Parity implementation is a shared responsibility. Individual providers, provider systems with health plan products, health plans and their managed care vendors that oversee behavioral health benefits, governance entities, and consumers as well as consumer advocates are essential in ensuring access to appropriate levels of behavioral health care. Failing to monitor implementation of this legislation on the state, county, municipal, provider and consumer level will result in diminished access to care. There would be a lack of a continuum of care required to treat not just mental health and substance abuse treatment, but true integrated complex care and co-occurring disorders which encompasses 50-70% of avoidable admissions resulting in high PMPM rates.
Following are some essential actions and change processes needed to ensure you are playing your part.
If you’re an individual provider:
- Ensure your documentation and authorization request process meets standard of care and communicates the medical necessity criteria for the level of care and specific diagnostic criteria set. Clarity in documentation and communication are of utmost importance.
- Gather information from collateral contacts on the patient’s current needs and make sure there is a clear presentation on functional level and level of care needs noted in your request for service authorization.
- Understand the client’s benefit policy across different levels of care and the annual units of service allowable for a particular level of care request. Have a comprehensive understanding of parity requirements across medical/surgical and behavioral health units of services.
- Develop a tracking system regarding request for services, authorizations received, units of services used, claims sent and reimbursement received. Most importantly, track your denial claims diligently and identify denial trends that may occur across certain at-risk populations.
If you’re a provider system developing a health plan:
- Develop policy and procedures that recognize and implement parity treatment requirements and ensure full consumer access, particularly as it applies to specific levels of care.
- Ensure staff are trained and have knowledge of assessment practices and procedures that comply with diagnostic findings and evidenced based practices as it relates to level of care and functional needs.
- Provide fail safe procedures in your EHR that support accurate and precise documentation of medical necessity requirements and protocols across your multi-disciplinary team process.
- Analyze your provider network to ensure compliance with treatment referral capacity and specific levels of care across specific clinical populations.
- Develop a strong QI trend analysis of referral for treatment authorizations with a close eye on claims denials and the appeal processes that may hinder treatment parity and access to care.
If you’re an insurance managed care organization:
- Review current policy and procedures as it relates to parity treatment access across different levels of care for mental health and substance abuse treatment. Compliance across all levels of care is important in monitoring implementation of parity.
- Analyze and closely monitor claims and appeals, particularly for denials that may be reflective of practices not aligned with specific medical necessity requirements. Correlate findings of inappropriate claims denials with identified, and necessary practice changes in your review of claims denials.
- Consider whether a qualitative review is needed to identify and support practice changes and training needs. Monitor sustained changes needed to ensure parity access across all levels of care as an ongoing indicator of sustained organizational practice and compliance.
- Develop a metric algorithm comparing medical/surgical services and mental health/substance addiction services for comparable levels of care for a quantitative analysis of required data outcomes.
- Coordinate a QI process with your behavioral health vendor or internal behavioral health team to track in-network and out-of-network providers and level of satisfaction with treatment services to ensure quality of care as well as network capacity and compliance.
If you’re an entity tasked with governing and monitoring treatment parity:
- Analyze data outcome of practice and policy changes that reflect access to treatment across different levels of care and across the health plan’s different lines of business/products.
- Identify and monitor specific trend analyses that may reflect different outcomes for treatment access across different levels of care, across clinical populations and across different lines of business/products.
- Monitor trends of denial claims that may reflect a need for practice improvement and identify indicators of sustained practice change and outcome.
- Consider that some practice procedures and communication process may be barriers to treatment parity. Analyze levels of expected consumer literacy and language in all forms of communications and its impact on consumer knowledge and understanding of a plan’s policies, procedures and authorizations.
If you’re a consumer or consumer advocate:
- Understand your policy and treatment options as they relate to all benefits under your plan.
- Know that the benefits offered for medical/surgical care should have access to similar levels of care for mental health and substance addiction treatment, if mental health and substance addiction treatment is listed as part of the provided benefits. Keep a track of all communication received and note if the language is not understandable or clear in explaining claims or denials for treatment. If they are not clearly written as to why services/treatment is being denied or does not meet criteria for “medical necessity”, document a call to the patient advocate indicated for your plan.
- Track units of services approved across the different levels of care you have requested and utilized. Be knowledgeable about the appeal process for any denials for treatment that you receive.
- Understand a “fail first” policy that precludes a higher level of care without an initial course of treatment at a lower level of care is not in compliance with parity access.
MHPAEA is a landmark recognition of not just treatment access but the necessity of integrated care for population health. Treatment for a chronic medical diagnosis is not enough if depression or alcohol addiction impacts an individual’s wellness and ability to self care with positive choices and lifestyle. Treatment parity, in this light, is a move toward more complete population health goals. And, population health is everyone’s responsibility.
See SAE’s approach to Parity: https://saeandassociates.com/s/SAE_ICA-MHPAEA_Measuring_and_Ensuring_Compliance.pdf
Click on the links below for SAE’s first in a series of knowledge dissemination on Parity: