title: Benefit determination under managed care for substance abuse treatment clients.
abstract: The purposes of this study were to examine the process of benefit determination, approval, and variation among Substance Abuse Treatment (SAT) clients. A convenience sample of 20 SAT clients admitted to 1 of 2 treatment programs within Matrix Center were followed. Clients of clinicians who agreed to participate were given an invitation letter to hear more about the study. After informed consent, clients granted 3 interviews and gave permission for the researcher to examine client records to ascertain the benefit determination process. Referral sources were the clients' insurances, their MDs, a counselor, hospital, Employee Assistance Program, case manager, and another treatment program. Ten of the insurances were PPOs, 9 were HMOs, and 1 was a contract. All but 2 had benefits managed by a behavioral care organization (MBCO). Case managers of the MBCOs were all clinicians, most frequently ACSWs. All programs authorized outpatient care and the first approval authorized from 6 to 52 visits. From 1 to 5 different authorizations were used for each client. The co-pay ranged from $0 to $35 per visit. This study illustrates the details of how benefits for substance abuse treatment under managed care are negotiated and used.
authors.affiliation: School of Nursing, University of California Los Angeles, Box 956917, Los Angeles, CA 90095-6917, USA.
authors.forename: D K
authors.initials: DK
authors.lastname: McNeese-Smith
authors.forename: M W
authors.initials: MW
authors.lastname: Crook
authors.forename: P
authors.initials: P
authors.lastname: Marinelli-Casey
authors.forename: L
authors.initials: L
authors.lastname: Williams
authors.forename: R
authors.initials: R
authors.lastname: Rawson
mesh_terms: D000293:Adolescent; D000328:Adult; D019090:Case Management; D003669:Deductibles and Coinsurance; D004608:Eligibility Determination; D005260:Female; D006302:Health Services Research; D006801:Humans; D019458:Insurance Coverage; D015141:Los Angeles; D008297:Male; D008329:Managed Care Programs / Q000191:economics*; D012017:Referral and Consultation; D016320:Substance Abuse Treatment Centers / Q000191:economics* / Q000706:statistics & numerical data; D019966:Substance-Related Disorders / Q000191:economics / Q000534:rehabilitation*