Mind & Medicine - A Behavioral Health Podcast by Sentara
This podcast series is designed as a continuing medical education (CME) activity for healthcare professionals seeking to enhance their knowledge and clinical competence in behavioral health care. Through expert-led discussions and evidence-based analysis, the series explores a broad range of psychiatric topics relevant to contemporary practice. Episodes will feature continuing educational sessions focused on psychiatric interventions, modes of care delivery, emerging research, diagnostic considerations, and treatment strategies across diverse behavioral health conditions. Content emphasizes the integration of current clinical guidelines, translational research, and real-world application to support informed decision-making and improved patient outcomes. The podcast aims to foster lifelong learning by addressing evolving challenges in behavioral health, promoting interdisciplinary perspectives, and highlighting advances that impact clinical practice. This CME activity is intended for psychiatrists, psychologists, primary care clinicians, and other healthcare professionals involved in the care of patients with behavioral health needs.
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Mind & Medicine - A Behavioral Health Podcast by Sentara
Partnering with Managed Care, Behavioral Health Utilization Management with Cindy Hobbs - Part 1
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Hello and welcome to Mind and Medicine, a Sentara podcast. I'm Tommy Bateman, your host, and today we will be meeting with Cindy Hobbs to talk about partnering with managed care. But before we begin, some important CME announcements. This episode is accredited for AMA PRA Category 1 credits. For full accreditation, designation, and disclosure information, please refer to the show notes and now the show. Alright, Cindy, welcome to Mind in Medicine. Thank you for joining us.
Speaker 1Yeah, thanks for having me.
SpeakerSo before we begin, we're going to be talking everything, behavioral health, utilization, management. But before we start that, why don't you tell us a little bit about yourself and what got you here?
Speaker 1Yeah, no, no worries at all. So hi everyone, Cindy Hobbs. I am a registered nurse with a master's degree in business administration in healthcare. I've been a registered nurse since about 2010. And really before I found health plan authorization work, I tried everything, I think, as a registered nurse, trying to find my groove, you, I guess you would say. And once I discovered the world of healthcare within the health plan space, especially the work that goes on within the authorization space, I it really connected with me. Being good stewards of the almighty healthcare dollar we've been entrusted with, via you know, the government funds, or whether it be with the commercial payers contributions to healthcare, I think it's valid, very important that that work is taken into consideration and really focused on because I think it's it's a small world that people just don't know about. And I was intrigued by it. I I like to think in numbers, so this was a good fit for me. And and here I am, 15 years later, doing the same thing.
SpeakerSo what you're saying is you're the place where doctor orders life-saving medicine goes to die, is what I'm hearing. That's what utilization management does, right?
Speaker 1Uh uh a wrong preconceived notion, right?
SpeakerRight. Let's get into that. What is what is let's just start at basic. What is utilization review? What is utilization management?
Speaker 1Yeah, let's do that. So, really, this started back in the late 1980s, kind of a thing where authorization review came into play. So you go to your doctor, your doctor says you need this treatment. Well, as a health plan, we're going to determine does that treatment need an authorization before you can proceed with that treatment? If it does, then your provider, your physician partners that you see in the community will send in that request for an authorization along with supporting clinical documentation to determine from a clinical standpoint and a benefit standpoint, is this service going to be covered for what you need? Right. So that's our job is making sure that we're validating the information against a subset of criteria to determine if the member or the patient really truly needs this. And so, not to be that we're the gatekeeper of all things, right? Our goal is to, again, make sure that the services being received by the members who have entrusted us with the funds are getting the correct service at the correct time and in the correct place.
SpeakerSo, what what what happens when UM isn't isn't doing their job or UM doesn't exist? You know, what would happen to the healthcare system?
Speaker 1Well, we already know the healthcare system has got some uh some challenges in place. But if we do not have this measure of oversight, then we would not have the funds to be able to cover the services that millions upon millions of individuals need to really get the care that they need. If with no control measures and just an open floodgate, the money would red out very quickly. There would not be enough funds to cover the needed services that people really truly do need. So we are truly, we we really are a gatekeeper to ensure that the funds are spread out to the appropriate services across all health plan members instead of us losing the ability to cover services by having no gatekeeper in place.
