Privacy and Confidentiality

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

The MCOs we spoke with believe they collect only the personal health information they need to manage care. Those who commented directly on the APA guidelines do not believe that the guidelines provide for the sharing of enough information. The MCOs do not want to manage every outpatient case, but they do value the ability to flag outlier cases

6. Appropriate Information Sharing Depends on Who

Privacy Issues in Mental Health and Substance Abuse Treatment: Information Sharing Between Providers and Managed Care Organizations: Final Report. 6. Appropriate Information Sharing Depends on Who Will Review the Information and the Patient’s Explicit Consent

Who Will Review Information? The position of the American Psychiatric Association (APA) is that, when an MCO wants to question the quality or appropriateness of care, one qualified, independent clinician should review the case. Several provider respondents support this idea and commented that, to support such a review, sharing the patient’

Privacy Issues in Mental Health and Substance Abuse Treatment: Information Sharing Between Providers and Managed Care Organizations: Final Report. 5. Beyond Routine Outpatient Treatment

Providers and consumer advocates involved in intensive forms of treatment or representing the seriously mentally ill generally agreed that it is appropriate to share more personal health information to justify treatment that goes beyond routine outpatient care. In fact, this group of providers typically did not have specific views on what inform

Privacy Issues in Mental Health and Substance Abuse Treatment: Information Sharing Between Providers and Managed Care Organizations: Final Report. 4. Controversial Items

Most of the respondents who believe that some sharing with MCOs beyond basic administrative information is acceptable nevertheless feel that many MCOs request more information than they need. Certain items in particular are viewed as troublesome.

3. Some Additional Summary Information Is

Privacy Issues in Mental Health and Substance Abuse Treatment: Information Sharing Between Providers and Managed Care Organizations: Final Report. 3. Some Additional Summary Information Is Justified

Many respondents, including clinicians and consumer advocates in the mental health and substance abuse fields, believe that it is acceptable for managed care plans to routinely collect additional summary information specifically for outpatient care pre-authorization, that is, after the first set of sessions, which typically do not require review.�

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

One advocate and one provider association representative raised the issue of giving only ID numbers, rather than patient names, to a plan. 1 This arrangement was negotiated between one plan and a group of concerned providers, and was facilitated by the state psychological association. We came across one instance (in a third interview) i

1. Administrative Data Only for Most Cases

Privacy Issues in Mental Health and Substance Abuse Treatment: Information Sharing Between Providers and Managed Care Organizations: Final Report. 1. Administrative Data Only for Most Cases

One view is that for routine cases requiring outpatient treatment, health plans should not need more than the basic administrative data that was required for fee-for-service medicine, such as patient identification information; clinician identification information; procedure code; charges; and dates, type, and location of service. Three of the p

A. Provider Associations, Clinicians, and

Privacy Issues in Mental Health and Substance Abuse Treatment: Information Sharing Between Providers and Managed Care Organizations: Final Report. A. Provider Associations, Clinicians, and Advocates

The provider association representatives, clinicians, and consumer advocates we interviewed agreed that many MCOs request more personal health information than they need to manage care. There was less than full agreement, however, on just how much information MCOs do need. We begin by discussing the views that allow for the least information t

III. STAKEHOLDER VIEWS ON WHAT CONSTITUTES

Privacy Issues in Mental Health and Substance Abuse Treatment: Information Sharing Between Providers and Managed Care Organizations: Final Report. III. Stakeholder Views on What Constitutes 0 Necessary" Information for MCO Operations

In this chapter, we report on what the provider associations, clinicians, consumer advocates, and managed care plans we interviewed see as “minimum necessary” information. In addition, we identify which items of personal health information are especially controversial. We observed that in many cases, respondents’ views on privacy have be

Privacy Issues in Mental Health and Substance Abuse Treatment: Information Sharing Between Providers and Managed Care Organizations: Final Report. 4. Inpatient Authorizations

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 o

Privacy Issues in Mental Health and Substance Abuse Treatment: Information Sharing Between Providers and Managed Care Organizations: Final Report. 3. Appeals

If a request for treatment is denied, the patient and clinician have the right to appeal. The appeals process varies from plan to plan. The initial appeal may take the form of a telephone conversation between the clinician and a doctor on staff at the MCO. If the two are unable to reach an agreement on the course of treatment, the case will

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

Once a provider submits a treatment authorization request, an MCO case manager may call the provider to ask for further clarification. A great deal more information may be shared as a result. It is not clear how often this occurs, as providers and MCOs were not able to give precise figures. As mentioned in Chapter I, one MCO said that it hop

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

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

Privacy Issues in Mental Health and Substance Abuse Treatment: Information Sharing Between Providers and Managed Care Organizations: Final Report. D. How Data are Collected

Privacy Issues in Mental Health and Substance Abuse Treatment: Information Sharing Between Providers and Managed Care Organizations: Final Report. 2. Plan-to-Plan Variation

Information on patient history varies considerably from plan to plan. Three plans do not ask for any information on the patient’s history or previous treatment. Several plans ask whether the patient has received treatment for mental health and/or substance abuse; some plans provide the clinician with a checklist of treatment types (i

Privacy Issues in Mental Health and Substance Abuse Treatment: Information Sharing Between Providers and Managed Care Organizations: Final Report. 1. Variation By Type of Plan

Some respondents believe that the information requested varies by the type of plan. We reviewed whether the types of information requested varies by whether an MCO does or does not carve out behavioral health (Appendix E). While our data are limited, with only four examples from MCOs and seven from MBHOs, there do not seem to be any difference

C. Degree of Variation in Ttypes of Information

Privacy Issues in Mental Health and Substance Abuse Treatment: Information Sharing Between Providers and Managed Care Organizations: Final Report. C. Degree of Variation in Ttypes of Information Collected

B. Information Collected by MCOs for Outpatient

Privacy Issues in Mental Health and Substance Abuse Treatment: Information Sharing Between Providers and Managed Care Organizations: Final Report. B. Information Collected by MCOs for Outpatient Treatment

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 the

4. Case Management and Care Coordination

Privacy Issues in Mental Health and Substance Abuse Treatment: Information Sharing Between Providers and Managed Care Organizations: Final Report. 4. Case Management and Care Coordination

Case Management. MCOs may also use personal health information for case management and care coordination purposes. MCOs may assign case managers to patients who use a high volume of services, to help them coordinate care between providers and to help them access community services. Case managers may also be “go-to” peop

Privacy Issues in Mental Health and Substance Abuse Treatment: Information Sharing Between Providers and Managed Care Organizations: Final Report. 3. Audits

MCOs do audits primarily to make sure that clinicians are actually performing the services for which they are billing. In addition, several providers stated that MCOs may need to review records in order to comply with accreditation requirements such as those developed by the National Committee for Quality Assurance (NCQA).

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