The Pacific Source 26 Session Review is a Utilization Management Audit using Hidden, Ill-Defined, and Biased Objectives with Outdated Audit Controls
A Healthy Contract’s Discussion Paper
On January 1, 2024, PacificSource stated they will begin completing utilization management reviews for members who have received 26 or more therapy/counseling visits. Behavioral health (BH) providers will be contacted and asked to submit clinical information, which will be reviewed for ongoing service.
Clinical information requested will include:
Most recent assessment
Current treatment/service plan
Five most recent treatment/service notes
The purposes of these reviews are:
To ensure treatment is medically necessary and progress is being made toward treatment objectives/goals.
To ensure adequate access for all PacificSource members.
Note: This policy is applicable to non-Certificate of Approval (COA) agencies/providers. Only Oregon Medicaid providers are eligible to have a COA.
A PacificSource FAQ asks and answers,
Is this requirement a benefit limit?
This is not a benefit limit or a stop to services. If services are medically necessary and/or appropriate, the member’s treatment will continue. If the services are not medically necessary and/or appropriate, PacificSource will work with you on next steps.
For more information see:
https://pacificsource.com/article/behavioral-health-treatment-reviews-required-2024
The PacificSource 26 session utilization management audit is ill-defined, biased, has hidden controls and should changed.
Based in on an investigation and analysis, there is evidence that challenges the validity and utility of the utilization management program. PacificSource contract and policy requires provider to participate in an ill-defined, biased and unfair “utilization management” audit that has obfuscated criteria. The requested information and subsequent review is what certified internal auditors call a “control.” A control is a term used by auditors to mean processes, policies, procedures, and mechanisms put in place to manage and mitigate risks within an organization. They are designed to ensure that objectives are achieved, assets are safeguarded, operations are efficient and effective, and compliance with laws and regulations is maintained. Controls can be preventive, detective, corrective, administrative, technical, and legal and compliance oriented.
The PacificSource stated objective are (1) To ensure treatment is medically necessary and progress is being made toward treatment objectives/goals, and (2) to ensure adequate access for all PacificSource members. The is a misalignment between the objectives and value of this audit.
The Pacific Source audit objectives are unfair, and unreliable because the Center for Medicare and Medicare (CMS) standard was updated to provide more certainty when audited. PacificSource is implementing the outdated Oregon Medicaid standard which was eliminated by Medicare and Medicaid, and replaced with the phrase: “medically reasonable and necessary. (1)
(1) On January 14, 2021, CMS finalized a regulatory definition for determining whether an item or service is "reasonable and necessary" … CMS explained that codifying "reasonable and necessary" will "provide greater certainty … to ensure that this substantive legal standard is codified." The effective date of the final rule…March 15, 2021.
In healthcare contracting, the terms "appropriate" and "reasonable" are often used to describe the suitability and adequacy of medical services. Though they may seem similar, they have distinct meanings and implications in this context.
Appropriate
Definition:
Appropriate refers to treatments or services that are suitable and proper for a particular patient’s condition and circumstances. It emphasizes the suitability of the care in the context of current medical standards and the specific needs of the patient.
Implications in Healthcare Contracting:
Suitability: The term focuses on whether the treatment is fitting and proper for the patient's specific condition, taking into account the latest medical guidelines and evidence-based practices.
Contextual Relevance: It considers the individual patient's health status, preferences, and overall context, ensuring that the care provided matches their specific needs and situation.
Provider and Payer Perspective: Both healthcare providers and payers may use this term to ensure that treatments align with best practices and are tailored to individual patient cases.
Reasonable
Definition:
Reasonable generally refers to the fairness and appropriateness of a treatment or service based on standard medical practice. It emphasizes the practicality and common sense judgment of whether a typical healthcare provider would consider the service suitable.
Implications in Healthcare Contracting:
Practicality and Judgment: The term allows for flexibility, relying on the clinical judgment of healthcare providers. It involves considering whether the service is practical and makes sense in the context of the patient’s condition.
Standard Practice: It reflects what is typically accepted as standard practice among medical professionals, allowing for a range of acceptable treatments.
