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Wisconsin Department of Health Services

WI-UPC FAQ

The following is the list of Frequently Asked Questions (FAQ), scroll through the list and click on your desired question to see the answer lower on the page.  When you are finished, use the Return to the top of the list link to return to the top of the list.

These questions are also in the Uniform Placement Criteria (UPC) Manual (PDF, 973KB), pages nine through fourteen.

  1. Is WI-UPC a requirement for program certification?
  2. Will managed care follow these criteria? What do we do if they do not?
  3. Do providers have to offer all levels of care? If we do not operate a level of care, do we refer the patient to the next highest or next lowest level of care?
  4. When does WI-UPC go into effect?
  5. What about Medicaid? Will they fund all levels of care?
  6. Will HMOs or managed care fund the level of care that we determine to be necessary?
  7. If the consumer refuses a level of care, what do we do?
  8. Will funding be tied to outcome studies? Will funders use this to decide who is awarded contracts?
  9. How are various psychosocial factors, such as cultural background, lack of child care, etc. addressed?
  10. What level of education or certification will be necessary to work in the field or at different levels of care?
  11. How do you resolve differences between different providers and between payers and providers regarding level of care? Will a peer review process be used to resolve such differences?
  12. Is there liability with placing or not placing an individual at a certain level of care?
  13. Will inpatient treatment still be a part of the continuum?
  14. Who do we call when we have questions?
  15. How do we reconcile differences between standards and the placement criteria in the short term?
  16. Will there be a review of this process and a feedback mechanism? How will changes in the criteria be made?
  17. Does this process apply to both private and public sector substance abuse treatment providers?
  18. Are there any situations when the criteria would not be applied? If so, when?
  19. Is there a way to override the placement criteria?
  20. How much room is there for clinical discretion?
  21. Will treatment cost more or less?
  22. Will training be made available? If so by whom, at what cost (if any) and when?
  23. Do you need a diagnosis prior to determining level of care?
  24. Is the WI-UPC Scoring Instrument a screening instrument or an assessment instrument?
  25. How often does the WI-UPC Scoring Instrument have to be used?
  26. Will there be new state or other funds available with the use of WI-UPC?
  27. Will WI-UPC result in the development of more specialized services?
  28. How will Level D-1, Residential Intoxication Monitoring Service, be funded since it is not based on medical necessity?
  29. Does the CIWA-Ar or the SSA need to be conducted by medical personnel?
  30. Is there any part of this program that can be dissected for special circumstances (i.e., individual comes in at night and is up and gone before seeing the counselor)?
  31. Should the counselor who administers WI-UPC initiate referral or simply present a number of options and leave the referral initiation to the consumer?

 

 

Is WI-UPC a requirement for program certification?

HFS 75 , the Department of Health Services Community substance abuse service standards, has integrated the requirement for use of a Department approved placement criteria into the certification standards for alcohol and other drug abuse treatment agencies. The initially approved criteria are the Wisconsin Uniform Placement Criteria (WI-UPC) and the American Society of Addiction Medicine (ASAM) criteria, or similar placement criteria that may be approved by the Department.

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 Will managed care follow these criteria? What do we do if they do not?

Managed care organizations have been involved in the development of WI-UPC from the beginning of this effort. It is expected that payer organizations will continue to express support for this process as it will improve the placement decision-making process and thereby should lead to improved treatment results. However, as in all treatment decisions, it is the responsibility of the treatment facility to make treatment decisions based on the needs of the individual. The criteria are designed to represent a "best practice" standard for placing individuals at the most appropriate and least restrictive level of care. The criteria provide rationale for treatment decisions that are clinically based and subsequently should be accepted by managed care. MCOs who contract with the state to provide health care services are required to utilize providers who are approved by the Department of Health Services and who meet the minimum standards set forth in HFS 75

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Do providers have to offer all levels of care? If we do not operate a level of care, do we refer the patient to the next highest or next lowest level of care?

No. It is envisioned that not all providers will have the resources or the need to develop services at all levels of care. Several factors can influence service development, including geography, demand, other community resources and accessibility. However, the criteria are designed to place individuals at the least restrictive level of care. It is expected that providers will have the ability and creativity to develop individualized treatment plans to meet needs by modifying the levels of care that are available or by working collaboratively with other treatment providers within the community or geographic area.

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When does WI-UPC go into effect?

HFS 75 Community substance abuse service standards went into effect August 1, 2000. The Departmental - approved criteria are the Wisconsin Uniform Placement Criteria (WI-UPC) and the American Society of Addiction Medicine (ASAM) criteria, or similar placement criteria that may be approved by the Department.

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What about Medicaid? Will they fund all levels of care?

Most of the Medicaid population will ultimately be enrolled in managed care organizations. Payment for individual levels of care will be negotiable dependent upon federal limitations and existing waivers of federal guidelines. Medicaid has identified two residential detoxification levels (D-1 and D-3) and two medically monitored rehabilitation levels (1-A and 3) that are reimbursable.

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Will HMOs or managed care fund the level of care that we determine to be necessary?

