On-Demand: Get More Days Approved

Joanna:

Welcome everyone. What Carrie Lynn and I are going to talk about today is how you can use patient data to get more days approved and attract more patients.

I'm Joanna Conti and I'm founder and CEO of both Vista Research Group and a nonprofit called Conquer Addiction. And I'm really here as much as a moderator. I am thrilled to have KerryLynn Baca join us. She has 15 years of experience negotiating with payers and just really honored to have her join us today. So, Carolyn, can you talk a little bit about your background? 

KerryLynn:

Hi there. Thank you for asking me to join in. I currently am a consultant and provide in-network services and contracting for providers but have come from an extensive background of working with a larger organization with over 120 facilities across the country as well as one currently in the state of Utah. And so I bring with that 15 plus years of experience in negotiating on contracts, payer relations, claims adjustments, and many other things.

Joanna:

Super. So, before we get started, I just wanted to make a little disclosure statement. We are going to be showing throughout this presentation examples that come from Vista Research's summary reports and data analytics platform and so forth. Please, this is being shared only as examples of the type of data that you may wish to collect yourself and use in your negotiations.

So, we're going to talk about one primary area today and that is how do you use patient data to negotiate effectively with payers. Carrie Lynn's going to talk a little bit about the importance of having real data for negotiations and then she's going to focus on how you might use that at multiple different points to negotiate more effectively. So first of course you need to negotiate with the payers when a patient first comes into treatment for as many days as you can justify and then separately applly once they their initial authorization period is almost up you'll need to negotiate in most cases for additional days. And then finally, a third type of negotiation that's also really important is how do you use patient data to negotiate to with a payer to accept your treatment program for in network status or preferred provider status or possibly to negotiate higher reimbursement rates or a pay-for-performance bonus. So that is going to be the bulk of our presentation today and then I'm going to talk about a separate use of your patient data and how you can use it to attract more patients including the all important cash pay patients that can add so much to your bottom line.

So KerryLynn take it away. 

KerryLynn:

Thank you. So I want to tell you that all research and out all outcomes that are used within the industry are great. It's important to have that supporting data. It really dramatically improves you building a case and putting together presenting the medical and clinical criteria needed for authorization for treating clients that are coming in with insurance and hopefully resulting in a in a longer initial authorization.

The independent third party data is valued much higher than it is if you do it internally. I personally have worked for organizations that have their they're large enough to have their own research and outcomes department inhouse and provide beautiful brochures with exceptional data and then I've come from the other side where I have used third-party data to initiate those outcomes and provide that research that's been taken and I can tell you from my experience that the independent third party data is valued at a much higher level than the ones that you have internally and that is basically because they know that you've had a third party review everything and produce that data and take it to a different level. And so if you're fortunate enough to be working with a third party company that actually produces your research and outcomes, you'll be able to really utilize that for many many things throughout the steps of becoming in network.

And negotiating at intake. The reason we use the word negotiating is because I know that you're seeking authorization and you're seeking to treat someone that has a specific insurance plan at intake. It is very much a negotiation from the day they walk in your door.

And your goal at that point is to seek authorization for five to seven days of initial authorization of residential treatment prior to negotiating a lower level or having to ask for additional days of stay. What's really important is for you to understand the payer's goals. And once you understand the payer's goals and what they have in mind, it helps you to pull together the information that you need to reach your goal. And their goal is basically to justify the fewest number of days of treatment at the lowest possible level of care, minimizing the cost that they're spending to treat their members that are in treatment.

Joanna:

I find it just kind of upsetting as you know the parent of a child who needed residential treatment for her substance use disorder that you know that that payers start with saying you know 5 to 7 days and I guess sometimes they even authorize less than that because I can't imagine even in 5 to 7 days that a patient has recovered to the point that they could possibly be ready to drop down to a lower level.

KerryLynn:

It's very true. And unfortunately, when you're seeking that initial authorization, a lot of times it's coming from one care manager or UR manager at the very beginning. And they're likely going to authorize you for one to three days. And in order to get the extra five to seven for your initial authorization before this is case is turned over to a case manager that will follow it throughout that level of care and treatment. You've got to develop a strong enough case and basically build a story to present in order to reach your goal. Again, it's understanding the insurance payer's goal, which is to spend as little money as possible on bringing them to that point of recovery or what they think is recovery.

And so this process begins as we said right upon intake or prior to intake if you know that you've run a verification of benefits and a person's plan requires it a  true pre-op which is prior to them attending and coming to your program. And you're going to get a brief story from them over the phone with an assessment. You're going to track that information. And here we have a short story that gives you an idea of just a real quick and dirty on what this patient has gone through recently.

And so what's important in comparison here is you've got this short story that explains to you that someone  came to treatment, they were dropped off by a parent, they had quite a bit of drug usage and things  went on here within this particular story. As you'll notice, they’ve been arrested. They're willing to try treatment, but they've had a rough time and they're just not they're just not really playing well. And so, what the payer wants to know from you is they want to know the addiction severity. They want to know what co-occurring disorders this person may have already been diagnosed with. 

They want to know why the level of care that you're requesting is medically necessary. Before they even discuss to you the clinical need, the medical necessity is what really hits them hard in the beginning. Your drug of choice and frequency of that self-harming and suicidal ideation, excuse me. Those have become a hot topic currently within the industry right now because of this pandemic and then wanting to make sure that suicide prevention is being addressed.

And of course, then you've got the last day of use. 

Joanna:

So how do you answer those questions if that's all you know?

