Privacy Issues in Mental Health and Substance Abuse Treatment: Information Sharing Between Providers and Managed Care Organizations: Final Report. 1. Outpatient Utilization Review

01/17/2003

Providers generally request treatment authorization by telephone or by submitting a written form.  However, as mentioned in Chapter I, several MCOs have recently implemented interactive voice response (IVR) systems for outpatient treatment authorizations.  The provider calls into an MCO and supplies basic patient information—including the patient name, social security number, diagnosis, and services requested—to an automated system.  How the system is used varies from company to company.  For two of the MCOs we spoke with, the system automatically gives the provider an authorization number for the services; the only reason for a denial would be if the member or provider is not eligible.  Master’s level case managers then pull reports off the system and review them retrospectively to ensure that services are being used appropriately.  The case managers therefore only need to review a limited number of cases, not every case.  (A third MCO requires the provider to supply clinical information to the system, and the approval is granted within five days.)  Compared with standard treatment request forms, the IVR system provides somewhat more privacy.  Because there is no need for a data clerk to enter information into a database, the systems eliminate the need for an additional person to see patient information. 

Despite the growing popularity of IVR systems, most providers requested authorizations for services by completing paper treatment request forms or by speaking to a case manager over the telephone.  The providers we interviewed differ somewhat in terms of whether they prefer sharing information over the telephone or in writing.  Two providers believe that phone conversations are more intrusive.  One said that a form allows providers to clearly state only the necessary information, whereas in a telephone conversation, the case manager might be more likely to ask for additional information.  Another provider believes that clinicians might be more likely to reveal more information than they intend to when they are on the telephone.  However, a third provider prefers telephone conversations because she feels she has more control over what she says, telling case managers what she thinks they need to know without revealing anything she feels is irrelevant.

Another concern that providers raised regarding telephone reviews is that the MCO staff taking the calls may not be sufficiently trained in mental health and substance abuse treatment, making them less-than-responsive, in the providers’ eyes, to requests for authorization.  A number of providers said that it is frustrating to give information to a clerical staff person who simply reads from a script and enters the information into a computer.  One provider described a situation in which a patient was actively suicidal and under supervision until an ambulance came, during which time the MCO staff member was reading through a set of questions on the patient’s hygiene that were not relevant to the case.  However, at some plans, the case managers are master’s-level clinicians who are knowledgeable about treatment.  One substance abuse provider at an inpatient clinic has interacted with case managers who are already familiar with the clients before they enter her facility and take an active interest in the treatment.

Several providers expressed concern regarding the treatment request forms, notably about the security of faxing this highly sensitive information.  One provider noted that an MCO she works with asks that forms be faxed without a cover page.  Another provider recalled a case in which an MCO had given out the wrong fax number, so information was inadvertently sent to a private residence.  Still another provider mentioned that she always calls the MCOs after she faxes forms to make sure that they are properly received.

A few providers mentioned that MCOs are increasingly accepting records electronically.  A representative of a large national managed behavioral health organization that has a number of Medicaid managed care contracts said that, in some states, doctors work with electronic medical records that feed directly into the managed care plan’s system.  Several providers we spoke with have strong concerns about the security of transmitting confidential patient information in this manner.  One provider said that her attorneys have advised her not to transmit records electronically until greater security measures are in place.  Another stated that patients should be informed if their medical records are being transmitted in this manner.

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