February 2025: ROC Monthly Mastermind Call
Optimizing UR & LOS in Behavioral Health Treatment
Optimizing Utilization Review & Length of Stay in Behavioral Health Treatment
Using Metrics, Payor Knowledge, and Process Expertise
As providers, it’s crucial to empower your team and partners to navigate insurance challenges by teaching payors how to collaborate with your facility and training your staff to advocate effectively for your organization and patients.
Thank you to Linda Shulman, Director of Payor Relations and Advocacy at Hansei Solutions, for an insightful discussion on optimizing UR and LOS within your facility. She emphasized shifting from adversarial relationships with payors to collaborative partnerships, using metrics, payor knowledge, and process expertise to drive better patient outcomes.
View Recording:
Passcode: X5@O!WUZ
Key Takeaways:
Treat the treatment plan as a recipe for success. With the right strategies, providers can optimize reimbursement, improve patient care, and streamline operations.
We encourage you to listen to the recording (Passcode: X5@O!WUZ) for specific examples and case-by-case strategies to implement these approaches effectively.
🔹 Use Data & Metrics – Track LOS trends by payor, diagnosis, and ASAM/Locus scores to make evidence-based decisions on extensions.
🔹 Know Your Payors – Build relationships with care managers, understand approval patterns, and personalize communication to secure additional days.
🔹 Strengthen Documentation – Use detailed scoring systems and proactive appeals with new clinical data to improve approval rates.
🔹 Be Strategic with Appeals – Appeal denials with clear, compelling evidence, and escalate only when necessary to maintain credibility with payors.
🔹 Train Your Team – Ensure UR teams communicate trends and insights with clinical staff to align documentation with payor expectations. The more communication, the better.
Submitting Effective Appeals: Key Strategies
A strong appeal is more than just a request—it’s about presenting clear, compelling evidence that payors can’t ignore.
Essential Appeal Components:
✔ Claim number & demographics – Get the details right upfront on the documentation.
✔ State the reason clearly – Begin the appeal letter with a direct statement explaining why the appeal is being submitted.
✔ Highlight key points – Summarize critical facts and reference supporting documents.
✔ New information is key – Every appeal should include something not in the initial review. Ask questions that pretty much require an answer from them. By keeping the conversation going, you naturally keep the relationship consistent and trustworthy.
Example: "The ASAM/Locus score at the time of denial was [X], which meets the criteria for continued stay. Can you clarify how this was assessed differently?"
✔ Invite collaboration – End the letter with, “Please call us—we’re open to discussion to find the best solution for this client.” Yes, some may not call back, but a majority will if you stay persistent!
✔ Leverage pressure points – Expand on your passion to help the patient the best you can. Saying things like, “We would hate to escalate this to the state…” is a great way to prove for advocating efforts.
Strategic Approaches
📊 Score it – Use a tool to maintain accurate ASAM/Locus scores to support your case. We’ll be sending out a scoring template soon, so stay tuned!
🔍 Look through questions – Identify payor-specific criteria and trends in denials.
📄 Appeal templates – Have a structured format ready for consistency and efficiency.
🗣 Use impact buzzwords – Frame the argument around functionality and symptoms.
An example for RTC: “The client cannot function without 24-hour care due to severe emotional dysregulation, anxiety, and self-harm tendencies, which impair their ability to perform daily tasks and maintain safety.”
Member vs. Facility Appeals
When calling a payor, refer to the appeal as a member appeal rather than a facility appeal, as it carries more weight in the decision-making process. Whenever possible, involve the client or their family in submitting the appeal, as this increases the likelihood of receiving attention and approval.
Pro tip: Want a payor-specific appeal template? Use ChatGPT to generate one with payor criteria built in for a customized approach.
We encourage you to listen to the recording for real-life examples and case-by-case strategies to implement these techniques effectively!
If you have any additional questions or would like to suggest a topic you would like to learn more on for ROC, you can email us at roc@hanseisolutions.com.