In Consultation - Page 2

 

Under the new law, she'll have access to as many outpatient sessions as she needs to keep her stable and out of the hospital. In fact, since inpatient costs for this kind of client account for such a large portion of health plan payments, your skill at crisis management, hospital-prevention work, and maintenance therapy with chronic, high-utilization diagnoses will be very attractive to health plans trying to contain hospitalization costs. Practitioners who can work closely with health insurance utilization managers will find themselves in a good position to get a steady stream of referrals, and a much easier time getting approval for additional sessions.

Though mental health parity means that clients will have access to an unlimited number of sessions, it doesn't mean that every client will get as many sessions as a therapist requests. Consider a 38-year-old client diagnosed with an adjustment disorder, unspecified. He's been seen the maximum number of times that his benefits allow each year for the last three years. Under the new law, utilization reviewers will be taking a close look to insure that the length of treatment matches the severity of illness. It's likely that adjustment disorders won't meet criteria for extended treatment.

According to Andrew Sperling, a lobbyist for the National Alliance on Mental Illness, "Under the new law, we will probably see more aggressive management of mental health benefits because insurers can no longer impose arbitrary limits" (The New York Times, October 6, 2008). Since the federal law doesn't limit the number of sessions, insurers will be putting a strong emphasis on defining and enforcing "medical necessity" before authorizing sessions.

Many practitioners have a hard time understanding "medical necessity" from the insurer's viewpoint. Practitioners often believe, "If I say the client needs it, then it should be necessary, right?" Medical necessity is a complex concept, but it has three general principles:

1. Establishing the presence of a mental illness. To meet medical necessity, a client needs to be diagnosed with an AXIS I disorder. Treatment for a stressed client who doesn't have a diagnosable disorder wouldn't be covered.

2. Treatment methods should conform to established general practices. Methods used should be accepted as legitimate approaches and not considered experimental. The therapist would need to show that the client is benefiting from the approach, with improved functioning. It's likely that evidence-based approaches would be preferred.

3. The level of treatment intensity should match the severity of illness. If a practitioner requested to see a client with an adjustment disorder every week for the next two years, the utilization reviewer would be likely to authorize 8 to 12 sessions, followed by another review.

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