Request Prior Authorization

Once you identify clients that can have services paid for by a third-party, it's important to know that most plans also require prior authorization for services. Prior authorization is the process of obtaining approval of coverage for a service or medication with a specific provider and network.

Since most third-party payers now require you to get authorization before you deliver services, it is common for a client's bill to be based on the treatment and services that the payer allows.

But what information do you need to obtain authorization? Information requirements vary for each payer. Some companies will authorize an initial course of four to six outpatient sessions with minimal information. Others may want a full bio-psycho-social evaluation and diagnosis before authorization. Find out by talking to the provider relations service representative for the third-party payer, and then create a checklist so that your clinical or intake staff are guaranteed to collect the information needed for authorization. Frequently, the clinical team must actually see the prior authorization for the inpatient stay. For outpatient treatment, prior authorization may be completed prior to the first session. Always check the third-party payer's website for guidelines and expectations for the services provided. And remember, using their terminology will assist in getting services authorized.

Questions:

Does your agency currently have a process for obtaining prior authorization? If so, what is the most difficult or time-consuming part of the process?

Do your clinicians prefer tailoring a treatment plan around services allowed by payers? Or do they prefer creating their own treatment plans regardless of prior authorization guidelines? If they prefer creating their own, how do you get services without prior authorization paid for?

Verifying Patient Insurance Coverage

Many treatment agencies are realizing the benefits of working with third-party payers. The collected fees can stabilize income flow, making it easier to provide charity care to a larger population. But even more agencies struggle with this process.

What happens when a client with insurance comes to your agency? Since you probably already gather information from clients at first contact, you can add another question to the process: Do you have insurance? You should ask the next client that says "yes" to bring their insurance card to their first appointment.

The first step of efficient billing is to learn everything you can about that client's coverage. Check the back of the patient's insurance card for contact information. You'll also need to know:

. Primary care physician information

. Total benefits covered

. Calendar year and lifetime max status

. Deductible: any met, and if yes, how much?

. Co-pay for all levels of care

. Claims address

. Certification (pre-authorization) phone number

. Lifetime maximum amount met

. Policy termination date

. Effective date

. Authorizations required

. Name of person you spoke with

These are simple, yet important, first steps in starting a third-party collection system. Does your agency collect from third-party payers? Do you gather all of the information listed above before or during a client's first appointment? Is there any reason why you cannot make this part of your agencies intake process? Please leave your comments, questions and stories below...

A new way to find and organize NIATx promising practices

Last month we sent out a survey asking for feedback on the NIATx website. One of our goals was to determine which resources people used. Of the twelve options, four were closely bunched together as the most popular. The Process Improvement 101 online tutorial and the Provider Toolkit, which features a step-by-step guide to conducting a successful change project, tied for third place. Our Forms and Templates page came in second, and our catalog of Promising Practices topped the list.

The NIATx Promising Practices are a rich resource. They teach and inspire by using the successes and failures of other agencies. In an effort to help you find the promising practice that best suits your needs, we've added some new features that allow you to refine your search.

Located under the NIATx Resource Center tab, the new Promising Practices page alphabetically lists all of the promising practices available to you. A new "Refine Promising Practices" feature on the right side of the page allows you to quickly sort the list by aim, ease of implementation, expected benefit, and financial impact. Just check the boxes that apply to your agency's goals.

If you prefer the original organization of promising practices, those pages are still available and links to them are located above the "Refine Promising Practices" search options on the right side of the page.

As you're using this new tool, please let us know what you think. Your feedback helps us determine which new services and tools to offer.

Send your comments or questions to webmaster@niatx.net

NIATx/SAAS Seeking Nominations for Leading Innovations in Behavioral Healthcare Services

Behavioral healthcare organizations who are leading the way with innovative approaches to management and process improvement have an opportunity to be recognized as leading innovators with the 2010 iAward.

Sponsored by Washington, D.C.-based State Associations of Addiction Services (SAAS) and NIATx, based at the University of Wisconsin, the 2010 Innovation in Behavioral Healthcare Services Awards highlights innovations in process improvement practices that position an organization to meet the challenges of future service delivery.

The iAwards aim to provide national recognition of agencies that are using innovative approaches and provides a venue for them to share how they have adapted to meet the changing needs of clients, staff and the addiction healthcare field.

To be eligible for the iAward, provider organizations, coalitions, or state, county or local government payors/agencies must have developed and implemented an innovative practice in either management or process improvement within the previous three years. Innovations may be evidence-based or a best/promising practice and should be a new practice or an adaptation of a current practice.

This award is limited to entities engaged in addiction treatment and recovery services. Other behavioral healthcare organizations are eligible if the innovations relate to services integrated directly with treatment and/or recovery, e.g., co-occurring disorders, criminal justice, child welfare, primary healthcare. This could also include organizations that have implemented recovery-oriented systems.

