Managing Behavioral Healthcare ManualApollo Managed Care, Inc.January 1, 2013 443 Pages - SKU: APO4938596 |
- Managed behavioral health care – Introduction
- Managing behavioral health care; Psychiatric Consultation and Care; Integration of care/Collaborative care; Group therapy; Levels of care – criteria for acute inpatient hospital, day/partial hospital, residential treatment centers, adults and children/adolescents (I, II, III, IV secure), ambulatory care; Medical Necessity defined; Health and Behavioral Intervention Services; Brief therapy or short-term therapy; Behavioral Health Benefits; Telehealth benefit; Evidence for a ‘chronic’ diagnosis; mental health benefit interpretation examples; typical behavioral health limitations/exclusions; Medicare payment criteria for part B Mental Health Services;
- Behavioral/Mental Health Services Coverage Criteria
- Court ordered mental health services; Psychiatric Diagnostic Interview; Pathologic gambling; List of non-covered conditions/treatments; Transcendental meditation (TM); Eye movement desensitization and reprocessing (EMDR) therapy; Marital counseling, ‘72 hour hold’ admissions; \
- Psychotherapy: Psychotherapy, introduction, coverage considerations; Family Medical Psychotherapy; Group Psychotherapy; Interactive Group Medical Psychotherapy; Hypnosis/Hypnotherapy; Individual psychotherapy, insight oriented, behavior modifying, and/or supportive; Interactive Individual Psychotherapy; Narcotherapy;
- Testing: Psychological testing; Neuropsychological Testing; Developmental skills testing; Screens;
- ‘Rebirthing techniques’; Autism, Lovaas therapy for the management of; Brain mapping or quantitative EEG for the diagnosis of psychiatric disorders; Stereotactic Cingulotomy; Dyslexia; Electroconvulsive therapy (ECT); Home Health – Skilled Care for Psychiatric Services; Learning disabilities; Vision therapy/training; Music therapy; Play therapy; Smoking Cessation; Psychiatric Pharmacotherapy; Social services, outpatient; Transition of behavioral health care services;
- Behavioral health treatment programs
- BH treatment plans; Triage with screening form; Outreach – monitoring the course of therapy; Partial Hospitalization Programs/Day Hospital; Group Therapy; Psychosocial Rehabilitation Programs; Treatment plan and authorization form.
- Provider issues
- Access standards; therapy goals; behavioral health staffing; productivity incentives; Provider profiles; Provider compensation; Patient management ‘control’ issues; Telephone Communications – a risk management issue; Transition of behavioral health care services; Discharges Against Medical Advice (‘AMA’).
- Admission and Discharge criteria for Mental Health Disorders
- Inpatient criteria; Observation status; Support network considerations; Intensity of service/Severity of illness criteria; Severity of illness criteria justifying acute inpatient therapy; Age-related considerations; Hospital care reviews; Review for continued medical necessity; Day/Partial treatment programs; Retrospective review; Criteria not justifying inpatient admission; Criteria justifying discharge; Case Management; Discharges Against Medical Advice (‘AMA’)..