The availability of funding may continue to vary according to benefit designs. It is hoped that the implementation of consistent placement decisions based on the criteria will establish the value and cost-effectiveness of alternative levels of care. This information may influence benefit designs in the future. Most HMOs and managed care companies are looking to establish relationships with providers that offer a variety of levels of care. It is anticipated that WI-UPC will, over time, demonstrate its efficacy and be voluntarily adopted as a means of objectively determining individual placement and maximizing uniformity of the public and private payer/treatment system.

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If the consumer refuses a level of care, what do we do?

Consumer choice has been included as a basic element in the development of the WI-UPC criteria. Though treatment must be medically necessary, the decision on the part of the individual to participate is voluntary. Placement decisions will have to be negotiated, on an individual basis, by the payer, the treatment staff and the individual. Refusal to accept the recommended care does not necessarily indicate that placement into a higher level of care is appropriate. It is at the discretion of the provider to offer the individual services in a lower level of care than the criteria recommend. However the ability to effectively and safely address identified risk factors must be documented if a lower level of care is selected.

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Will funding be tied to outcome studies? Will funders use this to decide who is awarded contracts?

WI-UPC represents current thinking as to accepted clinical care guidelines. Clinical outcomes are expected to be used as a basis for negotiating performance contracts between payers and treatment providers.

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How are various psychosocial factors, such as cultural background, lack of child care, etc. addressed?

WI-UPC defines a level of care based upon medical necessity. The cultural and psychosocial components of a specific service vary dramatically. Every effort should be made to appropriately match need/preference with available resources. Wraparound services (child care, transportation, etc.) must be accounted for, addressed and included into an effective case management system. Funding of wraparound services (or bundled services) remains uncertain and will need to be negotiated among the payer, the individual and other available resources.

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What level of education or certification will be necessary to work in the field or at different levels of care?

Program standards, professional credentialing requirements and external accreditation processes will continue to dictate educational requirements. Training will be made available on a regional basis through training events, conference presentations and in other venues to familiarize treatment staff and others with WI-UPC.

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How do you resolve differences between different providers and between payers and providers regarding level of care? Will a peer review process be used to resolve such differences?

It is the goal of the standards to provide the foundation for making consistent placement decisions throughout the substance abuse treatment delivery system based on objective criteria. Disparity may result due to individual interpretation of the criteria, especially those criteria more subjective in nature. It is believed that most differences can be resolved through open discussion between providers and payers. However, when agreement cannot be reached, particularly in regard to providers and payers, it may be necessary to request the opinion of and/or an appeal with an independent peer reviewer.

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Is there liability with placing or not placing an individual at a certain level of care?

Liability remains the same as with any clinical decision for both provider and payer. Providers must make treatment decisions based on their assessment of the clinical presentation of the individual. The WI-UPC criteria has been established to place individuals at the most appropriate, least restrictive level of care. Appropriate application of the criteria should ensure proper placement.

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Will inpatient treatment still be a part of the continuum?

Yes. The severity of an individual's medical and/or psychiatric need is part of the criteria that will recommend placement in any of the levels of care. For a recommendation to Inpatient Treatment Service, an individual's medical and/or psychiatric needs must be sufficiently severe to require hospitalization as determined by a physician.

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Who do we call when we have questions?

The Bureau of Substance Abuse Services will have staff available to answer questions regarding WI-UPC implementation. Phone numbers are listed on the last page of Appendix C in Section V of this manual. A toll free hot line is also available (888-PLACEMT or 888-752-2368).

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How do we reconcile differences between standards and the placement criteria in the short term?

There will be a transition period during which the Bureau of Substance Abuse Services and the Division of Supportive Living program certification staff will work cooperatively with programs to maximize the smooth implementation of WI-UPC and minimize problems associated with interpretation of Wisconsin Administrative Code HFS 75.

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Will there be a review of this process and a feedback mechanism? How will changes in the criteria be made?

Yes. Evaluation and revision of the criteria will be a continuous process based on feedback from providers and payers, as well as treatment outcomes. Principles of continuous quality improvement will play a key role in enhancing the criteria to increase usability and effectiveness. Providers will receive updates and additional training as needed. A Clinical Q&A site will also be maintained on the BSAS web site and be updated monthly to address WI-UPC questions.

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Does this process apply to both private and public sector substance abuse treatment providers?

The use of placement criteria will be required by any certified treatment provider in the state. Establishment of a uniform tool will provide consistent data for outcome studies, evaluation and comparison of treatment services.

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Are there any situations when the criteria would not be applied? If so, when?

In extenuating circumstances there may be the need to deviate from the recommendation provided by the criteria. However, it is anticipated that this will occur very infrequently and will be based on the clinical presentation of the individual. This would preclude the individual's ability to function within the level of care identified by the criteria or the identification of additional resources available to the individual that would allow safe and effective placement in an alternative level of care. These situations will require resolution on a case-by-case basis. The resolution should include review by a clinical supervisor, concurrence by the paying agency and clear articulation of the basis for the alternative placement decision.

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Is there a way to override the placement criteria?

