Managed care has created major changes in how psychotherapeutic treatment is provided.
When you pay for treatment on your own with no insurance coverage, you are free to consult any psychologist or other mental health professional of your choice and pursue a course of treatment formulated and agreed upon by you and your therapist. The privacy and confidentiality of your treatment is stringently protected by laws and professional ethical standards.
Under traditional insurance plans you are free to consult any licensed psychologist or psychiatrist and pursue a course of treatment formulated and agreed upon by you and your therapist, just as when you pay for treatment on your own. The privacy and confidentiality of your treatment is changed minimally insofar as you give written authorization to your therapist to file an insurance claim which specifies the diagnosis and dates of visits to the insurance carrier in order to have the visits covered by insurance.
Now many insurance plans use managed care organizations to control the cost of medical and mental health treatment. This creates a radical change in treatment planning and issues of privacy. The differences are essentially as follows.
Usually you are required to call the managed care organization to request authorization to see a therapist. You may be asked what your problem is, and you probably will be speaking to a person who has no training as a mental health professional. You will be required to see a therapist who is on the managed care "panel of providers." Usually one to five visits will be authorized initially.
If further visits are required, your therapist must ask you to wish to sign a release authorizing him to make a detailed psychological assessment and treatment planning report to the managed care "case manager." If you agree to do so, the case manager, who has never seen you, and who often does not have the level of professional training and experience of your therapist, will then decide whether the additional treatment requested will be authorized. If you decline to authorize your therapist to make the required report, no further visits will be authorized under your insurance coverage.
The information provided about your managed care coverage will specify a limited number of psychotherapeutic sessions per year, for example, 20 visits, or 50 visits. Under traditional insurance plans a limitation of 50 visits per year means that you will be covered for all 50 visits if you and your therapist agree that it is needed. However, under managed care coverage this is not necessarily so, and it is important not to confuse this figure with the number of sessions a case manager is likely to authorize. Managed care is designed for cost containment, which means brief psychotherapy. Your case manager might conclude, for example, that your problems can be resolved within 8 visits, or that further treatment is not "medically necessary."
What are your options? If you have a choice of different insurance plans you will be making an important decision about the type of treatment that will be available to you. The list below specifies four different types of plans starting with the plans that interfere the least in your treatment planning and going on to the most restrictive, limiting and intrusive.
The best choice is a traditional indemnification plan, which allows you to choose any qualified therapist of your choice and clearly specifies the cost of, or number of visits covered without the involvement or interference of any third party in treatment planning.
The next best choice is a PPO, or preferred provider organization, which allows you to pick the qualified therapist of your choice from a large number of therapists in your community, usually without the involvement or interference of any third party in treatment planning.
Next comes a managed health plan, which has the limitations which have been described above, but allows you to chose from a somewhat smaller number of therapists in the community who are on their particular panel.
The most restrictive are health maintenance organizations or HMOs, which sometimes require that you see a therapist who is their employee on their premises. Treatment is usually the most limited in an HMO plan. For example, the level of the training of the therapist may be lower and there may be great pressure on the therapist to restrict the number of visits provided. Sometimes treatment may be limited only to group therapy, or medication rather than psychotherapy may be pushed as a treatment modality.
The best of the above plans will cost more, but with the cheaper plans you may not be getting the treatment you need, or you may wind up having to go outside of your plan and pay for private treatment to get proper care.
If you are dissatisfied with the actions of your health maintenance organization (HMO) is taking, regarding the authorization of necessary and appropriate treatment for you, most states have a regulatory agency to handle complaints. In California, consumer complaints regarding HMOs is handled by the Department of Corporations at (800) 400-0815.
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