Physician and nonmedical reviewers (case managers, care managers, etc.) for MBHOs should have firsthand knowledge of clinical matters subject to their decisions. Physician reviewers should have a valid Texas medical license as required by rules of the Texas State Board of Medical Examiners.
Admission and continued stay reviews of inpatient psychiatric or chemical dependency services should be assigned only to reviewers with direct experience in caring for patients with these disorders in hospital settings. Patient care is compromised if utilization decisions are based on manuals or software programs rather than familiarity with real patients in actual treatment settings.
Physician reviewers should demonstrate clinical competence by being engaged in active psychiatric practice at least twenty hours a week. Certification of inpatient admissions or continued inpatient stays should be performed only by physician reviewers who are in active hospital practice.
It is essential that good patient care and professional ethics not be compromised by economic incentives. Decisions by MBHOs to hire, promote, engage by contract, or retain nonmedical or physician reviewers should be based on reviewers’ clinical experience, expertise, judgment and skill in communicating with psychiatrists and other professionals. These decisions should not be based on frequency of denials or approvals, number of inpatient days approved or denied, number of outpatient visits authorized or denied, or claims paid or not paid as a result of reviewer decisions. Such information should not be made available to individuals making human resources or contracting decisions with respect to nonmedical or physician reviewers.
MBHO reviewers should not engage in threats or intimidation but should communicate with psychiatrists and members of their office staffs in a respectful manner. They should recognize that psychiatrists are trained professionals with time pressures and significant responsibilities. Bullying tactics, e.g., telephone messages such as “if we don’t hear from you by 2:00 p.m., it will be denied” are inappropriate and engender animosity on the part of psychiatrists toward the MBHO.
Reviewers’ attitudes and behaviors towards psychiatrists and other providers should be an important consideration in their selection and retention. MBHOs should hire reviewers with flexible and clinically realistic views of patients’ needs and should avoid those with arbitrary or rigid views of medical necessity (see section above on medical necessity).
TSPP recommends that MBHOs conduct confidential surveys of network psychiatrists and hospital utilization review coordinators to learn about their experience with individual nonmedical and physician reviewers. Information obtained from these surveys should be reviewed only by MBHO executives who are independent of review functions and should serve as a basis for evaluating the performance of reviewers.
The American Psychiatric Association practice guidelines for psychiatric disorders were developed at considerable expense and reflect the current state of the art with respect to patient care.
MBHO reviewers should be familiar with these guidelines and rely upon them when assessing care provided by psychiatrists.