Psychologist doctor discussing with patient

Behavioral Health Utilization Management: Closing the Gap Between Needs and Resources

Even before COVID-19, the need for behavioral and mental health services in the U.S. was rising steeply. From 2006 to 2014, ER visits by patients with mental or substance use disorders increased by approximately 44%1, and in 2019, nearly 50 million adults experienced some form of mental illness.2 Now, pandemic-related uncertainty and anxiety are accelerating this trend. A recent report published in The Lancet warned that the mental health effects of the pandemic could “exceed the consequences of the 2019-nCoV epidemic itself.”2 Compounding the problem, more than a quarter of the need for mental health professionals across the U.S. is unmet.3 This not only impacts clinical settings but makes it hard for payers to recruit the behavioral health reviewers they need.

With treatment needs—many of them urgent—on the rise, costs are high for patients and payer organizations. Acting quickly to meet this challenge, many payers are turning to health utilization management (HUM) and independent review organizations (IRO), like AllMed, for support. HUM/IROs provide on-demand behavioral health utilization management expertise and flexible capacity to help payers optimize existing resources and scale as needed.

COVID-19 Pandemic Fueling Increased Claims

While the pandemic did not precipitate our national mental health crisis, it undoubtedly is amplifying it. Isolation and the disruption of routines combined with many losses and distance from friends make maintaining mental wellbeing challenging and may exacerbate pre-existing mental health conditions and substance use disorders.

A recent Kaiser Family Foundation poll found that 45% of Americans surveyed said that the pandemic has negatively affected their mental health.4 To cope, many are reaching for short-term, unhealthy solutions that will only make matters worse. Sales of alcohol and cannabis have jumped at the same time that many people, encouraged to stay at home, are eating more and exercising less.2 Not surprisingly, calls and texts to mental health lines are surging. According to The Wall Street Journal, the nonprofit Crisis Text Line has seen a 40% rise in traffic, with the vast majority of conversations focusing on virus-related anxiety.2 For payers, an increase in behavioral and mental health diagnoses and episodes could severely impact already strained resources and budgets.

Payers who provide Medicare and Medicaid services feel the pressure of the ramped-up demand perhaps most keenly. Medicaid is the largest payer for behavioral health services in the U.S. With over 38 million unemployment claims filed since the public health emergency was declared, Medicaid enrollment will continue to increase, indicating that healthcare resource utilization in Medicaid will increase overall.4

Changing Regulations Fueling New Patterns of Engagement

As the need for behavioral health services grows, and member demographics shift, payers are contending with other changes as well. At the federal level, broad bipartisan support is driving increased access to telehealth as an alternative to face-to-face treatment. Telemental health offers many opportunities for improved patient experiences, increased healthcare access, and reduced healthcare costs.5 Even before the pandemic, it was on the rise.6 Now, the Centers for Medicare and Medicaid Services (CMS) are easing restrictions on telehealth visits, giving additional coverage flexibility for Medicare and Medicaid patients.7 The rule changes promise to accelerate the transformation in the way patients and providers interact—and increase the number of behavioral health claims further still. With so many significant transitions happening simultaneously, planning for the future has become more challenging than ever.

Specialized Expertise and Flexible Capacity to Meet Changing Needs

In this dynamic environment, forward-looking payers are looking at innovative ways to meet the growing need for behavioral and mental health-related services while maintaining high-quality standards. Many see value in partnering with a health utilization management (HUM) and independent review organization (IRO) for timely support. Though mental health utilization reviews and appeals require specialized knowledge, they can be outsourced to a HUM/IRO, like AllMed, easily and securely, while ensuring high quality.

When you partner with AllMed, our broad panel of behavioral health specialists act as an extension of your team, augmenting your internal resources and mental health utilization review process. Drawing on our vast knowledge base and deep understanding of government programs and regulations, we provide expertise and flexible capacity to help you manage complex cases and provide detailed, defensible determinations that meet your turnaround time (TAT) requirements. We have experience processing more than 35 types of subspecialty cases, including:

  • Developmental-Behavioral Pediatrics
  • Psychiatry
  • Addiction Psychiatry
  • Child and Adolescent Psychiatry
  • Geriatric Psychiatry
  • Psychology

Specialty-Matched Review Services for Medicare and Medicaid

Using AllMed’s specialized experts at the beginning of the utilization management process fosters accurate, medically necessary approval or denial—reducing the need for downstream appeals. Our reviewers have expertise in using various criteria, from policies and guidelines to Local and National Coverage Determinations and Articles (LCD/LCA/NCD).

In addition to specialty-matched reviews, we also provide appeals review services. Our appeals review solutions range from first and second-level internal reviews to state and federal external appeals. All reviews are conducted by board-certified specialists and sub-specialists who are in active practice. Each appeal review is performed in compliance with URAC, NCQA, CMS, state, and other federal regulations and is subject to oversight and audit through our Quality and Compliance programs.

An Extension of Your Team

Today’s shifting healthcare landscape is motivating payers to reassess their business models. For many, finding the most effective way to meet the growing need for behavioral and mental health services while controlling costs is top of mind. Industry leaders are making the strategic choice to partner with health utilization management and independent review organizations, like AllMed, for flexible capacity and timely, specialized expertise.

At AllMed, we work closely with your team to help you deliver evidence-based determinations that meet your high-quality standards and turnaround time requirements. With our customized services and solutions, we are ready to help your organization navigate and thrive through the changes ahead. For more information, contact us today.