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 ensures 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. 

Prior to SFY21, the CIU was not consistently tracking PHP and IOP levels of care due to infrequent requests. In SFY21, the CIU began to see an increase in the request of these services and began to track authorizations. The increase in requests coincides with the COVID pandemic. Providers have reported that they’ve seen an increase in disordered eating and therefore the increased need for PHP and IOP levels of care.  The pandemic increased member isolation and lack of structure, as well as heightened anxiety, all of which may be triggers for disordered eating. The need for PHP and IOP levels of care increased again in SFY22, likely due to residual impact of the COVID pandemic. Given the above-mentioned changes to authorizations, the data going forward will include all Medicaid members regardless of ACO attribution for inpatient and residential levels of care, however will no longer include PHP and IOP levels of care. 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. Additionally, there is one adolescent member with significant needs who has had two inpatient and one residential admission during Q3. 

Narrative last updated:  04/12/23

• 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. Additionally, the CIU will connect providers with the DVHA Reimbursement Unit to assist with rate negotiation.