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MedCert: Meeting the First-Level Pre-Authorization Needs for Behavioral/Mental Health

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Mental health and substance abuse problems are a growing concern. Because of the expanding number of claims payers are seeing in these areas, the need for a first-level preauthorization medical review solution to bridge the gap has become vital. Learn the drivers behind the expanding number of behavioral and mental health claims and how AllMed’s MedCert Solution is bridging the gap.

Mental health and substance abuse problems are a growing concern. Because of the expanding number of claims payers are seeing in these areas, the need for a first-level pre-authorization medical review solution to bridge the gap has become vital. AllMed Healthcare Management, as one of the nation's leading independent review organizations is helping payers handle this ever-growing workload by expanding its MedCert solution to include behavioral/mental health. Let's take a look at what is driving this growing need. 

More than 43 million adults in the United States experience some form of mental illness in a given year. In fact, one in five adults in the United States experiences a mental illness. Yet, about 60% of adults with mental illness did not receive mental health services in the previous year. And, approximately 50% of children ages 8-15 suffering from these conditions didn't receive mental health services in the previous year. 

Chronic mental illness can begin wreaking havoc in patients' lives very early with 50% of all chronic mental illness beginning by age 14 and 75% by age 24. It also takes a huge financial toll on patients and the nation as a whole, with depression as the leading cause of disability worldwide. 

The rising rate of substance abuse further compounds the problems. In 2015, more than 21 million Americans ages 12 and older had a substance use disorder. 4.5 million had problems with drugs, but not alcohol and 14.4 million had problems with alcohol only. 

Many individuals need treatment but are not receiving it. In fact, a 2007 National Survey of Drug Use and Health (NSDUH) estimated that 20.8 million out of 23.2 million people needing treatment for drug or alcohol use did not receive it. 

Co-occurring mental illness and substance abuse is another serious factor. As many as 10 million adults have co-occurring mental health and substance abuse disorders. 

To meet the growing needs these problems have driven, AllMed has expanded its MedCert First-Level Pre-Authorization Medical Review Solution to include mental health and addiction. MedCert is designed  to provide physician review of suggested denials from utilization review and case management. It also provides the advantage of freeing up in-house Medical Director (MD) resources. By outsourcing routine or non-strategic processes Medical Directors are able to focus on strategic, value-added activities. 

A further benefit of using MedCert is the ability it extends to handle changing medical review caseloads and volume fluctuations. With MedCert, expenses associated with medical review activities become variable (based on caseload), instead of fixed. 

MedCert also allows for review of coverage and experimental and investigational procedures and treatments to determine whether clinical criteria have been met. Case requests are routed through PeerPoint's MedCert workflow. State-of-the art technology allows integration of MedCert into your clinical operations workflow. 

MedCert provides quick turnaround time with defensible determinations. It provides "Certify" or "Non-certify" determinations and an abbreviated rationale in electronic format that can easily be copied and pasted into your care management software. Electronic integration of PeerPoint MedCert with standard care management software is also possible for high-volume clients. 

With these advantages it is easy to see how AllMed's MedCert First-Level Pre-Authorization Medical Review Solution proves an advantage in dealing with mental health and substance abuse determinations. MedCert's expansion to behavioral/mental health will be a vital tool in meeting the growing number of these claims and ensuring the highest quality of patient care. 

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