How to Prepare for Insurance Company Treatment Reviews

Tips for Proving Your Therapy is Medically Necessary

Barbara Griswold

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.

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.”

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.

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. 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. 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.

This blog is excerpted from "Surviving Treatment Reviews: How to Speak the Language of Insurance Plans". The full version is available in the May/June 2015 issue. To subscribe, click here. >>

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Topic: Business of Therapy | Anxiety/Depression | Children/Adolescents

Tags: addiction | Affordable Care Act | bereavement | conversation | depression | Diagnostic and Statistical Manual | DSM | family | insomnia | loss | major depression | psychotherapy | therapy | networker | insurance | review | treatment | Barbara Griswold

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1 Comment

Sunday, February 4, 2018 4:07:54 AM | posted by Brenda Thomas
Thank you. This article was exactly what I was looking for. I have a very important report to prepare but find I keep drowning in details. The insurance company agent (new guy on the block!) has sent me an extremely lengthy, detailed, complicated set of questions to respond to. And at that I feel that confidentiality prevents me from replying to many of these questions. Your article has been very helpful in that it speaks specifically to the type of questions the insurance company wants answered and how best to respond. I am so pleased that I shall also sign on. Once again, thank you.