Coverage Decisions: Insurers may use "reasonable" to determine if a service should be covered based on its general acceptance and utility in standard medical practice.
Key Differences
Contextual Focus:
Appropriate: Focuses on the suitability and propriety of the treatment for a specific patient’s condition and circumstances, emphasizing individualized care.
Reasonable: Focuses on the fairness and practicality of the treatment in the context of standard medical practice, emphasizing broader acceptability and common sense.
Flexibility:
Appropriate: May be more stringent and aligned with specific guidelines and best practices tailored to individual patient needs.
Reasonable: Offers more flexibility and relies on the provider’s discretion and judgment within the bounds of accepted medical practice.
Subjectivity vs. Objectivity:
Appropriate: Can be more subjective, as it considers the unique aspects of each patient’s situation.
Reasonable: Often seen as more objective, based on what is generally considered acceptable and fair in the medical community.
Implications for Coverage:
Appropriate: Insurers might use this term to ensure that treatments are specifically suitable for the patient's condition, possibly leading to more stringent coverage criteria.
Reasonable: Insurers might use this term to ensure that treatments are broadly acceptable and practical, potentially allowing for a wider range of covered services.
Necessary
Definition:
Necessary refers to services or treatments that are essential and indispensable for diagnosing or treating a patient's medical condition. It emphasizes the need for the intervention to prevent significant harm, improve health, or manage symptoms effectively.
Implications in Healthcare Contracting:
Medical Necessity: This term is often used in insurance policies to establish criteria for coverage. A service must be medically necessary to qualify for reimbursement.
Stringent Criteria: The determination of necessity is typically more stringent, requiring clear evidence that the service is essential for the patient's health and cannot be omitted without compromising care.
Objective Standard: "Necessary" is more objective and often relies on established clinical guidelines and evidence-based practices to justify the need for a specific treatment.
Key Differences
Flexibility:
Reasonable: Offers more flexibility and relies on the provider’s discretion and judgment.
Necessary: Requires adherence to stricter, evidence-based criteria, often leaving less room for provider discretion.
Appropriate: May be more stringent and aligned with specific guidelines and best practices tailored to individual patient needs.
Subjectivity vs. Objectivity:
Reasonable: Subjective and context-dependent, varying with individual provider perspectives and patient circumstances.
Necessary: More objective, based on established medical standards and clinical guidelines.
Appropriate: Can be more subjective, as it considers the unique aspects of each patient’s situation.
Coverage and Reimbursement:
Reasonable: Insurers may cover treatments deemed reasonable even if they are not absolutely essential, provided they align with general medical practice.
Necessary: Insurers typically only cover treatments that are medically necessary, focusing on essential interventions that have a clear impact on health outcomes.
Appropriate: Insurers might use this term to ensure that treatments are specifically suitable for the patient's condition, possibly leading to more stringent coverage criteria.
Clinical Standards:
Reasonable: Involves a broader interpretation of what is acceptable in medical practice, accommodating a variety of treatment approaches.
Necessary: Involves a narrow interpretation, focusing on interventions that are critical and indispensable for the patient’s condition.
In practice, healthcare providers and insurers must often balance these concepts when determining treatment plans and coverage. Providers aim to offer care that is both appropriate and reasonable, ensuring that patients receive suitable and effective interventions that align with their specific needs while also adhering to standard medical practices. Insurers use these terms to manage costs and ensure that they are paying for treatments that are both suitable for the patient's condition (appropriate) and generally accepted in medical practice (reasonable). “Appropriate” gives Healthplans’ ultimate authority. “Reasonable” gives providers’ reasonable authority. The word “appropriate” is not adequately defined. The criteria that define medically necessary and appropriate is not transparent.
CMS is the prevailing standard in the U.S. Healthplan. Oregon adopted the CMS “necessary and appropriate” standard when Oregon created the Oregon Healthplan. Healthplans in Oregon have not adopted the new CMS standard, even though they provide services on behalf of Medicare and Medicaid. This may be because it gives PacificSource an unfair advantage to the detriment of healthcare providers.
