Psychological and psychiatric peer review at CHAMPUS.

Abstract

Professional reviews of psychological and psychiatric services have been conducted by third-party payers for a number of years by various arrangements. It was not until 1979, however, that a major third-party payer, the Civilian Health and Medical Program of the Uniformed Services (CHAM- PUS), developed a comprehensive operational peer review activity. This action was stirred by the need for the program to account for quality of services provided its beneficiaries and to ensure cost-benefi- cial care. This article traces the development of col- laboration between the program and major profes- sional organizations—the American Psychological Association and the American Psychiatric Associa- tion—and the successes and problems encountered thus far. The author concludes that peer review should be a consistent aspect of future third-party determinations. Among the significant program innovations that have evolved in the administration of third-party payment activities in recent years is peer review of professional health care services. In fact, the intro- duction of peer review programs has followed a need within health insurance and benefits programs for professional evaluations of the medical and psycho- logical necessities for services rendered and billed. The traditional focus of such in-house review has been on cases in which there were significant variances in diagnostic or procedure codes, billed costs, or utilization patterns, which resulted in ad- ministrative restrictions or denials in payment. When professional opinions were rendered, the out- come has tended to be directed more at a simple decision to pay or not to pay, and not to assume concern or responsibility for the factors that might contribute to the presence or absence of quality of care, except when outright fraud or extreme incom- petence were manifested. In general, most actions have not directly been primarily professionally de- termined but rather have been made by nonprofes- sional persons using variable professional and ac- tuarial-utilization criteria. There have been few in- stances in such businesses where professional reviews