Up to ten awards recognizing innovations in management and process improvement will be presented. Examples of areas in which innovations have occurred include (but are not limited to): workforce development, client access to treatment, client engagement /retention in treatment, continuity of care, staff engagement and retention, creative funding models, performance management, and community engagement.

Awards will be presented at the NIATx Summit and SAAS Annual Conference in Boston, July 10-13, 2011.

All expenses for travel and registration will be covered for one representative of each award. Deadline for submissions is February 15, 2011. For more information or to nominate your organization, download the award nomination form at www.saasniatx.net.

Are you ready for health reform?

Are you ready for Health Reform?

Or other major trends impacting how behavioral health will be delivered in the future?

NIATx has developed a Health Reform Readiness Index that is easy to complete and free. The brief tool assesses your readiness based on the organizational processes you need to have in place to participate in accountable care organizations or Medicaid; achieved desired clinical outcomes; and participate in the general health care system. Complete the Health Reform Readiness Index today and begin making your plans for pending changes in how behavioral health services are delivered.

The "Health Reform Readiness Index" was developed and tested in the twenty-two organization national "Accelerating Reform Initiative" project. The Accelerating Reform Initiative gives behavioral health care organizations the tools and peer supports they need to respond to the sweeping changes that parity, health care integration, and decreased grant funding may bring. Click here to see a list of additional Accelerating Reform Initiative resources.

Reclaiming Futures Looking For New Executive Director

"Reclaiming Futures at Portland State University, in downtown Portland along the tree-lined Park Blocks, is an excellent place to work. As our full-time national executive director, you will provide the vision, leadership, and direction to spread Reclaiming Futures -- a proven model used by 29 communities to help teens overcome drugs, alcohol and crime -- to new sites across the country. For position description and application instructions, visit: www.hrc.pdx.edu, under "Faculty and Administrative Opening." To learn more about Reclaiming Futures, visit www.reclaimingfutures.org."
"Application review begins mid-November and position is open until filled. The successful applicant is expected to start work April 2011. PSU is an AA/EO institution and welcomes applications from diverse candidates and candidates who support diversity."

Victor Capoccia on health reform and the Accelerating Reform Collaborative

With the announcement of the NIATx Accelerating Reform Collaborative, we asked NIATx Senior Scientist Victor Capoccia to share his views on health reform and how NIATx will position itself within that new environment.

1. What is your view on the current state of affairs in behavioral health?

Without question, this is the most exciting period I have experienced in my 40-year career in social welfare and behavioral health. Here is why:

• There is greater knowledge about mental and substance based disorders and successful treatments. We have medications as well as counseling protocols that are tested and efficacious.
• Despite a slow economy, there are more resources to prevent and treat mental and addiction disorders than ever before; and there are more to come with the provisions of the Accountable and Affordable Care Act.
• There is greater understanding and awareness of addiction as a treatable health condition than at any previous period. Stigma still exists, but it exists in tandem with a better public understanding of mental health and alcohol and drug misuse.

Take these three forces, and they shout: OPPORTUNITY! Shame on us if we fail to make the changes needed to reach those who continue to suffer with untreated addiction and mental health conditions.

2.What kind of opportunities do you see health reform presenting to behavioral health organizations?

I feel that health care reform presents the following opportunities:

• Coverage of 32 million uninsured Americans that largely include a mental health and addiction benefit; this coverage includes dependents up to 26 years of age and low-income adults up to 100% of the federal poverty level.
• Insurance coverage if these conditions existed prior to coverage.
• Parity with general medical care for addiction and mental health treatments.
• Medical homes for chronic and acute patients.
• Prevention screening and intervention for Mental Health and Addiction disorders.
• Workforce development and training for behavioral health professionals.
• And many others...

3. What is the NIATx Accelerating Reform Collaborative?

The Accelerating Reform Collaborative comes from a simple premise: in a period of great opportunity where the "stars have aligned", we need to transform our treatment systems to reach more of the 20 million untreated people with addiction disorders and the 1/3 untreated of those with mental illness. Our current system is designed to reach 10% of 23 million people with addiction disorders, and 66% of people with mental illness. "Every system is perfectly designed to produce the results that it produces".

Only transformation of the system will reach beyond current performance.

The Accelerating Reform Collaborative is a collection of innovators from provider, academic, consumer and policy groups who are willing to share their ideas and experience to redesign the system to reach the untreated.

4. What's special about this collaborative? Why should organizations join?

It's the PEOPLE. The colleagues, the experience, the ideas. This is where the leading edge is being cut.

5. What is NIATx's future role with health care reform?

NIATx has and will continue to focus on the customer, understand the patient experience, and design systems that will help meet those patient needs.

That is our core, our soul.