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Managed Health Care In Residential Treatment Facilities

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Category: English

Autor: anton 26 April 2011

Words: 1732 | Pages: 7


With Managed Health Care in Residential Treatment Facilities, the facilities are over whelmed with all of the red tape they have to get through just to get the funding needed to run the facility; the patients are losing out on the services that they are there to receive in the first place. Before going into to much detail, let me explain to you what a Residential Treatment Facility (RTF) is. Residential Treatment Facilities provide intensive clinical care for psychiatrically and emotionally distressed adolescents who have experienced difficulty in adjusting to a less restrictive environment. The goal is to help children resolve issues which led to placement and to develop self-management skills that lead to greater self-awareness and proficiency. Children referred for participation in the RTF program must be approved by the Office of Mental Health. To establish a child’s eligibility, an Interagency Team meeting must be held, with the team being made up of involved agencies, the child and the child’s guardians. Residential Treatments Facilities are less restrictive and less intensively staffed than hospital-based programs, the program is to help a child improve his or her daily functioning, develop coping skills, support the family and to ensure appropriate community linkages and supports to ensure successful transition to the community. Residential Treatment Facilities range in size from fourteen to fifty-six beds and serve and average of seven hundred and sixty children per year between the ages of five and twenty one years (NYOMH, 2003). Some people confuse a residential treatment facility with a boarding school or detention center. They differ in several ways and the biggest difference is the qualifications of the staff.

Some centers are licensed through an organization known as the Joint Commission on Accreditation of Healthcare Organizations or (JCAHO). If a residential treatment center is licensed through JCAHO you will have much greater success being able to access insurance benefits to assist you with the payment. Some residential treatment facilities are designed to be only a short term placement which some people believe lessens the success of the treatment. Others feel that if you place a child in a long term residential treatment-style placement you might have the best of both worlds. The biggest drawback to this type of placement is usually the cost associated with it. A combination residential treatment center/boarding school will begin in price at $4,300 per month and go up as high as $8,000 per month. One quarter (twenty seven percent) of the nation’s treatment facilities offer residential care (The DASIS Report, 2006). Residential facilities for children with mental illness are owned by a wide variety of public and private entities and are operates under the auspices of various state agencies (Goldstrom, 2001; Pottick, 2004). Many children in State custody are placed in residential treatment because no foster or adoptive families are available. The state officials are obligated to ensure that these children receive effective services (SAMHSA, 2006). Residential treatment facilities are expensive, and most states mental health budgets are limited. Seventy five percent of residential treatment facilities are not-for-profit organizations (The DASIS Report, 2006). That would be where the need for funding and managed health care would come in.

There are several definitions for managed health care. Wikipedia explains it as, “A concept in U.S. health care which rose to dominance during the presidency of Ronald Regan, ostensibly as a means to control Medicare payouts. The rise of managed care was touted by the U.S. health industry as a way to lower the rate of medical inflation in the 1990’s. But managed care has not been successful in lowering the rate of medical inflation. In fact, U.S. medical inflation is now two or three times the rate of overall inflation, as it was during much of the 1980’s.” In short, when the government sets aside money for, let’s say residential treatment, instead of just giving the money to the facilities, there is now a managed health care organization (MCO) involved. They receive the money from the government, and make sure that the facilities are providing the services that the client needs. This all sounds great, but managed health care organization’s have more strict policies than the government and require more paper work, more tests, and more time for the same services. In the long run treatment facilities are having to higher more administrative staff to make up the work load, and are still struggling for the funding. This is an ongoing problem. Managed care can take credit for restraining the growth in health care costs which resulted from a largely unconstrained market. However, the huge administrative costs required for managed health care cannot be ignored. Funding agencies and policy makers often criticize residential treatment because the cost is typically higher than for outpatient services (PubMed, 2002).

