Courtesy of Ken Pope’s prolific posting service, which provided brief excerpts form the article, here is a summary of an interesting article by a Minnesota psychologist and psychiatrist colleague about how to work with managed care reviewers. The article, “Managing Managed Care’s Outpatient Review Process: Insights and Recommendations From Peer Reviewers at a Health Services Company” is by Kathleen J. Papatola. Ph.D., L.P. and Stuart L. Lustig M.D. and was published in Professional Psychology: Research and Practice, May, 2015. It is available for purchase online. Dr. Papatola is a psychologist and Dr. Lustig is a psychiatrist, and both work for Cigna.
They begin in the abstract with some ambitious goals: “To help practitioners save time and advocate more effectively for mental health outpatients, we provide guidance on the peer review process for psychotherapists who interact with MCOs, either as members of insurance networks or as psychotherapists for self-pay patients who, in turn, must justify to third-party payers the medical necessity of treatment in order to obtain reimbursement themselves.”
They go on to cover a lot of territory in 6 pages. They provide background information about how utilization review policies are typically determined, describe the process of utilization review, discuss some common triggers fore review, and review the structure and processes of the typical review team. Most of this information is an overview, but they go in to more detail about the specific elements of medical necessity and discuss specific case examples to highlight how providers can “advocate most effectively for treatment that is medically necessary.”
Their information about medical necessity, and related issues about how to effectively communicate symptoms and treat goals is likely to be particularly helpful to the average therapist who is struggling with the utilization review process. For example: “Peer reviewers are interested in symptoms because they are benchmarks for psychiatric disorders, the major prerequisite for meeting medical necessity criteria. Other patients may come for supportive psychotherapy focused on emerging or chronic life issues. Insurers recognize that a supportive therapeutic frame is necessary for a patient to initially trust and value the psychotherapist enough to make positive psychological and behavioral changes. That said, psychotherapy that is primarily supportive and does not empower the patient to gain greater health and autonomy is generally not considered medically necessary.”
And: “One of the most consistent challenges for the provider and, subsequently, the peer reviewer is separating events from the effects of those events. When reviewers ask about psychological symptoms or indications of human suffering, the most common initial response is the psychotherapist’s list of the patient’s psychosocial stressors.”
Papatola and Lustig go on to briefly review the problems of underdiagnosising and providing excessive diagnoses, and end by providing guidance about how to respond to denials. Their final summary includes, “Regardless of the treatment modalities employed, clearly defined goals with realistic end points also help to communicate that treatment is well-formulated, expertly planned. and a joint venture between the provider and the patient to reduce psychological suffering and to restore function.”
MHConcierge’s take: This is an informative and well written summary, in a mere 6 pages, about common problems that therapists experience with managed care companies. Most importantly, they also provide pragmatic advice about how to reduce your grief while working to minimize review problems and obtain authorizations and payment. The article is well worth the $11.95 fee for downloading a PDF version.