Behind The Care: What is Utilization Review?
We look under the hood of addiction treatment services and what Utilization Review (UR) is, and why it is so important for families to be knowledgeable about it.
What Utilization review is and how it is beneficial to families and individuals seeking addiction treatment
Levels of care within addiction treatment and how the process of utilization review makes sure the individual gets the recommended level of care (LOC) treatment stay through the insurance coverage
The reasons why insurance companies sometimes won’t support, or provide coverage for the length of stay recommended by treatment providers
How Utilization Review is saving lives
Time in treatment saves lives, and time in treatment comes through good utilization review, and good utilization review simply means leaving no stone left unturned, understanding fully what an insurance company’s criteria is, looking at a client’s clinical presentation before making that request and advocating on behalf of the client. And if that means reaching out to the provider’s office to get more information, or if that means I have to go in and look through years of cases to find a similar case where they were able to give us more time, and also fighting on the phone for these clients. Of course, it’s diplomatic, but at the end of the day we are on the phone and we are pulling for every single day possible leaving no inches on the field because one extra day in treatment can be the difference between life and death. We fully understand that and we take it with a huge responsibility.
all right everybody welcome back to another finding peaks episode uh here on a beautiful day in colorado we’re doing a little bit of experimental mode today inviting guests through google meetings today clinton and jason are not with me as promised we’re trying to expand upon and build upon you know the foundation of recovery journeys what it means to not only go through those journeys but also to kind of peer through the lens of administrative protocols and procedures um that support patient care at the end of the day that are often not talked about so we’re really hopeful in this episode um to invite families into the discussions to hear kind of about the the under the hood aspects of addiction treatment centers and um you know kind of a backdrop to this is that one of our you know one of the challenges in addiction treatment that we hear often you know is that you know addiction treatment is expensive or addiction treatment centers are charging a great deal of money for patient care and it is true that that is abused um you know within our industry on some you know varying occasions but um for the most part to provide quality of care really takes an incredible team an incredible amount of resources and quality professionals and so i want to invite uh christian pantoja uh on to our uh finding peaks episode today he is the ceo um and founder of pantoja consulting um which is a utilization review firm and he also is the ceo and founder of uh good for you billing so christian welcome to finding peaks thank you so much brandon i’m stoked to be here seen some episodes uh i love you guys so excited to be here thank you yeah wonderful so to kick things off um before family starts scrolling through the social media to find some other video to talk about hold still families like this is important i think you’re going to learn a lot about today’s through today’s episode about how some of the underhood aspects of addiction treatment culture work so to kick things off um we’re we are we’re going to shy away from billing conversations today and really focus in on this concept of utilization review or you are for short and to start this off christian you know kind of kind of fill us in on you know a couple of minutes about how and what utilization review is yeah so utilization review is basically the practice of a provider’s office reaching out to an insurance company to request authorization to provide their services utilization review typically takes place at the front end of a treatment episode so it usually starts with that phone call to the insurance company a provider’s office will have had already assessed a client and they’ve already determined which level of care they feel would be most beneficial to help this client increase their functioning and decrease their symptoms once that assessment has taken place we reach out to the insurance company on behalf of the provider and we advocate for that level of care request what’s interesting about these level of care requests is that every insurance company has criteria that must be met in order for them to deem the level of care medically necessary so understanding the different elements of that criteria and kind of putting the pieces together from the client’s clinical presentation to the insurance companies value system is where a lot of the fun takes place but there’s also a lot of complications in there that a lot of providers miss as well and uh in thinking about what you everything that you had just stated in regards to level of care i just want to talk to the families really quick about you know levels of care and relationship we’re talking about detox residential treatment inpatient uh partial hospitalization php and iop and so forth down the ladder um so from from your pers your professional perspective christian um i just want to you know families are calling addiction treatment centers and you know getting an admissions team that’s talking about you know curriculum and insights into care and so forth um but they’re not super familiar about the backdrop of processes that are actually going to support their loved one as they advance through these levels of care and so just curious from your professional lens what is it about utilization review that you’ve seen as a process that is beneficial to ensure that each individual is moving through those levels of care accordingly certainly so like you mentioned there are multiple levels of care the first of which