhonda Robinson Beale,M.D. Health Care Consultant Legna Business Group."— Presentation transcript:
Definition and Application of Rhonda Robinson Beale,M.D. Health Care Consultant Legna Business Group
Health Plans must disclose: Benefit requirements Exclusions Management parameters
National Coverage Determination (NCD)states: whether a particular item or service is covered or excluded. the population for whom it may be covered. under what specified situations for payment.
Under the MHPAEA, the expanded coverage of MH/SUD treatments gives the opportunity for consumers with chronic condition from being pushed into the public sector “safety net” for continuous care and/or paying out-of -pocket for all the care due to maxing out their day and/or visit limits for that coverage year.
The Federal Mental Health Parity and Addiction Equity Act, (MHPAEA). The “Good” creates parity of benefits with medical/surgical coverage, eliminates previous imposed visit and day limits The “Complication must relay more heavily on three processes and sources of evidence: health technology assessments, credible practice guidelines and medical necessity definition.
Health Technology Assessment focuses on answering these questions to determine coverage: What is it? Is it effective? ( how, when, for who?) Is special training needed? Is it comparatively effective and efficient? Is it safe?
Practice guidelines are a set of recommendations on diagnosis, assessment and treatment approaches that have been proven to be effective and/or generally accepted standard of practice as defined by a credible subspecialty organization. Example: provider recommends swimming with Dolphins as a treatment for depression. Evidence to support treatment alignment Use of the scope of acceptable treatment(s) or treatment approaches as outlined in the practice guideline. Use of the appropriate trained/experienced clinician(s) or milieu to deliver treatments
Key Components DepressionAutism - ABA Diagnostic Parameters XX Scope of Treatments XLimited Defined Medical Necessity XLimited Treatment/Response Benchmarks XLimited Level of Care Guidelines (LOCG) XLimited Establishment of Provider Competencies XFor BCBAs only 8 How does the Autism field compare to more well established fields?
Due to the Kaiser settlement, MCO’s and MBHO’s changed to a standard medical necessity definition as of July 1st 2004.
Except where state law or regulation requires a different definition, shall apply the following definition of “Medically Necessary” or comparable term in each agreement with Physicians, Physician Groups, and Physician Organizations: “Medically Necessary” or “Medical Necessity” shall mean health care services that a Physician, exercising prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease; and (c) not primarily for the convenience of the patient or Physician, or other Physician, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease. For these purposes, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer- reviewed medical literature generally recognized by the relevant medical community, Physician Specialty Society recommendations, the views of Physicians practicing in relevant clinical areas and any other relevant factors.
“Medically Necessary” or “Medical Necessity” shall mean health care services that a physician/clinician, exercising prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are: (a)In accordance with generally accepted standards of medical practice(GASMP) and (b)delivered by a clinician who is actively licensed to practice board eligible or in the case of physician extenders certified deliver services within the scope of DSM IV and CPT codes covered by insurance meets the qualifications for credentialing by insurance
Prudent clinical judgment- is interpreted as the clinical diagnosis and case formulation based on: the appropriate use of the current DSM or its equivalent in ICD as the classification system for identifying critical clinical factors relevant to the diagnosis and design treatment interventions that are relevant to the diagnosis, case formulation and are based on evidenced based practices guidelines or where absent uses “generally accepted standards of medical practice”.
Clinically appropriate, defined in terms of type, frequency, extent, site, duration and effectiveness, Type –practice guidelines, research models and sources for GASMP, ( expert consensus panels) Frequency – based on practice guidelines, successful research models, MBHO and/or national benchmark data Extent of treatment– based on generally accepted treatment domains in alignment with LOCG and/or practice guidelines/GASMP Site – based on MBHO LOCGs, practice guidelines, specialty society evidence-based recommendations Duration – MBHO and/or National benchmarks by like populations Effective – based on reported response as aligned with expected response according to practice guidelines and/or research modeling or practice based evidence using valid quantitative outcomes tools
“G enerally accepted standards of medical practice” (GASMP)- means standards that are based on credible scientific evidence from: Published in peer-reviewed medical literature, Evidenced based consensus panels, i.e.Texas Algorithm Group) Evidenced based specialty society recommendations, New technological assessments Credible practice based evidence and not from Single case studies Personal opinion
Medical necessity denials may fit into one of these categories as the bases for the denial. Inappropriate intensity of services – too high or too low, too frequent or not frequent enough the restrictiveness of the treatment setting is not needed Treatment not aligned with practice guideline(s) and no justifiable clinical reason for exception. Delay or inefficient treatment delivery
making medical necessity determinations in individual cases do not always address the particular needs of beneficiaries with chronic conditions. Chronic care differs from acute care, where the treatment goal is improvement and/or cure, and end of life care, where the treatment goal may be palliation. The goal for a patient with chronic conditions may be to prevent deterioration and/or to maintain functioning. A patient with one or more chronic conditions may have a medical need for, and accepted medical and nursing practice may require, observation and assessment, therapeutic care, and care management on an on-going basis.
Parity sets the expectation of comparable services Are medical emergency rooms comparable to true psychiatric crisis centers/front room services?