Overview
The philosophy at ValueOptions is to provide a care management system that offers easy and immediate access to the most appropriate, quality substance abuse services for members. In addition, ValueOptions has adopted a utilization management system that supports providers in delivering clinically necessary and effective care with minimal administrative barriers.
The utilization management program encompasses management of care from the point of entry through discharge. ValueOptions believes in macro-management of care as much as possible through the use of objective, standardized, widely-distributed clinical protocols and outlier management programs. Intensive utilization management is reserved for high-cost, highly restrictive levels of care and cases that represent clinical complexity and risk.
ValueOptions’ Clinical Case Managers (CCMs) base their review on clear and concise criteria developed by the American Society of Addiction Medicine PPC-2R and adopted by ValueOptions to guide level of care, treatment and length of stay determinations. CCMs are trained to match the needs of members to appropriate services, levels of care and community supports. This requires careful consideration of the intensity and severity of clinical data presented, with the goal of quality treatment in the least restrictive environment. The clinical integrity of the utilization management program ensures that members who present for care are appropriately monitored and that comprehensive reviews of all levels of care are provided. The documentation of the clinical criteria is placed in the Kansas Clinical Placement Criteria Screening Instrument (KCPC-SI) and forwarded to ValueOptions via the “Service Request/Authorization” Screen in the KCPC and submitting the information electronically over Citrix in the KCPC.
Those cases that appear to be outside of best practice guidelines are referred for specialized reviews. These may include evaluation for intensive care management, clinical rounds, Peer Advisor review or more frequent CCM review.
ValueOptions has designed a system of care that is based on principles of quality care, and one that maintains flexibility in meeting the needs of diverse populations, communities and customers. ValueOptions’ system:
- Provides easy and early access to appropriate treatment;
- Works collaboratively with providers in delivering quality care according to accepted best-practice standards;
- Addresses the needs of special populations, such as children and the elderly;
- Identifies common illnesses or trends of illness;
- Targets high-risk cases for intensive care management; and
- Emphasizes prevention, education and outreach.
Organizational Structure and Staff Accountability
ValueOptions places a high value on the selection, training and performance evaluation of clinical staff performing utilization management services. All staff involved in clinical care management activities holds terminal degrees and licensure in their field. ValueOptions’ physician Peer Advisors (PA) and Medical Directors are experienced, senior level clinicians, many of whom remain active in private practice. The majority are Board-certified in their specialty areas and are required to maintain a current knowledge of behavioral health research findings and nationally recognized practice guidelines. Licensed Clinical Psychologists provide peer reviews for psychological testing and outpatient treatment.
The clinical care management staff at our call centers is multidisciplinary and able to manage care in all general psychiatric, psychiatric subspecialty and substance abuse areas. ValueOptions requires that CCM’s be fully licensed mental health professionals with a minimum of three years prior clinical experience in a mental health/substance abuse setting providing direct member care. First-level reviews are generally conducted by nurses (RN or MSN), masters-level, or doctoral-prepared licensed behavioral healthcare clinicians. These clinicians complete all types of reviews for higher levels of care and complex outpatient reviews, including precertification, concurrent review, discharge planning and care management.
All providers are required to comply with the review process.