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|In Consultation - Page 3|
Once the law is implemented, on January 1, 2010, insurance companies will need to provide the medical-necessity criteria to practitioners so they know the rules. As psychotherapists, we'll need to make the case for the medical necessity of any care we provide under insurance coverage by clearly defining the problem and setting mutually defined and attainable goals with each client.
Another likely insurers' strategy will be to "carve out" the mental health treatment benefit to a large behavioral health managed-care company to handle for them. The "carve-out company" charges insurers a set rate, so they're assured of stable costs. If the carve-out company can provide treatment at less cost, it keeps the difference, so there's an incentive to limit treatment. Many practitioners find such companies the most difficult to deal with because they often set up barriers requiring extensive paperwork every few sessions, so that practitioners get frustrated and end treatment prematurely. Individually, practitioners can combat these issues by carefully choosing the insurers they'll work with. Collectively, they can form practice associations, such as the Northwest Behavioral Health Independent Provider Association in western Washington State, to lobby and negotiate with insurers.
A positive byproduct of this legislation is that it may force health plans and the practitioners who contract with them to work together, rather than to maintain an adversarial relationship. If this happens, both will benefit. Our experience as managers of a behavioral health network in Washington State bears this out. For 15 years, we've had a balanced budget by being clinically focused and developing close collaborative relationships with our contracted providers.
Since the new law removes the session limits, the focus will be on clinical issues and how practitioners and utilization reviewers can work together. This is a great opportunity for practitioners to do what we do best: focus on the clinical issues and help clients improve functioning and remove barriers so they can resume their process of growth and development.
Mark Lanci, M.S.W., and Anne Spreng, M.Ed., are clinicians who've had extensive experience managing a behavioral health network for a nonprofit insurance company. Mental health parity and other relevant topics are discussed in their book The Therapist's Starter Guide: Setting Up and Building Your Practice, Working with Clients, and Managing Professional Growth. Contact: email@example.com. Letters to the Editor about this department may be e-mailed to firstname.lastname@example.org.