KerryLynn:

The best way for me to do this is by having the member, client, or patient, whichever whichever side of the street you're standing on, take an assessment and over either beginning with it online where they can actually fill out a questionnaire.

Your over the phone assessments will also serve as that as well, but it's always better to have the member client patient engaging in their own treatment. Outcomes will show that those that are invested in learning how to self- advocate for themselves are much more successful in their recovery.

And this is just the first step is by giving them a questionnaire to fill out that answers the questions of what brought them to treatment. What happened? You want a story around this.

You want to know what brought them into you. The next thing you want to know is what their primary drug of choice and their usage history is. This actually tells a lot about the person, where they've been, what's been going on, and what possible next steps are going to be for them if the intervention isn't successful.

Self-harming and suicidal ideation is really important. There's a lot of people out there that use this as a way out of dealing with the situations that they're in or relieving themselves of pain, self-harming, and the other is screenings for likely co-occurring disorders.

The reason this is so important is that in this survey that they fill out or intake questionnaire, you may not likely get to the bottom of if they haven't had a diagnosis for a co-occurring disorder. How do you find out if there truly is one? And that is just by doing this type of assessment, asking these questions so that you can then give this to the doctor that is going to be overseeing their treatment.

And what we may find is that if they didn't have a co-occurring disorder, we may find that there is one. 

Also, the quality of life, where they're living, whether they're working, relationships, just basic things about that quality of life. Are they staying indoors all day? Are they out meeting with people? Do they grocery shop? Are they able to get out? Are they in all the time? Those all also speak to the state of mind and the clinical side of where this client is. Also, any underlying physical health issues. As we all know, it's almost impossible for someone to have a substance abuse disorder without having some physical health issue.

The substance abuse itself lends to having your body do many number of things. And so we want to find out what those underlying physical health issues are.

And that will help us to determine how extreme they are or if they're in a position where they're at the next level of it getting worse.

The last piece of this is the basic demographics which is who they are, how old they are, male or female or whatever gender they identify with.

Whether they're single or married or in a relationship, do they have a family? Are they disconnected from family? Do they have friends? Do they have co-workers if they work? And just basically their academic information as well. Have they gone to school? That type of thing. It helps us to paint a picture of where they're at today or maybe where they were and why they're where they at today. Yeah. Which is even more important.

And so in negotiating and going through these things and speaking to them at intake, you're going to take this summary or basically questionnaire that they're going to be filling out and you're going to take the information from this and right here is an example of the drug usage. You'll see that this particular member is addicted to methamphetamines usage 30 days prior. They've done four or more times a day. They're injecting it, the last day used. It gives you all of that information in here and how long it's been going on.

 So, they're reporting they've been doing this for twelve to seven months. The addiction is severe. They've experienced some things, and this is all going to be noted in this questionnaire. 

It looks as though this one's also been on MAT, which is the medicated assisted treatment, and it speaks to what they've been on. And you're able to take this information from here and begin to build upon the story of who this person is and what they're actually experiencing.

Joanna:

One of the things you had mentioned to me in the past is how important the last day used is. Why is that so important to the insurance companies? 

KerryLynn:

The last day used actually shows how actively they're engaged in it and particularly that they're using now and at this time. And so the last day used was an hour ago or four hours ago or yesterday and they're seeking treatment. They're actively in the depths of this addiction and yet they're in a place where they're seeking recovery or the family has intervened and is pushing them to recovery. 

Whatever's gotten them to this point. But many times you'll note that they are all actively using within 24 hours of admission.

Joanna:

Wow.

KerryLynn:

The other item is in this is they'll report as we noted on the previous page that they reported the use of methamphetamines.

But we didn't break it down for them.

And so here on this questionnaire we're actually breaking it down so they've got a box to check. We noticed that they've been heavily using heroin in addition to the methamphetamines within the last 30 days. Prior to that, they've also used or in that time period, excuse me, they have also been using other drugs of choice. And you can go down this list and see what their actually is that they have been participating in.

Joanna:

Pretty much everything. 

KerryLynn:

It looks like they've used just about everything in there and some that they've used not within the 30 days of treatment show that they've used them in the past.

And so you can actually take a look at this and build upon this that that they started out with alcohol and base it on some of the things that they tried, the inhalants and stimulants and then from there within the 30 days after using the multitude of these other drugs they've moved over to more and then from there you can see that they've moved into where they're really using heavily the heroin and methamphetamines.

And so that is really important for the insurance companies to know that because that shows the depth and helps you build that story that I keep talking about that you're going to portray for that initial authorization.

The next is their demographics. These demographics again will show their age, gender, marital status, ethnicity, education. Educational attainment is I always find this to be very interesting because we do you do hear people speaking those that are using and that they're not as maybe not as educated as those that are out in the world working. And what you don't realize is it doesn't matter what your education is. Doesn't matter what your walk of life is. It doesn't matter. Everyone at any time has experienced this. What's important is that you know that they've been through this and chances are if they've got a degree, they've been working in the a corporate world, they're dealing with stress possibly in a different way, using substances. All of this is really important. And so you want to take every bit of this information where they've been living, how they've been living, and within the last year, what are the major things that have happened? And so they've been charged with a serious crime.  They spent jail time, yes. Caused an accident while driving, no. But knowing that they've had these other areas also have impacted their life, they're spiraling downhill.

One of the disclaimers I want to give to you is I want to just cover this because within the past year, this particular John Doe or Jane Smith as we're calling her looks as though she's been charged with a serious criminal justice-related offense. She has spent time in jail.

