Inside Managed Care

Family Therapy In A Changing Environment

Judi Aronson

• Publisher: Routledge
• Year: 2013
• eBook ISBN: 9781135062804
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Papers presented at the International Symposium on Asymptotic and Computational Analysis, held June 1989, Winnipeg, Man., sponsored by the Dept. of Applied Mathematics, University of Manitoba and the Canadian Applied Mathematics Society.

1

Here’s What Everyone Needs to Know

Once therapists¹ understand the language that the managed care company uses, they will be better prepared to work with the case managers who will review their treatment. This chapter begins by looking at various benefit programs and how a given program may affect the clinical treatment plan. For example, a basic Health Maintenance Organization (HMO) may have a yearly limit of only 20 outpatient sessions. This limit would cover the care by the therapist and any psychiatric sessions that may be needed as well. By looking at different benefit programs, therapists will begin to understand the importance of working from a systemic, brief model of therapy.

So often, the key to surviving in a system is to understand the language of the context. This correlation could not be more clear than in the world of therapy where the key to successful therapy is to meet the client² where the client is (Rosen, 1982; de Shazer, 1985). However, to be a successful therapist means more than simply to provide good therapy. In order to be a successful therapist, the practitioner needs also to understand the language of doing business—the business of doing therapy. One of the largest segments in the world of therapy today is managed care (Poynter, 1994). Many practitioners hear the term “managed care” and become anxious, but it does not need to be this way. Learn the language, learn the players, learn how to play. This process is isomorphic to the process of therapy.

The first step to understanding the business of therapy is to understand the various benefit programs in which a client may be enrolled. The following scenarios give pragmatic examples of the various types of insurance programs.

Jonathan is enrolled in an HMO. The HMO has a network of providers who are credentialed. This means that the HMO has: verified the provider’s education; verified the provider’s liability insurance; established a written contract with the provider; interviewed the provider to get a clear understanding of the provider’s specialties; and conducted a site visit to assure that the provider has an acceptable, handicapped-accessible, and secure office. The client may only have benefit coverage if a contracted provider is utilized. Therefore, Jonathan must contact the MCO to receive a referral to a contracted provider when he wants to utilize his benefits, as all of his care must be precertified.

Jonathan has 20 outpatient sessions in a contracted year and each session has a copayment of $10. When Jonathan goes to see a therapist, he is financially responsible for only his copayment. The therapist, who is under contract, must make sure that all the subsequent care is precertified by following the guidelines of the particular MCO. It is usual and customary that if a provider does not follow the procedures for obtaining ongoing (concurrent) authorizations, the provider shall hold the client financially harmless. In addition, the care requested by the provider will be reviewed by the MCO case managers to determine if the services are medically necessary. Only care that is medically necessary will be authorized.

Matthew is enrolled in a Preferred Provider Organization (PPO). The PPO has a network of providers with whom the MCO has contracted in order to get guaranteed reduced prices. Matthew was supplied with a directory of providers when he enrolled in the program. When Matthew wants to use the services, he only needs to call one of the providers in the directory. As the provider selection is different from that of the HMO, so is the financial arrangement of the PPO.

Matthew has an outpatient limit of S 1,500 per calendar year after he meets a $300 deductible. His provider has a contracted rate and Matthew is responsible for a specified coinsurance. In Matthew’s case, his coinsurance is 10% of the contracted rate. Matthew’s care will not be managed clinically or financially. It is Matthew’s responsibility to keep track of the amount of money accumulated. In addition to Matthew’s in-network benefits, his PPO program also includes out-of-network benefits. If Matthew should choose to see a provider who is not on his preferred list, he would be responsible for a 30% coinsurance. There most likely would not be discounted rates for an out-of-network provider and, therefore, the 30% is of billable charges.

Sylvia’s employer has purchased an Employee Assistance Program (EAP). The EAP is a prepaid service that allows Sylvia to get a free assessment and referral. This is particularly helpful when Sylvia knows she has a problem but is not sure what kind of services she needs. The services generally covered by an EAP are assessment and referral, legal counseling, and financial counseling, as well as a referral source to community-based services. This benefit is available to all the members of Sylvia’s household even if they are not covered by her major medical insurance. The EAP is set up to be an assessment program so there are usually no barriers to access.

