A Tale of Two Guidelines – Part Deux

Clinical Guidelines for Utilization Management and Authorization

It was not until about 4 years ago that I learned about the second type of CPG we are going to learn about for this article.  Prior to my time working in utilization management I was very ignorant to the process of authorization required by health plans.  I was just handed a form by the office manager and told to fill it out. After that I was clueless.  

I had lots to learn back then, and I don’t want you to stay in the dark like me.  I thought decisions on how many visits were approved all came down to some algorithm created by non-clinicians.  I was pleasantly surprised to learn shortly before starting my non-clinical career that utilization management companies and health plans also utilize guidelines to structure their decisions.  

Please take note: clinical guidelines created by utilization managers and health plans serve a different purpose than the peer reviewed type.  Clinical guidelines used in utilization management are there to guide the decisions being made on if a member’s specific benefit should be used.  It is often based on “medical need”. I already have a super terrific blog post about medical need. Please go check it out if you need more detail on that. 

Utilization guidelines are primarily there to dictate what level of care would be authorized based on that patient’s presentation. So please, don’t confuse guidelines for clinical review with peer-reviewed Clinical Practice Guidelines discussed in part 1.

Although I cannot speak for each utilization manager out there, the majority of these guidelines are created through rigor and the integration of current published peer reviewed evidence. In fact, many will incorporate the recommendations of published CPGs to how authorization decisions are made.  This is another reason why I so strongly recommend providers being familiar with peer reviewed published CPGs. They are often the backbone of what payers will also be using to create their decision guides.

Guidelines for utilization management can vary significantly one from another.  There is not one standardizing body when it comes to how a payer is going to approve the use of a skilled care benefit.  The published peer-reviewed CPGs in part one have both national and international standards. That is not the case with these ones.  So it will be important to familiarize yourself with those for whom you see patients. These guidelines are generally easily available to providers. Often on the UM company website.  Here is just one example .

Over the past three years I have been part of the team that creates the guidelines used for physical therapy and occupational therapy authorization decisions where I work.  It may not take us 5 years to complete, but the process is taken very seriously. Here is what is involved when we create authorization guidelines where I work:

  1. Comprised of a team of 6-8 licensed PT and OT who review and update the guidelines annually as requested by the health plans.
  2. Specific sub-guidelines (broken down by body region and diagnosis type) are assigned to one or more team members to act as lead.  Assignment is based on clinical experience.
  3. New sub-guidelines are created based on new best evidence.  We try to use level III (link to levels of evidence hierarchy) or better evidence.  Current CPGs, systematic reviews and randomized trials are most sought after. Articles are reviewed and then categorized for inclusion based on level of evidence and strength of recommendations.  
  4. Drafts are written based on the found recommendations. The more strong evidence there is for a certain treatment, the stronger recommendation it receives.
  5. Updates to old guidelines go through a similar process, but only if there has been new evidence since it was created.  
  6. All drafts are reviewed by others on the team and revisions are made. 
  7. All drafts are submitted to our clinical content team who checks for appropriate strength of references used, proper citation, and that they comply with all applicable regulations (i.e. health plan rules, insurance laws, Medicare guidelines, etc)
  8. These guidelines are submitted to health plans for their approval. 

Note: this is just the process I went through where I work. I cannot speak to the process of that others UM companies or health plans might take in creating what guides their decisions.  Furthermore, the process used to create guidelines for UM is not equal to that of peer-reviewed CPGs. Remember, they serve different purposes and are not interchangeable. You need to familiarize yourself with both.

Need to know the evidence, or lack thereof

I find the work of creating and updating the clinical review guidelines very interesting work.  It keeps me close to the strong evidence for skilled care treatments and the weak evidence that is also out there.  I have become much better at evaluating published evidence. It has helped me see that just because there is a study for something does not mean I should immediately integrate it into clinical work.  There little to no research on dosage of visits, length of visits, combination of treatments or techniques. In the grand scheme of the medical world, rehab research is still very new.  

