BEHAVIORAL HEALTH REVIEW SERVICES

Behavioral Health (Mental Health and Substance Abuse) is a major area of cost excess and overutilization. We review inpatient, outpatient, professional and facility, both in and out of network. We combine medical necessity review with line audit and repricing, if needed. The focus is on quality and cost-effectiveness while working to ensure that patients receive the level of care that is appropriate for their condition and diagnosis.

Behavioral health is a high potential savings area that some groups and health plans retain in-house rather than using a carve-out mechanism. Since mental health parity has increased payer coverage, there is a concomitant need for appropriate medical and billing review as well. We are ideally suited to assist those plans who manage their own behavioral health services. We also perform a great deal of reviews in the ABA therapy area for autism.

Our medical review specialists include MD Psychiatrists, Psychologists, and Licensed Professional Therapists, including addiction, child and adolescent psychiatry, and eating disorder specialists.

Key Behavioral Health review elements include:

Medical Necessity: intensity, frequency and duration of care
Level of Care: inpatient, residential treatment, partial hospitalization, intensive outpatient, ongoing outpatient therapy and counseling
Prior authorization
Residential treatment center medical necessity review, including drug screen laboratory
ABA (Applied Behavior Analysis) therapy for Autism Spectrum Disorder
Appropriate coding of services including psychotherapy CPT codes, HCPCS “H” codes, telephone and remote provider consultation
Facility and provider credentials verification for substance abuse and mental health treatment locations
Claims audit and repricing - commercial and/or Medicare
Line charge audit verification: Itemized bill vs. Medical Record
Peer-to-Peer telephone review with treating practitioners as requested
Focused provider batch audit
Quality and appropriateness of care at appropriate level of care
Prior authorization program for outpatient therapy using different reviewer levels