This integration of managed care into treatment facilities is more often referred to as the MA Re-alignment or the Integrated Children’s Services Initiative. In Pennsylvania, we have “Health Choices”. No matter how you refer to it, the general idea is to prevent fraud in medical assistance. The purpose of this realignment was to identify behavioral health treatment services, both residential and non-residential; those are eligible for Medical Assistance funding and determine how those services could be paid for by the Medical Assistance Program. This realignment fit hand in hand with the Health Choices implementation across our state. As payment was transitioning to Medical Assistance, agencies were directed to adapt services to capture this revenue source.

This is where JCAHO steps in; Health Choices prompted an industry wide cultural shift for providers, bringing additional regulations from accrediting bodies such as this. It also meant additional regulations from the Office of Mental Health and Substance Abuse (OMHSA), Department of Health, Office of Children, Youth and Families, and the Department of Public Welfare (DPW), regarding restraint use, psychiatric services, nursing services, credentialing of employees and so on. The way of running the RTF had drastically changed for providers. Executive directors, administrators and Board of Directors needed to make decisions to collaborate with state officials, learn Health Choices and its processes or continue to be reimbursed through the child welfare program funding sources, which was paid for directly from county budgets. Because of Ma re-alignment and children being identified for MA eligible services, county funded programs were drying up as more and more clients are being referred through Medicaid funded sources. In fact, the transition would shift over 77 million dollars of a 1.8 billion dollar budget of child/welfare/juvenile justice funds to funding from Medical Assistance and ultimately through managed care organizations (DPW, 2005). The providers have had to change the every day way of doing business. Different funding sources meant a different way of billing and admission requirements. Chief financial officers, business departments and case management services would now have to verify the need for behavioral health services with in a pre-certification process. The previous fee-for-service method of medical assistance would not be the way to bill for MCOs. In order for a child to be admitted for services with payment from medical assistance, a medical necessity would have to be determined. This meant a behavioral health provider would have to facilitate a utilization review process to coordinate the length of stay for a client. Clients could no longer stay in care indefinitely, periods of authorization would be determined with preset review dates for continued stay. This authorization process would need to be in conjunction with all of the parties involved with the child’s services. The child’s guardian, psychiatrist, therapist, county referring agency, the child and the court appointed officer would all have to be in agreement of a clients need for the level of service. All of this could lead to delays in getting the child into placement.

Organizationally, a provider, in order to keep up with industry changes would have to establish new relationships with the managed care organizations. It also altered the way the billing process was conducted. Managed care brought the need for new billing software, procedures and service codes. These were needed in order for a facility to be able to receive payment from the MCO for services provided, and each MCO has its own nuances only identifiable to that specific MCO. So, depending on the area that you cover and have contracts with as a provider, this could mean several different MCOs, all with different regulations, paperwork, forms, services codes, etc. This meant the altering of multiple internal processes.

For example, a client with Community Care Behavioral Health Organization for coverage of mental health services, will only be authorized for ninety days at a time and the are specific forms that are to be filled out for the reauthorization packet. A client with Magellan coverage can be authorized for up to one hundred and twenty days, and the majority of the forms in the packet are standard, with the exception of three. A provider who does not realize nor understand the difference between each MCO would lose payment and coverage for the client.

Overall, the industry has made a drastic turn to stay up with industry changes. Although a lot of providers, due to lack of coordination of the Health Choices implementation with all counties at the same time, were left in the dark. MCOs did conduct trainings within the counties that they were contracted to proved services within; however, the Office of Medical Assistance Programs did not facilitate the joining of the two. Organizations were left on their own to figure out what, when where and how to keep up. To date, mental health organizations have seen a decline in admission rates. There have been clients caught within both systems. Children & Youth agencies do not understand how to authorize a client for services under the mental health medical necessity requirements. Before Health Choices and Managed Care, a county case worker could make independent decisions as to the client’s admission. This is no longer the case, as preauthorization is needed and thus could delay a client’s treatment.

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