in substance use treatment typically starting with detox moving into residential your partial hospitalization stay iop and then perhaps some long-term routine outpatient but from a process standpoint i believe that typically in any field you have a level of due diligence that is pretty universal whereas with utilization review that due diligence varies across the board so you might have one provider’s office where you’re speaking with their admissions department and everything sounds great let’s bring them on in but perhaps some questions to ask are what are your typical lengths of stay what does your utilization review process look like because those those levels of varying due diligence sometimes do cut short the treatment episode for somebody’s loved one so for instance that process looks like we receive information from the facility some updated clinical documentation which is typically reflected in the patient’s medical record and then once that information is received it’s the job of the utilization review specialist the ur specialist to call the insurance company and request the be it detox or residential or maybe even a continuance in a level of care such as detox maybe they’re four days in and we need an additional three days which is pretty consistent by the way having to call an insurance company just about every three to six days is consistent amongst most levels of care certainly inpatient ones but once that information is received we make that phone call but before making that phone call we need to first understand that there is this element of historical data that we need to tap into ourselves which simply means the facility has a level of care that they would like to request be it detox or whatever it is we have information to support that request it’s our job as utilization review experts to look at the information and make sure that it’s actually going to meet the insurance companies medical necessity criteria because our job doesn’t end at simply making the phone call and reading off what’s in front of the form anybody could do that so our job is to actually look at the information and ask ourselves is this a viable fit for authorization if it’s not a viable fit our job’s not over at that point we have to go back to the provider’s office and we ask clarifying questions perhaps we’ll say hey this is a cigna policy or a blue cross blue shield policy for instance blue cross blue shield requires um three out of five stressors within the client’s psycho-social life so their personal life and then we might ask the therapist are there any of these three stressors present so once we’ve done that clarifying bit of information and we know that the clinical picture that we have in front of us is the accurate one and it’s best represented then we can go ahead and make that call throughout that call the insurance company will ask us a lot of questions these calls can take anywhere from 20 minutes to an hour and a half where they’re basically asking questions to see if our request is medically necessary but they’re looking at it through the lens of could this client be fit into a lower less expensive level of care and still increase their functioning it’s our job to speak to reasonable foreseeability to be able to state that any therapeutic entry attempt into a lower level of care would exacerbate this client’s condition thus preventing them from being able to improve and likely leading to another admission so understanding that’s important and then another element to understand too is that these are publicly traded companies so they answer to shareholders that’s a good thing to remember when you’re understanding why it is that the insurance companies have these cost containment measures their for-profit companies so they clearly need to make a bottom line and as more people opt to go to treatment clearly their cost containment measures are going to increase so it’s our job as utilization review to understand the different trends that are happening in our field and to make sure that the provider’s documentation are not even the documentation but to make sure that the provider’s level of care request is supported by the documentation before calling it in once you have that information set in stone calling in the request itself is a little bit of an art form quite honestly you’re basically making a level of care request while being able to state that should you not authorize this this will likely cost you more money blue cross blue shield but you want to do that in a rather diplomatic sense as well so understanding where the client currently sits today and how that fits into the insurance company’s clinical criteria is of the most important certainly and that information um is constantly changing so it’s not something that you can sit into and automate and get comfortable what worked in 2014 doesn’t work in 2021 certainly right i’m actually seeing level of care criteria shift down the way so perhaps a client that used to meet for residential in 2017 an insurance company’s criteria might say today that that same clinical presentation can be best served at php or iop yeah and i i appreciate that it’s always just such a pleasure hearing you wrap uh utilization review practices um because um you know from my position as ceo of you know peaks recovery centers it is um something that’s constantly being explored constantly being updated and changed in the background you know and following all of that really requires you know a a a quality lens to see all of that through you know before i got to know you in this industry and in this uh you know field certainly christian um there would be episodes where you know individuals would come into treatment and i would see them getting you know their authorization denied by the insurance carrier or we hear and i know families watching this can think about it or know this to be true for themselves that you know they got johnny into an addiction treatment center and then eight days later the addiction treatment center removed him under