Sylvia can easily access this benefit by calling the Employee Assistance Program and explaining her situation. The intake specialist will either provide Sylvia with the information requested or refer Sylvia to an EAP-contracted provider for an assessment. When Sylvia goes to the EAP provider, she has no financial responsibility; the EAP provider will be reimbursed by the EAP program based on the contracted rate. The EAP provider will make a referral and help Sylvia get connected to the appropriate services. In addition, the EAP will perform a follow-up to make sure that Sylvia is comfortable with the referrals provided. If she is not, new referrals will be offered.

Jennifer has insurance coverage under an indemnity/managed indemnity plan. This is a traditional insurance program with a deductible and an 80/20 split. The only portion of her care that the insurance company reserves the right to manage would be surgical or inpatient services. This is done to make sure that the care is medically necessary. Whenever Jennifer needs services, she goes to any licensed professional she selects. She is financially responsible for meeting her $500 deductible, after which she will be responsible for paying 20% of the professional’s fees. Some professionals accept assignment, whereas others expect payment in full and the insurance reimbursement is then forwarded to the client.

Under an indemnity or managed indemnity, any licensed professional can accept third party payment. Under the PPO, third party payment will be available to providers who have a contract for reduced fees. Providers usually have the most questions about becoming credentialed for a HMO/MCO.

There are many reasons for an MCO’s wanting to credential its providers. These reasons include, but are not limited to, assuring quality of service, establishing/documenting quality of care, defining quality, and meeting specifications of credentialing bodies. Although providers are often put off by the need to supply a large amount of information when becoming credentialed, they must be prepared to do so.

Credentialing requirements often include information regarding quality care reviews. Quality care reviews are focused on how therapy is done and the effectiveness of such therapy. Therapists who are trying to become MCO panel members may run such studies themselves. There is much literature on outcome studies (Giles, 1993), but the point is that the study that is designed must not be too cumbersome. Simple follow-up studies may provide all the information needed to show that the therapy was effective. Therapists should get permission from their clients to contact them by telephone 90 days after therapy is completed. A simple questionnaire can be formulated to query the client about his/her impressions of achieved goals and the process of therapy.

Utilization review based on average length of treatment by diagnosis may be another tool for credentialing. An MCO may ask you what your average length of treatment is. The answer to this question can often be deceiving, especially if you have a high level of chronicity in your client load. Therefore, it behooves therapists to gather these numbers ahead of time and break the response down by diagnosis. For instance, the therapist should have a lower average number of sessions for adjustment disorders and V-Codes than for major depressive episodes.

MCOs are very interested in the voices of their members. Therefore, member satisfaction surveys are usually part of the credentialing/recredentialing process.

Therapists can easily produce and administer their own satisfaction survey to show how their services are perceived. A simple and brief Likart Scale questionnaire can be filled out by clients as they sit in the waiting room. Questions regarding office surroundings, helpfulness of support staff, therapists’ understanding of the problem, and confidence in the therapist will indicate to MCOs how your clients perceive you and your services. And therapists should not feel obligated to filter out responses that are not overly favorable, as it is expected that clients do not always find a good fit with provided services.

In addition, on-site visits with structured review of medical records may be conducted. During the site visit, the MCO will make sure that the office surroundings are adequate, that the office is handicapped accessible, that the therapeutic space is presentable, and that the clinical charts are kept in a secured place. Questions that might be asked on the site visit may revolve around clinical specialties. The application and site visit provide opportunities to show that you, the family therapist, are a natural match with the MCO. This is your opportunity to educate the MCO representative about how your ability to do family therapy allows you to help find solutions that incorporate all parties who may be involved with the problem. This is also a good time to explain the benefits of brief systemic therapy.

Some of the other information that the MCO will look for is administrative in nature. The MCO may gather information about your managed care experience and may ask you to produce a list of all the MCOs with which you are currently connected. In addition, the MCO will gather information regarding the provider’s current license, work history, liability claims history, legal history, and malpractice insurance, as well as get a statement attesting to good physical and mental health. All of these are ways for the MCO to make sure that therapists are who they say they are. The MCO will verify the information and materials that are provided. Although this may all seem a nuisance, it protects clients as much as it does MCOs. In addition, such vigilance protects therapists since the MCO evaluates whether a given therapist is a good match for their services. If it turns out that the therapist and the MCO are not compatible, the process will have saved the therapist a lot of time and much energy trying to fit in.

