This measure is important because the Clinical Integrity Unit (CIU) ensures that Vermont Medicaid members have access to eating disorder treatment when clinically appropriate and medically necessary.  The CIU monitors to make sure the services are of good quality, at the appropriate level of care and length of stay and are consistent with prevailing professionally recognized standards of practice.

Prior to 01/01/23:

The CIU monitored and provided authorizations for four levels of care specific to eating disorder treatment:

• For inpatient and residential levels of care, providers were submitting clinical documentation for the CIU to review prior to admission of the member for both ACO and non-ACO attributed members.  The CIU would then do concurrent review for non-ACO attributed members only.
• For partial hospital program (PHP) and intensive outpatient program (IOP), the CIU was performing concurrent reviews during the admissions for non-ACO attributed members.

Beginning 01/01/23:

• DVHA now requires authorization and concurrent review for all Medicaid members for inpatient and residential levels of care regardless of ACO attribution and members are now assessed prior to admission by the admitting facility to determine medical necessity.  These changes were implemented to allow parity and to streamline the process for all Medicaid members as well as to reduce the barrier of a clinical review and submission of documentation prior to admission. 
• DVHA no longer requires prior authorization (PA) or concurrent review for PHP or IOP levels of care specific to eating disorder treatment. This applies to all Medicaid members regardless of ACO attribution. This change was made to reduce the barrier of a PA and allow members to access services more quickly.  

The data above indicates an increase in total number of admissions from Q2 SFY23 to Q3 SFY23. This can be attributed to the CIU now monitoring and authorizing stays for ACO attributed members. Since Q3 SFY23, there has been a continued with no obvious explanation to provide. We anticipate that there could be an uptick beginning in SFY24 Q3 due to the residential eating disorder benefit expanding the age limit for members over the age of 20 years. 

Narrative last updated:  03/06/24

• Walden Behavioral Health
• Cambridge Eating Disorder Treatment Center
• DVHA Provider Relations
• DVHA Reimbursement Unit
• Gainwell Technologies

The CIU will continue to work to enroll new providers at all levels of care (inpatient, residential, PHP and IOP) specific to eating disorder treatment. When a provider is interested in enrolling with VT Medicaid, the CIU will connect them with DVHA Provider Relations for assistance with enrollment.  One new residential provider enrolled during Q4 of SFY23.