Health Plans

Reduce Total Claims and Administrative Costs by Consolidating Physical and Mental Condition Products

Four fifths of health plan members with mental conditions are seen primarily or only in the medical setting. These members represent a huge untapped reservoir of potential claims cost savings that can be recovered by consolidating the general medical and behavioral health claims adjudication process and by integrating physical and mental health care management. This is true regardless of whether behavioral health claims are carved-out, i.e., subcontracted to an independent managed behavioral health company, or carved-in, i.e., owned and managed by the parent medical managed care company. Adding mental conditions as a part of essential physical health benefits in insurance products does away with competing physical and mental health budgets and dis-integrated adjudication processes, which necessarily fragment the delivery of outcome changing mental condition services to members seen in the medical setting. When mental conditions do not improve in the medical setting, physical health costs more than double, physical and mental complications ensue, and a spiral of persistent poor health, treatment non-adherence, and high health costs becomes established.

If one or more of these describes your situation...

• Per member per year costs for members with behavioral health issues are double or more than for those without
• Per member per year costs for members with chronic medical illnesses and behavioral health comorbidity have 1.5 to 4.5 times greater general medical service use (and cost) than for those without
• The majority of members with high claims costs have both medical and mental conditions (~60% to 80%)
• Few with high annual claims costs and concurrent medical and behavioral comorbidity (complex members) receive any mental condition treatment (~15% to 25%)
• Claims payment practices discourage outcome changing behavioral health service delivery in the medical setting where most of members with mental conditions are seen
• Medical and mental health personnel within the health plan rarely communicate, rather they work in largely independent operations
• Medical and mental health case, disease, and utilization managers operate in their own geographic locations, handoff members to other managers when interdisciplinary problems arise, and infrequently communicate about members with comorbid conditions
• Cross-disciplinary claims for patients with concurrent/comorbid medical and mental health conditions creates claims adjudication competition, which perpetuates delivery of ineffective care due to payment hassles or non-payment

...Ways that Cartesian Solutions, Inc.™ can help

Cartesian Solutions, Inc.™ experts have an intimate understanding of the interaction of medical with mental conditions, independent claims adjudication, and the effect both of these have on health outcomes and health care service utilization. In short, seventy percent of members with behavioral disorders who are primarily seen in the medical setting do not receive any mental health treatment. This is especially concerning in members with chronic medical conditions or health complexity, the small percentage that use the fifty to seventy percent of claims dollars.

Cartesian Solutions, Inc.™ experts help health plan leadership reduce administrative and claims costs by reorienting health plan benefit descriptions and payment models so that they support the delivery of coordinated and outcome changing mental condition services in the medical setting, especially to members with chronic conditions and health complexity. Experts partner with health plan personnel as they:

• Identify targeted cost saving opportunities through analysis of aggregate claims data on members’ physical health, mental health, and pharmacy service use
• Assess mental and behavioral adjudication processes and care management practices contribution to member wellness, prevention of disease, and coordination of illness intervention, e.g., provider contracts, plan designs and contract benefit descriptions, wellness/health coaching programs, disease and case management design and capabilities, and the value of utilization management. Special attention is given to cost savings opportunities.
  • Contract review and parity compliance
  • Care management and pharmacy benefit management review
  • Key informant interviews of executive leadership, program directors, program staff, and external vendors
  • Onsite audits of organizational work processes and personnel interactions
• Advise on opportunities to support improved care delivery and to reduce administrative and claims costs through changes in provider contracts; health product benefit descriptions; the approach to actuarial projections; claims adjudication, denial, and appeal processes; provider network organization; customer and provider services; care management work processes and organization, data warehousing and analysis; and external vendor offerings
• Define steps to efficiently transition to consolidated physical and mental condition products with the potential to maximize health, productivity, and cost savings, especially in members with health complexity

Click the following links if:

• You are a medical managed care company that adjudicates mental condition claims through a managed behavioral health organization (Carved-Out Behavioral Health)
• You are a medical managed care company that adjudicates its own behavioral health claims internally (Carved-In Behavioral Health)
• You are a medical managed care company that allows mixed mental condition adjudication (Carved-Out & Carved In Behavioral Health)
• You are a behavioral health department within a medical managed care company (Internal Behavioral Health Operation)

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