Although we view these as really important and devastating experiences to have in life, the insurance company does not.

And their concern is more of a medical and clinical level. They want to spend as little time as possible. And in their eyes, if somebody spent time in jail, they've spent time detoxing for free.

Joanna:

Hahaha Goodness. 

KerryLynn:

And so it's important that you understand that and you know that. And so when you gather your data from these questionnaires, you want to put together the highest amount of information based on the medical and clinical side of the story that you're telling to that person, bringing them in for that initial authorization.

Their health status, physical health, emotional health. These are all very important factors as well. They paint a picture of who this is.

They're in poor emotional health, which we don't question after seeing the previous, you know, parts of the questionnaire.

Their physical health is fair, which says that there's a lot of things going on within their body, and it's probably attributed to the substance use and what they're doing. This particular case, if you'll notice, the chronic condition on here is asthma and that chronic pain is moderate. And then you go down and it says tobacco use,  moderate. They're smoking between five to 20 cigarettes a day or it's equivalent. And right there, the thing that grabbed me when I first saw this is it felt kind of conflicting, but of course they've got chronic asthma and they're smoking that much a day, Their addiction is the tobacco use and the nicotine and it's an addiction nonetheless. And although they're not treated in a residential setting for that type of addiction, it's not held to the regard of course as the severity of this other substances. However, it's a gateway into the other areas and the other drugs that are being used. And this particular client has been to the emergency room two or more times during this year.

That is an expense to the insurance companies. The unplanned hospital admissions there are none. So they haven't gone in and had anything done in the hospital other than something that's been emergent in nature which tells you that they've gone in because something has happened and it's you know I'm sure due to the substance use that they're experiencing.

And then on the other side of this, this shows that they have not met with their primary care physician or a medical professional to discuss their overall health. So, they're really not taking care of themselves.

And so, by getting them in treatment, they're going through that whole process of the doctor coming in and doing his assessment, the clinicians coming in doing their assessments, and they're going to get down to the nitty-gritty and what's going on. And your side of this is to build that story upon all of this information that you're gathering. 

Joanna:

It's interesting that somebody with asthma is smoking.

KerryLynn:

It is, but you'd be surprised that I mean that is it's A-typical it's sometimes it's self-medicating. There's something else going on and they're solving a problem by using something else and then before they know it they're addicted and here we go, we start this process. So, the insurance company wants to minimize the amount of money they're spending on this client. and if they can get them in treatment to help with the addictions, not only are they helping with the addiction itself, but as you can see, this particular client is likely going to be seen less in the emergency room and possibly increase their overall health by going to the doctor on a regular basis. 

One of the other ways that the data that's collected during these questionnaires is they're taken and put into a graph form. And I like graphs myself. I like being able to use them. A lot of times if I'm working on a case and having a discussion with an insurance company, I don't have the time to sit down and read and summarize the entire summary that's been put together. And both your doctors and your clinicians counselors are great for writing all of those things down, but in order to cover everything, they're a lot more detail oriented. And so for me to be able to use a graph like this, which shows within 30 days of admitting where their depression symptoms are at. And so this this bar graph here will show you where their depression levels were at. They're, you know, they're midway through the severity piece of it. They're not close to moderate at all.  They're also exhibiting anxiety symptoms, which you'll see in the graph to the right. Again, it's within the 30 days, and it's showing you just where they are.  They've had trauma symptoms and they've also may have had this particular client is off the charts. They've actually thought about killing themselves and planned their suicide and had it ready to go.

Joanna:

In the 30 days before they came to treatment, huh.? 

KerryLynn:

Yes. And so this is what they were doing within those 30 days prior to coming to you and filling this out. So you're able you're able to gather this information from them and again you're the mouthpiece for this person that's in treatment and you're advocating on their behalf for them to be treated. And so it the reason this is so important is it breaks this down into the depression and anxiety and trauma symptoms, but then it also shows where they're at with their suicidal ideations, and really important for that to be portrayed.

 Joanna:

And it could be that part of the reason they're using so many different drugs and stuff is to self-medicate against the trauma and the depression and the anxiety they feel.

KerryLynn:

And that's really what we found. Anytime you've got someone that's been through a traumatic situation, they are trying to figure out how to work their way through it. And self-medicating is one of the ways they begin to do that. And a lot of times it'll start out as we saw in the graph before that. It starts out with a real minimal step into something and then the drugs don't cut it anymore. They're into the next and into the next until they're severity is much higher.

The other piece of this is their physical withdrawal symptoms and emotional withdrawal symptoms which these will take place while they're in a detox situation and very important to note where those are at. Detox is one of the levels of care that is often shortened by insurance companies feeling that they can put them into residential treatment and they're still going to be in a safe place. And so in order to keep someone in the detox level of care for the length of time that you feel is necessary you know to basically be safe and transitioning down. It's important to utilize graphs like this that will actually show you where they are at. In those right now this person is right smack in the middle of the severity for physical withdrawal and they're still very high up there with their emotional withdrawal. And so, for an insurance company to suggest that they've already been in detox for 5 days, it's time for you to us to step them down. You can use this data to help argue that on their behalf and maybe get a few more days. 

Okay. And the next is negotiating additional days. So once you've once you've been given your initial authorization, that is usually granted from a case manager who then will turn it over to a permanent case manager. That first person isn't likely the one that's going to follow your case through. So, remember as much of a story as you told the first time, you will be doing that again with the care manager.

But this time this care manager is invested in the treatment and their entire length of stay at that level of care. And so, what's important is to have this information again used as you did before and remembering that your goal is to get authorization for as many days of additional treatment as the patient needs at the level of care to quickly and fully recover.

