The Pacific Source 26 Session Review is a
Utilization Management Audit using Hidden Requirements
A Healthy Contracts Position
"Effective January 1, 2024, Pacific Source will begin completing utilization management reviews for members who have received 26 or more therapy/counseling visits. Behavioral health (BH) providers will be contacted and asked to submit clinical information, which will be reviewed for ongoing service. (Pacific Source Policy, 2024)
Recent contact with this payer demonstrated that Pacific Source staff will not discuss the values used in creating these audits. Why?
The values in these audits will not support Oregon Health Authority (OHA) values: (1) evidence based treatment, (2) patient centered care, and (3) improved quality and health outcomes at an appropriate cost. The values in the Pacific Source audit plan seems to be profit, not access nor improved quality and outcomes, despite the payer’s assertion that one purpose is to “ensure adequate access for all Pacific Source members.” Pacific Source has not identified the objectives of the audit. Nor the risk-impacting objectives that could undermine public health and provider practices. Pacific Source has not described a program that will gather, aggregate and analyze provider data. There is no commitment by Pacific Source to publish key indicators of success. If providers are threatened by this audit, it is more likely provider practices will screen out patients who might require more 26 sessions. For example, (1) patients with more than one medications, (2) need and don’t have a physician or psychiatrist, (3) people who have been to an ER, (4) children involved in a divorce, (5) divorce and domestic violence, (6) personality disorders, and (7) patient with chronic illness. There is no accounting that it is quit possible that the utilization review program will cause providers to avoid treating patients who have chronic problems in order to keep their risk exposure and stress level low. Logically, the program will almost certainly result in a higher degree of under-utlization.
Pacific Source staff refused to discuss the objectives of these audits. Why?
The objectives are not to ensure treatment. Nor are are the objectives to prevent undertreatment. The impact will almost certainly be undertreatment for some plan members. The objectives are almost certainly aligned with Healthplan profit values, not clinical objectives shared with providers’ practices or OHA values.
Pacific Source provides no transparent requirements that could justify audit results. Why?
The Pacific Source audit criteria uses an outdated standard. They are implementing the outdated Oregon Medicaid standard eliminated by Medicare and Medicaid, replaced with the phrase: “medically reasonable and necessary. (1)
(1) On January 14, 2021, CMS finalized a regulatory definition for determining whether an item or service is "reasonable and necessary" … CMS explained that codifying "reasonable and necessary" will "provide greater certainty … to ensure that this substantive legal standard is codified." The effective date of the final rule…March 15, 2021.
There is a great difference between the words “appropriate” and “reasonable”. “Appropriate” gives Healthplans’ ultimate, arbitrary authority. “Reasonable” gives providers’ reasonable authority.
CMS is the prevailing standard in the U.S. Healthplan and Oregon adapted the CMS “necessary and appropriate” standard when Oregon created the Oregon Healthplan. Healthplans in Oregon have not made adopted the new CMS standard, even though they provide services on behalf of Medicare and Medicaid, presumably because it gives them an advantage to the detriment of healthcare providers.
As part of their audit program Pacific Source will require:
The patient’s most recent assessment.
Their current treatment/service plan.
Five most recent treatment/service notes.
Withholding a credible standard for a chart to be compared (i.e. values, objectives, controls), by which an independent auditor could replicate the audit process, the purpose of the Pacific Source audits almost certainly will not to improve charting, nor access, prevent undertreatment, or improve quality and heath outcomes. This conclusion is probable because Pacific Source is not receptive to discussing and explaining the value, objectives, and controls (i.e., standard) for which the provider is audited. One can surmise, with probable to almost certainty, that the purpose is to restrict services and the resulting cost.
For more information see:
What is the value of psychotherapy charting?
https://www.mentorresearch.org/value-psychotherapy-charting
There needs to be a legislated solution that creates accountability with guardrails that protect provider practices and public health. Healthplans are unwilling to listen to providers. Health plans do not have conversations with mental and behavioral health professionals about values, objectives, measures and what leads to quality and improved outcomes.