PacificSource 26 session control is not fair.
PacificSource 26 session control is not fair. It was not even negotiated. It is a consequence of a contract of adhesion (i.e., take it or leave). Contract of adhesion are have detrimental effects on providers and patient.
For more information see:
What Problems are Created when Healthplans offer Providers “Take it or Leave it” contracts (contracts of adhesion)?
https://www.mentorresearch.org/take-or-leave-contract-in-healthcare
PacificSource values and objectives as implemented in their utlization management program are not fair and not reasonable if their objectives are to increase access and certify that services are justified.
PacificSource 26 session not a quality or access control, it is a cost control .
The values in the Pacific Source audit plan seems to be profit, not access nor improved quality and outcomes, despite the payer’s assertion that one purpose is to “ensure adequate access for all Pacific Source members.” Pacific Source has not fully identified the objectives of the audit. Nor the risk-impacting objectives that could undermine public health and provider practices.
Pacific Source has not described a program that will gather, aggregate and analyze provider data. There is no commitment by Pacific Source to publish key indicators of success. If providers are threatened by this audit, it is more likely that provider practices will screen out patients who might require more 26 sessions. For example, (1) patients with more than one medications, (2) need and don’t have a physician or psychiatrist, (3) people who have been to an ER, (4) children involved in a divorce, (5) divorce and domestic violence, (6) personality disorders, and (7) patient with chronic illness. There is no accounting that it is quit possible that the utilization review program will cause providers to avoid treating patients who have chronic problems in order to keep their risk exposure and stress level low. Logically, the program will almost certainly result in a higher degree of under-utlization.
The PacificSource objectives are not to ensure treatment. Nor are are the objectives to prevent undertreatment. The impact will almost certainly be undertreatment for some plan members. The objectives are almost certainly aligned with Healthplan profit values, not clinical objectives shared with providers’ practices or OHA values.
Withholding the requirements of a credible standard for by, the purpose of the Pacific Source audits almost certainly will not to improve charting, nor access, prevent undertreatment, or improve quality and heath outcomes. This conclusion is probable because Pacific Source is not receptive to discussing and explaining the value, objectives, and controls (i.e., standard) for which the provider is audited. One can surmise, with probable to almost certainty, that the purpose is to restrict services and the resulting cost.
Withholding a credible standard for a chart to be compared (i.e. values, objectives, controls), by which an independent auditor could replicate the audit process, the purpose of the Pacific Source audits almost certainly will not improve charting, nor access, prevent undertreatment, or improve quality and heath outcomes. This conclusion is probable because PacificSource has no mental and behavioral health charting control. They do have a general healthcare guidelines. PacificSource is not receptive to discussing and explaining the value, objectives, and controls (i.e., standard) for which the provider is audited. One can conclude, with probable to almost certainty, that the purpose is to restrict services and the resulting cost.
For more information see:
What is the value of psychotherapy charting?
https://www.mentorresearch.org/value-psychotherapy-charting
· Charting Requirements Are Not Patient-Centered
https://www.mentorresearch.org/charting-requirements-are-not-patient-centered
There needs to be a legislated solution that creates accountability with guardrails that protect provider practices and public health. Healthplans are unwilling to listen to providers. PacificSource does not appear willing to have conversations with mental and behavioral health professionals about values, objectives, measures and what leads to quality and improved outcomes.
The PacificSource 26 session audit has no value or shared objectives to providers and patients
Based on the content from the PacificSource 26 Appointments Audit, several issues and recommendations must be implemented to ensure that the control mechanisms in place could actually monitor and support the objectives of increasing access, reducing overtreatment, and minimizing undertreatment.
The following is description of what data must be gathered and used, along with key leading indicators and additional data required for improving quality and improved health at an appropriate cost.
If PacificSource is sincere about gathering data, monitoring and achieving the objectives of increasing patient access, reducing over-treatment, reducing under-treatment, improving patient satisfaction and health outcomes within the control required by the PacificSource 26 Appointment Audit, the following data should be gathered and utilized:
Data to be Gathered
1. Appointment Availability and Utilization:
Number of Appointments Offered and Filled: Track the total number of appointments available and the rate at which they are filled.
