Medicaid Managed Care - U.S. Senate Special Committee on Aging

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b) Utilization-Review Criteria
Utilization-munagement standards are required to be based on 'reasonable
scientific evidence.' However, it is also appropriate and, in the
public sector, often necessary that services be provided if they are considered
'best practice.' Waiting for the publication of 'reasonable scientific
evidence' can stifle the service system's capacity to provide the
most promising interventions.
NCQA does not require utilization-management criteria to be made
available to the payor or to the public, yet these criteria will determine
what services are provided to members, under what circumstances and
for how long.
c) rne'liness of Utilization Managemnent Decisions (LTM 4)
NCQA requires that the plan establish standards for timeliness of
its utilization-management decisionmaking. In the case of public systems,
the payor may wish to establish its own requirements as to what
those standards should be in (1) emergency. (2) urgent and (3) routine
situations.
d) Medical Necessity (UM 5)
NCQA requires that the plan 'consult' with the treating professional.
However, the role of treating professionals and the weight to-be
accorded their recommendations should be more clearly spelled out.
NCQA makes no references to the member's choice. Yet in determining
whether a service is necessary, a member's preferences should be
taken into account. This is particularly true if the member has rejected
one form of treatment but seeks an alternative that is also an effective intervention.
NCQAkappropriately makes no specifications in the accreditation
standards regarding what is an acceptable definition of ffledical necessity.
Public purchasers should insist on creating this standard themselves.
For more information on derisionmaking regarding when a servire is
medically necessary, see the Bazelon Center issue paper, Defining 'Medi-
cally Necessary' Services to Protect Plan Members (see resource list).
e) Utilization-Management System: Inceitixgs
NCQA standards do not address several areas of concern regarding
managed care plans' relationships with providers in their network,
through which the plans may encourage, or even force, practitioners to
NCQA Accreditation Standards for <strong>Managed</strong> Behavioral Healthcare Organiations 7
POLICY ANALYSIS BY THE BAZELON CENTER FOR MENTAL HEALTH LAW 7