SpeakerRight, right. And and so then when you're making the decision, though, it's not like do how much how many how much funds do we have? It's more like, is this clinically appropriate? So the funding part doesn't really come into question, but uh at this point, it's mostly like is this a needed thing, yes or no?
Speaker 1Absolutely, absolutely, and that's a great point, uh, Tommy, is that we're not really looking at the financial piece when we're making these decisions. We're looking at the clinical information submitted to us by the treating provider and the criteria utilized to make these decisions, right? So every service that we do really has a subset of criteria that we review it against. So we're looking for things that have been tried before, things that have not worked in the past. We're looking at the members' clinical presentation, what severity of symptoms do they have, and does that match up with the criteria to get that service? Now, if it doesn't, that's where we come in and go, hey, we are clinical, we are clinicians doing these reviews. We don't think you need this service, but we do think you need this service, and that comes out in the decisions that we make.
SpeakerExcellent. So let's let's narrow this down to uh BH in particular, you know, because I can imagine, you know, I worked in UM for BH, but not for medical. But I can imagine on the medical side of the house, it's leg broken, need surgery. Here's the x-ray. You know, uh, I'm just I'm not a doctor, so I don't know. But I figured it was it can be pretty cut and dry in many cases. But with BH, there's a little bit new a little bit more nuanced. How does the behavioral health factor kind of stir things up for utilization?
Speaker 1Oh man, when I started diving into working within the BH space when it came to authorization reviews, that was where the challenging piece came versus medical, right? Medical is very much more, in my opinion, cut and dry. To your example, you broke your leg, you need to get it fixed, right? You had a heart attack, this is what needs to happen after a heart attack. Well, with behavioral health, it's all symptomatic and objective, right? Somebody is saying, This is how I feel, or somebody is observing somebody, this is what they did, right? And then we need to take that objective, that documented symptoms and determine, right, is this severe enough for X type of service? So it's a little bit more challenging because we're really relying on what a patient is saying and what clinicians are observing, right? Before we can make those decisions against the criteria we've been given for the behavioral health space. So let's use an example of a psychotic episode, right? And I have one in mind right now of a member who unfortunately went into a psychosis state and chose to run around a neighborhood in little to no clothing, vandalizing statues, jumping on cars, those kind of things, right? That one's a little bit more easy to document, right? You've got that documented, you can document it. Well, when a person is describing their feeling as grief or sadness or passive, maybe suicide thoughts, those are a little bit more challenging. So then you're looking for cues in body language. You're trying to, as a clinician, pull out for documentation additional feelings or thoughts. Well, if you have thoughts of suicide, are they passive, right? Do you have a plan in place? What is that plan? Are you going to execute it? Is that your plot? So it's really engaging in those questioning to pull out the valid information that would be needed for an authorization review to determine the services that are appropriate for that individual.
SpeakerYeah, that makes it so hard because how do you is there a blood test to validate suicidal audiation versus someone not having the language to properly express how they feel, but they say, I want to kill myself. They may just be saying, I feel really, really sad, but it comes out, I want to kill myself. What do you do? You know?
Speaker 1And that's where we rely on the clinicians in the field, right? Those practitioners that are seeing these patients, these members in the community to really pull out that additional information with their with their skill training and questioning, to go, okay, well, let's let's dive into this a little more, right? Let's get this all out. Let's determine really truly where you're at mentally, right? To to really gauge what service is going to be the most appropriate to really get you where you need to be in a better control, you know, in a better state to be able to live life to the fullest for uh lack of a better term, right? So that's where those providers in the community really help us gather that information that they put in their clinical notes that we utilize when we're making those decisions for authorizations.
SpeakerSo what really, you know, you're looking at authorization requests from from these providers. What really separates a strong one from a from a weak authorization?
