Negotiating Managed Care : A Manual for Clinicians

For many psychiatrists and other mental health professionals, the clinical review is the most burdensome and disagreeable part of managed care. In that review clinicians are asked by a representative of the managed care company to justify their patient's need for care and to defend the treatment they are providing. Clinicians usually feel at a disadvantage in these discussions because they are never quite sure what information will convince the reviewer to approve the patient's care. The goal of this text is to teach psychiatrists, mental health professionals and administrators how reviewers think and how to present a case in a manner that greatly increases the likelihood that a reviewer will approve the request for care. Beginning with four questions that must be answered in every managed care review, the author demonstrates how to: present effective requests for inpatient, partial hospital, and substance abuse care; negotiate with a reviewer to get approval for your patient's care; respond when you and the reviewer disagree; write clinical notes that substantiate your request for care; deal with unethical reviewers and managed care companies; and appeal denials of care. These and many other important issues are highlighted in brief vignettes illustrating a clinician's presentation of a patient's case and a typical reviewer's comments.