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TREATMENT RECORD REVIEWS: RESULTS FOR 2007
The Importance of Treatment Records
Well-documented treatment records facilitate communication, coordination and continuity of care and promote the efficiency and effectiveness of treatment. It is Cigna's policy that a participant record be established for each individual receiving mental health or substance abuse services through a contracted practitioner. Each participant’s record of care must also be confidentially maintained in a manner that is current, detailed and organized, and allow for quality review.
The Review Process
Treatment record-keeping practices of selected high-volume practitioners are monitored to ensure compliance with practitioner treatment record-keeping standards. A goal of 80 percent compliance has been established for each item and for the overall compliance score on the standardized 30 item Treatment Record Review Tool that is available for review in Appendix D of the Medical Management Program Guide. The tool is used by a staff reviewer, who has undergone inter-reviewer reliability training to learn how to use the tool , and has undergone auditing practices using five clinical records and two Employee Assistance Program (EAP) records (if applicable) from each practitioner selected for audit. Selection is based on a monthly report identifying practitioners due for re-credentialing in six months and the number of participants each practitioner treated in the prior 12 months. From this report, High Volume Practitioners are selected for review by Professional Relations Representatives. A High Volume Practitioner is defined as:
• Any physician who has seen 90 or more Health Solutions participants in the previous 12 months.
• Any Ph.D. psychologist who has seen 35 or more Health Solutions participants in the previous 12 months.
• Any master’s level therapist who has seen 30 or more Health Solutions participants in the previous 12 months.
The selected High Volume Practitioners will receive a letter requesting to send blinded records for the purpose of the audit
2007 Findings
Behavioral health practitioners achieved an overall compliance score of 92.2% for behavioral records and 90.8% for EAP records in 2007. Both of these scores exceeded the goal of 80%. In both 2006 and 2007, psychologists had the lowest scores on both the behavioral and EAP records, compared with other practitioners.
| Summary - Behavioral | 2006 | 2007 | | MD | PhD | MA | NP | Total | MD | PhD | MA | NP | Total | | Total # of practitioners reviewed | 57 | 40 | 78 | 9 | 184 | 30 | 36 | 75 | 21 | 162 | | Total # of charts reviewed | 285 | 200 | 388 | 45 | 918 | 144 | 168 | 347 | 105 | 765 | | Total # of practitioners with scores below 80% | 2 | 7 | 13 | 1 | 23 | 0 | 2 | 4 | 0 | 6 | | Percentage of practitioners with scores below 80% | 3.5% | 17.5% | 16.7% | 11.1% | 12.5% | 0.0% | 5.6% | 5.3% | 0.0% | 3.7% |
Nationally, the following three items on the behavioral treatment records failed to meet the 80 percent goal:
#27. For children and adolescents, prenatal and perinatal events, and a complete developmental history (physical, psychological, social, intellectual, academic, and substance abuse) are documented. (score: 76.6%)
#22. The record reflects attempts to coordinate behavioral care with the primary care physician at ANY time during treatment when coordination of care is indicated. (score: 72.3%)
#23. The record reflects attempts to coordinate behavioral care with other behavioral clinicians or institutions or ancillary providers as indicated at any time during treatment. (score: 72.0%)
| Summary - EAP | 2006 | 2007 | | PhD | MA | Total | PhD | MA | Total | | Total # of practitioners reviewed | 9 | 38 | 47 | 14 | 34 | 48 | | Total # of charts reviewed | 14 | 69 | 83 | 27 | 67 | 94 | | Total # of practitioners with scores below 80% | 6 | 11 | 17 | 3 | 3 | 6 | | Percentage of practitioners with scores below 80% | 66.7% | 28.9% | 36.2% | 21.4% | 8.8% | 12.5% |
Nationally, the following four items on the EAP treatment records failed to meet the 80% goal:
#15. Initial goals include timeframes (score: 72.3%)
#22. Coordinate BH care with PCP (score: 77.0%)
#23. Coordinate BH care with other BH practitioners (score: 75.0%)
#27. Child/Adol: Developmental History documented (score: 50.0%)
Significant improvements were also seen in the 2007 scores for coordination of care measures (with PCP and with other behavioral health practitioners). Interventions included:
1. Beginning January 1, 2007, the letter sent to practitioners informing them of the results of their treatment record review also included a statement about their score on the continuity and coordination of behavioral care item. The letter also encouraged practitioners to always coordinate care as appropriate.
2. A newsletter article in the First Quarter 2007 Cigna Practitioner Connection entitled “Primary Care Physician Communication” discussed requirements for the “exchange of clinical information between participating behavioral practitioners and PCPs.”
3. The Medical Management Program document (formerly known as CBH Provider Guide), available on the Cigna website, includes a description of the Cigna policy on Coordination of Behavioral Health and General Medical Care.
If a practitioner does not meet compliance requirements, notification in writing is made and evidence that the problem has been corrected within 90 days of the original review is requested. A second record review is performed for resolution of issues and the practitioner may be subject to a site visit. When a practitioner fails to score 80 percent on the second record review, additional corrective action may be required, up to and including suspension or termination from the network.
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