The recent Wit vs. United decision made it clear that nationally-recognized and evidence-based clinical guidelines need to be used for level of care determinations when health plans are deciding what is covered or not under a health insurance policy.  This requirement is especially true for mental health and substance use disorders (MH/SUD) coverage determinations to ensure the recommended treatment plan falls within “generally accepted standards of care”.

The list of MH/SUD clinical practice guidelines might seem like an alphabet soup – APA, ASAM, LOCUS, CALOCUS and others.   In addition, health plans often use their own internal criteria or commercial guidelines like InterQual and MCG.

The administration and application of clinical “review” guidelines varies, with some using numeric scoring systems, while others follow a sort of restaurant menu logic – one from column A, one from column B, etc. There are differences in emphasis and intended population – some apply to children or adults and can address multiple diagnoses, while others, such as the ASAM criteria, are specific to substance-related disorders.

Payers have an interest in making sure that resources are used appropriately but sometimes these decisions are made on narrow grounds. The risk of danger is determined based on whether a patient is at imminent risk of suicide or violence to others.  While an evaluation of the risk of harm is a necessary element of multidimensional assessment, it never should be the only factor in making a decision about patient care.

Best practice guidelines can provide a way for clinicians and payers to find common ground.  When both sides use these tools health care providers can better support people throughout their health care journeys, and health plans, often through their utilization management programs, are more likely to approve evidence-based care.

A straightforward way to remember the key elements of a comprehensive assessment is the acronym “CHEERS”, which stands for Comorbidities, History, Engagement, Environment, Resilience, Social:

• Comorbidities –Are there medical conditions, substance (or polysubstance) use and/or developmental delays?  Are there symptoms associated with a comorbid condition that may complicate treatment (e.g., breathlessness from asthma in a patient being treated for an anxiety disorder)?
• History – Is this an initial diagnosis? If not, what was the previous experience of treatment like – was an entire course of treatment delivered or was it cut short for some reason? Was there a complete remission, or did some symptoms persist?
• Engagement – Are there barriers to engagement in care? Are there language or cultural factors that require additional support?  Are there oppositional features of the disease that might need special care planning, such as motivational interviewing?
• Environment – Is the environment a factor contributing to destabilization (e.g., stressors such as violence)? Does the community environment have the necessary resources? (e.g., a partial hospital program might be available 15 miles away from a person’s home, but without a car or access to public transportation, it would not be a realistic treatment option).
• Resilience – When two people are presented with the same conditions, it’s unlikely that they will respond in the same way – some people are simply more resilient than others.  What is the resilience level of the individual?
• Social – What is the level of social support that is (or isn’t) available? Are family and friends available to assist with recovery?  Is there a social network that actively sabotages recovery?

The clinical practice guidelines identified in Wit support best practice and give providers a way to both standardize and personalize care.

Contact Schooner Strategies and our team of medical management experts if you want to discuss best practices associated with how insurer’s should leverage clinical practice guidelines when making coverage determinations.