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News & Updates

General Commercial Payor Landscape

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Behavioral Health

Substance Abuse:

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  • Commercial plans have experienced an increase in the utilization and demand for substance abuse treatment due to an increase in prevalence and an increase in awareness of substance use disorder

  • As a result of the increased utilization and demand for treatment, some plans have been focused on the utilization in higher levels of care (inpatient/detox, in particular), which are more expensive than lower levels (partial hospitalization and intensive outpatient), to ensure that care is being provided in the least costly setting possible

  • Commercial plans’ increased level of spend overall and on a per-patient basis for substance abuse treatment has led to greater scrutiny on out-of-network (OON) care, the rates for which can be two to three times higher than typical in-network rates

  • Plans have worked on convincing providers to join their networks, employing strategies such as slower payment, benchmarking of out-of-network reimbursement to lower rates, and requests for medical documentation

  • Plans typically use per diems for higher acuity care settings and fee schedules for lower acuity care settings

Eating Disorders:

Eating Disorders:

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  • Plans expect utilization to increase given growing awareness of EDs and increasing social and media pressure on body image

  • Plans indicate that they will continue to direct care to lower acuity care settings when medically appropriate, as part of their prior authorization process

  • Across care settings, most payors maintain “open” networks for ED treatment providers, i.e., will accept any-willing, credentialed provider that wants to join their network.

  • In many areas of the country, treatment has been shifting to in-network from out-of-network

  • The most common reimbursement method for ED residential treatment is a per diem.  Some payors have recently implemented or have considered putting case rates in place for certain providers, whereby they pay a certain amount for the entire stay at a treatment facility so that the provider will be incentivized to reduce the number of days

Autism:

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  • Commercial health plans believe they are appropriately managing ABA services, though plans had previously been concerned as utilization rapidly increased along with the commercial mandate rollout

  • Plans will either manage the benefit themselves or outsource this to a behavioral health benefit manager as these entities often have personnel with specialized knowledge to help better understand how to create a benefit package that is cost effective and clinically appropriate

  • Access has become less of a concern for plans and so they have focused less on the active recruiting (with the exception of providers in hard to serve areas or for particularly difficult or non-English speaking children) and more on ensuring the network contains high quality providers

Physician Services

Commercial payors’ areas of concern:

  • Radiology

    • Radiology services are generally an area of high focus for commercial payors due to the area’s associated expensive costs. Compared to freestanding outpatient centers, reimbursement for radiology services provided in the hospital setting can be higher

    • Anthem BlueCross BlueShield has led the movement in shifting utilization towards freestanding outpatient centers by implementing a strict policy limiting the coverage of hospital outpatient (HOPD) radiology services in 13 states. Though there are exceptions, the policy generally restricts reimbursement for outpatient MRI and CT scans to freestanding imaging centers only

  • Pain Management

    • Commercial payors are typically concerned about over-utilization and inappropriate use of pain management services, specifically addictive opioid medications

    • Most plans distinguish between interventional pain management providers and pain management providers through their use of opioids, but some view interventional services with just as much focus due to the high cost and limited evidence of efficacy of treatments

  • Anesthesiology

    • Plans are placing either the same or greater utilization management focus on anesthesiology relative to other services given the high cost, particularly for out-of-network providers, but note that there is little they can do to limit utilization of anesthesia services if the principal surgery is approved

    • Plans will continue to drive members towards lower cost care settings, and away from the inpatient hospital, for procedures that require anesthesiology services, most notably orthopedic and GI (i.e. endoscopies).

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