Most clinician notifications by Optum related to potential risk issues are in the form of letters. However, certain potential risks warrant a Clinical Review with the treating clinician.
When such a case arises, you will receive a phone call from a Optum Care Advocate who is a licensed mental health professional. A Care Advocate will call as soon as the potential risk is identified. In an effort to be time-effective in the intervention, Care Advocates request a call back within two business days. It is important to return the Care Advocate’s call, even if you are unable to do so within this time frame.
The purpose of these calls is to inform the clinician of potential risk(s) identified through ALERT that may affect the member’s treatment outcome. This conversation might include, but is not limited to, a discussion about the member’s engagement in treatment, current mental status, and/or whether Optum can help mobilize additional resources that may support outpatient therapy. The use of clinical reviews is limited to members identified with certain targeted potential risks.
In the event that a Care Advocate is unable to speak with a clinician within the two-business day timeframe, the Care Advocate will make a call directly to the member, or member representative to discuss the identified risk(s). However, the preferred ALERT care advocacy contact is with the treating clinician.
Presented below are risks identified by ALERT which may result in a phone call. Various Optum algorithms are used to identify potential risks that could affect outpatient treatment.
- Risk for treatment at a level of care higher than routine outpatient treatment in order to ensure the safety of member or others.
- Risk for a deviation from normal baseline functioning, substance use, days missed from work, medical visits and a recent history of a higher level of care.
- Combined risks that if found in isolation would result in a letter. Some combinations we frequently see include: The need to assess for care higher than routine outpatient together with chemical dependency risk; high level of stress and medical-behavioral co-morbidity; workplace risk and chemical dependency risk; and caregiver strain and workplace risk
- Some members may not be identified with any risk targeted by the ALERT algorithms. However, information derived from claims may still result in a call from a Care Advocate
Information that may be reviewed in the Care Advocate Call
- Confirm or rule out the identified potential risk
- Confirm that the member meets the Level of Care Guidelines for Outpatient Treatment, thereby taking into consideration that his or her needs are able to be met on an outpatient basis rather than at a higher level of care
- The Level of Care Guidelines that may be appropriate for the member in the event they are need to step up or down in level of care. Consult a Care Advocate with assistance regarding benefit eligibility for potential services.
- Best Practices that may be applicable for the member’s presentation
- Supplemental and Measurable Guidelines, if clinically applicable
- Check that treatment interventions address any confirmed risks
- Review coordiantion of care with collaborating clinicians
Participating in a Clinical Review:
- Return the Care Advocate’s call. Otherwise you will receive additional calls on the same Optum member
- Begin by identifying the Optum member by name
- Be prepared to speak about the clinical status of the member in outpatient therapy and identify potential needs of the Optum member, including any gaps in treatment
- If you have more than one Care Advocate calling you on more than one member, give the name of each of the members in question when you call. You can usually do all the clinical reviews in one phone call