Speaker 1Oh, that's a great question. Let's dive into that a little bit because I see so much clinical documentation that says patient is experiencing grief or sadness. Well, what does that look like? Patient is curled up in a ball holding their legs, they're crying uncontrollably. They have it their appearance shows they may not have showered or groomed in well over a week, and that's evidenced by strangled, you know, tangled hair, dirt on the face, and underneath the nails, right? So, so the documentation really needs to paint a picture. It's almost like you're writing a story of this member, right? So if you're a book reader, think about a good book that you read. How do you get engaged in that book, that story, right? They're describing the the individuals in this book. You can you can see them visually almost in your head by the way it is described. And that's what we really truly need when we're we're receiving some of these the clinical information for for BH services, for behavioral health services. We need it described. We need to have that visual of how that member is, how they're reacting to services, what are their barriers, right? What are their challenges? And we need it very descriptive, not just them telling you something. We need to know really what the whole picture looks like in detail for them to really make sure so that we can make sure it is meeting requirements of a service that is being requested.
SpeakerSo, like what causes you to uh dig in further and say we need more records? Like what is I know you can't you you you probably already said a lot of it already, but when do you go from, you know, I'm denying, you know, because it's just doesn't meet medical necessity to I want more records, I need some more information here.
Speaker 1Yeah. Well, we try and make sure if we don't have enough information on every single authorization request, we are asking for additional clinical documentation. So I think that's an important call out. People think that something gets sent into a health plan company, they look at it, they make a decision and send it out. That's not accurate, right? We get information in with request for a service, we're reviewing the clinical information. If we can't authorize the service, we are absolutely reaching out to the provider and saying, hey, I'm not being able to process or approve the service. We need this additional information. What additional information do you have documented, right? So we're always giving that opportunity to the provider to give us that additional information if we're not able to approve that service, right? And then we wait for that to come back, right? And we we are really focused on that provider education. This is what we're not seeing, right, within the information you gave us. We can't get to the yes based upon X, right? So we're looking at that criteria, comparing it to the clinical submitted, and then requesting that additional information, right? So we really try to help always guide the provider in what we're missing to be able to get it. Now, if the provider tells us when we reach out to them that that's just not there, then our goal is to really guide them into more appropriate services. Well, based upon your clinical picture you submitted to us, this member appears more appropriate for XYZ service within the behavioral health mental health space. And that's our job, right? It's not just to say yes or no, but to help guide the members through the authorization process and providers to get to the right level of care. So we are reaching out, we're asking for that additional information if we can't get to yes immediately, and really working through how do we get there. And if it's not the appropriate service, right? What is the appropriate service and what do we do for that?
SpeakerSo it first off, it sounds like you it this job requires people that know what they're talking about. It's not just you're looking at a list of criteria and then reading it. Absolutely. So tell let's let's I want to kind of take a quick excursive down that lane, the qualifications lane. Who are the people that are making these decisions?
Speaker 1Yeah, that's a great question, right? Because we really have uh a very strong job profile when we are hiring individuals to make these decisions. I would say um 99% of all of our clinicians that work within our BH space have worked in the community. They've actually performed the services or been a part of performing the services to members, to patients in the community. So they they know what it's like to be in the community and deliver the service, right? So they're understanding the nuances of it for all of the different ones. So when we're looking at hiring staff on the clinical review side, right, we're looking for staff members that have actually performed this service or a subset of this service. And that's what we're focusing on. And then we we never want to leave out the secondary review process, right? So authorizations come in, they go through the subset review from uh the initial clinical reviewer, which is a combination of registered nurses and social workers in all different specialties, right? And then, really truly, if we're still not able to get to the yes, and we still have concerns even after outreach to providers, we have a group of psychologists and psychiatrists that are clinically trained as well in the community that do secondary reviews on this. So, right, they go through multi-level processes. This isn't just a one and done. Then the psychologists and psychiatrists that are specialty trained are really making that ultimate decision of what the authorization decision should be using their skill set, which of course is a higher skill set than even the registered nurses and the clinical licensed social workers and other specialty social workers. So I think it's it's very important for the people to understand that that that takes place in all the different levels of specialty.
SpeakerAs a as a licensed counselor, I would debate their higher qualifications and ability, those psychiatrists and psychologists. I'll but we'll have a different podcast on that one. Uh but tell us about that though, real quickly. Um, you know, of course, counselor, social workers, nurses, they're in the field doing that work, but a lot of times we're not just picking psychiatrists and psychologists that that do solely outpatient work. These are folks that have been involved in the specialty services as well.
