Reduce utilization reviews for SUD care
Recommendation
The Centers for Medicare and Medicaid Services (CMS) should encourage the use of case rates for substance use disorder (SUD) care that set a predetermined rate for each level of care once prior authorization has been approved, eliminating the need for further utilization review in levels of care including detoxification, rehabilitation, partial hospitalization, and intensive outpatient services.[1]
Background/summary
Continuous care and treatment improves involvement and outcomes for people with substance use disorders (SUDs).[2] However, the cost for SUD treatment can be expensive, even with health insurance.[3] The use of case rates for SUD care that set a predetermined rate for each level of care once prior authorization has been approved would eliminate the need for further utilization review for each level of care, including detoxification, rehabilitation, partial hospitalization, and intensive outpatient services.[1][4] This would ensure individuals receive continuous care based on their treatment plan and not what is dictated by cost or insurance.[4]
citations
1. The Kennedy Forum. Recommendations of Congressman Patrick J. Kennedy to the President’s Commission on Combating Drug Addiction and the Opioid Crisis. Last Updated October 2017.
2. McKay, James R. “Impact of Continuing Care on Recovery From Substance Use Disorder.” Alcoholic Research Current Reviews 41(1): 01. Last Updated January 21, 2021.
3. Li, Mengyao, Cora Peterson, Likang Xu, Christina A. Mikosz, and Feijun Luo. “Medical Costs of Substance Use Disorders in the US Employer-Sponsored Insurance Population.” JAMA Network Open 6(3). Last Updated January 3, 2023.
4. The Kennedy Forum. Payment Reform and Opportunities for Behavioral Health: Alternative Payment Model Examples. Last Updated September 2017.