Short-Term Analysis to Support Mental Health and Substance Use Disorder Parity Implementation. Utilization Management


  • Outpatient psychotherapy is often subject to plan review after a certain number of visits, to authorize reimbursement for further visits. According to some panelists, psychotherapy is an example within the behavioral health field where there is a high degree of uncertainty about the nature of the problem (diagnosis), about what treatment will work, about what type of provider is required, and with high variability in quality and duration of treatment. These considerations suggest that different UM practices for outpatient psychotherapy may be justified relative to outpatient visits for many general medical conditions.

    • The panel noted that psychotherapy is a specific procedure (not a class of benefits like outpatient services) and so comparability of UM should be evaluated at the level of the procedure, not the benefit level. Panelists pointed out that there are comparable procedures in medical care that are characterized by clinical uncertainty and practice variability, for example, physical therapy. Parity requirements imply that if psychotherapy is subject to a particular UM practice, similar procedures (e.g., physical therapy) in the medical benefit should not have a less intense level of UM.

    • Panelists pointed out that diagnostic uncertainties and high variability in treatment/provider choices exist for some behavioral health conditions, but are also found for other general medical conditions (e.g., lower back pain). If certain behavioral health diagnoses (e.g., adjustment disorders, substance abuse) are selected for differential and more aggressive UM practice than others, such differences would be justified under parity regulations only if these were comparable to or less restrictive than UM practices for comparable general medical conditions.

  • Requiring prior authorization for all outpatient behavioral health services is not clinically appropriate, as this may unnecessarily delay clinically appropriate services, and inhibit access to appropriate clinical services. Such prior authorization practices for behavioral health care would meet parity requirements only if similar prior authorization is required for all medical outpatient care.

    • Plans may require prior authorization or conduct concurrent review of targeted behavioral health services or procedures, for example, psychological testing. This may be justified on the basis of clinical appropriateness, but in order to meet parity requirements, similar considerations should result in similar UM management practices for medical services.

  • Plans may utilize concurrent review for inpatient psychiatric hospitalizations that are reimbursed on a fee-for-service basis, and retrospective review for general medical hospitalizations that are reimbursed as a total fee based on DRGs. Differences in UM practice in this case are justified because DRG-based fees are not established for psychiatric hospitalizations. DRG-based reimbursement creates incentives for the hospital to actively manage utilization, but in the absence of incentives for the hospital to control costs, concurrent UM by plans is clinically appropriate.

    • For general medical hospitalizations that are not reimbursed based on DRGs, parity would require similar or no more stringent UM practices for behavioral health inpatient care than for these types of general medical inpatient care.

  • Plans may require prior authorization for medications like Suboxone (used to treat opiate addiction), if this practice is justified by clinical appropriateness considerations, such as risk for abuse, that are similarly applied to other medications (e.g., Oxycontin). If psychiatric or addiction medications like Suboxone require prior authorization based on different standards than other medications, then parity requirements would not be met.

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