Yes. Individualized circumstances may require deviating from these criteria, for example, geographic inaccessibility to all levels of care, lack of available funding for the recommended level of care, or the identification of additional resources necessary to the fully engage the individual. Such an override or selection of an alternative level of care should be based upon extenuating circumstances which are clearly defined, have been reviewed by a clinical supervisor and agreed upon by the provider, the consumer, and the payer.

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How much room is there for clinical discretion?

WI-UPC represents good practice guidelines that have been developed to assist clinicians with the treatment placement process. They are not intended to replace competent clinical judgment. The section titled "Interviewer's Comments" is provided as a means of incorporating case specific clinical comments and recommendations.

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Will treatment cost more or less?

Resources available for substance use disorder treatment will not increase due to implementation of the criteria; however, WI-UPC will result in more cost-effective treatment due to the treatment matching process.

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Will training be made available? If so by whom, at what cost (if any) and when?

Initial training will be made available by the Bureau of Substance Abuse Services on a regional basis; there is a charge for the training. In addition, in-service training may be sponsored by associations or by the Wisconsin Certification Board. There may be costs associated with the latter training events.

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Do you need a diagnosis prior to determining level of care?

No. You don't need a diagnosis to use this instrument or to determine level of care recommendations. Screening is the first step in administering WI-UPC, and the assessment does not occur until the individual reaches a provider at the recommended level of care. Since screening does not necessarily provide a diagnosis, one is not required to use WI-UPC or to determine recommended level of care. However, some funding sources may require a diagnosis in order to approve a placement. Sufficient information is gathered through the screening process conducted prior to the WI-UPC application to identify at least an initial diagnosis. As in any case, the diagnosis may change as ongoing assessment and evaluation occurs throughout the treatment process.

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Is the WI-UPC Scoring Instrument a screening instrument or an assessment instrument?

It is neither. WI-UPC is a scorable placement determination instrument. Although a substance use disorder and possibly a withdrawal screen must be conducted in order to obtain the information necessary to score the placement instrument, it should not be considered a screen in and of itself. WI-UPC is designed to enhance rather than replace any existing prior authorization process.

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How often does the WI-UPC Scoring Instrument have to be used?

The scoring instrument must be used at initial entry into the treatment service delivery system and should follow the individual to an appropriate level of care. Ongoing review of the individual's condition should be conducted using the WI-UPC Assets and Needs Criteria. Sufficient change in the severity of the individual's condition(s) will indicate the appropriate change in the necessary level of care, e.g. transfer to another level or discharge. An individual would remain in the current level of care (continued stay), if they continue to meet all of the Assets and one or more of the Needs Criteria for that level of care. It is recommended (though not required) that the Assets and Needs Criteria be reviewed on at least a bi-weekly basis for individuals who receive clinical services more frequently than one time per week.

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Will there be new state or other funds available with the use of WI-UPC?

WI-UPC is not designed to produce new funds for treatment; however, it will help in managing existing dollars.

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Will WI-UPC result in the development of more specialized services?

One impact of WI-UPC and HFS 75 is the diversification of services within both individual agencies and provider networks. These service delivery systems may be able to include the availability of more levels of care in one setting as barriers are identified and removed from HFS 75. As agencies and networks begin to diversify, they may also increase their marketing potential to funding sources by providing a full range, or at least full access, to the continuum of care. In this way, specialty services can be included as the needs of the treatment population demand. The emphasis is on the service needs of the consumer rather than on fitting consumers into pre-defined program structures.

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How will Level D-1, Residential Intoxication Monitoring Service, be funded since it is not based on medical necessity?

While this service is not likely to be funded by private or public insurance because it is not a medical service, other funding sources may be available. This level of care most closely resembles the level currently known as "Social Setting Detoxification," which is usually funded through county funding systems, foundations or other grants. It is important to note that this level is an intoxication monitoring service. If withdrawal symptoms develop, the individual should be referred to the appropriate level of withdrawal service, if necessary. Individuals in Level D-1 may never have a diagnosis of either dependency or abuse, and, in fact, may not develop any significant withdrawal symptoms.

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Does the CIWA-Ar or the SSA need to be conducted by medical personnel?

Neither the CIWA-Ar nor the SSA requires medical training to administer. The SSA does require the ability to determine pulse rate and temperature. If your agency's current practice is to evaluate more detailed vital sign conditions, this can be continued. However, documentation available on the CIWA-Ar suggests that while vital sign monitoring may be necessary in the treatment of withdrawal symptoms, it is not necessary in determining placement. Please refer to HFS 75 for specific staffing and personnel requirments.

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Is there any part of this program that can be dissected for special circumstances (i.e., individual comes in at night and is up and gone before seeing the counselor)?

WI-UPC is expected to assist in the development of good practice standards. In the example given here, WI-UPC will not change the ability for a consumer to leave a service against staff advice; however, every effort should be made to screen and refer the individual to the appropriate level of care.

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Should the counselor who administers WI-UPC initiate referral or simply present a number of options and leave the referral initiation to the consumer?

While it is necessary to offer the individual information on the available options, it is important for the counselor to make every effort to initiate the referral for the individual as soon as possible.

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Last Revised: April 08, 2014