Q: I just got a call from an insurance company asking to review my treatment of a client. What kind of questions am I likely to face and how can I best prepare for them?
While treatment review has always been a part of insurance reimbursement, therapists in the last few years have reported an increase in such phone calls from insurance companies. This is an unintended side effect of the 2010 Mental Health Parity and Addiction Equity Act, which states that if a health plan had no limit to a client’s covered visits to a primary care physician, there could be no limits on visits to a mental healthcare provider—for any covered diagnosis. While some plans were exempt from this legislation, in 2014, the Affordable Care Act extended this equal coverage to even more clients.
However, even if a client has coverage for unlimited visits, the insurance company can still deny reimbursement for any visit it deems not “medically necessary.” This is true even for out-of-network providers. As soon as a claim or superbill is submitted, the insurance plan has the right to interview the therapist (and even review client records) to determine whether treatment is necessary and appropriate. This means that all health professionals need to be able to defend the medical necessity of their treatment. But what’s the health plan looking for when reviewing for medical necessity? What does the language of medical necessity sound like, and how can you learn to speak it fluently?
Medical Necessity Criteria
Each health plan has its own criteria for defining medical necessity. These criteria vary between plans, but commonalities occur. It’s usually required that treatment attempts to relieve some diagnosis or suspected diagnosis given in the Diagnostic and Statistical Manual (DSM), and most plans require more than what the DSM once called V-codes, where the focus of treatment is not an illness, but something like a relational or phase-of-life problem, an academic or career issue, or simple bereavement. Therapy can’t be solely focused on personal growth, self-esteem, or communication, but must be aimed at reducing medical symptoms (e.g., insomnia, anxiety, or depression) or reducing impairment. Treatment must be deemed necessary, not just desired by the client.
The reviewer needs to believe the type of treatment you’re providing is a proven treatment, consistent with the best standard of care, and the most cost-effective for the client’s symptoms. The emphasis is usually on brief, cognitive, and/or behavioral approaches. The reviewer will also want to hear that the client is making progress, or at least that therapy is preventing a deterioration of functioning. For example, the client may have gone a longer-than-usual time between sessions and a noticeable decline in functioning occurred. When appropriate, the reviewer will look for a referral for medication evaluation, care coordination with other treating providers, and inclusion of family therapy when working with a child.
Treatment Review Tips
Don’t go in blind. If you have an upcoming treatment review, contact the health plan, request an outline of the questions that will be asked, and ask for the plan’s medical necessity criteria. This is often posted on their website or included in their provider manual.
Focus on observable symptoms. When reviewing treatment with an insurance plan reviewer, avoid lengthy discussion about the client’s history or any theoretical analysis of the case. Focus on the present, describing current, observable symptoms from the DSM. Cite severity, duration, frequency, and scores on diagnostic tests (even simple self-report scales). For example, instead of saying, “The client is depressed because of attachment problems and a disengaged family system in childhood,” a better picture of the same case would be “The client is experiencing symptoms of major depression, including insomnia five nights a week, social isolation, severe lack of appetite, a weight loss of 10 pounds in the last month, loss of pleasure, poor concentration, and lack of motivation, and scores a 29 on the Beck Depression Inventory.”
Identify problems in functioning. Be sure to identify how these symptoms have negatively affected functioning regarding work, family, friendships, finances, and activities of daily living (ADLs), including self-care, showering, dressing, and grooming. For example, you could say, “Because of depression, the client missed five days of work this month, reports reduced work performance and productivity, stopped going to support-group meetings, and his partner complains that he demonstrates lack of attention to their children.” Here’s another example: “Since the rape, the client has had symptoms of PTSD, such as flashbacks twice daily, insomnia and nightmares averaging three times weekly, hypervigilance, and intrusive recollections of the rape, interrupting her focus at work. She experiences intense anxiety when alone, which has led to complete avoidance of being home alone, and has three drinks nightly to deal with anxiety.”
The Global Assessment of Functioning (GAF) scale was phased out with the DSM-5, but some health plans still ask for a score, so be prepared with an answer. Many health plans list a GAF of 40–69 among their medical necessity criteria for outpatient sessions. Know that if your client has a high score, reimbursement could be seen as not (or no longer) necessary.
Identify diagnosis and risk factors. In addition to your diagnosis, have details about current health conditions, with psychiatric medication dosages and who prescribed them. Be ready to outline risk factors in the case—for example, the client’s weekly alcohol/substance use and whether the client is a danger to self and/or others—and past history of substance abuse, suicide attempts, and psychiatric hospitalizations.
