Most of the providers we spoke with agreed that there is a great deal of variation in the amount of patient information requested by MCOs for outpatient authorizations. The one exception, a provider who works only with Medicaid managed care firms in her state, has not observed much variation among the plans. The other providers agreed that there is variation from company to company, and even within companies, depending on the type of contract an MCO has with an employer and on state laws that may restrict the types of patient information that can be shared with managed care firms.
To determine what information is shared between providers and payers, we asked both if they would be willing to share copies of their outpatient treatment request forms and telephone review protocols. We collected a total of 10 forms and one telephone protocol. From these, we were able to identify a number of topics that are fairly standard in treatment authorizations and others that vary considerably from company to company. The documents we collected include:
The Maryland Uniform Treatment Plan Form.This form is used to collect the only patient health information that insurers can routinely collect in Maryland, per state law. The form went into effect in October 2000. Self-insured(ERISA-exempt) plans are exempt from this requirement (Appendix B).
· The Magellan Treatment Request Form. Magellan is a national managed behavioral health care organization with an enrollment of approximately 70 million people. Magellan adopted the form in August 2000 (Appendix C).
· The ValueOptions Outpatient Treatment Report. ValueOptions is a national managed behavioral health care organization that manages services for over 23 million people. The ValueOptions Outpatient Treatment Report is available on the firm’s website at www.valueoptions.com/provider/forms.htm.
· Two forms used by other national managed care firms but not publicly available.
· Five forms from small or local managed care firms. Two of these plans serve primarily Medicaid populations.
· One telephone protocol used in at least one market by a large managed behavioral health care organization.
We created a list of the information that was requested by the managed care plans and recorded the frequency with which each item occurs in all the forms or protocols we reviewed (Appendix D). Items that occur in at least six of the forms or protocols are identified in Table II.1. Information on whether the item is requested in a categorical format (usually checklists or yes/no questions), in narrative form, or in both is also included in the table.
While we found wide variation in both the amount of information collected and the processes for collecting that information, we also found some similarities across plans. All plans ask for administrative data, including the patient’s name, date of birth, social security or insurance identification number, and identifying information for the practitioner. Most plans ask for the DSM-IV diagnosis code, including axis five, the Global Assessment of Functioning. Treatment information, including the requested procedures or types of services, the frequency and duration of treatment, and expected outcomes are also fairly standard. Most plans also ask about the patient’s current medications and compliance with the regimen. Finally, many plans ask for information about the practitioner’s coordination with the primary care provider and about the patient’s involvement in other community services.
"MHPrivacy.pdf" (pdf, 768.25Kb)
"appen-b.pdf" (pdf, 224.4Kb)