Last week I discussed a bit about managed care and preparing to make the clinical review call. This week I will finish discussing ways to increase effective communication and results with managed care by explaining and focusing more on the review process itself. When a CA calls the office to perform a review they are not calling to second guess, overrule or ridicule the clinician (though many clinicians have told me they felt that this was the case). They are performing a review to ensure that all that can be done for a client is, but also to ensure that there is no needless duplication of service, excessive amounts of service that could foster overdependence on the clinician on the part of the client. They also want to ensure that the treatment is as cost effective as possible. This sometimes leads to disagreements in treatment planning which may lead to the clinician and or the client filing an appeal (the appeals process is beyond the scope of this blog and differs from company to company). It is true however that you must show medical necessity in order for the services to be covered. A client who would benefit from therapy but who it cannot be shown medically needs services will often be denied care. Insurance companies are for profit companies; they are not in the business of simply giving folks whatever they would like, instead they will cover services that are included in the particular plan that they are enrolled in. This coverage may differ greatly from client to client. For the most part, the review process can be positive or at worst neutral- they rarely need to be seen as negative. The CA is looking for clear and concise information pertaining to the client and their treatment. The clinician’s job is to supply the information so that a professional collaboration can occur. Reviews can take as little as 5-15 minutes, provided the communication remains cordial and the information presented is clear. They can take up to or over an hour in situations where information is lacking or the relationships are strained. You have a great deal of power here regarding how the call goes. Go in prepared, be clear and direct and you likely can make this a short call once you get the CA (some companies utilize phone trees which can be time consuming). Once the information has been collected, authorizations usually follow as will information pertaining to the need for future reviews. Reviews can be ordered very often, I have seen them ordered every 4 sessions, or yearly depending on several factors such as medical necessity, quality of information provided, plan etc. Effective and proactive treatment planning is the best approach to reduce review times and ensure positive outcomes for your clients as the information sought in the review process is often found in the clients’ DSM IV TR Assessment and Master Treatment Plan. A brief outline follows: Diagnosis-be prepared to provide a detailed diagnosis. Know all 5 axis and their meaning. When asked for symptoms, use the DSM as a guide. Know the difference between a diagnosis and a symptom. “They worry a lot” is a symptom- it describes their behavior; “they have Anxiety D/O NOS” is a valid and easily understood diagnosis. Be specific- "she worries a lot" or "he is angry" are not valid diagnoses Symptoms include- Depressed mood, anhedonia, anxiety, social isolation, agitation, delusions, hallucinations, anger outbursts, fatigue, psychomotor retardation, flat affect, low self-esteem, sleep disturbance, decreased appetite, suicidal ideation. Treatment goals should be able to be measured (though you do not have to measure them), they do not need to be overly complicated- “decreased depression” in a depressed client is valid. Goals should be targeted to the symptoms. Examples: Decrease depression, improve coping skills, increase self-esteem, stabilize mood, improve regulation of affect, foster insight, improve marital relationship, improve level of functioning. Interventions should be clear treatment techniques, avoid the common mistakes such as “behavioral therapy” or “psychoanalytical therapy” as those are theories and NOT techniques. Interventions include- Cognitive reconstruction, reframing, problem-solving,, identifying triggers, psychoeducation re: alternative coping strategies, collateral couple’s sessions, journaling, relaxation training, systematic desensitization, exposure/ response prevention, safety planning, refer for med.eval. GAF-perhaps the most subjective part of diagnosing clients but still very important. Be as accurate as possible- again use the DSM as a guide. Clients in outpatient care typically fall between 60-75 range; if the client does not, this may indicate that the level of care needs to be adjusted. Estimated length of treatment, is very difficult to do with any certainty-guesstimating is the norm. Try to imagine what the client would look like if they were ready to discharge: what would they have achieved? Give a ballpark guess as to how long it will take to get there. This is not a binding estimate. Examples: "When she has returned to her level of premorbid functioning. When he is able to significantly reduce or eliminate his panic attacks. When his depression has decreased to a minimal level." Once this information has been supplied you typically get the results immediately from the CA. In some cases they may advise you that it has to be escalated; this is typically when a client has been labeled as a high utilize and requires a supervisors review and determination. High utilizers appears to be defined according to the plan. I want to thank several anonymous CA’s that helped me write this blog and brochure. They are unnamed due to contractual reasons but I feel the need to acknowledge their support as without it this would have been very difficult to write. One interesting point: I was advised that these measures were in place to insure quality for all clients and to make sure that the client was receiving everything they needed. Many clinicians have pointed out however that only the cheaper or midrange policies have this process and that the higher end plans have no such requirement. Many have said that this points to the fact that this is all really just a ploy from the companies to reduce costs through reducing care, the CA’s that I posed this question to of course denied this statement but offered in my mind no cogent reason why the more expensive plans by their definition had less to protect and insure quality of care than the cheaper plans. I do not know the real reason but will say that I personally appreciate it when I can reduce my uncompensated paperwork and telephonic communication times that are found in these higher end plans. Ok, so here you have it folks. I hope it helped. Mark this as one of the few blogs that did not mention the farm, tractors or wooded trails. Copies of a brochure on this topic can be downloaded for free at http://docwarren.org/images/Managing_With_Managed_Care.pdf
Warren Corson III (Doc Warren) is a counselor and the clinical & executive director of a community counseling agency in central CT (www.docwarren.org).