By: Philip Hensarling, Director of Utilization Review on Quality of Care
Renewal Lodge by Burning Tree
Renewal Lodge by Burning Tree is a substance abuse treatment center located in Elgin, Texas. Treatment at Renewal Lodge includes a 12-step approach, dual diagnosis, medication management, psychotherapy, and comprehensive discharge planning. Our facility accepts private insurance to supplement the cost of treatment. Renewal Lodge by Burning Tree is also JCAHO accredited and is licensed by the state of Texas for residential substance abuse treatment. Since December 2017, I took on the role of Director of Utilization Review at Renewal Lodge after serving as an Admissions Specialist. As an alumnus of Burning Tree, I’ve developed a passion for helping families and their loved ones in the recovery process. As Director of Utilization Review and with the help of the Burning Tree leadership team, we have been able to make significant progress in improving the quality of care. By moving from outsourced utilization review to in-house utilization review, Renewal Lodge has increased authorized days for a residential level of care by 25% from 2017 to 2018.
Quality of Care Review Process
The utilization review (UR) process begins with a UR representative making a pre-certification call within 24 hours of admission, once the verification of benefits (VOB) has been reviewed. The insurance company is provided with patient and administrative information such as client name, DOB, ID number, facility name, tax ID and address. Clinical information is then relayed from three assessments: pre-clinical, intake and nursing. Insurance companies will review from either the national criteria, American Society of Addiction Medicine (ASAM)[i], or state criteria, Texas Administrative Code (TAC)[ii]. Insurance companies can also go a step further and establish their own medical necessity criteria, such as 24/7 on-site nursing. After the pre-certification call, the insurance company will authorize or deny an initial number of authorized days, which are offered in portions of approximately 4-14 days. Per TAC standards, the average length of stay for 24-hour residential treatment is between 14-35 days. Length of stay is determined by applicable criteria or standards met for continued stay3. The responsibility of the UR representative is to convey, with the help of clinicians and doctors, how the information presented in the client’s chart meets the appropriate criteria or standards. Clinical reviews are typically requested on the last authorized day of each portion of authorized days. A licensed therapist or nurse from the insurance company evaluates the information presented then provides a decision to authorize, step down to a lower level of care or discharge a client. If authorized, the insurance company will issue an authorization number which enables the facility to bill appropriately. If denied, a peer review will be scheduled with a medical doctor. An appeal may be requested thereafter by an independent 3rd party if authorization still isn’t granted.
Substance abuse treatment facilities often have UR representatives either working off-site or out of sight, which potentially allows for a higher caseload. This may even make a great deal of sense as far as the bottom line is concerned. On the flip side, contact with co-workers by phone or email only can limit their ability to communicate and problem solve effectively. When working in a high-stress environment, delays in communicating critical information can lead to team members feeling helpless awaiting a response. Negligence is more likely to occur in a bottleneck of communication within an organization. Pressure also creates a potential to manufacture dishonesty which leads to more mistakes. Finally, something is bound to slip through the cracks, i.e. lack of medical follow-ups, missed appointments, missing pertinent past diagnoses and/or medical history, incorrect or incomplete treatment plans and/or therapeutic interventions, missed collateral contacts, issues with discharge planning, etc. This ultimately impacts the quality of care.
In order to manage the flow of information between operations, clinical and medical, it is essential to establish a role dedicated to utilization review within the leadership team that operates on-site. Direct contact mitigates problems, insulates clients from negligence and creates an environment for meaningful relationships to culminate, which everyone can agree is the foundation of both good business practice and long-term sobriety.
- Democratic Approach: Burning Tree maintains a democratic approach to the treatment of substance abuse clients in residential treatment. Collectively, our professional clinical staff weigh in and vote on therapeutic interventions, treatment plans and individualized discharge plans. A democratic approach addresses two main problems that are often a pitfall in counseling: counter-transference (the emotional reaction of the counselor to the client’s contribution) and lack of communication. This approach provides oversight and limits the risk of errors due to work overload by maintaining a level of accountability in a system of checks and balances called “Master Treatment Planning,” which is a weekly meeting attended by clinical, operations and medical staff. By working directly with operations, adjustments to scheduling can be arranged to coincide with scheduled reviews for UR. Questions asked by care managers can be answered by operations, clinical or medical in minutes rather than hours. If your life were at stake wouldn’t you rather have a team of professionals making decisions on your life rather than just one professional?
- Increased Accountability and Protection Against Negligence: Paired with a treatment team the utilization review department is an asset rather than an adversary to clinical, medical and operations. My experience of most UR relationships is one department is always “doing it wrong” and playing the blame game. When UR specialists are either off-site or tucked away in a separate building, they do not have direct communication which influences the quality of care. Establishing the UR department in an on-site leadership role creates a layer of accountability that protects counselors from “dropping the ball” which inevitably trickles down to the client. After all, it’s easy to overlook emails and miss phone calls from the UR department regarding specific information. Medical appointments and follow-ups must be scheduled timely. Clinical problems must be identified, and treatment plans or therapeutic interventions followed up on. Direct flow of communication creates a symbiotic relationship between medical, clinical and operations. It would be illogical to assume that having the one department that relies on operations, clinical and medical not be on-site to coordinate the flow of vital information which must be relayed accurately to insurance providers. The right hand must talk to the left in order to be effective in any treatment-based platform. An on-site UR department is the glue. An on-site Director of UR has direct contact with medical and clinical daily which allows problems to be identified quickly, solutions implemented and progress to be measured then relayed to providers. An added benefit is having answers to the care manager’s questions before they’re asked.
- Non-Clinical Relationship: The UR representative’s role within the organization should also include a non-clinical relationship with every client. Burning Tree offers a daily “Community Group” which focuses on accountability through a 12-step lens. Pertinent information can be charted then presented to the treatment team by the UR representative. From the insurance company’s perspective, a chart on a screen suddenly becomes more like a real human being suffering from a chronic disease, with the help of an established non-clinical relationship. For example, if you’re in the market for a used car, would you rather buy a car from someone who knows the car inside and out or buy sight unseen from someone states away?
An on-site Director of UR, with proper processes and procedures implemented, helps create a client-focused continuum from admission to discharge. A client-focused approach is the way out of the dark shadow unethical treatment centers have created for the industry. My personal belief is authorizations and dollars will flow provided we act with integrity in our business of serving others first and providing the high level of quality of care. When non-clinical, clinical, operations and medical work together the client wins.
[i] ASAM Criteria
[ii] Texas Administrative Code – Admission Criteria for 24-hour Residential.
[iii] Texas Administrative Code – Continued Stay Criteria for 24-hour Residential