We did not review the process for inpatient authorizations systematically, but some providers in the study have worked with both inpatient and outpatient treatment requests and said the two are very different. Inpatient authorizations are much more intrusive, probably reflecting the fact that most of the costs in behavioral health are incurred on the inpatient side. Processes for inpatient reviews vary considerably from plan to plan but, in general, consist of telephone discussions between hospital staff and MCO case managers. Reviews occur frequently, sometimes every day or every couple of days. The questions are usually open-ended and may be tailored to the specifics of the case. In some cases, the MCO case managers are very familiar with the patient’s history and may suggest treatment strategies. At one MCO, case managers may even visit the facility in person to meet with the patient and providers. If an MCO issues a denial, there is an appeals process similar to that for outpatient treatment: a first round with a doctor-to-doctor review and a second round in which the MCO may request the full medical record. One MCO said that inpatient cases reach the second round of appeals more frequently (about one to five percent of the time) than outpatient cases do.
"MHPrivacy.pdf" (pdf, 768.25Kb)
"appen-b.pdf" (pdf, 224.4Kb)