The reason I say quickly and fully is because the insurance company's goal is to justify the fewest number of days of treatment at the lowest possible level of care. Again, minimizing their expense to treat their member. And so for you, you want to let them know that you're willing to step them down as soon as they are stable and ready for that lower level of care. But in order to fully recover at that level and not prematurely step down or discharge if it's a lower level of care, you want to maintain the story and build upon it throughout their treatment. And these questionnaires are not only done when they when they're ready to come in for treatment, but they're also done throughout their treatment stay while they're there. 

It becomes part of their treatment plan is to fill out their questionnaires and assessments because it helps gauge where they are. And it's important that the therapists that are involved in their treatment and the doctors and nurses that are involved in their treatment are also aware of what they're filling out in these questionnaires because this helps build upon their individual treatment plan. It helps make changes in the treatment plan. If you're heading to the left road and you find that there's something on the side of that road that's not going to be helpful to their treatment, you may have to exit on the right instead. 

And you won't know that if you're not gathering information throughout their treatment.

And so here this shows the physical withdrawal symptoms and emotional withdrawal symptoms. Again, the patient is still having substantial withdrawal symptoms and what the payer is likely trying to do is step them down to residential prematurely. And in here you can see that they improved after a couple of days, but then it came back up again, which is typical in treatment. The same thing showed a change. However, the emotional withdrawal symptoms went up before it came down, which does happen. Our bodies all handle things very differently. The main part of this is to explain that there is a variation. There is change. We're seeing the body and mind go through things. However, they're now making some progress. And this is what you'll want to use this for.

In this particular part of the questionnaire, you're following up on the symptoms for the withdrawal and they're still having these substantial, you know, symptoms as we showed in the slide previous, but this actually breaks it down even deeper. So you're able to see what those extreme symptoms are that they're having. And you can use this while having that conversation or sending over whether it's a fax. Sometimes you're sending over a fax for this. I realize you're not speaking to an actual care manager. If you are able to get a live review, this is where you're able to put the dialogue around it. If you're not, this is where you can take this information and report it in the facts as you send it over that this patient reported still having the chills, still sweating profusely.  a feeling of hopelessness, they're still very fatigued.  they're cramping.  they've got other physical symptoms. And this actually explains a lot to the care manager.

Another way to look at this is as you're gathering this information from these graphs and you're also gathering the information from the client is to remember that the insurance company hasn't seen this person. The only way that they know what this person's history is or what is being reported is through the comments that are made in their medical records through you or from previous doctors and clinical workers. And so having the data in front of you to help build upon this story, it is extremely helpful. And I have to say when I first started doing this years and years ago, people were not doing this. We did not have research and outcomes.  You were just a face-to-face assessment most of the time before we got to the point where we are today. And so fast forward to today, this has made my job so much easier as a contract negotiator within major insurance companies as well as advocating for single case agreements for clients when they come through is to have this information. And I used to sit for hours and read medical records and charts before I called an insurance company. And so having something like this minimizes your cost as a facility or a program because you're able to provide this detailed information to those that need it and can present it and put the actual story together. And so, it's been a great it's not only been a timesaver for me, it's been a cost saver, but it's also taken me quite a bit further in the process with the insurance companies.

This again is going to show your depression and symptoms. You've got two types of measurements here that you could actually see. And this is really important because it still shows they're still struggling with co-occurring disorders.

And the co-occurring disorders are as important as the primary diagnosis coming in. So, someone may step through the door and you're looking at that primary diagnosis, but this ary or continued co-occurring disorder and the symptoms that they're feeling are as relevant.

So, make sure that you gather as much of this as possible.

Joanna:

Would the payer be more concerned about the depression or the suicidal thoughts or together or what would you think? 

KerryLynn:

I think they're both very valid and important and it depends on what the diagnosis is what where their depression or severe depression takes them. However, when you've got suicidal ideation and you can actually see them putting things in motion, that's when it becomes very emergent. And so, they're obviously going to be more concerned about them acting out and succeeding with that, but the other actually shows why they're acting out. And so, you've got to take both of them into account.

And then many programs are out of network which is something that we've typically seen historically.  It's been a lot easier to work out of network with payers than it has been to go in network with all the restrictions, guidelines, rules, and just everything that comes with it. 

And so, when you're negotiating for in network or preferred status or even higher reimbursement rates if you are already a provider this information is really helpful.

And so, when negotiating for preferred status, your goal is to be able to show your program differentiators that put your cent's treatment as to none and provide payers a reduction in cost by sending their members to your facility. And that is why you feel that your organization is superior, and you can use these the research and the outcomes to drive home the point that you're doing things that are different and above what a typical treatment center would be doing.

 And by following those steps, keeping your clients in at the levels of care as long as they're medically and clinically meet that criteria and not discharging or stepping down prematurely helps with that recidivism rate. And anytime that you are seeing someone through recovery from detox through outpatient, you know, there's going they have a much higher percentage of being successful in their recovery. Maintaining it for a longer period of time, if not hopefully really for good. And the payer's goal in this is to provide adequate care at the lowest possible cost. 

So, you're going to attract employer groups. you're going to attract smaller TPAs that want to come into their networks because they can't afford to be in a in a pool because of the cost that's associated with it. So, the payer's goal is to actually attract these groups, provide them with adequate care, and spend as little money as possible. And so, on your side, as we explained it again, the goal is to show how much less it costs to come to a program such as yours because you've got these differentiators in place. 