Wait Times: Measure the average wait time for an appointment to assess accessibility.
2. Treatment Metrics:
Number of Sessions per Patient: Monitor the distribution of therapy sessions per patient to identify trends in treatment duration.
Clinical Outcomes: Collect clinical outcome data, such as improvements in standardized mental health assessments.
3. Provider Practices and Capacity:
Provider Capacity: Assess the current caseload and capacity limits of providers.
Provider Engagement: Measure provider participation and compliance with the audit requirements.
4. Patient Demographics and Health Status:
Demographic Data: Gather information on patient demographics, including age, gender, socioeconomic status, and insurance type.
Health Status: Track the prevalence of chronic conditions, medication use, and comorbidities.
5. Emergency and Hospitalization Data:
Emergency Room Visits: Record the frequency of ER visits and the reasons for these visits.
Hospital Admissions: Track hospitalization rates and the conditions leading to admissions.
6. Patient Satisfaction and Experience:
Patient Surveys: Conduct surveys to gauge patient satisfaction with access, quality of care, and overall experience.
Feedback Mechanisms: Implement systems to collect patient feedback and complaints.
Analysis of Data
1. Increasing Access:
Identify Gaps: Use appointment availability and wait time data to identify areas where access is limited and develop strategies to address these gaps.
Optimize Scheduling: Implement scheduling practices that maximize appointment availability and reduce wait times.
2. Reducing Over-Treatment:
Analyze Session Distribution: Evaluate the number of sessions per patient to identify potential over-treatment patterns.
Review Clinical Outcomes: Ensure that extended treatment durations are justified by clinical improvements and necessary for patient health.
3. Reducing Under-Treatment:
Monitor Under-Utilization: Identify patients who receive fewer sessions than clinically indicated and investigate the reasons.
Address Barriers: Work to remove barriers to adequate treatment, such as financial constraints, transportation issues, or stigma.
Additional Data for Quality and Cost Objectives
1. Quality of Care Metrics:
Clinical Improvement Scores: Track patient progress using validated assessment tools.
Care Coordination: Monitor the effectiveness of care coordination efforts between mental health providers and other healthcare professionals.
2. Healthcare Utilization and Cost:
Routine and Urgent Care Visits: Track the frequency and reasons for routine and urgent care visits.
Cost Analysis: Analyze the cost of care provided, including direct treatment costs and associated healthcare expenses.
3. Outcome Measures:
Readmission Rates: Monitor rates of readmission to hospitals or emergency rooms to evaluate the effectiveness of ongoing care.
Preventive Care: Track the use of preventive services and their impact on overall health outcomes.
Key Leading Indicators of Success
1. Appointment Availability:
Increased number of available and filled appointments indicating improved access.
2. Wait Times:
Reduction in average wait times for appointments.
3. Session Distribution:
Balanced distribution of therapy sessions per patient, reflecting appropriate treatment duration.
4. Clinical Outcomes:
Improved scores on standardized mental health assessments.
5. ER and Hospital Visits:
Decreased frequency of emergency room visits and hospital admissions for conditions that could be managed through regular care.
6. Patient Satisfaction:
High patient satisfaction scores and positive feedback.
7. Provider Engagement:
High levels of provider compliance and participation in audit processes.
8. Cost Efficiency:
Reduced overall healthcare costs without compromising the quality of care.
By systematically gathering and analyzing the above data, the PacificSource 26 Appointment Audit could effectively monitor and achieve its objectives of increasing access, reducing over-treatment, reducing under-treatment, improving quality, and managing costs appropriately. Because they don’t, their commitment to improving quality and outcomes is questionable.
DISCLAIMER and PURPOSE: This discussion document is intended for training, educational, and or research purposes only. The information contained herein is based on the data and perspectives available at the time of writing. It is subject to revision as new information and viewpoints emerge.
For more information see: https://www.mentorresearch.org/disclaimer-and-purpose