Mind & Medicine - A Behavioral Health Podcast by Sentara
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Mind & Medicine - A Behavioral Health Podcast by Sentara
Partnering with Managed Care, Behavioral Health Utilization Management with Cindy Hobbs - Part 2
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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.
SpeakerWell, I think some of the trends we notice is when people aren't using services as well. So we notice when people are overutilizing services potentially inappropriately. We'll dive into that. And we're noticing when when patients and members are potentially not using services enough, right? Maybe they're utilizing the ER as their go-to, where the emergency room is not a go-to, right? What other services, what other things need to be in place? And how do we work with others within our health plan to help us get members there, right? We have a gamut of people. Let's call out the case management team, right? That is our partner in crime. So our job is looking at these authorizations, picking up things, calling things out, getting members to the appropriate services, but then we partner with our care coordination and case management team, like, hey, we're noticing this on this member. Can you help reach out to the member, to the member's caregiver, whatever it may be? So we can identify where the gaps are and really start closing some of those gaps. So the members have got and the patients have got everything that they they need to really live a complete and successful life in whatever way they want to.
Speaker 1And so, you know, you're looking at folks that aren't getting the care they need. What's the consequences? I mean, from a UM perspective, what what trends do we see when that doesn't happen?
SpeakerOh man, that's a great question. What what happens when members don't get the care that they need, right? Well, you're gonna see higher utilization in higher uh care services, hospital-based services, right? So the goal of our our team is to get members the care they need in the lowest level of care that will meet their needs, right? Nobody wants to spend a long amount of time in a hospital, right? Hospital is your highest level of care. That means something failed in the lower levels of care, and hence why you're in the higher level of care, or a tragic something happened that that really preceded or had that event of getting you into the higher level of care. So when we are not doing what we need to do, or when members are not getting the appropriate care or receiving care that they need, then that usually escalates to where they're in a higher level crisis situation and then they're in higher care. And that costs the organization money, but that costs ultimately the members money, right? Because that means we're spending more money than we really should be on higher levels of care that could have been taken care of in the lower levels of care if the members got the care that they need at the right time and in the right place.
Speaker 1Excellent. So it sounds like you know, it's it's a win-win-win. The system benefits, the member benefits, you know, everybody. The bottom line's better. And then that, you know, when when we're when our utilization goes down, it sounds like members are generally healthier unless they're not getting the services that they need, is what I'm saying.
SpeakerCorrect. Absolutely. Absolutely. And that means we're being a good steward of the dollars. I mean, yes, we we started off saying that we're not tied to financial, but in the end, right, you all are paying your taxes into government programs. If you have a commercial plan, right, you're paying your part of the premiums into the the commercial plan, right? You want to make sure who's ever watching over this money is really utilizing it optimally.
Speaker 1So I want to pivot a little bit. Let's let's go down the the the path of okay, we have a problematic, we have an issue here. And you mentioned some people using AI notes, copy and pasting. And and and it's I'm guessing it's one thing to use AI for the same thing over and over again. It's a it's but it's another if let's say they they took their clinical notes and they're just discussing, so they threw them into an AI to organize them better. That's another thing. And that's that's we're doing a little bit better. But what when we're starting to look at problematic providers, those red birds, what what are those things that start getting your antenna going about a provider?
SpeakerYeah, besides the items that I just described, the overlapping notes, um, we're looking at you know, requests coming in that are really excessive in units and care, really extremely long length of stay that that's not normal for a service. Things like that is where those triggers or those flags start getting up. Right. And then what do we do as a as the utilization management department of a health plan? Well, what we do is we loop in additional partners in crime. Hey, this is what I'm seeing for XYZ case. Can we dive into them? So at our our at our disposal within other teams and within the health plan, right? We have auditors, right, underneath certain uh departments that will take these cases and perform a more lengthy, in-depth audit, right? They're looking at different uh flags within a larger subset of clinical information. So we may ask for a small subset of clinical information to make a decision. They're gonna ask for a very large subset of information. They also may, of course, go to the provider's offices. They're gonna want to go in there, they're gonna want to see the files, they're gonna want to see how the operation is running, right? They're gonna want to see all of that to determine do we have a concern or an issue here that we need to address, or is their operations running as it should be, and we just flag something that maybe was not something to flag, but we need to investigate that, right? We need to investigate these concerns, we need to make those determinations if the providers in the community are doing the right thing by our members and patients and and getting them into the appropriate services. So there's a lengthy process that goes on in the the back end when some of this is identified. And Tommy, I know you you help and work on part of that team and and and how we really then deep dive. We don't we're not looking to to penalize providers, right? We're looking to actually prove what they're doing is actually correct. But if we prove that what they're doing is not um really following the guidance and the guidelines and the the intent of the service, that that tech that takes another course, right? That takes a whole nother course.