And they do make they do make a big difference.

The solution to this is using the patient data to show that you have world-class treatment versus the industry norms. And so as we all know you know there are averages and industry norms you know across the country and overseas.

We view them and see them and realize that they're there but how do we exceed them? Well, by using the research and data that you gather, you're able to take those outcomes and actually make changes to your program that will benefit your program, benefit the clients, show that they've successfully completed this recovery.

And so, putting this together, you're able to see the graphs here, which we've got the norms on the right, and then we've got a fake organization here on the left, which is showing that they've got a 76% success rate in people making it through the entire program and versus the average norm on the other side of the 60%. And so, you can take this information and use that and explain it to the insurance companies. And once they've had this to look at, they're able to see that that will reduce their cost overall. And that's how you become a preferred provider.

And also, a great reason to ask for an increase if you've already got a contract in place.

And here is another graph showing the research norms and the fake Apollo recovery on the other side. And what you'll see here is these are the co-occurring disorders. And it's showing you how they've improved. So the fake company over here on the left has got a 68% of the clients took this. And you'll see that when they did this, they came in, the clients that we tested came in at 68% and this is where they were of the initial survey.

Joanna:

I'm sorry that's 68% of the patients were reporting moderate or severe anxiety at intake?

KerryLynn:

Yeah. And then once they completed the last treatment episode survey showed that those same symptoms had decreased to 9%.

Joanna:

So only 9% of the patients So yeah 68% had a problem with anxiety moderate or severe anxiety before at intake and then it dropped to only 9% of the patients by the time they left treatment? That sounds really good. 

KerryLynn:

It does. And then you compare it to the industry norms, and we were very close on the percentage that came with and exhibited these symptoms. But where you'll see the difference is on the last day of treatment or at the end of the treatment episode.  We've got a five, you know, 5% difference here from the norm to the company that actually used the data.

Joanna:

Yeah. So what you can see is they actually had a higher percentage of their patients reporting moderate or severe anxiety intake at the fake center than the norm. And yet by the time they left they had a substantially lower percentage. So, they were clearly doing a really good job anxiety. Yeah. Yeah.

KerryLynn:

And here we're shown the satisfaction survey. So, the clients have continued to fill out these and surveys and were able to see that the very satisfied client that went through treatment was at a 76% versus the 68% on the norms. And so, it's really important that your patient, you know, the client himself be satisfied with the treatment. If they're satisfied and in treatment, they're going to be much more successful in their recovery, which means it equates to a longer period of time where they are still in recovery. And so, this to me is extremely valuable.

Joanna:

Do you think the insurance companies pay a lot of attention to patient satisfaction? 

KerryLynn:

They do. The insurance companies send out questionnaires.

I'm sure that you've gotten them as, you know, a member having insurance. They always want to know how they're doing. What's happening with the centers they've been sent to or referred to for treatment and patient satisfaction is extremely valuable. It's marketing for them.  If you're not happy with what they're providing, authorizing, and producing, you're going to go to a different insurance company.

And right now, we've been able to see this last year we've got major insurance companies stepping one on top of the other just kind of trying to get ahead. So, they're the biggest in the industry. 

Joanna:

Yeah. There's been a tremendous amount of consolidation. Holy cow. 

KerryLynn: 

There really has. 

Joanna:

I don't think that's going to help bring our insurance rates down.

KerryLynn:

I'm afraid not. We can only hope for something like that, right? The other piece of this post treatment outcomes is staying in touch with the clients post treatment. And I know that there are other providers many providers are out there doing this. Everyone wants to know how their clients are after they've left treatment. And it's often difficult to get them on the phone to talk to them after they've been in treatment or to get them to participate in something when you're calling them. If you've got someone behind you collecting this data it's really really helpful because this is what we turn over to the insurance company and post treatment what we can show here is the patients are reporting no drug usage or alcohol usage you can see one month after recovery six months after recovery and twelve months after recovery and so you're able to compare those with the norm and as you'll notice here. There is an increase in each of these and that is extremely important which is a huge cost savings to an insurance company and just very valuable information for you.  This is broken down in two areas as well so you can see those that have been absent from it and where that was. 

Joanna:

Yeah. So that's the percent who've been abstinent in the last 30 days at least. The top number and the bottom I guess the dark green is those who've been absent since treatment. So, they said they never used and then the light green is they did relapse but they were able to regain active recovery. So yeah, I would think that that is comparing that to norms I would think would be very useful.

KerryLynn:

And so this here shows a projected medical savings. This unfortunately is what the insurance companies need and want to know. And in order for you to become a preferred provider within their network and to actually increase your per diem rate with them once you've already obtained a contract, you have to show continued growth and change and evolvement. 

And again, we mentioned the awful part of cost savings because that is what matters to the insurance companies. It matters to all businesses that we're minimizing our expenses, but insurance companies are just trying to find ways to save all the time. So, if you can provide them with an analytic review of how their ER visits at intake were versus twelve months after follow up, you're showing an actual deduction in cost savings on their end as well as unplanned hospital stays, their detox treatments, and mind you, people go in and out of detox without going fully into a residential program and they try to maintain and so you can see how often they've tried to do it that way and then versus a residential treatment and the 12-month follow up. 

Joanna:

So, I guess you try and make the case that if 54% of their patients went to the ER at least once in the year before they started treatment and that had dropped to only 21% in the year since they left treatment that this savings right here is a direct result of your treatment? 

Yes. And therefore, do you compare this savings to the total cost of your treatment? Can you do that or you just have to, you know, just estimate? 

