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 they 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 the reviewer needs to approve the patient's care. This does not have to be the case.
The goal of this book is to teach psychiatrists, mental health professionals, and administrators how reviewers think and how to conceptualize, present, and document clinical care in a manner that greatly increases the likelihood that reviewers will approve their request for care. Beginning with five questions that must be answered in every managed care review, the author discusses the following key topics and many others.
- Presenting your case to a reviewer—How to effectively present requests for inpatient, partial hospital, and substance abuse care and avoid common mistakes that decrease the likelihood that your request will be approved. How to answer the four clinical questions that must be addressed in every review even if they are not asked by the reviewer.
- Negotiating with the reviewer—How to negotiate with a reviewer who is reluctant to approve the care you request.
- Writing effective notes—How to write effective clinical notes in the patient's record that substantiate your request for care and increase the likelihood that it will be approved.
- Dealing with unethical reviewers—How to identify and take action against unethical reviewers and managed care companies that are insensitive to your patient's clinical needs.
- Appealing denials of care—How to appeal denials of care when you do not agree with the reviewer's decision.
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. This tremendously useful volume will be welcomed by every mental health care practitioner who must negotiate the current managed care landscape.
- Chapter 1. Introduction
- Chapter 2. Clinical monitoring, standards, and liability
- Chapter 3. Presenting your case to a reviewer
- Chapter 4. Presenting an inpatient case
- Chapter 5. Presenting a partial hospital case
- Chapter 6. Presenting a substance abuse case
- Chapter 7. Fundamentals of clinical documentation
- Chapter 8. Documenting an individual patient's care
About the Authors
Michael A. Fauman, Ph.D., M.D., is Clinical Associate Professor of Psychiatry at the University of Michigan School of Medicine in Ann Arbor, Michigan. He is also Medical Director and Vice President for Medical Services at Magellan Behavioral of Michigan, Inc. in Farmington Hills, Michigan.
This is a useful and easy way to read a book about negotiating with managed care reviewers.—Doody's Health Science Book Review Journal, 5/1/2002
Negotiating Managed Care: A Manual for Clinicians is an excellent, practical, detailed handbook every psychiatrist should read carefully and keep handy. In 8 chapters pertinent topics are discussed with good and poor examples included and reasons for each. Dr. Fauman presents convincing specific reasons with examples of practitioner frustration with reviewer denial of patient treatment. Tables list specific areas of disagreement, examples of records, which justify treatment with convincing details, which will result in positive reviewer decisions. Dr. Fauman shares his excellent clinical examples of doing requests and reports the right way and the wrong way. Reading this manual will assist clinicians in achieving correct care for patients by being prepared with timely, proactive information and evidence. Very well worth reading and imitating.—Leah J. Dickstein, M.D., Professor and Associate Chairperson for Academic Affairs; Director, Division of Attitudinal and Behavioral Medicine, Department of Psychiatry and Behavioral Studies; Associate Dean for Faculty and Student Advocacy, University of Louisville School of Medicine, Louisville, Kentucky
Whether managed care continues or not, this manual should be a valuable resource for any clinician. Why? Simply because it addresses what any good clinician should want to do for their patient, including cost-effective care, accountability, proper documentation, and maintaining the highest ethical standards. This manual contains almost everything you might want to know—or didn't want to know—about how managed care operates so that you can be as successful as possible in your interactions with a managed care company. It's as close as most clinicians will ever get to discovering the 'secret ingredients' of managed care's review process. A few hours spent reading this manual, and having it available for reference, can save clinicians much time, frustration, and reimbursement.—H. Steven Moffic, M.D., Director, LUMINOUS Managed Behavioral Healthcare Organizations; Professor, Med College of Wisconsin, Dept of Psychiatry & Behavioral Medicine, and Family & Community Medicine
This is an excellent book that is a must read for all psychiatric residents and early career psychiatrists. Dr. Fauman presents a well-organized and succinct review of how to document and present the clinical care of a psychiatric patient to a managed care reviewer. Dr. Fauman illustrates common pitfalls in reviewing cases and provides psychiatrists with sound strategies to avoid these common errors. The rich clinical vignettes illustrate his points and make this a readable book. The cases that are discussed reflect the clinical ambiguity of psychiatric care and Dr. Fauman provides strategies for documenting and discussing such cases in a way that reflects his own extensive clinical experience. Dr. Fauman's willingness to share his own clinical experiences gives the book credibility.—William R. Dubin, M.D., Professor of Psychiatry, Temple University School of Medicine, Psychiatrist and Chief, Temple University Hospital-Episcopal Division, Philadelphia, Pennsylvania
An excellent, straight-forward, readable, practical and succinct how-to-do-it manual for getting what you need for yourself and your patients. . . I recommend it highly.—Howard S. Sudak, M.D., Clinical Professor, Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
Although it is addressed to clinicians, this book will also be a good primer for managed care reviewers. Proper and improper reviewer responses to clinicians are illustrated and discussed. Interspersed with the cases are handy tables that outline the generally accepted medical necessity criteria that apply at different levels of care. Overall, this short book is worth the two hours or so that it takes to read.—Jay M. Pmerantz, M.D., Psychiatric Services, 5/1/2002