The next few blogs are in response to email requests I have received asking me to expand on the discussion about managed care. A free brochure on the topic can be downloaded and printed at a link that will be supplied in part two. Feel free to share it. When asked about their views on Managed Care Organizations (MCOs), clinicians often respond with “they are a necessary evil,” “they are evil” or “it’s us against them.” Very seldom will you hear a neutral or positive statement regarding the existence of MCOs. While I once shared this view I have learned that it is in fact unproductive to take this stance as the folks that you work with have no control over the system they work in and venting anger towards them does nothing to make your job easier. MCOs are not new and there is no sign that they are going away anytime soon. Most clinicians find themselves dealing with MCOs, their paperwork, processes and reviews more than ever. Though these processes can be frustrating and time consuming, they can also have benefits as well, depending on the clinician & Care Advocates (CAs) relationship & attitudes, communication skills and level of respect. Like working with a difficult client, poking them with a stick will do little to improve the relationship; instead work on finding common ground and adopting a pragmatic approach is likely the best approach. This blog series is not designed to change clinician’s feelings or opinions of MCOs, nor is it designed to explore any of the political arguments surrounding health care in the USA; it is designed to help improve the process of clinical reviews between clinician and CAs which can help increase the number of authorizations for sessions, decrease the length and frequency of reviews so that more time can be spent focusing on the client. Regardless of personal views, MCO’s are common; it is in the clinician’s best interest to work well with them and foster a team relationship. Working within the system can assist the clinician and client by reducing obstacles and increasing access. To put it another way: don’t spit into the wind; you have to deal with these folks if you work with insurance companies, be solution focused instead of adversarial. You can still hate them if you must, but treat them well when dealing with them. Some companies simply want you to fill out a form and fax it to them while others force you to call them, make an appointment or to simply do the review with whoever answers the phone. This blog deals with telephonic reviews. Before returning the call keep the following tips in mind: • Review the client’s chart prior to the meeting to refresh yourself with the entire situation. • Don’t feel threatened-no one is suggesting you are not doing your job correctly. • Don’t be on the defensive or offensive-be calm and professional. • Be clear-you know this client better than anyone. Give the diagnostic issues based on the DSM, present symptoms, goals, interventions etc. • Keep answers short-stay on task. • Know the level of care guidelines. • Keep sessions to 1 time per week, unless urgent need can be documented and only then increase sessions for a short period of time in order to stabilize. (this one is often a sticking point for clinicians who feel the insurance company is forcing them to change what they feel is best for their clients). • Be nice-how do you like to be treated? How do you respond best to people? Being rude, because you hate the process only makes the process longer and can create undue animosity. Being nice can make the CA advocate for you and your client. You may need their support in the future. • Collaborate-the CA often has access to information that you may not. Ask questions about your client’s health, history etc. The CA may have information that was not shared or was minimized by the client. The CA may also be able to serve as a case manager to help facilitate services not offered by your office. ASK! • Know best practice guidelines and use them. • Know parity laws and regulations as well as their limitations. • Create a team-work as a team with the CA, building a partnership with the CA creates ownership in the client’s treatment and often increases advocacy rates and incentives. Part Two will focus on the process of the review and ways to help the process go a bit faster and hopefully have better results.
Warren Corson III (Doc Warren) is a counselor and the clinical & executive director of a community counseling agency in central CT (www.docwarren.org).