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Revisiting Efforts to Manage “BHRS Redesign”
May 30, 2014

In a May 13 meeting, community providers of child/adolescent mental health services from across the commonwealth continued to report prescription changes, reductions, and denials and the curtailment of many medically necessary rehabilitative services. These are services developed by the state, often in compliance with Medicaid Early Periodic Screening, Diagnosis and Treatment (EPSDT) criteria. Participants suggested several actions that providers should consider in efforts to manage the substantial changes in service prescriptions, access, dosages, and consumer involvement and choices related to “BHRS Redesign.”

  1. Encourage and expect evaluators to rely on their clinical training and experience to prescribe the level and dosage (hours/units) of Behavioral Health Rehabilitative Services (BHRS) and other treatment and rehabilitative care based on the biopsychosocial needs of the child as essential to the treatment planning process.
  2. Inform and encourage families to consider exercising their Medicaid grievance and appeal rights when recommended/prescribed services or service levels are “compromised,” reduced from the clinical recommendation, or denied. Families may seek the assistance of health advocates at the Disability Rights Network, Pennsylvania Health Law Project, and others.
  3. Inform families that they may have the right to advocate for schools to replace reduced, denied, and discontinued services in school through changes in their child’s Individualized Education Plan (IEP). Encourage schools to quantify the costs of the shift of service from a Medicaid provider to the IEP and special education budgets.
  4. Track the multi-year adverse life domain and clinical impact for children served by the provider organization as a result of service reductions or “fail first” policies.
  5. Inform community leaders and families that providers across Pennsylvania are under continued pressure to reduce the prescribed quantity of home, community, and school services. Share state, local, and agency-specific data where it is available.
  6. A significant number of providers reported experiencing action by managed care organizations that may constitute punitive or retaliatory responses to evaluation and prescribing practices, resisting pressure to compromise and reduce prescription levels and efforts to support families in challenging or appealing service reductions. RCPA asks that provider agencies document and report on any such actions or patterns to the association.

As is always the case, behavioral health service interventions must be medically necessary, prescribed, and properly delivered and documented. Prescribers have the ethical and professional obligation to request authorization and provision of the quantity and type of services they deem to be clinically needed. Families should be encouraged to appeal reductions or denials of services prescribed. Meeting materials from May 13 are available from the Members Only section of the RCPA web site. Questions may be directed to Connell O’Brien.

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