Article – Insurance or Private Pay?
"Why I Do Not Accept Managed Care Reimbursement For Mental Health Services"
(by Lyn Kelley, M.S.Ed., LMFT — used with permission)
Reason #1: Lack of confidentiality
All managed care plans (MCPs) 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.
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: Difficulty getting treatment authorized
Due to the direct care management by MCPs 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.
MCPs 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 go 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 MCPs 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. 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 resolved.
Reason #3: Mis-diagnosing and/or over diagnosing in order to get treatment authorized
Some MCPs 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 MCPs do not cover marriage counseling, family counseling, 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.
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.