- Disease State Management/Therapy
- Special populations – Geriatric, Obstetric Mental Health; Childhood and Adolescent w/clinical pathway; Suicide – suicide prevention; Therapeutic preschool; Residential treatment centers; Wilderness/Camping/Outdoor Programs
- Case Management (CM)
- Policies, Procedures, ‘Red Flags’, Triggers, CM and Clinical CM functions; Children and Adolescent behavioral health case management; Client Assessment Record (CAR)
- Review Criteria and Case Management Guidelines, by disease state WITH VISIT AUTHORIZATION BENCHMARKS
- Alcohol/Chemical Dependency/Substance Abuse; Detoxification – includes: outpatient, Detoxification – inpatient, Continued stay criteria, Discharge criteria; Chemical Aversion Therapy; Electrical Aversion Therapy; Treatment of Alcoholism and Drug Abuse in a Freestanding Clinic; Treatment of Drug Abuse (Chemical Dependency); Methadone treatment; Childhood and adolescent treatment; Inpatient Hospital Stays for the Treatment of Alcoholism; Outpatient Hospital Services for the Treatment of Alcoholism; Alcohol and drug rehabilitation centers; Criteria for admission to a substance abuse rehabilitation program, ‘Open access’ referral P & P for chemical dependency, Chemical dependency benchmarks; Insurance denials for alcohol-related emergency treatment; Web resources;
- Auditory Processing Disorder/Central Auditory Processing Disorder (APD/CAPD);
- Delirium;
- Eating Disorders – Anorexia nervosa, Bulimia nervosa, Residential and outpatient treatment criteria for eating disorders; Obesity; Web resources;
- Schizophrenic and related disorders, Transcranial Magnetic Stimulation for the Treatment of Schizophrenia;
- Delusional disorders;
- Mood Disorders – Depressive disorders; Cognitive Behavioral Therapy; Transcranial Magnetic Stimulation (TMS); Telephone psychotherapy for depression; Vagal nerve stimulation for depression;
- Bipolar Disorders;
- Anxiety, Phobias and Somatoform Disorders – Anxiety disorders, Panic disorder, Anxiety disorders of childhood or adolescence; Post-traumatic stress disorder;
- Obsessive compulsive disorder (OCD); Psychosurgery for OCD;
- Somatoform disorders;
- Dissociative Disorders;
- Personality Disorders; Dialectical behavior therapy for borderline personality disorder;
- Adjustment Disorders; Impulse-Control Disorders, not otherwise classified: Intermittent explosive disorder, Conduct Disorders, Oppositional defiant disorder, Attention Deficit/Hyperactivity Disorders; Cognitive/Mental disorders d/t general medical condition, children, adolescents; Web resources.
- Utilization management
- Behavioral Health Care: Authorization models; Adult Levels of Care for Psychiatric Diagnoses: Authorization criteria; Levels of Care Covered Services Model – summary table/grid;
- Authorization procedures; Authorization Process, Forms; Discharge Summary Format; Encounter Form for Providers; Case Management policy and procedures; Inpatient Continued Stay Review Form; LOS and other utilization benchmark data for population groups and by DRG for all payers and for NY State Medicaid patients; Referral authorization form examples;
- Other forms related to UM/QM; Pharmacy Therapy Compliance Improvement Strategy.
- Medical/Behavioral Health Records
- Behavioral Health Patient Information Intake form; Acknowledgment form for new patients; Medical Records Release – policy and procedures, example forms; Treatment/Visit Report form; Psychotherapy notes; Psychiatry Summary Information Form for Primary Physician; JCAHO Medical Record Review Form; Web resources.
- Quality Management
- Accreditation/certification; Quality Indicators; UM/QI example plan; Performance Improvement Measures; Readmission Rates; Utilization management; Medication; QM/QI Work Plan, annual with list; Patient satisfaction survey form; Quality Management Policy and Procedures; Quality ‘red flags/indicators; operational standards; Access to care (appointments, in-office wait times) policies and procedures; QM Special Access Audit; QM/QI Committee policies and procedures: membership, agendas, minutes; Patient’s Rights and Responsibilities Statements.
- Consent forms
- Introduction, capacity to consent; Consents for treatment (adult, child), Audio/videotaping release; Standard introduction to consent statement for any consent; Non-covered services disclosure format; Treatment of child by Psychiatrist release form; Confidentiality Agreement; Employee/staff Non-disclosure Agreement; Permission to contact form; Non-covered services disclosure format; Consent to release/exchange information; Employee/staff non-disclosure agreement; Permission to Contact form; other forms.
- Addenda
- Contract to provide capitated behavioral health care services – example; CMS Pub 09 Rehabilitation Manual, Section 260. Partial Hospitalization Coverage Criteria for Medicare; CMS Pub 10 Hospital Manual, Section 212. Psychiatric admission coverage criteria for Medicare.
- Glossaries
- Glossary National Associations/Organizations For Health Care; BH review firms, ‘Carve-outs’; Accreditation/Certification for Behavioral Health Care Organizations; Consultants; Accreditation readiness check lists.
- References and resources
- Extensive literature references are embedded throughout the manual and listed in this section.
- Disease State Management Strategies. II. Behavioral Healthcare is a companion manual containing comprehensive clinical guidelines for common behavioral health diagnoses.
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