External review of health plan denials of mental health services: lessons from Minnesota

Impact of Illness Severity Tools on Adolescent Psychiatric Managed Care in California

Youth with mental illness struggle to receive essential behavioral health care. One obstacle is denial of coverage by insurance. In California, managed care consumers may apply for independent medical review (IMR) which potentially overturns an insurance denial through the California Department of Managed Healthcare (CDMHC). The authors aim to analyze IMR appeals for psychiatric treatment among adolescents and elucidate factors associated with obtaining coverage of care. We performed an analysis to identify factors that are associated with depression and substance use disorder (SUD) treatment claim denials in 11-20-year-olds from 2001 to 2022 using CDMHC data. Logistic regression modeling was used to identify specific factors related to claim characteristics and medical society instruments that are significantly associated with overturning a denial by IMR. Behavioral health IMRs are overturned at a higher rate than non-behavioral health claims. 54.5% of those with depression and 36.3% of those with SUD initially denied care coverage were overturned by IMR. For those seeking depression treatment, we found a significantly greater odds of overturn by IMR if there was a reference of CALOCUS [1.64, 95%CI (1.06-2.5)]. The odds of a SUD treatment denial being overturned was significantly greater if referencing CALOCUS [3.85 (1.54-9.62)] or ASAM [2.47, [4.3 (1.77-10.47)]. After the standardized implementation of illness severity tools in IMRs, the odds of a medically necessary claim being overturned was 2.5 times higher than before the standards. With a high percentage of claims being overturned after IMR, the findings suggest that health plans inappropriately deny medically necessary behavioral health treatment. The use of medical society instruments was associated with higher odds of overturning a denial. The recent decision of CDMHC to implement standard use of CALOCUS and similar illness severity criteria is supported by our findings and may facilitate more equitable care.

Can administrative claim file review be used to gather physical therapy, occupational therapy, and psychology payment data and functional independence measure scores? Implications for rehabilitation providers in the private health sector

PURPOSE

Rehabilitation costs for spinal-cord injury (SCI) are increasingly borne by Canada's private health system. Because of poor outcomes, payers are questioning the value of their expenditures, but there is a paucity of data informing analysis of rehabilitation costs and outcomes. This study evaluated the feasibility of using administrative claim file review to extract rehabilitation payment data and functional status for a sample of persons with work-related SCI.

METHODS

Researchers reviewed 28 administrative e-claim files for persons who sustained a work-related SCI between 1996 and 2000. Payment data were extracted for physical therapy (PT), occupational therapy (OT), and psychology services. Functional Independence Measure (FIM) scores were targeted as a surrogate measure for functional outcome. Feasibility was tested using an existing approach for evaluating health services data.

RESULTS

The process of administrative e-claim file review was not practical for extraction of the targeted data.

CONCLUSIONS

While administrative claim files contain some rehabilitation payment and outcome data, in their present form the data are not suitable to inform rehabilitation services research. A new strategy to standardize collection, recording, and sharing of data in the rehabilitation industry should be explored as a means of promoting best practices.