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<p>The objective of this study was to describe the clinical experiences associated with billing for short-term residential care for substance use disorder (SUD) under a Medicaid managed care organization (MCO) payment structure requiring prior authorization. The authors conducted a qualitative analysis of focus group data collected from residential adult services (RAS) facilities staff in West Virginia between 2020 and 2022. These primary data were derived from 17 semi-structured focus groups across 11 distinct RAS facilities, which included 28 administrators, 23 clinicians, and 10 peer recovery support specialists, and were recorded and transcribed before being coded. A phenomenological thematic analysis was employed using data describing reported experiences of RAS staff members billing MCOs under the 1115 Medicaid SUD Waiver. Two main themes arose related to billing MCOs for residential treatment. First, providers felt powerless in their roles as their focus moved from clinical to administrative due to the administrative burden of prior authorizations. Second, providers felt that the shorter lengths of stay for patients that resulted from the prior authorization requirements reduced the quality of care they could provide and that the low quality of care increased the risk of relapse among patients. Thus, MCOs’ utilization of prior authorization as a cost management tool may create barriers for providers to fulfill their clinical roles and provide high-quality care. More research is needed to investigate the prior authorization process from the perspective of MCOs and to quantify the effects of prior authorization on patient outcomes.</p>

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Clinical and Administrative Perspectives on Prior Authorization for Residential Substance Use Disorder Treatment: A Qualitative Analysis

  • 期刊论文

  • 发表日期：

    2025年8月14日

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  • Rebecca Wallis,
  • Lindsay Allen,
  • Stephen M. Davis,
  • Herb Linn,
  • Anh Ngo,
  • Yilin Cai,
  • Carrie Speck,
  • Thomas Bias

摘要

The objective of this study was to describe the clinical experiences associated with billing for short-term residential care for substance use disorder (SUD) under a Medicaid managed care organization (MCO) payment structure requiring prior authorization. The authors conducted a qualitative analysis of focus group data collected from residential adult services (RAS) facilities staff in West Virginia between 2020 and 2022. These primary data were derived from 17 semi-structured focus groups across 11 distinct RAS facilities, which included 28 administrators, 23 clinicians, and 10 peer recovery support specialists, and were recorded and transcribed before being coded. A phenomenological thematic analysis was employed using data describing reported experiences of RAS staff members billing MCOs under the 1115 Medicaid SUD Waiver. Two main themes arose related to billing MCOs for residential treatment. First, providers felt powerless in their roles as their focus moved from clinical to administrative due to the administrative burden of prior authorizations. Second, providers felt that the shorter lengths of stay for patients that resulted from the prior authorization requirements reduced the quality of care they could provide and that the low quality of care increased the risk of relapse among patients. Thus, MCOs’ utilization of prior authorization as a cost management tool may create barriers for providers to fulfill their clinical roles and provide high-quality care. More research is needed to investigate the prior authorization process from the perspective of MCOs and to quantify the effects of prior authorization on patient outcomes.