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Why I Am Reluctant to Accept Managed Care Reimbursement for Mental Health ServicesDear Clients:![]() If you are a member of an HMO, PPO, or other insurance plan that provides reimbursement for mental health counseling, please read the enclosed before making your choice regarding accessing those benefits with me or any therapist. If you still wish to use your insurance, please contact me as several of our staff are providers with various insurance companies and provider networks. Thank you, D. Lee Stoltzfus, M.A., M.S., Ph.D. Founder and President L.I.F.E. Management Systems Licensed Psychologist #8607 Marriage and Family Therapist #6746 Certified Executive Coach 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 sometimes 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, possibly
with limited clinical and ethical judgment.
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
many people without your knowledge or permission. The FBI and law enforcement
officials can probably 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: Difficulty 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, and some refuse
treatment for serious, chronic problems and only cover “short term
stabilization.” 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 even be anti‑therapeutic to
specific patients. 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. The financial bottom line, many times, is
more important to the MCP than treating the patient. The conclusion of many therapists is that
managed care can be dangerous to the mental health of the patient and the
therapist. Reason #3: Mis‑diagnosinq and/or over� diagnosing in order to
get treatment authorized Most 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 or family counseling, and some don’t cover
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 a diagnosis. The
therapist may be inclined to "make up" or "guess at a diagnosis,” which is not in the
best interest of the client. 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. If you have questions about this
important but confusing subject, please contact me so we can talk further.
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