Options Health Care discovered firsthand that managed care can overmanage providers and bog them down with unnecessary paperwork.
Last year the Norfolk, Va.-based behavioral health managed-care company found that of the nearly 1,400 outpatient treatment reports from providers it reviewed each month, only a small percentage required case management.
"There has been a lot of shifting of paperwork to providers from managed-care (plans)," said Pete Biagioni, chief information officer at Options. "We were authorizing 10 (psychiatric) sessions to a provider (for each enrollee) and would require a report after every session."
However, none of Options' enrollees was using all 10 visits. In fact, the majority used only four to eight sessions, so there was no need for authorization forms to be filled out for all 10 visits. Plus, enrollees weren't trying to find ways to extend the benefit beyond 10 sessions.
"Nobody was misusing that benefit," said Nancy Grden, Options vice president of corporate communications. "So do we even have to manage that? We didn't think so."
The company didn't want to hassle providers whose time could be better spent caring for its enrollees than on paperwork. So during an all-day summit in September 1995, 30 Options representatives began developing a model for an interactive voice response system that would allow providers to use their own judgment in offering care.
"We looked at ways we could be substituting all of the paperwork," said Ellyn Saren, Options vice president of Norfolk operations.
Options' staff developed the interactive voice response system, known as CareFirst, in less than 21/2 months. Providers are guided by phone through the 24-hour interactive system to register patients, check enrollees' eligibility and benefits, and inquire about claims. The system became fully operational Dec. 1, 1995.
"Providers no longer have to call or fax us anything when they want an authorization, and they no longer have to submit an outpatient treatment report," Saren said.
Options expects to save more than $600,000 this year through CareFirst. The system has allowed the company to reallocate clinical resources toward care; reduce printing and mailing costs from authorization letters; and decrease the volume of calls needed to complete outpatient treatment reports.
The system cost $94,208 to implement, which includes software, hardware and design. Options, which has more than
5 million managed-care enrollees, anticipates 1996 revenues of $210 million.
Providers love the freedom the CareFirst system offers them, said Ronald Dozoretz, M.D., Options' chairman and chief executive officer. "We're not micro-managing our providers," he said. "We want our providers to do their job, and we don't want to interfere with their work."
In the future, Options hopes to have providers use the system to participate in outcomes research and patient satisfaction surveys.