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Payers Use UCR Data to Drive Behavioral Health Outcomes

  • by Margaret Klasa DC, APN BC
  • May 10, 2017, 12:51 PM

Payers will be asked to drive population health outcomes as ACA and payment models focus on containment, quality and patient access. For instance, chronic illness for members with multiple disease conditions will cost more than an insured with only one condition.  Examples include heart disease, stroke, hypertension, diabetes and asthma.

Multiple studies have proven the large financial impact of chronic conditions.  The CDC estimates $ .85 of every health care dollar is spent on chronic conditions.  The Robert Woods Johnson Foundation found people with chronic conditions utilize 75% of all hospital days, office visits, home-health and prescription drugs.  It’s not surprising that insurance companies are laser-focused on reducing their impact.

Behavioral Health issues compound the chronic condition scenario.  ACA has exposed a hidden population with mental health issues.  The United States spends more on mental health and addiction than on any other medical condition including heart disease, trauma, and cancer. Within this spending, there’s been a shift toward the use of opioids, outpatient care and other types of community treatment in lieu of inpatient care.

While payers utilize the data from claims (i.e. pharma, outpatient, inpatient), Behavioral Health issues in the population can be difficult to identify.  Many patients are lost in the system and often not compliant on medication protocol or therapy.

Using UCR data (usual, customary and reasonable fees) that contains a procedure code, diagnosis and related zip code and a price point gives the payer an additional way to identify a population that it would cover. The payer could better plan preventative healthcare and wellness programs, negotiate professional fees and provide proven treatment options for better Behavior Health outcomes.

A payer can easily determine who in their population could be at risk by finding the targeted zip code by diagnosis and procedure. For example, one could start by reviewing the top 10 Behavioral Health issues such as:

F41.1 – Generalized anxiety disorder
F43.23 – Adjustment disorder with mixed anxiety and depressed mood
F41.9 – Anxiety disorder, unspecified
F43.22 – Adjustment disorder with anxiety
F43.10 – Post-traumatic stress disorder, unspecified
F33.1 – Major depressive disorder, recurrent, moderate
F43.20 – Adjustment disorder, unspecified
Z63.0 – Problems in relationship with spouse or partner
F43.21 – Adjustment disorder with depressed mood
F34.1 – Dysthymic disorder
F32.9 – Major depressive disorder, single episode, unspecified


This might be done by linking the Behavioral Health diagnosis to claims data for chronic conditions. Once the highest cost population is identified it can be targeted for where outcome measures can appropriately applied.


Context 4 Healthcare has been the only source of healthcare UCR fee data derived from provider transactions for over 20 years.  Straight from the source.  Zero payer adjustments.  Over 1,000 organizations have relied on our UCR.

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