Utilization management in a large managed behavioral health organization

Objective: The utilization management process of a managed behavioral healt h organization was examined to determine the frequency and types of reviews and the extent to which rationing of sen ice was achieved through the deni al of services. Methods: A case study of the utilization management program of a large managed behavioral health organization was done. Information na s gathered from claims for 1997, and utilization review data were drawn fro m 51 plans. Data were examined by review type and authorization actions. Re sults: The utilization management program performed a total of 9,639 review s. The most common type was concurrent review for additional outpatient the rapy visits (46 percent). The second most common type was concurrent facili ty review (12.9 percent). The vast majority of authorizations were approved at the level requested by the provider (91.8 per-cent). Very few Services were denied (.8 percent) or approved at a. level lower than requested by th e provider (1.3 percent). Conclusions although concerns have been raised ab out the high denial rates of utilization management programs, this study fo und very low denial rates. Further studies are needed to determine the prec ise mechanisms used in utilization management programs to control utilizati on. In addition, the large number of reviews raises questions about the tim e and opportunity costs of the review process.