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THE RELATIONSHIP BETWEEN CLAIM SUBMISSION AND ENGAGEMENT OF PEOPLE IN CHEMICAL DEPENDENCY TREATMENT
Do you treat individuals for alcohol and/or other drug dependence (AOD)?
If so, you know that it can be a challenge to get individuals who are alcohol or drug dependent to initiate treatment and to engage in that treatment. The National Committee for Quality Assurance defines Initiation and Engagement in treatment as follows:
• Initiation of AOD Treatment. The percentage of members who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of the diagnosis.
• Engagement of AOD Treatment. The percentage of members who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visit.
How successful has CIGNA and its network of behavioral healthcare professionals been in helping individuals with a diagnosis of AOD initiate and engage in treatment?
During the 2007 calendar year, 43.9% of individuals diagnosed with AOD initiated treatment and 23.5% engaged in treatment. These rates have not improved over the years.
What is CIGNA doing to help improve these rates?
As soon as CIGNA care management staff becomes aware that an individual has been diagnosed with AOD, they attempt to contact them or their providers to offer assistance in identifying and accessing additional resources. Unfortunately, the staff is often not aware that an individual has been diagnosed with AOD before the 14 day window for initiation has passed. This is a critical measure as the 30 day engagement measure is captured from the population identified as having initiated treatment.
Here is what frequently happens:
1. Individual goes directly to an outpatient therapist without calling CIGNA. The person is diagnosed during this visit (i.e. initiation).
2. Some time later (days, weeks, or even months later) the therapist submits a claim to CIGNA. The claim includes a diagnosis of AOD. The claim is mailed or submitted online.
3. CIGNA receives the claim.
4. CIGNA care management staff learns that the person was diagnosed with AOD.
5. CIGNA takes action. However, 14 days have passed since diagnosis and it is too late for the individual to meet the initiation measure. Therefore, the individual is not counted in the 30 day engagement measure.
What can you, the behavioral health care professional, do to help improve these rates?
• You can submit the claim as soon as possible. The sooner CIGNA care management staff know that an individual has been diagnosed with AOD, the sooner they can attempt to contact individuals or their providers to offer assistance in identifying and accessing additional resources.
• You can encourage the individual to make and keep 2 follow-up appointments for AOD treatment within 30 days of initial diagnosis.
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