Speaker 1Absolutely. People that have worked within residential facilities for substance use treatment, people that have worked um specifically with children with autism diagnosis, right? That's a that's a highly specialized one. We're looking for people that have worked within crisis services. Do they understand crisis work? What does that look like? How do we make sure members are getting the care they need in that? So, I mean, we're we go through a list and a gamut of all different specialties when we're looking to hire uh clinical review specialists within each one of those uh areas.
SpeakerSo thank you. And and thanks for going down that that rabbit hole with me. I wanted to I wanted to come back to records, but I was like, wait a minute. This this sounds like people that need to they need to hear who is actually looking at this stuff. It's not AI going yes or no, it's it's it's uh actual clinicians with ground experience.
Speaker 1But uh you know, AIs can get to, yeah, I'll piggyback Tommy. AIs can get to yes very fast. And I want to make sure because that is the part of the future, right? AI. AIs can get to yes fast, and we love that. We want to get to yes to as fast as we can, right? Where AI stops and where people start is when AI can't get to yes, right? When when when when the answer is no, they're not meeting, that's where humans get involved, right? That's where we need somebody with experience to touch this case and really make those determinations. So I think that's a critical point out within these this work.
SpeakerSo it sounds like you know, it just the whole process is biased towards yes, because you know, we're we're also contractually obligated, I'm hearing, to to if there's a yes, we have to say yes. You know, there's no there's no saying no for any other reason.
Speaker 1Absolutely. Agree. If it meets criteria and it meets the benefit, then absolutely that's the goal.
SpeakerExcellent. Excellent. So um back to the record stuff. Yeah. What can a provider do to prevent us going down the long rabbit hole of saying, all right, send us send us some documents, you know, let's let's chat. What what can what can we do ahead of time to prevent um you know, the delays in care, delays in authorization and things like that?
Speaker 1Yeah, right. So let's go back to the records and and really part of why you and I wanted to have this discussion today, too, which is not only what is appropriate to be sending us so that we can make those decisions faster, but what throws up red flags for us, right? What throws up the red flags where general generality and consistent generality, right? We have been able to identify notes that are derived from from AI itself. Like so a clinician using AI not in the appropriate way to capture the information, but to actually use it to falsify information. And then we see that very specific falsification pretty much choosing the exact same language over and over in multiple records, right? That's where we're gonna go, whoa, wait a second. We just looked at XYZ patient, and it's exactly the same as this patient, right? So we're we're really because we have the specialty services and individuals reviewing same and similar services consistently, they pick up on that. They pick up and go, you use this for this patient, this patient, and this patient. Something's something's amiss here. Not all three of these patients, if you saw them individually, would have the exact same symptoms, exact same language, exact same, you know, body language or whatever it is. So that's when our red flag starts going up. As well as, I don't want to put this just on a provider standpoint, abuse of services by members to extract something that they need that they're not getting as well. Members have or patients have gotten really good about saying um to clinicians certain words and describing it to get a service to resolve possibly homelessness, uh, get them off the streets, let's say. Or, hey, I don't have food, and the easy button for me to get food is to pull the trigger on a potential crisis service, and then a provider who really shouldn't be giving food will give me food, right? Because I'm saying the correct words, I'm getting the service, and that's what it is. So we're also looking at members that are overutilizing a service over and over and over and over again versus, hey, we need to link you to the correct service, but it appears you're utilizing this service for gaps in your life that we need to work on as well. So those are some of the things that we're looking at when we're looking at records, when we're looking at clinical information that's going to flag us, right? To go, wait a minute, we need to look at this a little deeper. And that's another part of our job within UM, right? That's a little unknown part that people don't know about when they're thinking through. I need this authorization, but here's another facet of what we do. We're looking for that fraud, we're looking for that waste and abuse, and we're trying to nip it in the bud and align with more appropriate care.
SpeakerYou've been listening to Mind and Medicine, a Sentera podcast. As a reminder, please check the show notes for details on how to claim your continuing education credits as well as any resources mentioned in the episode. That's it for now, but keep an eye out for another episode and more evidence based education for healthcare providers on the go. See you well.