KerryLynn:

I think you're doing an estimate on what that is.  They can take this information, and you can actually take these and you know, copy these and send these on to an analytic team. One of the one of the changes I know that Joanna and I had been talking about recently in the industry is that when you previously I started doing this back in the old days when you reached out to a payer and wanted to become a network provider and you had a great discussion about your program. They sent you paperwork, you filled out the credentialing forms and off you went and then you negotiated a fair rate and you were done. And in the last year and a half, there's been a huge change in flow with the major insurance companies. And when I say major, I'm talking about your Etna, your UHC, Sigma, the Blues, Anthems, people like that where they're taking the information, you submit initially a form with your tax ID number on it, and they're actually running an entire analytic review of your tax ID internally.

And they take that information and they start with claims. What claims have you submitted?  How many were denied? How many medical records have been pulled?

What is the clinical side of these clients and their medical records? And they actually pull this information, stick it in a machine that spits out this analytic data and they determine whether they want you in in their network or not based on what the outcome of that analytic review is. And so having worked with multiple providers over the years, I've seen where those have proven to be great and you're able to get the highest rate at in that market share area and then I've seen it backfired to the point where well we really aren't interested in having you as a provider and this is why and so having data like this helps you in that discussion. If an insurance company says we have a closed network, but your program has differentiators that are so different from others that they already have. If you can prove that you have something that is that much different, you may be able to open the door on a closed network because your program is different and you're able to explain how it is.

So these measurements here are very helpful. 

And then again, this is access to care. We know that insurance companies are all very interested in in providing the quickest amount of access to care for their clients as possible.  

This is a brief rundown of what, you know, what the average is and could be. And it's important to know that from the time they've reached out and they've gotten in the door, what is it? What's it taking to get them in treatment? 

Joanna:

Those numbers look really good. 

KerryLynn:

Yeah. Well, they, you know, they don't want their members calling and then finding out, oh, we've got a member coming to talk to you and they're they want to admit and it taking a week or two to get into a program. When someone's ready for treatment within the behavioral health side of business, they're past due needing to be in treatment, You know, so you can always you can always count on that. So, you want to make sure that your access to their care is at this type of a percentage. 

Joanna:

Okay. Excellent. Any last thoughts before I talk about how you can use patient data to attract more patients? 

KerryLynn:

I just want to I guess I want to overall I know that becoming a network provider is it's like eating a whole elephant at one time. It's just not something you can do. And so taking it step by step and bit by bit, you can obtain and build relationships with the payers in a positive way by seeking to obtain the research, by doing the questionnaires, by doing all of these things by tracking the clients that are coming through, producing an outcome and following that outcome and using it to better the treatment for the member, you are helping to build a relationship with that payer. And the relationships I have with payers to me are just at the top of my list. Those people there are there to help. And if you've got that relationship established and you begin establishing it from actual data, your relationship is going to be much stronger.

And the trust then that you have between each other is going to be even greater.

And that is what equates to being able to advocate for these members and clients as they come into your programs. And then from there, being able to carry that relationship once you've started treating them and established that you want to become a provider and moving through raising yourself to the preferred status and maintaining that throughout your contract with them.

Joanna:

I had one question. What do you do when you have a patient coming into your treatment center and your treatment center is not in network with their insurance company? Do you just have to turn them away?

KerryLynn: 

You know, I've seen providers do several things. Of course, all providers have a cash pay private contract you can enter into, but what most members don't realize is that their out-of-network benefits will allow them to be treated anywhere they choose.

The problem with utilizing some of those out of network benefits is that your out-of-pocket expense is much higher.

And when someone is suffering and in treatment or their family is helping to fund treatment, that is just really something large and stressful to add on top of the recovery itself. And so, I am always sending members to their insurance companies to ask for a member advocate, to get a member advocate on their side to help them through this process and to have them initiate the use of what is called a single case agreement. A single case agreement is known as an SEA through some of the insurance companies, an LOA through others, or an ad hoc through the others, but they're all three one and one and the same, which is a single contract to authorize your treatment at an in-network benefit level. And so, you have someone that will go in and negotiate an in-network rate for that level of care. And sometimes when you're lucky, you can actually negotiate all three levels of care at one time and have them covered. But it's a one-time contract. And it's something that I do on a regular basis. I have done hundreds, if not thousands of them for members in the past. and it just helps to minimize their out-of- pocket expense during that difficult time.

Jonna:

What's most useful in terms of getting the insurance company to agree to what did you call a single case agreement? 

KerryLynn:

A single case agreement or an SDA.  it's very helpful to have the member advocate on their own side by asking for a member advocate and then to have the provider themselves during the initial UR request that single case agreement and it has to be authorized at the time of intake in order for it to be valid with most insurance companies and then from there it is turned over to somebody who does the contracts and negotiations for you on your behalf to actually read them and sign and execute them and negotiate those rates and terms.

Joanna:

I've never heard of a member advocate at an insurance company. What do they do and how does that work?  

KerryLynn:

A member advocate is usually paid for by a county or city or another organization. So, they're not employed by the insurance company.

Sometimes a hospital will have them on staff. They're the equivalent to a social worker. When the county is assigned social workers to cases, a lot of times they become the members advocate. Within the doctor's office or the insurance company, that membership department should have a member advocate that is actually working to help you through anything you need as a member.

So they're a third party with no interest in either side is basically what they are. 

Joanna:

And are they often effective breaking through any log jam?

