05.24.2023

What Are Payers Looking for at Utilization Review for Behavioral Health Treatment?

Everyone who seeks mental health or substance use treatment deserves high-quality care that is appropriate for their unique needs. A common hurdle to this, however, is making sure that a patient’s treatment is covered by their insurance provider.

This is where utilization review often comes into play.

So, what is utilization review? This is the process through which insurance companies determine if they will continue to pay for a patient’s mental health or substance use treatment. Because access to treatment is so vital to a patient’s successful recovery, it’s so important to be prepared for the utilization review process.

Focus on these five essential areas to ensure that your behavioral health organization’s UR team is best prepared to advocate for your patients.

1. Prepare Detailed Utilization Review Documentation

Thorough documentation is the foundation of a successful utilization review of mental health or substance use treatment. Without accurate records and reporting, the utilization reviewer will have an extremely difficult time demonstrating to a payer why they should continue funding a patient’s care at your behavioral health organization.

When preparing utilization review documentation for patients in mental health facilities, focus on the six evaluation parameters in the Level of Care Utilization System (LOCUS):

  1. Risk of harm
  2. Functional status
  3. Medical, addictive, and psychiatric co-morbidity
  4. Recovery environment
  5. Treatment and recovery history
  6. Engagement

For patients who are receiving treatment for substance use disorders, adhere to the six assessment dimensions that were established by the American Society of Addiction Medicine (ASAM):

  1. Acute intoxication and/or withdrawal potential
  2. Biomedical conditions and complications
  3. Emotional, behavioral, or cognitive conditions and complications
  4. Readiness to change
  5. Relapse, continued use, or continued problem potential
  6. Recovering/living environment

While you are compiling this information, don’t forget to consider your audience: the care manager who will be reviewing your report to determine whether the insurance company will continue to pay for your patient’s mental health or substance use treatment.

“Write as though you are presenting a clinical picture for someone who doesn’t know anything about the patient,” advises SimiTree Behavioral Health Utilization Review Manager Carly Dotoli. “Make a case for your patient.”

2. Personalize Each Utilization Review Report to the Patient

Clinicians understand the importance of personalized care to help people overcome mental health challenges and substance use concerns. But the value of personalization isn’t limited to the services that your behavioral health organization provides.

Resist the urge to copy and paste or use forms that auto-populate descriptions for common clinical scenarios. To help your utilization review team make the most effective case to the insurance company, you need to be sure that the information you provide is unique to the patient.

“Insurers don’t want to see cookie-cutter phrases,” Dotoli says. “You don’t want every patient to have the same statements across the board. Make your reporting specific to each person.”

3. Document Treatment Goals for Utilization Review — Not Just the Care Plan

Clinicians understand the value of helping patients set specific, measurable treatment goals. But they may not realize the value of documenting these goals for utilization review purposes.

Goals can be especially important for patients who have a history of unsuccessful treatment experiences.

If a patient has relapsed, or if they have struggled to appropriately manage the symptoms of a mental health or substance use disorder, providing details about their goals is an excellent way to demonstrate to the care manager that you’re not simply trying to replicate what didn’t work during the patient’s previous times in treatment for a mental health or substance use disorder.

4. Share the Patient’s Progress

In addition to establishing measurable treatment goals, you need to be sure that you are documenting the progress that your patient is making toward these objectives.

This is an area where balance is extremely important.

If you indicate that your patient has achieved everything you set out for them to accomplish, then the care manager may understandably balk at continuing to fund their behavioral health treatment. However, if you aren’t able to show that your patient is making any improvements, they may also refuse to authorize continued payments.

This doesn’t mean that you should misrepresent what your patient has done while they’ve been in your care. It just means that you need to put their successes (or lack thereof) in proper context.

For example, if a patient in a residential setting has met their substance use or mental health treatment goals, you can document this, along with information that explains why step-down care such as a PHP or an IOP would be ideal.

Conversely, unsatisfactory progress at the outpatient level could be used to justify transferring the patient to a residential or inpatient program for continued mental health or substance use treatment.

5. Show Plans for Aftercare

Even though the payer may not be funding aftercare services for your patient, they want to see evidence that you have considered their long-term progress and continued needs. Ideally, you should try to incorporate aftercare planning into your documentation from day one.

“The insurance companies want to know about aftercare planning as early as possible,” Dotoli notes. “They will ask, ‘What is your plan for after this?’ It’s important that everything is documented so [that] they can see that the patients are getting the care they need.”

Knowing what payers are looking for can help you improve utilization review outcomes. That means better outcomes for your patients and better financial health for your organization.

How SimiTree Behavioral Health Can Help

SimiTree Behavioral Health can help your organization with utilization review and many other administrative responsibilities. We offer an array of customizable solutions to help mental health and substance use treatment facilities streamline their processes and grow their businesses.

Call 1.800.949.0388 to speak with an expert today or complete the contact us form at the bottom of this page to learn more.

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Let's work together to improve the health of your organization. At SimiTree, we balance financial expertise and clinical excellence to help our clients grow. How can we help you? Call us at 866.839.5471  or complete the form below.