Interventions paint a picture of you. When the insurance plan asks about your treatment plan or interventions, the reviewer won’t be satisfied with vague answers like “weekly individual therapy” or “validation and support.” Instead, you need to identify what you’re doing in session, what homework is being assigned, and how these interventions will reduce symptoms, reduce impairment, or prevent relapse or hospitalization. Also, you should discuss any referrals and coordination of care with other professionals. For example, you could say, “I’ve assigned the client to keep a journal, recording panic-attack frequency, duration, severity, and triggers, as well as coping skills used, and we review her entries together in session. I’ve referred the client for medication evaluation, and I monitor her medication compliance and her self-report of its effectiveness and side effects. I’ve taught her relaxation exercises, mindfulness meditation, and breathing techniques to use when experiencing periods of high anxiety.”
Another example would be to say, “I’ve been teaching the client emotional regulation techniques to deal with the anger that’s affecting his work performance and parenting. I’ve assigned him to read three chapters of the book When Anger Hurts between each session and do written exercises, which we discuss in session. I referred him to a divorce support group to increase his support, which he’s attending. I gave him handouts on parenting after divorce. Given his history of alcohol abuse, I check with the client each session about his current alcohol use, and am monitoring his use for signs of abuse.”
Tie goals to symptoms. Avoid open-ended goals like “improve self-esteem,” “increase self-confidence,” or “find new meaning in life.” Also not recommended are statements such as “help client identify feelings” or “heal inner child.” Remember, for treatment to be covered by a medical health plan, the goal must be to reduce observable, medical symptoms, such as depression or anxiety. But treatment goals must be more specific than “decrease anxiety.” In fact, when writing treatment goals, it can be helpful to go back to your list of symptoms and identify a measurable and realistic goal for each symptom.
So instead of saying the goal of therapy is simply to “reduce anxiety,” you might say it’s to “reduce the client’s panic attacks from once daily to less than twice monthly. Her anxiety will be of shorter duration and less severe, as reported in her anxiety journal, and her score will be greater than 14 on the ABC Anxiety Quiz. She’ll be using relaxation techniques learned in therapy, in stress-reduction class, and from the Anxiety Workbook.”
Pick an identified client. Even when treating a family or couple, insurance companies require one identified client. For this reason, it isn’t enough to cite the goal “help couple communicate better.” A better goal might be “the client will be using conflict deescalation skills taught in session and from a workbook, and will demonstrate the ability to take time-outs to avoid violent or abusive behavior when interacting with her husband.”
Watch out when discussing progress. When it comes to treatment reviews, paradoxes arise. To be covered, a client must have a diagnosis and be “sick” enough to need therapy, but not be too sick to engage in treatment and follow treatment advice. The plan won’t want to cover more treatment if your client isn’t showing progress, but if too much progress is demonstrated, the reviewer may feel treatment is no longer medically necessary and may ask why the client couldn’t be supported by a self-help group, or at least seen less often. Thus, be prepared to identify progress, however small, as well as what’s left to work on. Be ready to discuss why your frequency of sessions is clinically necessary, especially if you have sessions more than once weekly.
Don’t take it personally. Above all, don’t think of the reviewer as the enemy. Be friendly and cooperative. Don’t be defensive, even if you feel challenged. Take the approach that you need to educate the reviewer about the case and your clinical reasoning. Remember, if the plan doesn’t approve treatment, you can always appeal the decision using the plan’s appeal process, or take your case to the state department of insurance. Alternatively, the client may choose to pay for the treatment out of pocket.
Unexpected Benefits
You may naturally be anxious before a treatment review, but it may help to know that sometimes a review has unexpected benefits. I’ve found that reviewers have offered helpful ideas, advice, and resources. One reviewer told me about a free online smoking-cessation program the insurance plan had for members—a resource I hadn’t known about, which turned out to be quite helpful to the client. And some of the benefit of a review comes from simply preparing for the conversation with the insurance plan. It causes me to think more deeply about a case—about my client, what techniques and approaches I’ve tried, what’s worked, what hasn’t. Before a review, I often go back and read all my notes on the case, and I may notice some important piece of his history that I’d forgotten—perhaps that the client made a suicide attempt as a teen, or that his father was alcoholic—which may change my current assessment of his risk of suicide or alcohol abuse. When I have an upcoming review, I also do something I should do more frequently: ask the client for feedback about his experience of therapy, what progress he feels he’s made toward his goals, and what I’ve done that’s helped and hasn’t. This type of conversation can lead to both client and therapist reengaging in treatment with renewed focus and enthusiasm.
Photo by Michael Burrows/Pexels
Barbara Griswold
Barbara Griswold, LMFT, is the author of Navigating the Insurance Maze: The Therapist’s Complete Guide to Working with Insurance – And Whether You Should. She has a private practice and provides consultations to therapists nationwide with insurance questions and problems. She writes a monthly blog for therapists on insurance and has been interviewed on National Public Radio’s “Morning Edition”.
