Health Plans
Manage Their Own Mental Condition Benefits
Reduce Claims and Administrative Costs by Adjudicating "Owned" Mental
Condition Benefits with Medical Benefits
For health plans that own and manage their behavioral health business
(carve-ins) but continue to adjudicate claims as if they were carved-out,
i.e., use independent coding, billing, and utilization management practices,
Cartesian Solutions, Inc.™ experts help walk them through the consolidation
of mental health with medical claims processing and management practices.
Most health plan executives and administrators do not realize that
internal separation of physical and mental health claims adjudication and
utilization management is as destructive to integrated care delivery as that performed
by a carve-out. Ultimately, payment processes should facilitate access
for members to coordinated physical and mental condition services regardless of service
location, i.e., medical in mental condition settings and mental condition in medical
settings.
There are three main reasons for moving to an integrated physical
and mental condition product (see Table below).
- First, it allows medical
health plans to close the gap on the "medical" claims cost excess for members
who have concurrent mental and physical problems.
- Second, it allows a reduction in administrative
costs by decreasing the staff needed to service accounts and by
simplifying adjudication complexity.
- Third, it allows the development
of more effective and efficient preventive and acute clinical health care services for
patients at risk for health complexity or with health complexity.
Basically,
the integrating general medical and mental condition benefits and associated health plan work processes predictably saves money and brings a substantial return on investment by improving
support for work processes that improve health in the most costly patients.
| Rationale for Health Plan Integration |
Health plan implementation of business practices which support general
medical and mental condition integration can:
- Immediately impact high cost areas of business by:
- Case managing 100% of the 1% to 5% of members with complex high cost illness using
integrated case management practices, both in those
with chronic
medical disorders (asthma, CAD, migraine, etc.) and mental
conditions (bipolar, autism, eating disorders, etc.)
- Disease managing 100% of the 5% to 20% of members who have:
1) chronic physical disorders
with concurrent mental conditions &
2) chronic
mental conditions with concurrent general medical illness,
using integrated disease
management practices
- Improve rational psychotropic pharmacy
use in chronic high cost patients seen primarily in the general
medical setting (80% of
psychotropic
prescriptions are prescribed by non-psychiatrist physicians)
- Lower administrative costs
while reducing health plan complexity and improving support for "total
health" services to members
- Do away with the independent behavioral
health administrative structure and workflows
- Consolidate physical and
behavioral health information technology (IT) systems
- Streamline "total health" actuarial and quality of care analyses
- Facilitate the
development of clinical care environments which support integrated
general medical and mental condition services
for members
with comorbid illness
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If this describes your situation...
- Behavioral health management is performed by an independently functioning
organizational structure within the general medical health plan
- There are separate administrative divisions for medical and behavioral products,
e.g., marketing and sales, customer service, provider networks,
utilization and care management, claims adjudication processes, IT
documentation systems, actuarial analyses, data warehouses, etc.
...Ways that Cartesian Solutions, Inc.™ can help
- Use internal claims data to assess opportunities for lowering total cost
of care for members insured by medical products through consolidation
of medical and behavioral business practices
- Reorient existing behavioral health personnel in the value of integrated medical and mental
condition products and the important role they will play in the transition and implementation
- Establish the stepwise process through which a transition from independent to integrated medical and
behavioral health work processes in each health plan division can be accomplished
- Provide complexity-based integrated care management training and implement integrated medical and behavioral
work flows
- Provide supervised project management during the transition process
(It should be noted that existing medical and behavioral health personnel,
both critical in the transition process, will be affected by
the implementation of integrated practices. Budgets will be redirected.
Organizational structures will be reconfigured. Supervisory roles will change.
Some job descriptions will no longer exist while others will be created. Some employees
will adapt, some will leave, others will be hired. Cartesian Solutions,
Inc.™ is familiar with "adaptive" change dynamics and the need to shift culture
along with business practices. It can be of assistance with this as well through
its educational programs and project management capabilities.)
For more information or to set up an appointment contact: Mary
Kathol, Director of Project Implementation.
Cartesian Solutions, Inc.™
3004 Foxpoint Rd. - Burnsville, MN 55337
Phone: 952-426-1626 - Fax: 952-426-1200
E-mail: integration@cartesiansolutions.com
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