After decades of working with a third-party vendor, Marlton, N.J.-based Virtua Health is bringing behavioral health intake and insurance authorization in house, with the new model set to go live in late January.
Russ Micoli, vice president of behavioral health services at the system, told Becker’s the decision was driven by persistent prior authorization challenges, limited transparency and denial risk tied to how behavioral health patients move through emergency, medical and psychiatric settings.
Virtua does not hold behavioral health patients in the emergency department for extended periods. Instead, when patients cannot be placed quickly — depending on emergency department volume and acuity — they are admitted to medical-surgical beds. These admissions are not reimbursed because the patient does not have a primary medical diagnosis, Mr. Micoli said.
Complications increase when patients later transfer from a medical unit to an inpatient psychiatric unit.
“To unsort and work with the insurance companies, ‘Yes, the patient was admitted Monday, but they were transferred today. We’ll cover this and this day we won’t’ was pretty messy and we were experiencing, at least for our stomachs, more denials than we needed.”
Many of those denials stemmed from a lack of prior authorization. Mr. Micoli said the system ultimately decided it needed to fully control the process for transparency purposes.
Bringing intake and insurance authorization in house required coordination across multiple departments, including behavioral health, outcomes management, revenue integrity and case management, he said. Under the new model, a director of the service oversees a dedicated intake team providing 24/7 coverage for patients entering through the emergency department or waiting on a medical unit for a psychiatric bed. The team manages the entire process, from prior authorization through bed placement and logistics.
Mr. Micoli said inefficiencies in the previous model affected both patient care and hospital costs.
“Regardless of where the patient waits, a couple of things happen,” he said. “One, most significantly, they’re not getting the level of care that they need. They’ll see a consulting psychiatrist, but they won’t be on a unit that has treatment to begin addressing their issues.”
At the same time, the hospital absorbs unreimbursed costs.
“And that bed on med-surg, we’re not going to get paid for we’re providing all of the services we would provide any patient in that bed. We’re going to reduce some of those extraneous costs by having a more efficient process.”
By bringing intake and insurance authorization in house, Virtua expects to reduce denials, improve throughput efficiency and better understand the true cost of caring for behavioral health patients across settings.
“Being able to get your hands on the data you need to appropriately manage your throughput is important. It is critically important to make sure that you’re being efficient,” Mr. Micoli said. “… Your cost data in terms of what is costing you to be able to manage that patient in the emergency room or on the general medical floor can help to incentivize.”
