California Psychiatric Association
Policy Statement on Managed Care*
2-26-05
Policy Statement on Managed Care*
A number of conditions are necessary to ensure timeliness and quality in the delivery of medically necessary treatment and to provide for an adequate supply of providers in managed care provider networks.
To the degree that these conditions are not met, patients will suffer distress, frustration and failure accessing services, and will find appropriate treatment delayed, denied, or otherwise not readily available.
It should be understood that to the degree that large amounts of unpaid administrative time are required by plans from providers to obtain and justify authorizations, it will diminish the time and resources available to provide clinical treatment, and ultimately impact access to and quality of care.
Every effort must be made to ensure that medically necessary treatment is provided at the earliest possible opportunity in order to intervene in the early stages of mental disorders. Lack of early intervention will result in avoidable and needless suffering and more intensive and costly interventions later as the severity of untreated or under-treated symptoms increases.
The necessary conditions are:
One, contracts must be understandable and fair to physicians and other providers.
Two, reimbursement rates must be fair, equitable and meet “community standards.”
Three, reimbursement must be reliable and timely.
Four, a treatment and/or reimbursement denial dispute resolution and appeal processes must be user friendly and render decisions expeditiously.
Five, utilization review and dispute resolution must be rational, use evidence based standards, and serve the medical needs of the patient first and foremost.
Six, psychiatrist, primary care physician and other provider relationships must “mesh” and work smoothly to provide easy communication and close collaboration for necessary treatment.
Seven, behavioral carve-outs and parent health plans must work together closely to maintain continuity of care for beneficiaries served by both, and to ensure timely coordination of services, authorizations, and reimbursements.
*Adopted by CPA Council February 26, 2005
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