this kind of notion that the insurance company dropped them from um or wasn’t willing to pay for treatment moving forward now for me when i hear those things i take a lot of responsibility for that an addiction treatment center mental health or otherwise has to have its ducks in a row to be able to help the family system navigate that insurance aspect of things by checking all of the boxes along the way so we’ve heard a lot of positive features for how utilization review has to go for it to go well but when you hear people getting dropped off you know in a sense seven to eight days into treatment episodes that we’re planning on being there for 30 60 90 days you know what do you find in your experiences are negatively happening within those operations and and what’s being missed that we can share with the family system so that you know in in relationship to you know one of my visions for peaks recovery centers is to disrupt this industry and to do that in a way really is to empower families to have this access to information to call back you know the addiction treatment center and say hey this doesn’t make sense to me because johnny’s been using you know intravenous heroin for the past four years and it makes no sense to me for how we’ve arrived at no medical necessity um in that regard so just kind of curious how you might see you know as a thought experiment kind of how negatively or what negatively would have happened that would have led to an individual only getting you know a few days in a treatment episode where they were promised you know 30 60 90 days sure i actually really appreciate you bringing that up brandon thank you for that question because it’s pretty frequent that i find myself saying that from my from my position where i sit i genuinely believe the greatest issue i see on a day-to-day basis is clients who are meeting their insurance companies criteria but the provider is unable to for some reason accurately relay that client’s clinical presentation onto a paper or into an electronic medical record system that accurately supports their level of care request so the client’s actually meeting but the documentation isn’t necessarily stating that so where’s the disconnect and there’s a few variables that i’ve identified over my time that can kind of uh relieve some of those short links to stay the first of which is making sure that we are assessing clients appropriately far too often are we going through our questionnaires that end up becoming information that we send to the insurance company we’re going through these assessments in a rather passive way letting clients kind of dictate the flow of the assessments at some point in assessments things have to be done within an open-ended questioning manner and sometimes they have to be done within a closed-ended questioning manner so for instance um understanding that this is one of if not the most manipulative patient demographics in all of healthcare is very important right so for instance when i go into a urgent care because i broke my arm let’s say the provider will take an x-ray it’ll show a break in my bone the break in the bone shows that the cast is medically necessary whereas we don’t have that in our field we don’t have a lot of biometric data showing that someone has cravings to use so within that there’s this element of creative licensure that has to be utilized by our team when getting this information back from the clients outside of that certainly making sure that you’re having the correct person calling the reviews i personally see it as a cost to have clinicians calling in reviews to the insurance company for a few reasons nothing against clinicians but clinicians go to school for a lot of different reasons but at no point do they ever receive education on what cigna deems is medically necessary for residential care that’s a really important part of treatment you have a lot of clinicians in the industry in the country rendering services for a level of care that they don’t really know what meets and what doesn’t meet with our pair sources so making sure and then another thing when they call in their own reviews frequently they kind of want to highlight the good elements of their work which is certainly not the place to be done on a utilization review when we’re trying to discuss why this person needs more treatment so i always suggest having a somebody else calling the reviews that is specifically an expert at utilization review if they’re a clinician that’s great but their main understanding needs to be of what insurance companies deem to be medically necessary and then also being able to take the information in front of you and painting a clinical picture because the insurance company asks questions in a rather rapid-fire way and you have the answers in front of you but just simply reading them off from the medical record can certainly get you into trouble a quick example is um frequently i see in medical records that a client is resistant towards an intervention or perhaps towards a therapist or towards a day of service resistance towards treatment to an insurance company means that there’s no need for treatment that the treatment as efficacious as it might be it’s not going to work out because you have an unwilling um component being the patient so we flip that word into um ambivalent because ambivalence towards treatment speaks to a low readiness for change it speaks to limited insight into illness and it certainly speaks to the need for continued stay at a level of care so somehow a change in terms like that and understanding those through just engaging with insurance companies um over a long period of time gives us the understanding to to change the wording a bit without actually changing the nature of the clinical requests and certainly of the details that are accurate and truly represented within the milieu so i would say it’s a plethora of things you don’t want your clinicians calling in your reviews if you don’t need to and certainly i would suggest if it’s on the clinician’s caseload it might not be the best person to call in another element of that is that you want to be diplomatic within these conversations and the insurance companies as they’re trying to fit your patients clinical presentation into a less expensive lower level of care at times they come up with statements that can be rather offensive if heard through certain people um and certainly responding in annoyance or in anger diminishes your ability to persuade so at times i feel as though if it’s going to be a clinician perhaps somebody that um doesn’t have that client on their caseload and as i had mentioned previously certainly somebody that has a great understanding of medical necessity criteria and how it varies from pair to pair
