Why I Do Not Accept Managed Care
Reimbursement for Mental Health Services
Reason #1 Lack of confidentiality
All managed care plans (MCP’s) involve direct clinical management by the
plan’s case managers. If you access therapy through your MCP, it makes it
necessary for your therapist to disclose anything and everything related to your
case to your MCP.
This information is used by the MCP for determining benefits, which they
allocate at their own discretion. This impacts your right of confidentiality,
and it is possible that your information will be stored in a computer system
which could be accessed by anyone. Insurance companies share information about
you when you apply for a new policy.
The FBI and law enforcement officials can access your insurance information at
any time. This information could be used to your disadvantage should a legal
problem arise.
Furthermore, this lack of confidentiality could impact your minor children even
more negatively. Should they ever desire to apply for certain jobs or
educational programs, such as law enforcement or the military, the information
in their insurance files could be used against them.
Reason #2 Difficulties getting treatment authorized
Due to the direct care management by MCP’s and their desire to keep costs to
a minimum, getting therapy sessions authorized often becomes cumbersome and time
consuming. Every plan has different requirements and standards for
authorizations. Usually they require many hours a week of paperwork and phone
calls by the therapist in order to get authorizations. Some will deny therapy in
lieu of taking prescription medications.
MCP’s allow a certain number of treatment sessions per year for each plan. Let’s
assume your MCP allows up to 20 sessions per year of outpatient psychotherapy.
This does not mean you can automatically access your benefits. Often you first
have to be referred by a primary care physician member of the MCP. Then you may
have to go through a phone interview with an MCP case manager. Then you may have
to contact several plan providers to find one who is accepting new clients, who
has a convenient location, or who has expertise in your issues. Once you have
found a provider, there may be a long wait for an appointment due to
pre-authorization requirements. Then you are often given only one to three
sessions to start (50 minutes per week -- though you may feel you need more), as
an assessment. Then you may need to wait for more visits to be authorized —
often weeks of phone calls and paperwork flow back and forth between your
provider and the MCP. Then the MCP may only authorize three sessions at a time,
with this continual waiting period in between. This causes your treatment to be
inconsistent, broken up, and can cause you more anxiety not knowing if you will
in fact get your benefits authorized at all. Some clients give up on their
treatment due to these frustrations.
Furthermore, some MCP’s want to control the treatment plan. Some will even
dictate the specific treatment plan, which is often very subjective and may be
even be anti-therapeutic. Some plans will determine when it is time to terminate
treatment, even when the client continues to be in distress, or their problem
has not been sufficiently solved.
Reason #3: Mis-diagnosing and/or over
diagnosing in order to get treatment authorized.
Some MCP’s will not cover treatment unless it is a “medical necessity.” This may
mean the client has to “pretend” they are “sick,” or worse off than they are, in
order to receive their benefits.
Most MCP’s do not cover marriage counseling, family counseling, sex therapy, or
adjustment counseling, unless they are part of the treatment plan for a serious
mental disorder or drug/alcohol problem.
This situation puts both the therapist and client in a negative situation. Often
the “assessment” sessions that are initially authorized are not sufficient to
give an accurate diagnosis, yet the MCP will not authorize more visits without
one. The therapist may be inclined to “make up” or “guess at” a diagnosis, which
is not in the best interest of the client (could come back to harm you at some
point)..
Most importantly, you, the client, should not be given a mental illness
diagnosis that is not correct, or is more serious than what is true, simply to
get treatment paid by the MCP.
Frankly, I refuse to play these games and I hope that you will agree.
That said, if you
want to use your insurance, I will file it for you so you can be reimbursed by
your company directly as per your specific policy.
Patrick
B. McGinnis, PhD, LMHC