KerryLynn:

They're one of the things that they do is they actually provide that self-advocation that you need when you're in recovery or for a family to take a step back and start fighting for themselves.

And so the positive result is that the secondary piece is you either find out right in the beginning if you use one and I'd say you've got a 50/50 shot at that point of where excuse me of where the SDA is either going to be approved or denied. And so, sometimes you will get an insurance, your plan will say if you have out of network benefits, you cannot use in network benefits. So, if your plan specifies that language, they're not able to give that to you. But you're more likely to get that authorized if you don't have out of network benefits and you need that treatment. 

And so the job of the UR or the contract negotiator is to go in and actually establish a reason why you need it. And so the data you pull from these reports that we just went through is exactly what I've used to advocate for single case agreements and get them authorized.

Joanna:

Perfect. Carrie Lynn, I can't thank you enough for sharing all of your years of expertise here. Don't forget to people who are watching this, please type in your questions in the chat because we're going to have plenty of time to answer them afterwards. So, please, this is your opportunity to ask Carrie Lynn any of those questions that have been bothering you for  days or years or whatever. So, we're going to stop talking about the payer side for a minute and I'm going to start talking about a separate way you can use patient data and that is to use your patient data to attract more patients. So, what we found and I will say that I came into this interest in addiction treatment because I had a daughter who had a serious alcohol addiction and so I'm I started my journey providing research to addiction treatment facilities from the standpoint of a family who was very frustrated by the challenges of finding treatment that we could be confident was effective.

So, what we've heard from admissions counselors is that there are two primary questions that patients and their families searching for treatment really want the answer to. The first is how much is it going to cost? And the second is what is your success rate?

And the challenge in this industry is that very few treatment centers were doing any kind of post treatment outcomes research 5 years ago and there's still it's still a small percentage of treatment centers that are doing this type of research to prove how effective they are. And so, until recently there hasn't been any type of agreement on what how do you have to do this type of outcomes research so that you can compare outcomes research that's done by you know one outcomes company or another or an internal research department. So, I am thrilled that one of the things that the nonprofit that my daughter who was the original start of this whole process who's now succeeded in being sober for seven and a half years, she and I have launched an organization called Conquer Addiction that helps families find the treatment centers with the best proven outcomes. And as part of that, we asked a number of true experts in true academic experts in addiction treatment and outcomes research to develop a set of standards that would be could be used to compare the outcomes research that is conducted by different organizations or the centers themselves. And there is now I'm thrilled to report actually a standard of this is how you can this is how you should be doing outcomes research and this is what the results mean. So, what they've required what the judges have come together is to make a couple of requirements that improve the accuracy of outcomes research. One is the judges have said you must promise the patients confidentiality because if they know that you know if they report using heroin again and it would devastate their clinician they can report it as part of the research and it will not get back to that clinician except in aggregate form in total number form. Another thing they have required is that to do outcomes research effectively you need to ask a standard series of questions.

You need to follow a script outline or a survey where you ask the same questions of each patient and take from their answers you know the next questions to ask. You cannot cherry-pick patients. You have to have at least 70% of the patients that enroll in your treatment center have to be eligible to be followed up with after they leave.

That doesn't mean you have to follow up with all of them. You can do a random selection process. But what this avoids is you can't wait to see which patients have, you know, been in treatment for 2 months and say we're only going to do the research among them. You need to do the research among all patients who have stayed in treatment for a minimum at least a minim period of time.

And finally, to comply with all of those, their requirement is that outcomes research be conducted by an independent research company or an internal research group that has no direct responsibility for patient care so that they can maintain that patient confidentiality.

So, as Vista Research Group, we've now been doing post- treatment outcomes research for almost five years with a wide variety of treatment centers across the US. And we found what it takes to get high response rates. And as we all know, this is a notoriously difficult population to stay in touch with. We have found that we need to make 10 to 15 attempts each time to reach the patient.

We have a whole outcomes caller team.

Yes, exactly. We have a whole outcomes caller team that that's what they do. They text and email and pick up the phone and they talk to the patients and convince them that this is real research that will help the patients, help the treatment center they left provide even better treatment for future patients. We've also learned we need to pay the patients something to take the surveys. So, what we do is we can instantly text or email gift cards to Starbucks or Target to the patients as soon as they complete the survey. It can come right back to their phone or we can mail it to them. And then we also get information from the patient while they're still in treatment about other family members or friends that we have their permission to contact in case we can't reach the patient themselves after treatment.

Perhaps their cell phone number changed or their email changed. we will call the mom or the spouse and say we've been trying to get in touch with your son Joe. He had agreed to be part of the research that we're conducting.  And we'll ask the patient in advance. Do we have right to say we're calling on behalf of a particular treatment program or not? That helps too when we can say yes, we're calling from Apollo Recovery to follow up on how he's doing now. And you know we can't reach him on his old cell phone number anymore. Is there by chance he gotten a new cell phone? And if so, would you mind giving us the number? And so, because we work so hard to reach these patients, we are typically able to reach 50 to 60% of the patients every time  at one month, six months, and twelve months post treatment.

