Use common courtesy. Standing up for your patients and practice is reasonable and appropriate. At the same time, treating managed care representatives respectfully and professionally will go a long way as you advocate for your patients.
Document clearly and concisely. Documenting your impressions, goals, and care plans succinctly and well in your notes will save you and the managed care company time, frustration, and dollars. Managed care representatives do not want to review illegible, poorly organized, or overly inclusive documentation.
An alternative to managed care: Practicing ‘out of network’
Some practitioners choose to practice outside of managed care networks—such as in fee for service—thus freeing themselves from guidelines and care limitations associated with managed care. Most health plans permit patients to seek treatment from out-of-network practitioners, although usually with higher out-of-pocket expenses.
Out-of-network practitioners who submit claims to managed care companies must follow many of the in-network rules, such as establishing medical necessity, submitting treatment plans, and undergoing utilization review.
Advantages of being an out-of-network provider—especially in a fee-for-service model—include practice independence, freedom from managed care paperwork, and the possibility of increased revenue by not having to accept reimbursement rates set by managed care contracts.
Disadvantages include potentially seeing fewer patients because of higher out-of-network costs, excluding lower-income patients, and receiving fewer referrals from managed care companies.
Out-of-network practitioners also have not gone through managed care companies’ credentialing, a process that assures patients that network practitioners are licensed and have not had serious quality-of-care or malpractice events that might adversely affect patient care.
Denials take managed care representatives more time than approvals. These busy people often look for reasons to approve reasonable care rather than to deny unreasonable care. If your documentation is clear and practice patterns are sound, your inpatient and outpatient treatment plans are much more likely to avoid the harsh scrutiny of the authorization denial process.
Managed care companies rely on the information you provide. The most common reason for denials being reversed on appeal is that additional information unavailable to the company at the initial review has been provided in the appeals process.
Learn from denials. Whenever you are issued a care denial, find out why. If a pattern emerges, you might need to change your practice or accept that certain types of care will not be covered routinely. For example, you might obtain psychological testing for every patient, whereas many managed care companies authorize testing only in specific circumstances. Thus, you could:
- modify use of testing
- or accept that this practice will not always be reimbursed.
Wellness and prevention programs
Managed care plays an important role in developing and implementing wellness, disease prevention, and disease management programs for employers and government entities. These patient programs reduce health care costs, decrease time away from work (absenteeism), and improve productivity (“presentee-ism”).5,6 Benefit plans often provide free programs and offer financial incentives for patients’ participation.
Health risk assessments, life-style coaching, and condition-specific management programs—such as for diabetes care, smoking cessation, or depression treatment—are becoming common in employee benefit packages. These programs try to improve patients’ health through care coordination with the patients’ health care providers.
As programs are developed, you can expect to regularly receive clinical information about your patients from managed care case managers who are trying to integrate their programs with your patients’ care. Case managers’ goal is to improve clinical outcomes through initiatives such as treatment adherence, patient education, and early detection of treatment resistance or symptom relapse. To take advantage of these resources, be aware of available programs and consider referring patients into them.
Related resources
- Fauman MA. Negotiating managed care: a manual for clinicians. Washington, D.C.: American Psychiatric Publishing; 2002.
- Tuckfelt S, Fink J, Prince Warren M. The psychotherapist’s guide to managed care in the 21st century. Northvale, NJ: Jason Aronson; 1997.
Disclosure
Dr. Sutor is a practicing psychiatrist at the Mayo Clinic, Rochester, MN, and has been assistant medical director for behavioral health at MMSI (the Mayo Clinic’s managed care entity) since 2001.