Speaker 1So I mean, as a UM um reviewer, are you are you nitpicking every little thing? Or I mean, what is it like when it comes to looking at that compliance are uh you know what what are what are we are we are we trying to nail them to the wall or are we trying to uh improve their services? I know I'm I've I loaded that question because I already have the answer on that one.
SpeakerYeah, you did, right? You did load that question and you do have the answer, right? Our goal is to identify maybe gaps in things that they're doing that are not aligning with the compliance and regulatory requirements, coaching them to let them know and giving them the opportunity to become successful, right? Here's what we're seeing, here's what we need you to do, and here's where how we're gonna monitor you until we feel you're reaching the optimal level that you need to be, right? Now, sometimes the the findings are very egregious, right? If they're really egregious, there's a different path we take because we don't want to partner with providers that are truly, truly doing egregious work that is is intentional, right? But if it's unintentional, right, they just didn't know. That's where we want to do that coaching and provide them with the tools to be better, to service members better and reach and and to be able to obtain and consistently reach those compliance and regulatory requirements.
Speaker 1So then it sounds like UM can be a provider's best friend. So what are what are things that that provider how can providers utilize utilization reviewers to make themselves better, not just, you know, you did this wrong, did this wrong. What what what type of relationship could you have there with the providers that helps build them up?
SpeakerWell, you know what? There's something that I think providers don't know very well. You have access, even if you don't know it, to all of the criteria that we use to make authorization decisions. I would say in-house in providers' offices, understand that criteria. Really understand those requirements, right? Now you're saying, well, how do I get those? Well, every health plan, right, is now publicly putting that criteria on a provider-facing portal. And members can also have access to this. So if I'm a member and I want to understand, well, how do I get this service? Well, that criteria is available to you too. So one, get that criteria. Make sure you have a copy of that criteria. Then second, after you've reviewed criteria for the services you offer, then circle back to what I described in your note-taking when you're really painting that picture of the member, right? Going into those details of the member curled in a ball, crying, dis, you know, the hair a mess, there's dirt on the fence, right? Go into that documentation that's more thorough. Don't just list member has grief, member has suicidal thoughts. You're never gonna get an authorization that way. You need to go into that storytelling. So understanding the criteria and then going into the storytelling, right? That's how we become best friends. The providers in the communities with the members and then with the health plan is really understanding that.
Speaker 1We we talked about underperforming providers, providers that like we need to give give us more records, that we're digging in more. But what do those providers do that don't give you heartburn? What do they all have in common?
