RESUMO
As autism rates increase, providers of applied behavioral analysis (ABA) services are more frequently engaging with managed care companies to discuss the medical necessity of treatment. In an effort to maximize the efficiency and effectiveness of these reviews, we draw upon our experience as peer reviewers for a managed care company to guide ABA providers in discussions with managed care on behalf of their patients. In this article, we first provide an overview of the managed care peer review process. We then discuss the elements of medical necessity that managed care companies ask about during the review process. Finally, we review specific strategies that ABA providers can use during the process to optimize authorizations for payment for services. Throughout the paper, we provide sample dialogues between providers and peer reviewers based on our experience working for a managed care company along with specific recommendations that we hope will ensure a more collegial and effective peer review process for all involved.
RESUMO
Clinicians often resent behavioral health managed care peer reviews. However, such reviews need not be onerous. This Open Forum, written by managed care physician reviewers, attempts to help attending psychiatrists, specifically those on inpatient units, achieve more satisfying outcomes for patients by adhering to a few basic principles. Beyond the level-of-care guidelines, attending psychiatrists are advised to focus on immediate acuity, along with specific life events that may have immediate impact on the patient's well-being. A clear diagnosis, relevant treatment plan, salient updates, and strategies for preventing readmission can justify additional treatment time. By contrast, "time-based treatments," dispositional issues, or a patient's lack of acceptance or effective use of treatment are harder to justify.
