Controls in Fee-For-Service, Alternative and Value-Based Payment Contracting
In mental and behavioral health contracts for fee-for-service, alternative and value-based payment services, “controls” are mechanisms, policies, procedures, and practices implemented to manage and mitigate risks, ensure compliance with regulatory requirements, and achieve desired outcomes. The purpose of these controls is to enhance the quality of care, ensure patient safety, maintain financial accountability, and foster transparency and trust between providers and payers.
Administrative Controls:
Contractual Agreements: Clearly defined terms and conditions, including performance metrics, reimbursement models, and compliance requirements.
Policies and Procedures: Documented guidelines for clinical and administrative practices to ensure consistency and standardization.
Training and Education: Programs to ensure that providers are knowledgeable about value-based care principles, best practices, and compliance requirements.
Financial Controls:
Budgeting and Cost Management: Systems for managing and monitoring costs associated with providing mental and behavioral health services.
Reimbursement Controls: Mechanisms to ensure that payments are made accurately and in accordance with value-based contract terms.
Incentive Structures: Performance-based incentives to encourage providers to achieve specific quality and outcome measures.
Clinical Controls:
Standardized Treatment Protocols: Evidence-based guidelines for diagnosing and treating mental and behavioral health conditions.
Outcome Measurement: Tools and methods for assessing patient outcomes to ensure that care is effective and meets quality standards.
Care Coordination: Procedures for ensuring that care is coordinated among various providers and services to improve patient outcomes.
Charting Controls:
Clinical Perspective: Keeping a record provides the history a treating psychotherapist can review to further their treatment and help meet the client's clinical needs. Psychotherapists vary widely in their clinical use of records; some take detailed notes, others are sparse in their approach.
Organizational Perspective: Keeping a detailed record may facilitate efficient and effective administration provision of services, for example, in settings where an organization or clinic, rather than a specific treatment provider, is responsible for ensuring that clients receive the services to which they are entitled.
Reimbursement Perspective: An accurate record allows the party responsible for payment to confirm the nature and dates of services. The specific payment context--managed care, Medicaid, or private insurance, for example--may have its own record-keeping requirements.
Legal Perspective: State or federal law may require that a record be kept. What the law requires varies according to jurisdiction. Some states are nearly silent on the issue, while others are specific in what a record must contain.
Data and Information Controls:
Data Integrity and Accuracy: Ensuring that patient data is accurate, complete, and reliable.
Privacy and Security: Measures to protect patient information in accordance with regulations such as HIPAA.
Data Sharing and Interoperability: Systems for securely sharing patient data among providers to support coordinated care.
Compliance Controls:
Regulatory Compliance: Ensuring adherence to relevant laws, regulations, and accreditation standards.
Ethical Standards: Policies to promote ethical behavior and decision-making among providers and staff.
Audit and Monitoring: Regular reviews and audits to ensure compliance with contract terms and regulatory requirements.
Purposes of Controls in Value-Based Services
Improve Quality of Care: When implementing standardized treatment protocols and outcome measurement tools, controls help ensure that patients receive high-quality, evidence-based care that leads to better health outcomes.
Enhance Patient Safety: Controls such as data integrity and privacy measures protect patient information and ensure safe and effective treatment practices.
Ensure Financial Accountability: Financial controls, including budgeting, cost management, and reimbursement mechanisms, ensure that resources are used efficiently and that providers are compensated fairly based on performance.
Foster Transparency and Trust: Clear contractual agreements, ethical standards, and compliance controls promote transparency and build trust between providers and payers.
Promote Regulatory Compliance: Ensuring adherence to laws, regulations, and accreditation standards helps avoid legal and financial penalties and maintains the integrity of the healthcare system.
Support Coordinated Care: Data sharing and care coordination controls ensure that patients receive seamless care across different providers and services, improving overall patient outcomes.
By implementing these various types of “controls”, mental and behavioral health contracts for value-based services aim to create a healthcare environment that prioritizes positive patient outcomes, efficiency, and compliance, ultimately leading to a more effective and sustainable healthcare system.
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