SpeakerRight. Let's let's start with the authorization standpoint, and I'll piggyback into other things. From the authorization requesting standpoint, I mean their documentation is solid. They have described the member in detail as to why uh they need the service. They go into all of the variants. They're they're using all five senses. I think that's a best way to put it. They're using all five senses when they are describing the member's situation. They're making sure, right, that the member, you know, they're painting that picture for us to clearly see why this member is appropriate for a service. But they're also not asking for services that are not appropriate, which I think is great. They're not trying to start a member out in the highest level of care possible to obtain, right, the highest reimbursement. They're starting them out at the lower levels of care. They're they're really not asking for, you know, six months worth of service. They're starting them out with a month worth of service to determine if the service that they're going to be performing is the best fit for this member, right? Because sometimes when a member starts a new service or a patient starts a new service, we don't know if it's going to be the best fit. We think it is based upon a clinical presentation, but we don't know. And so they're not asking for an extended length of time. They're making sure the member, you know, they're giving it a trial run. They're they're asking for a minimal amount of units, a reasonable amount of time frame to gauge if the service will be a success for this member. Let's use ABA for an example because ABA is in the news quite a bit right now, right? CMS just reported, did a study that ABA utilization has increased 421%. I mean, that's astounding. And you you kind of dive in to go, why? Why is ABA increasing tenfold, if not more, year over year? They put together a little kind of workbook that's available to providers, to health plans, to anybody that wants to review this, right? And and really they're looking at and their guidance is something that I say we've been doing for well over a year now within our area, is what's reasonable, right? And when you're thinking of kiddos, like a kiddo can't be in a therapy program 40 hours a week. That's a full-time job. Right. So these providers, right, are being more reasonable. They're they're requesting units that are lower. They're requesting a time frame of a month or two versus six months, right? They're giving us enough leeway to review this case on a more frequent basis so that we can determine if the member is truly getting what they need from that service. They're making the progress, they're reaching the goals that are established with it within the initial start of care of this service to be able to do that. So reasonable. So to summarize that, what is a good provider look like, right? Reasonable authorization requests for appropriate units and for appropriate length of stay. Their clinical notes are detailed enough that we paint that picture of the member as to why they're needing that service, right? And then they partner with us. They're letting us know if member has gaps or they need additional services that they need help with. They're reaching out to us, not only in UM, but they're reaching out to our care coordination and case management team, alerting us of items that really are a gap so that we can assist those members in closing those gaps and getting them the care that they need.
Speaker 1Yeah, all those things really signal to me that you're not just looking to make money, which by the way, providers make money. I want you to make money. Do well, do well in your endeavors. We wish you well with that sort of thing. But it signals that that's not the primary focus. The primary focus is wellness of the of the client or the patient. Um, because you know, if we're if we're asking, you know, for two weeks' worth of service for high-intensity service, let's say, that could typically run three months, let's just say, but we're only asking for two weeks out the gate, that means you're gonna give me an updated clinical in two weeks.
SpeakerYeah.
Speaker 1Because it, yeah. And if we approve those two weeks, does that necessarily mean you're not that's you're you're two two weeks and done, you're not gonna get any more?
SpeakerYeah, that doesn't, right? That means thank you for letting us take a second look at this. Oh my goodness, the service is working after two weeks. Great, let's go ahead and approve more now that we know this service is working so that they can continue to progress to their goals, right? And that's what's critical. People, the the more frequent we're asking for this, and or the reduction in units and length estate providers are asking from us, gives that opportunity for us to gauge the progress towards goals. It also gives us the ability to gauge when they're not making progress. Okay, we tried this, it's not working. Let's see what other service could really work for this member to get them to where they need to be to reach those those goals. And it allows us to course correct to a different service if the result is that the service isn't working.
Speaker 1Like even a higher level of care that costs us even more money, but we will be fine with that as long as the members are getting healthier. All right.
SpeakerYep, absolutely. There's quite a few times we're recommending higher levels of care when we're looking at uh members' clinicals, like, hey, this person actually needs to be here in this higher level of care for a while, and then we'll step them down when it's appropriate to the lower levels.
Speaker 1And so, you know, I know as a as a therapist, one of the things that you know we were trained on was start treatment with the discharge in mind. Um, how how important is discharge uh among those you know high performing providers? What do y'all look for when it comes to discharge? Uh, that whole process.
SpeakerRight. I think that's very critical. You I you're calling out something that's great, but just not only in the BH space, just not only in an utilization management space in life. Do you start a project without the end result in mind? What's what are you trying to get to at the end? Right? What does that look like? And how do you set goals to get to that end, right? And so that's very critical. When we're looking at clinical information, we're looking at discharge planning. What are you trying to get to? What is the ultimate state this member needs to be in for them to move to lower levels of care? Right. Our goal is to get them outpatient, right? Everybody that is the lowest level, and that's a good maintenance type of program, is into outpatient services. You're seeing your therapists, you're seeing your counselors, those kind of things. But that is critical as we're working and helping plan for how much units do you need to get there, right? If you're requesting this, there's times we'll give you more units. If we're like, no, you really actually need more units, in fact, to get you to this that we feel. So let's help you get there. And for us to be able to do that, we need to understand what the discharge plan is. We need to understand there's a discharge plan in place and being worked towards for us to help with those authorization requests.
