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This manual defines Utilization Management and provides a simplified, hands on approach for Utilization Review for the Behavioral Health Care Provider when working with third party payors. It provides a systematic decision making process for the experienced clinician to decide and justify the severity of symptoms and the appropriate level of care placement for a patient - in terms the insurance/managed care industry understands and utilizes. Additionally, the manual provides different decision trees for psychiatry/mental health, substance abuse, and eating disorders and separates the factors into admission criteria and continuing stay criteria. As an added feature, factors are outlined that most likely would lead to the third party payor requesting physician review of a case prior to authorizing care or payment. Complete with worksheets and glossary.
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This manual, while intended to provide the Behavioral Health Care Provider with the tools in hand to work within the Managed Care environment, is also an excellent resource for Managed Care Organizations expanding into, or new to, the Behavioral Health environment.From the Author:
Healthcare today has, needlessly, developed into an adversarial arena pitting payors against providers. In the Behavioral Health field, in particular, providers are poorly equipped to work with managed care organizations to secure the authorizations for care needed for the patient. To make matters worse, clinicians and MCO's speak 'different languages' when referring to patients, leading to misunderstandings, distrust, and, usually, denials of care and/or payment. This manual provides the tools for the experienced clinician to put a sound assessment into a format and language most likely to secure treatment authorizations and, ultimately, payment for treatment rendered.
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