Just as speaking the language of your client is necessary, when approaching an MCO you need to speak its language— business. You want to explain to the MCO that family therapy is not only time-effective, it is cost-effective in that the goals of systemic family therapy include helping the client/client family find solutions to problems that are applicable across many life problems. This may mean fewer representations to therapy down the road. And, should the client represent, the likelihood is that it will probably be more for a mental health check (a reintroduction to the learned solutions) than long-term treatment. It is also important to present this in a realistic light. For example, solution-oriented approaches may not work with all clients; they work effectively with approximately 70% of all presentations (O’Hanlon & Weiner-Davis, 1989). Finally, it is important to indicate how your method of working can help with more severe presentations and can help to deescalate high-risk situations.

For example, if the MCO had a client who suffered from psychotic episodes, you would want to explain how you would bring the family into session to better educate them about the problem, and to enlist their help in recognizing the signs of when the identified client is starting to become disoriented. You would also want to describe how the client would be educated on how to use the family as a support system or be assisted in developing natural support systems in the absence of traditional families. Besides the basic clinical functions, you need to clarify for the MCO how your clinical skills translate naturally into case coordination and case management (discussed in Chapter 6).

¹ Because many therapists are not family therapists but do work in a brief systemic fashion, the word “therapist” or “provider” will be used synonymously with “family therapist” throughout this book.

² The word “client” will be used synonymously with “family client.”

2

The Scaffolding

This chapter focuses on the identifying information for each client/family that is necessary to obtain in order to retain authorization from the MCO. This easy how-to approach will help therapists remain organized both for their own private practice and for MCO requirements. In addition, sample forms are provided to help therapists understand the administrative world of managed care.

After the client calls the MCO and is given a referral to the provider, the client will call the provider to make the first appointment. Some MCOs will forward the intake information to the provider in detail, others will not. If the information is not sent, the provider can gather the demographic intake briefly.

The provider will want to get the name, address, home and work phone numbers, type of insurance coverage, date of birth and gender of the registered client, and the name of the group, employer, and the Social Security number of the insured. The MCO should have obtained a brief description of the problem, history of treatment, name of the family physician, and any substance abuse history during the telephonic intake process. The MCO would have gathered this information in order to make an appropriate referral. The provider may want to gather this information in order to determine the scheduling need of the client. If the case is urgent, then the provider will need to schedule the appointment quickly (e.g., within 48 hours). This type of responsiveness is critical to both the client and the MCO.

Develop Good Documentation

The most significant aspect of the provider’s case file is clear and precise documentation. This starts with a good understanding of why the client is coming to therapy. In addition, such documentation helps set up the boundaries for treatment. Probably the most important document a therapist could have on file is the therapeutic treatment plan. This treatment plan includes the demographic and clinical information that is required by law to be in each clinical file (e.g., Florida Law 495.54). An organized treatment plan will help the MCO case managers to follow your treatment.

The demographic information found on a treatment plan may include, but is not restricted to, the client/family name, the client’s address, the client’s date of birth, the client’s phone number, the insurance subscriber’s name and Social Security number, and the subscriber’s employer. This information helps the MCO to identify the client’s records and to verify the subscriber’s eligibility for benefits. Some MCOs may provide a form for supplying this information. Therapists should ask the case manager which is preferred. One shortcut may be for the provider to gather copies of all treatment plan forms from all of the MCOs with which the therapist is contracted (remember to keep an original on file so you can always have a supply available).

Map out the breadth of information requested from these companies and collect these data on each client whether a particular MCO is asking for the data or not.

For example, MCO “X” may ask for employer name and address, whereas MCO “Y” doesn’t want that information but asks for the Social Security numbers of the client and subscriber. If therapists simply get into the habit of gathering the most comprehensive of demographic information, they will be better prepared for all MCOs and will not need to remember different rules for various companies.

Each state outlines under its mental health laws information that is mandated to be part of a mental health file. The majority of states require that the mental health professional inquire about and document a client’s medical history. Besides satisfying the needs of the mental health law, suc...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright
• Dedication
• Contents
• Foreword
• Acknowledgments
• Introduction
• 1. Here’s What Everyone Needs to Know
• 2. The Scaffolding
• 3. Working with Employee Assistance Programs
• 4. Brief Philosophies
• 5. The Strategic, Structural, and Milan Approaches
• 6. Case Management
• 7. A Pragmatic View of Case Management
• 8. Remember This
• Glossary
• References
• Name Index
• Subject Index