Speaker 1So, you know, let's wrap up with a little bit of inside baseball. I know we this whole topic has been inside baseball, but you know, when we are looking at a good auth, bad auth, whatever, high performer, low performer, um well, each reviewer only sees one member's authorization at a time. So how do we eventually go, hey, this is a pretty good provider? You know, they they're doing some good work there. How do we finally, you know, say, not just off of one member, because that's not enough, that's an anecdote, but how do we look at it and go, this provider is is doing good work? How do how do we internally figure that one out?
SpeakerYou know what's great about having clinicians doing this work? I get a lot of feedback from them. So we'll just start with that first and foremost. Hey, I'll get asked, what do you think about this provider? And to that, I reach out to the frontline teams that do these reviews. Hey, what are you guys seeing with this provider? And they'll they are a wealth of feedback for me. Yeah, this provider does this really well. We never have to do this. We're looking at scorecard measures, right? We're looking at how are they performing of the authorizations that their requests sending in, how many are we fully or partially denying, right? How many of those are taking place? That means, you know, are you asking for inappropriate units or length of stay on those? So we're looking at those measures. We're looking at, you know, different kinds of complaints that come in from members, like any of those member complaints that say, hey, this this provider is doing X and I'm not getting what I need, or or we have, you know, at certain times members calling in going, this provider's not letting me leave. Right. So these kind of things are all part of the tracking mechanisms that we're looking at when we're gauging the success of the providers. And really truly, I know uh Tommy, you know this too. What we're looking for in the future as we're thinking about the RBH enterprise as a whole is who can we gold card? Who are those top performing providers that their utilization is appropriate based on scorecards, right? The feedback we always get is positive from the frontline review teams, right? Members just praise the way that they do things up and down. Well, gosh, you know what? I don't want to be as stringent with your reviews as I am with the partner out here in the community that has those high denial rates, right? How do we move you through the process of getting your services approved quick and getting you treating those members because you have shown us you can perform as expected. So I think those are some of the traits and things that we're looking at as we we stand up additional gold carding of providers.
Speaker 1I love it. And and and that's the thing. What what having a high trust you know situation between payer and provider, I think does require you know the quality of collaboration. Uh so you know, uh we we often say, you know, when I was a clinician, the the quality of the paperwork usually has a one-to-one correlation with the quality of the delivery of service. But I think based on what you're telling me too, is that the quality of their collaboration with UM and CM, excuse me, utilization management and case management care coordination, how they partner with us, how they do their peer-to-peers, how they do uh their appeals tells us a big story about how they are as a business and uh a provider as well.
SpeakerYep, agree. I I don't mind providers or members getting passionate about care they feel they need. Um, just do it professionally, right? We're here to help you. We're we're your partner, we're not your enemy.
Speaker 1Yeah. Hopefully we all have the same goal of the uh the client getting better.
SpeakerYep, absolutely.
Speaker 1Any parting words before uh we sign off?
SpeakerUh parting words, guys. UM can be your best friend. We really want to know utilization management, your authorization team, your health plan as a whole wants to be involved with you within the member's care. When you see obstacles, when you see gaps, when you see the member is going in a direction that's not aligned with the goals that they wanted to go for whatever reason, you please reach out to us. Please have us really truly help you in this. If you're not understanding anything, if you're not understanding certain services or how an authorization works for a certain service or what that entails, we provide education. You just have to reach out to us. We can't assume that you know everything. So unless you reach out to us, we can't be your partner. So my parting words is remember, we want to be your partner. We don't want to be your MME. So please don't hesitate to reach out to us with questions or concerns you may have.
Speaker 1You'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. You will.