Nothing brings terror to the heart of an Executive Director than to hear that a Managed Care Organization is coming to conduct a clinical audit!

Remember, the Managed Care Organizations (MCOs) are charged with among other things, to “bend the cost curve” for their client, The Department of Medicaid.  Their mission is to ensure that their member receives timely, high quality, clinically appropriate, cost effective care.

Currently, we are in what I call, “the getting to know you” phase.  Each entity (Provider/MCO) is getting to know each other and figuring out how to work with each other.  And although any Community Behavioral Health agency can contract with the Medicaid MCOs today, there is no guarantee this will continue in the future.

So, what changes should an agency be preparing for down the road?  What should proactive organizations do to position themselves in this new world?  Well, for starters, agencies should prepare themselves for future MCO clinical audits.

Since MCOs are now paying claims, they have begun to develop analytics around length of stays, successful discharges and readmission rates.  This not only pertains to Prior Authorized (PA) services but also applies non-authorized services like CD IOP and case management.  How will your organization stack up when it is measured against others that provide similar behavioral health services?

Do you have a systematic approach to make sure your organization’s clinical documentation meets managed care criteria for your various clinical services?

At Pinnacle Partners, we have a small, handpicked network of Subject Matter Experts (SMEs) that provide consulting services in critical clinical areas such as clinical documentation for higher levels of care (SUD Residential, SUD IOP).  In addition, our SMEs have extensive experience working with Providers to ensure that their clinical documentation will stand the scrutiny of any MCO audit.

If you believe your organization could benefit in preparing for MCO clinical audits, please feel free to contact me at ghumble@pinnacle-partners.org

As always, please let us know how Pinnacle Partners can be of assistance o your organization!