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Utilization management in a large managed behavioral health organization.
1Department of Psychiatry, University of California, Davis, USA. akkoike@ucla.edu
Psychiatric Services (Washington, D.C.)
|April 27, 2000
Summary
This study on managed behavioral health utilization management found very low service denial rates, contrary to concerns. Further research is needed to understand utilization control mechanisms and review costs.
Area of Science:
- Health Services Research
- Behavioral Health Management
- Healthcare Policy
Background:
- Managed behavioral health organizations (MBHOs) utilize utilization management (UM) to control costs and ensure appropriate care.
- Concerns exist regarding high denial rates potentially limiting access to necessary behavioral health services.
Purpose of the Study:
- To examine the UM process in an MBHO, focusing on review frequency, types, and service rationing via denials.
- To assess the extent to which UM leads to service denial in behavioral healthcare.
Main Methods:
- A case study design was employed, analyzing claims and UM data from 51 plans of a large MBHO for the year 1997.
- Data were categorized by review type (e.g., concurrent outpatient therapy, concurrent facility) and authorization actions.
Main Results:
- A total of 9,639 UM reviews were conducted, with concurrent review for outpatient therapy being the most frequent (46%).
- The vast majority of service authorizations were approved as requested (91.8%), with minimal denials (0.8%) or reduced approvals (1.3%).
Conclusions:
- Contrary to common concerns, this MBHO's UM program demonstrated very low service denial rates.
- Further investigation is required to identify specific UM mechanisms influencing utilization and to evaluate the time and opportunity costs associated with extensive review processes.