Reimbursement and Funding
In a community (outpatient or residential) substance abuse treatment center, revenues may come from:
Client fees: do not account for a major portion of revenue but they are collected on a sliding-scale basis. Family size and income are taken into consideration in determining the client’s copayments
Private insurance: The insurance company is billed first, before any federal insurance is billed or any applicable sliding-scale copayment is determined
Medicaid: is relied upon heavily as a source of revenue
Other government funding sources
The Substance Abuse and Mental Health Services Administration (SAMHSA) agency administers the SAPT (substance abuse prevention and treatment) grants
Data and information flow steps (reflects the course of treatment provided to the clients)
Intake process: the collection of client information and determining the appropriate treatment.
Development treatment plan
Documentation of Discharge Summary
Development of continuing care plan
Coding and Classification
ICD-9-CM and CPT codes are used in substance abuse facilities
The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR): a 5 character coding system. It is a classification system and nomenclature of mental disorders developed by the American Psychiatric Association
Has a multiaxial system that involves an assessment on several axes, each of which refers to a different domain of information that may help the clinician plan treatment and predict outcome.
The AHIMA published the DSM-IV Crosswalk: Guidelines for Coding Mental Health Information which provides an easy-to-use tool for translating DSM-IV codes to the equivalent ICD-9-CM codes
Information Management continued
In 1988 Congress passed Public Law 100-690 which required the collection of data on the national incidence and prevalence of both mental illness and substance abuse; states had to be able to substantiate the need for federal block grant money.
The Substance Abuse and Mental Health Services Administration are the federal agencies charged with the administration of the data sets.
The three data sets are: the Treatment Episode Data Set (TEDS) and the National Survey of Substance Abuse Treatment Services (N-SSATS), and the National Facility Register (NFR).
Information Management continued
A substance abuse treatment unit within a progressive acute care hospital will benefit from the hospital-wide information systems that are in place.
A public community treatment program with limited funds may not have much in the way of computer development.
Quality Improvement (QI)
The type of QI assurance activities found within substance abuse facilities is often related to the level of care provided and whether the facility seeks JCAHO or CARF accreditation.
Some states have specific Medicaid standards that also address the need for an organized QI or quality assurance process.
A substance abuse unit within a JCAHO-accredited hospital would participate in the hospital-wide quality improvement program which includes activities such as continuous quality improvement (CQI) and outcomes assessment using critical pathways.
Public outpatient facilities may rely on periodic chart review to meet their quality objectives
It is important that facilities ensure that each client receives the level of care appropriate to his or her severity of illness; severity indexes and other treatment review instrument have been developed for evaluating treatment and utilization of services within the substance abuse treatment community.
The American Society of Addiction Medicine (ASAM) publishes a placement criteria manual that defines levels of care and the specific criteria that should be used in placing both adolescents and adult clients in the appropriate treatment setting.
The Addiction Severity Index (ASI) is another instrument; it is designed to be administered through an interview process by a trained technician to measure seven substance abuse-related problem areas
Risk Management and Legal Issues
Risk management is a four step process designed to identify, evaluate and resolve the actual and possible sources of loss. The 4 steps are: risk identification, risk evaluation, risk handling, and risk monitoring.
Confidentiality and Release of Information
Clients must know and feel that they will not be subject to a law enforcement investigation if they seek treatment
The Comprehensive Alcohol Abuse and Alcohol Prevention, Treatment and Rehabilitation Act of 1970 and The Drug Abuse and Treatment Act of 1972 guarantees confidentiality of patients.
Federal regulations known as 42 CFR Part 2 implemented the confidentiality statutes; and disclosure of any information concerning clients is strictly prohibited
Risk Management and Legal Issues continued…
DUI convictions, child abuse, possession of illegal drugs, sexual assault, and underage alcohol consumption are examples of court procedures that lead to court-ordered substance abuse treatments.
Involuntary Commitment: is a legal process by which individuals who are deemed to be a danger to themselves or to others may be admitted to a treatment program even though they refuse or cannot consent to the treatment.
Governed by state statutes
The person being committed must have a mental illness or mental disorder.
The Role of the Health Information Management Professional
The changing health care environment is increasing the need for substance abuse facilities to collect, analyze, and maintain timely and reliable client information.
Managed care organizations and other payers, including the federal government, want proof that their enrollee are receiving quality services at the lowest possible cost.
HIM opportunities are found in areas such as client record management, electronic client record systems, risk management, utilization management, quality improvement, release-of-information services, and client rights coordination.
One of the most challenging aspects for the health information manager working in substance abuse treatment is to be an advocate for client confidentiality.
Include the growth of programs for women, adolescent prevention programs, and treatment for the dually diagnosed. Substance abuse treatment centers are involved with an increasing number of Employee Assistance Programs (EAPS) and are also becoming more active in identifying needs of inmates in city or local jails.
Economic or funding trends
Are related to the changing health care environment and to the government’s continuing struggle to spend taxpayers’ dollars wisely. Also, the changing political and economic climate will affect the future of the delivery of substance abuse services.
The increase in the role of managed care organizations
The trend of multiple health care organizations building alliances and partnerships to develop integrated health delivery systems
One significant trend is the government’s increased emphasis on the need for data to substantiate the effectiveness of governemtn-funded programs.