In Consultation

In Consultation

Surviving Treatment Reviews

By Barbara Griswold

May/June 2015

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…

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1 Comment

Saturday, June 6, 2015 1:03:58 AM | posted by Cheryl Davis
Very helpful article for me since note writing is an unpleasant chore.