yeah and and i’m i’m hoping that uh you know families for this episode are still tuned in at this point because this is all fascinating stuff um and especially for me but something that the family system should be aware of of how complex these discussions that are taking place you know an addiction treatment center says yes bring johnny into treatment but what happens in the background are these types of things and it’s these quality aspects of care that are going to ensure longevity namely a continuum of care so that your loved one can achieve you know experiencing a full addiction treatment center’s curriculum being able to go through it to work on grief and loss relationships and so forth as they go through it but we have to constantly identify these metrics with the insurance companies and you you mentioned it slightly but um it it i i guess just as a this is probably just a very direct and straightforward question with a with an easy answer but it sounds like we’re speaking to a insurance companies differently we can’t use things like the american society of addiction medicine manual a-sam criteria to advance a single narrative across insurers it sounds like in that regard that when we talk to united healthcare blue cross blue shield and cigna we’re having very different conversations because their cost criteria looks um significantly different at times is that correct absolutely so certainly the old acm criteria or the acm criteria is helpful to have documented but if you are just simply using dimensions one through six of the asam criteria um to assess a client and then expect to get full continuums for 30 days of residential whatever it is that treatment centers are promising up front you’re going to you’re going to find yourself ill-equipped for reviews because certainly there are some insurance companies that are still using dimensions one through six and asking in that format um but a lot of insurance companies are very creative they want to know for instance speak to me where in the asam criteria or through dimensions one through six you’re going to be able to answer uh blue cross blue shield or cygnus question as to what are the current barriers to a lower level of care why can’t this client be served at php you have an asam form filled out you’re not going to be able to answer that question so certainly you want all the components from asam within the information that you’re looking at because you’re looking at post-acute withdrawals and biomedical conditions and all of that information is there but insurance companies are becoming very creative on how they’re able to tell whether or not truly your service request is medically necessary and of course their own criteria at times can be rather arbitrary one insurance company might deem it necessary to give someone 30 days of treatment whereas another might deem it necessary to do 15 which tells us that it’s not streamlined and there is some level of um that this is arbitrary but um even at that you still want to make sure that you have a thorough understanding of things outside of dimensions one through six such as those barriers to discharge a full scope of somebody’s personal psychosocial stressors impacting their daily functioning their past treatment history there’s much more outside of that and even though if you were to call an insurance company and ask them what kind of information you need to be successful on these reviews they would certainly just point to something that’s rather canned as just a general progress note adapt note a nursing note but um it goes much past that it’s uh multiple things and it’s funny that you mention this too because i genuinely know and believe that you can have the same client assessed by two different people ethically done with true information in each of those assessments however one assessment can show for access to residential treatment whereas the other assessment would literally throw the client into a php or an iop level of care it’s the same person struggling with the same issues but a facility’s willingness to get curious roll up their sleeves makes all the difference in the world yeah yeah absolutely man and and again too man it’s all just music to my ears love love you uh uh spit in the ur game and and hopefully too this is being well received um by the family systems because this is such an important aspect to getting dates of service authorized that allow for the individual to move through greater lengths to stay within addiction treatment episodes that gives us more time to penetrate those craving states to introduce therapeutic interventions you know that soften you know the the the feeling of of needles that seemingly when you take away drugs and alcohol that they’re experiencing the sensitivity to the world and allowing more time for medical teams to manage medications to get those things right so that when the lower of level of care has come they’re prepared for it and are um in a great position to achieve recovery on a day-to-day basis moving forward and so um you know and i certainly prompted you a little bit about this you know prior to the episode and coming into this but peak’s mission each and every day is to save lives and our vision for saving lives is to disrupt an industry through quality of care in working with what professionals