And that's really critical because if you can't reach the patients, you have to assume there's a reason and that reason is that they've probably relapsed. I mean, one of the challenges in the in this whole field was that without these standards, treatment programs have had a tendency some of the some of the treatment programs have had a tendency to quote really high success rates. I remember when I was looking for my daughter and I had treatment centers that told me 80% of their patients were successful long-term or I had one treatment center owner tell me that 98% of his patients were still abstinent and I thought in what alternate universe do you think we live?  And so now by creating a standard playing field, people looking for treatment can have confidence that they're comparing when they when they somebody tells them you know we have a 43% success rate or we have a 46% success rate or whatever that they can be confident that they're comparing apples to apples. So, once you have done post-treatment outcomes research, we recommend that you use that research to attract more patients because they're desperate to know this type of information. They're desperate to know where can I send my child or my spouse or myself where I can be confident, they're providing effective treatment. And what we've had is a number of our clients have published their results on their website and the fact that they're from an independent third party gives them a lot more validity. But I'm also excited to say that there's now another way that you can publish your success rates. 

And that is that my daughter and I have launched a website called Conquer Addiction. It's at conqueraddiction.org or where families searching for treatment can actually find treatment centers that meet their needs that have proven they have high success rates. So, for example, somebody looking for treatment, say in oh, let's just say California, you know, could do a search and they could say, well, I know I need residential treatment or I need to find a special treatment for an adolescent child or it needs to, you know, accept Blue Cross Blue Shield or you know this patient also has would be more comfortable in a lesbian and gay facility or what have you. And you can do a search for whatever your criteria are. 

And those treatment centers who meet your search criteria will show up in a list and those with the best proven outcomes will show up at the top of the list. So, let's say you want to see more about one of these treatment centers. You can actually just click through to this treatment center page and you can click through to their website directly.

You can call their admissions line. You can also see who they're accredited by and any awards they've won. And you can actually see their real independently validated success rates. So, what you can see is what percentage of their patients are reachable and abstinent at six months or a year post treatment.

And not only that, but what impact did treatment have on those patient’s quality of life? So, you could see that before treatment only 17% of those patients reported feeling good or excellent and one year later 84% of the patients do.

You can see what impact that treatment had on their living in a stable environment or being able to work or go to school. And you can also see the improvement in their relationships with their family. And what percentage of the patients that were contacted at 12-month period reported being somewhat or very satisfied with the treatment they received at that center?

So you can compare this data and for each of the different treatment centers that you're considering and use that to choose which treatment centers to contact. 

Now the one thing I'll also say to this is you know there's a lot of you know there's 14,000 treatment centers in the US. Very few of them are still tracking their outcomes. So you know it may be that patients will have to choose a treatment center that is not available on conquer addiction. But over time, as patients become more used to the fact that this type of data exists and become more aware of it, they will start asking for and potentially even insisting on seeing accurate post-treatment outcomes research. So really encourage anyone who is trying to figure out how can we attract more patients and preferably cash pay patients or patients that you know can pay for longer stays or whatever, that you start investing in outcomes research. It's a lot less expensive than you may think.  Because we can randomly select a certain number of patients. We can cut the cost at 25 or $30,000 a year for post-treatment outcomes research which is often times just a drop in the bucket compared to you know marketing spending. 

Another thing I will say is that to be on conquer addiction, you don't have to use any particular outcomes research company and you don't have to even use any outside research company. You can do it internally as long as your research team complies with the  with the standards that have been set by Conquer Addictions panel of judges.

So, I'm going to stop there and just show that Carrie Lynn and I would be happy to be contacted after this if you had any additional questions or for any other information. And that concludes the presentation portion of our talk. We will now move to live questions and answers.

Dave:

All right, everybody. We're back. That was a great presentation. Thank you, Joanna and Jerry Lynn. Hi, how you doing? We're live, everybody. I'm Dave from Dreamscape Marketing. I'm just posting this in the background here. But we do have some questions that came in during the presentation and I see Kerrylynn’s been answering them, but maybe we can just touch on them again just so you know everybody hears the answers and if they weren't following the chat or the Q&A. So, Joanna, I just want to say, you know, at the end of your presentation, over here at Dreamscape, we're a marketing company, and we've been doing you know, we've been doing, we even did a presentation this year on the importance of marketing outcomes and documenting outcomes and how, you know, hearing from people in the treatment industry for, you know, decades who are pure complete experts versus someone who is not and how you can differentiate online between. So that presentation was perfect. I, you know, I was watching you the whole time there, but my ears really perked up for that point. So that was really good. 

Joanna:

Fantastic. No, it makes a huge difference. I mean, people are desperate for this information. Your kids or your spouses or your own life is on the line, and you may have just one chance. And how do you know that the treatment center that some you know somebody recommended is likely to be providing effective treatment or not? It's a life-or-death decision and there's no way to know. And now, I mean, this is, you know, this is this came from my own personal experience as a parent and you know, there's a ton of really excellent treatment centers out there.

Dave:

Yeah. 

Joanna: 

No, we need them because there are a few bad apples and you know, and there are treatment centers who think they're providing an excellent job, but if you've never done the research, how do you really know, you know? 

Dave:

Yeah. No, we did a whole presentation earlier this year looking at you know mainstream medical marketing such as like John's Hopkins or the Cleveland Clinic, you know what you would call hospitals, right? And you know we were looking at their marketing in particular and they're not you know they're not selling the size of their room. They're not selling a beautiful logo. They literally are marketing their outcomes and it's just and you're right and we talked to a provider earlier this year who you know was frustrated when some someone called him up and he'd been in the business for you know he'd been in the business of providing treatment for decades and  he got a call from a mom and you know looking for treatment for their child and she was like yeah but how do I know your website says everything like and you great reviews, but all that stuff, you know, can be, you know, faked. So, how do I know that you're different from the next guy down on the list in Google? So, or, you know, so, yeah, it's just, it's so, so important. And like I said, we did a whole presentation on it this year. So, I was glad to hear that and it was good stuff.  So thank you