Privacy Issues in Mental Health and Substance Abuse Treatment: Information Sharing Between Providers and Managed Care Organizations: Final Report. 2. Quality Management

01/17/2003

Although MCOs collect the patient information contained in outpatient treatment requests (OTRs) primarily for utilization review, many MCOs also use this information for quality management.  Several MCOs we spoke with use the information submitted in OTRs to identify outlier cases in which the diagnosis appears to warrant more extensive treatment than what is being received.  Examples include a patient with schizophrenia who is not on medication or a patient who is actively suicidal but for whom appropriate levels of care have not been indicated.  OTRs are also used to track patient progress.  For example, if a person with an adjustment disorder has been in treatment for several years with no apparent improvement, the MCO would want to flag the case and then call the provider for an explanation.  One MCO stated that it hopes to have to follow up on no more than 10 to 15 percent of cases. Procedures for quality management differ at one staff-model HMO, where the provider’s supervisor and other authorized personnel in the behavioral health department randomly review charts to ensure that appropriate care is received.

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