A Case Study in Integration

In all of our healthcare work, HCSpecialists promotes integrated organizational structures. Integrated delivery systems connect health plan members to case management, customer service, clinical operations, and information technology, as well as the most appropriate expertise available to care for health conditions.

HCSpecialists recently achieved such integration in collaboration with a large health plan, which serves over 10 million members in multiple states, during the implementation of a two year project to standardize operations and eliminate functional redundancies. We helped our client maximize resources in the following areas: Executive and Administrative Support, Clinical Operations, Technology and Systems, Compliance, and Training Programs.

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HCSpecialists’ Public Comment on Proposed Medicare Regulations to Create Accountable Care Organizations

Accountable Care Organizations – a key feature of healthcare reform – intend to establish an innovative delivery system for Medicare services. HCSpecialists believes that the “vision” of the currently proposed Medicare regulations includes a major blind spot. The goal of healthcare reform is a more functionally-integrated, patient-centered, outcomes-oriented and cost-effective healthcare system. The regulations fall short by ignoring the role that behavioral health services play in the U.S. health system.

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Evidence-Based Behavioral Health Medical Necessity Criteria

HCSpecialists created the Evidence-Based Behavioral Health Medical Necessity Criteria in 2009 to ensure quality and manage costs related to the utilization and delivery of behavioral health services. Most healthcare organizations lack standardized decision support tools for managing the complexities of behavioral conditions. Distinct features include comprehensive definitions and requirements for all levels of care; criteria for outpatient services unique to behavioral health; and effective, evidence-based treatments for specific DSM-IV behavioral health diagnoses.

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Mental Health Parity

The federal Mental Health Parity and Addiction Equity Act requires that coverage of behavioral health conditions be “no more restrictive” than a plan’s “predominant” medical benefits. The law provides patients with greater access to behavioral health treatment, but has the potential to increase health plans’ costs. What can health plans do to ensure compliance without increasing costs?

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Call to Action for Successful Healthcare Transformation: The Interdependence of Physical and Behavioral Health

The intense spotlight of healthcare reform is focused on the enormous challenges—as well as the opportunities —involved in transforming a “broken” service delivery system. One of the most challenging hurdles of healthcare reform: How to deal more effectively with the interdependence of physical and behavioral health. The current delivery system fails to consider behavioral health as a contributing factor to total health, despite indisputable evidence of the “mind-body connection”.

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Medical Loss Ratio

Beginning in June 2012, the healthcare reform law will require that insurers report the proportion of premium revenue spent on clinical services and quality improvement activities. Insurers must provide rebates if their medical-loss falls below 85% for plans with over a hundred enrollees and 80% for smaller plans and individual policies.

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Published Articles

- ACOs and Behavioral Health
- Healthcare Reform and Mental Health
- Small Businesses and the Affordable Care Act
- Autism Spectrum Disorders
- More ...