like you in our industry certainly allow for that quality of care platform and foundation so that we can move forward and disrupt an industry so in that regard you know to not just make it you know bullet points and talking points about utilization review how can we um what would be your answer to how utilization review um as sort of this sort of textbook tone thing operating in the background is contributing to our not just our mission here at peaks but for all families involved in addiction treatment episodes how is utilization review saving lives because time and treatment stay saves lives and time and treatment comes through good utilization review and good utilization review simply means leaving no stone unturned understanding fully an insurance company’s criteria looking at a client’s criteria or looking at a client’s clinical presentation before making that request and advocating on behalf of the client and if that means reaching out to the provider’s office getting more information if that means that i have to go in and look through years of cases to find a similar case where they were able to give us more time and for some reason they’re not giving it to us now and i’m able to cite precedent as to why did it take place here and not here whatever it takes in that regard and then also fighting on the phone for the for these clients of course it’s diplomatic but at the end of the day we’re on the phone and we’re pulling for every single day possible so leaving no inches on the field so to speak um because one extra day in treatment could be the difference between life and death and we fully understand that and we take it with a big responsibility so um you know i always say that at the end of the day i sleep better at night my dinner tastes better at night knowing that i did everything i could have possibly done to get these clients the treatment that they deserve and that typically comes in the form of collaborating deeper with um the clinicians and the therapists and not taking the easy way out because we could take the easy way out and families quite honestly can call their insurance companies and it would just note that it wasn’t medically necessary so again leaving no stone unturned in that regard getting very curious keeping up with trends because time and treatment is what saves lives and time and treatment typically comes through a utilization review department and in conjunction with the other departments that work well
beautiful man and again to i’ve i’m hoping that family systems in the coming years can be just as giddy about utilization review and some of these background under the hood features of addiction treatment behavioral health centers and so forth and i know you and your team at panto consulting and good for you billing have certainly expanded your services across the nation to provide services on the west coast certainly here in the state of colorado on the northeast side of the country as well and i just uh just with with gratitude thank you for taking your unique services and expanding it in a way that continues to save lives and impact treatment episodes for individuals and families and their loved ones moving through care so you know kind of going out here as a as an episode i just want to invite addiction treatment centers that may be struggling in getting lengths to stay solidified for their patient demographic um to reach out to christian directly by email christian at pantoja consulting dot com again he’s their chief executive officer as well too can provide billing services for your company through good for you billing services as well too with the deepest respect i have only met two individuals on this planet that can speak to insurance uh episodes efficacy length of stay in the way that christian can and of those two people he is one of them and so i highly recommend him um and his uh business for your billing purposes and utilization review needs families please excuse me for pitching it but i think it’s important like i said to disrupt an industry to spread these quality of care aspects across our industry so that your loved one can receive greater lengths to stay uh in treatment and uh before i take us out on this outro uh christian anything else for uh the family uh viewers professionals in this field that you wanna leave us with yeah keep disrupting the industry because it’s only driving positive change holding these insurance companies just liable to the lengths of stay that we should be seeing and that our patient demographic quite honestly deserves to have in treatment um continuing to disrupt the process and provide education to everybody as as peaks recovery does and thank you for the kind words you guys have been quite honestly our biggest muse not to do this back scratching for all the families here but um brandon and chris and and bobby and everybody over there your guys’s curiosity about the field and an unwillingness to just settle at the status quo because you truly are in the business of saving lives it has inspired us in so many ways so um thank you and uh keep doing what you’re doing absolutely and continued success on your end with a new baby in your life and the beautiful scenery and backdrop behind you in seattle washington man looking forward to the next time to be able to have you on here again to talk further about some of these underhood strategies that take place within addiction treatment and behavioral health in general so with that as we do here on our outro here at finding peaks recovery questions thought concerned and so forth please email us directly findingpeakspeaksrecovery.com we want to continue to bring new uh information invite guests on in the future um check us out on the instagram podcast um gosh facebook i forget what all the kids are on these days the twitter all of these sort of platforms look for us out there and signing off here uh ceo of peaks recovery centers looking forward to seeing everybody on the next uh episodes in the coming weeks and until next time love you take care