The Insurance Company's or Contract Manager's Treatment Authorization Process and YOUR Documentation in Client Records .... a.k.a. 'What Can Go WRONG in That Chart?' - 2 Credit Hours
SUMMARY: This course is a nice 'companion piece' to Ethics Courses 3D and 4D - which focus upon the ETHICS of documentation in client records and related issues, when insurance is paying the bill. This Course 2B takes it a step further, in demonstrating the typical 'holes' in clinical records and the 'holes' in the thinking of even the most experienced mental health and AOD practitioners, which must be avoided if you are to pass a clinical review of your treatment records, unscathed.
This material applies to those in private practice who have a Provider Agreement with either a commercial insurance company or an HMO which is administering the State's Medicaid or Medicare plan. Particularly with the coming of the new Federal Health Care Reform, no professional is unaffected, unless they limit their practice to private pay clients.
Much of the material in this short course also relates to how we - as treatment providers who are always at risk of falling into legal and professional potholes - can avoid setting ourselves up for problems which oftentimes result from failure to document crucial issues in our clients' records.
The course also provides a clear explanation about HOW those insurance companies make pre-authorization decisions to APPROVE or DENY your requests for treatment . . . and WHAT you must write in the client's chart to support that authorization. It's all about how to ENSURE that you will be ready when the MCO or State auditors appear at your door.
AVOID RECOUPMENT! Failure to properly DOCUMENT certain details of the client's treatment and his need for treatment is the primary reason for RECOUPMENT (taking back) of funds already paid to you by the government contractor or the insurance company. How we document treatment has CHANGED with the coming of Care Management! This course gives you clear 1-2-3 information about how to document effectively - within the bounds of good professional practice.
Click Here to Go Back to the Catalog for Course 3A Managed Care - Is There Anything GOOD About It? - 3 Credit Hours
This course emphasizes how innovative, non-traditional counseling, case management, and support services can be provided under the new managed care models, particularly for difficult, recidivistic, high-risk clients - a natural fit for EAPs and AOD providers of Dual Diagnosis services.
Although "managed care" has become known as an increasingly "medical" model – necessitating that services be deemed essential to recovery and adaptive functioning – in this course we address the positive changes which this shift has brought to the behavioral health field, as well as the challenges. The 'positives' include flexible home-, job-, and school-based interventions utilizing non-institutional case management and support services for children/adolescents, adults and youth with substance abuse issues, and adults with depression and other mental health problems.
The final lesson in this course focuses upon the details of how Care Management departments make decisions to approve or disapprove requested services, and how these decisions can impact your clients' recovery process. Such understanding is essential in order for EAP service providers to accommodate to this shift in treatment and counseling emphasis.
NOTE: Part of the material in this course is similar to some of the material found in MODULE 201 of FlexiCourses 4A, SA, and 10A.
1. Intro to goals and objectives of Managed Health Care - a.k.a. 'Why are they doing this to us and our clients?'
2. The Good, The Bad, And The Ugly of Managed Health Care plans, and how to adapt your therapeutic intervention approach constructively.
3. How does the 'Care Management' review process affect the way that we deliver services to clients with mental health and substance abuse issues?
4. Identifying some creative service options for providers to explore which allow more autonomy under a Care Management' system.
In most states, it's goodbye to flexible addiction Block Grants and other 'open access' State contracts for substance abuse and chemical dependency – which makes access to AOD services even more difficult. This course addresses the 'nitty gritty' of the major CHANGES in SA-CD programs – referral criteria, treatments and interventions available, documentation of need for treatment and response, and philosophy – due to the new health care reform environment. Applies to single AOD diagnosis and to Dual MH-AOD diagnoses.
COURSE 5B: This course is the same as Module 401 in FlexiCourse 10A. If you take Course 10A, DON'T take this course.
Negotiating for good professional and clinical options in delivery of care is Job 1 when working within a Health Care Reform environment. What type of flexibility might you or your program have in terms of how you can serve your clients - especially those with more serious mental health and AOD disabilities? This course will give you some good information about that.
You must learn how the Care Manager 'thinks' when making decisions about approval or denial of requests for treatment. This course addresses the basis of those decisions.
GOALS of this course:
1. Review the Issue of "How The Managed Care Company Thinks - What Is 'Medical Necessity of Treatment' At A Practical Level"
2. Understand Why the DOCUMENTATION in your clients' records must reflect the 'Level of Care' decision factors
3. Know how to AVOID making ERRORS that cause providers to lose AUTHORIZATION to provide treatment.
4. Know how to work effectively within a Care Management system, including how to deal with multiple issues which affect the treatment we are allowed to provide to clients and the funding we receive to do it.
5. Review specific EXAMPLES of creative ways of serving CD and Mental Health clients under a Managed System of Care, e.g., instead of repeated detox, unnecessary inpatient admissions, and '28 Day' Programs, offer Non-Medical 23 Hour Observation and more Day and Evening Intensive Outpatient Programs (IOP) for adults, and more Intensive Home- and School-Based treatment for children and adolescents.
6. Know to seek expanded credentialing flexibility wherever clinically appropriate (crucial for AOD).
Also learn when providers need to say NO to an MCO, when to say YES, and when to say 'How about if I do THIS?' Examples of some good alternative options to pursue with a managed care company, including expanded CREDENTIALING flexibility -- which is especially critical for AOD service providers.
Go Here to Read About Our 'FlexiCourses' - Earn Multiple Certificates in a single Managed Care Course.
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