As there is little solid ground on which to stand for the various treatments and plans of care seen in therapy, most utilization guidelines are going to fall back on peer reviewed CPGs and applicable research.  So when a peer-reviewed CPG recommends the use of functional measures and outcomes, you can now start to see why a utilization company is going to require them. Additionally you should start to understand why continuing care is based off of functional improvement.  That is what is most strongly recommended currently. You should also start to understand why most health plans have stopped reimbursing things like ultrasound. They are generally not recommended in the published peer-reviewed CPGs.

One of the hardest parts in skilled care is the number of visits. There just is not good research on this.

However, there is research to show that patients can improve with group care and home programs. Studies that show improvement from a particular treatment stop at some point.  Most between 8-12 weeks. Many of these studies do follow-up at 3,6 or even 12 months later and patients are doing better than baseline, even though they have stopped the trial.  These kinds of things are also looked at when developing a utilization guideline.

Because of gray areas there may also be guidelines determined more by the health plan or the utilization manager.  Like what level of disability is considered as “needing skilled care”. Go read my 80/20 article for more on that topic.  Some health plans may allow care for sports or recreation where others may not. Some may limit visits more, where others are more lenient.  This is their prerogative. Remember that health plans are a contract with premiums. Those plans that allow less visits likely have reduced premiums.  It may have nothing to do with you or the way you treat, it could just the way the health plan contract is written.

Beyond best evidence

General usage data is also incorporated.  Health plans most certainly look for patterns in their data.  As care moves towards pay-for-performance even more data will be scrutinized.  Ask yourself, if the health plan can see that most providers use 12 visits for diagnosis XYZ why would they be just fine with a handful of providers using 30, 40 or more for the same condition every time?  Health plans have instituted levels of review and requirements to stop the waste of unneeded treatments. Are they thinking of their wallets? You bet! Are they not thinking of the patient? Hardley. 

Think of it like this, if you found out your therapists were using an entire roll of Kinesio-tape on every patient even though it should only take a few strips would you just let it go?  Or would you create rules and a system to regulate the over use of tape? If you find a therapist that consistently spends more time each visit in a patient’s home for home health, but these patients don’t discharge any faster, would you do something about this?  These examples would affect your bottom line right? So does fixing these mean you don’t care about the therapists or patients involved? Or that you are just all about the money?

If you have never done so, I highly recommend you locate the guidelines created by the utilization companies that authorize the care you do.  Compare with the peer-reviewed CPGs. Unfortunately, each company’s guidelines may differ from the other. There will certainly be similarities as well. Being familiar with these is paramount to running a successful rehab business.   These should be accessible by you, likely on the company’s website or through a provider portal. 

Use it or lose it

I am sure at this point you are about to ask, so how do I use the guidelines for clinical review in my physical or occupational therapy practice?  That leads my right into my next topic.  

Once you start exploring these guidelines you will begin to understand their utility.  In the least, they should outline what is required to continue care or discharge a patient based on their benefits.  So it will list for you the information they want to see.  Like functional scores, pain scales, goal progression.  It should also list what criteria they are using to recommend discharging a patient.  So is it 80% ability?  Maybe pain levels below 3.  That kind of thing.  Some may define it with severity classifications.  Some may even get as specific as how many visits are allowed for a certain problem. 

They are literally a guide to what is going to be looked at during a clinical review of your authorization request.  By reading them, you will know what the information the utilization manager will look for when completing a review.  You want to avoid the frustration of holds and denials.  Follow the guides.  If you don’t use them you risk losing much time, patience, money and even patients.  Each one is going to be so varied I can’t really give specific tips on how to use it other than just find them and review them.  You will start to understand, and if you can’t reach out to the provider education team for that company!  

The Pitch – part deux

Now that you understand all of that much better…

I have a completely different idea of how I can optimize rehabilitation care.  This is way better than my charcoal and vinegar idea (however I am currently working on developing my own line of salad dressings!!).  This one you won’t want to miss out on!  

Its called Evidence Based Practice! 

Oh, wait, that is already a thing (wink, wink)

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