The authors examine the use of two sets of criteria, both dealing with substance abuse level‐of‐care determinations, yet having two different functions, and frequently yielding different decisions: The Green Spring Health Services (GSHS) Medical Necessity Criteria for Utilization Management and The American Society of Addiction Medicine (ASAM) Patient Placement Criteria. The GSHS criteria are used for rendering medical‐necessity determinations for individuals covered under a managed care program. These determinations involve assigning the least restrictive and least intensive level of care capable of meeting the patient's needs through the use of the complete continuum of treatment service options, including outpatient detoxification, intensive outpatient programs, partial hospitalization programs, and supervised residential settings. The ASAM criteria are oriented toward treatment planning within substance abuse settings to coordinate patient placement between levels of care within a treatment program.
The authors have worked in the mental health uti lization review and quality assurance field for several years now. One author (S.L.-A.) has been involved in the start up of several case management and utiliza tion review programs. Their approach has been to assess existing techniques for case management and utilization review and to draw from the most effective methods and programs in the development of their own mental health case management program.
The authors have developed a two-tiered method for utilization review of outpatient mental health services. The methodology looks at initial and continued treatment evaluation and uses diagnosis, symptoms, plan of treatment, and the Global Assessment Scale (GAS) among other indicators to determine appropriateness of treatment. Preliminary program experience has been positive and is included.
This article describes the use of an automated claims data base in reviewing the quality and medical necessity of ambulatory care provided to beneficiaries. The primary advantage to this approach is economy, since the data elements used in the review process are routinely collected as part of the claims payment process. This paper addresses issues relevant to the selection of physicians for review, strategies for improving the review process, and results of reviews conducted to date.Over the course of the last four years, the United Mine Workers of America Health and Retirement Funds has developed and implemented a medical utilization review (UR) system based on the review of claims data. The system has two primary purposes: (1) to improve the quality of medical care provided to Funds' beneficiaries, and (2) to reduce Funds' expenditures for unnecessary medical services. The approach we have selected is unique in that it relies primarily on a computerized claims data base in order to select physicians for review and in order to reach a preliminary assessment of a physician's pattern of care.To date, we have had the opportunity to examine statistically the practices of more than 600 primary care physicians who account for yearly billings in excess of $33 million. In addition, we have conducted peer review on more than sixty physicians and have intervened in nearly forty practices. Based on these experiences, we have gained valuable insights into effective strategies for using computerized claims data in the review of ambulatory care. In conducting such reviews, the Funds has one important advantage. The vast majority of Funds beneficiaries are elderly.
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