First, does therapy work?
To read some information on this, follow this link.
Insurance Quandaries & Questions (below):
If you choose to use your insurance, find out what services are covered by your plan and how many sessions will be covered. Please note: some highly effective strategies such as family or marital counseling or parent consultations may not be covered by your insurance. Some insurance plans list the maximum number of sessions allowed, but may only allow that number after a positive outcome from a utilization review. Check with your employer about the details of your plan. Make sure you precertify your care, if required. Your insurance company will require some personal information for reimbursement. This always includes a diagnosis and the types, dates of treatments. It may also include a description of the problem, functional status, personal background information, treatment goals, results of clinical tests, medication used, prognosis and progress to date. That information will be released to them only with your written permission. I will discuss diagnosis and treatment information and its implications with you so that you can make an informed decision. While this information is very sensitive and is generally treated as such by insurance carriers, I have no control over how any particular carrier or employer will handle this information after they have received it. Please note that if you choose to use your insurance benefits to pay for treatment, in some cases it may adversely affect your future insurability.
Some clients choose not to use their insurance. In these cases, decisions about treatment can remain entirely between my client and me. Treatment is usually more flexible. Without insurance, information about your diagnosis and life situation can be kept private. If you decide not to use your insurance, you may opt for less frequent and/or shorter, prorated sessions whose monthly costs may be slightly higher than typical co-pays. Many of my clients choose this option and avoid the pitfalls associated with some managed care plans. We can discuss this option at our first session.
Also, click on the following link to explore some of the possible ethical problems with manage care today. Managed Care on my end relates to any plan that requires that I must provide them a treatment report to get further authorization. Manage care on YOUR end relates to any plan where you must call someone at your insurance company and provide specific personal information to them before they will grant you an authorization. This probably applies to at least 80-90% of plans in the St. Louis area so it probably applies to you whether you know it or not. These are important issues to understand when you have a third party paying for part of your services (e.g. UHC, UBH, BCBS, Prudential, Aetna, Value Options, etc).
Link: Eleven Possible Ethical Issues related to Manage Care
How to understand and
evaluate your mental health benefits.
From: The consortium
for Psychotherapy, Brookline, Massachusetts, (617) 739-7083.
QUESTIONS
TO CONSIDER
WHAT CAN YOU DO?
Introduction:
Dear Mental Health Consumer:
As you undoubtedly know
there have been significant changes in the health insurance industry during
the past several years. The types of insurance options available vary greatly
- from traditional indemnity plans which allow you to receive services from
any appropriately licensed health care provider, to HMO plans where all of your
care is provided by a limited group of professionals.
In terms of mental health
care, the ways in which services are accessed, provided, and reimbursed have
changed a great deal. Until recently most states had laws which guaranteed a
basic mental health benefit. In most situations you could use that benefit for
any problem major or minor, in a way determined by you and your therapist to
best meet your needs. Now more and more insurers are turning to "managed
care" plans to monitor the delivery of psychotherapy and substance abuse
treatments. These plans serve "gatekeeping" and cost containment functions
by regulating who gets treatment, at what cost and from whom. The plans vary
enormously in terms of the benefits they provide, the procedures they follow
for reimbursement approval, and the amount of freedom they allow you in choosing
the type of treatment you want and the provider with whom you feel most comfortable
working.
These changes can be very
confusing to you, the consumer, as you try to understand and evaluate which
insurance plan will best meet your family's overall health care needs This pamphlet
is designed to clarify some of the confusion regarding coverage for mental health
services and to provide you with information you may want to consider when investigating
your insurance options or deciding to use your existing mental health benefits.
Reading this pamphlet may
raise questions which you'll want to discuss with your insurance company's service
representative, with the human resources department at your workplace, with
your therapist and your family. If you are uncomfortable with an insurer's policies
regarding provider choice length or type of care or confidentiality you may
want to consider other options. Remember that paying for therapy yourself is
not always more expensive than using insurance. Plans with high premiums deductibles
and co-payments that ultimately only allow you a few sessions of treatment may
in some cases cost more in the long run than paying privately. Weigh your family's
overall health care needs and consider all of your options carefully.
For additional information you may contact the Consortium for Psychotherapy at
(617)
739-7083. The Consortium is an association of experienced psychotherapists
working together to educate the public about the nature and goals of psychotherapy
.
For what purpose can I use my mental health or substance abuse benefit? Do I have to be "sick"?
With a Traditional Plan
Whenever you use insurance to pay for psychotherapy, the company requires that your treatment be "medically necessary". This means that your therapist must submit a diagnosis indicating the nature of your problem. Both mild and severe problems are covered.
With a Managed Care Plan
In addition to a diagnosis indicating medical necessity, managed care plans generally make decisions regarding coverage for treatment based on a number of plan determined factors, often including the nature and severity of your problem. Guidelines for w hat conditions w ill be covered may vary greatly from one plan to another.
When You Pay Yourself
You can seek consultation from mental health professionals for any reason you choose. People use therapy for personal growth, for help coping with stressful life situations, for marriage and difficulties, and for more chronic or serious problems.
How much therapy can I expect my insurance plan to cover?
With a Traditional Plan
Traditional plans offer a specific benefit defined either by a fixed amount of money or a fixed number of sessions per year. Deductibles and co-payments may apply. The full benefit is usually available for use in a way determined by you and your therapist to best meet your needs.
With a Managed Care Plan
These plans generally state the maximum number of sessions available. However, while your benefits may appear generous, access to those benefits is not guaranteed. Often only a few sessions may actually be approved for your use. Determination for approval may be at the discretion of the insurer's managed care case reviewer who, under some plans, reviews your therapy at varying intervals and then decides whether or not you meet the plan's criteria to continue.
When You Pay Yourself
The length of therapy and the frequency appointments are determined by you and your therapist, with negotiations about time and fee a private matter based on your needs.
What choice do I have about the therapist whom I see or the kind of therapy I receive?
With a Traditional Plan
You are allowed to choose among most licensed therapists, although some plans may limit your choice of therapists or exclude certain types of therapy.
With a Managed Care Plan
Your choice of therapist is limited to those who have a contract with the managed care company. Some plans publish a list of therapists and allow you to choose, some may assign you to a therapist, and others may allow your primary care physician to make the referral. When plans do offer the option of seeing non-contracting therapists, substantial deductibles and co-payments often apply. Managed care plans generally favor short-term and group therapy, and the use of medication.
When You Pay Yourself
You have freedom of choice in selecting a therapist you feel is right for you. Once you've decided with whom you want to work, you and your therapist can decide what type of treatment will best meet your needs.
What about confidentiality? Are my records private?
With a Traditional Plan
Therapists are usually obligated to disclose only minimal information to the insurer: diagnosis, dates of service, and type of therapy. The confidentiality of this information cannot be guaranteed by your therapist once disclosed. Some insurers submit medical data to national data banks - where the material then becomes accessible to other insurers and, potentially, to other parties.
With a Managed Care Plan
Therapists are required to disclose considerable information about you to most managed care plans. Information may include family background, psychiatric and substance abuse history, and relationship and work patterns. Confidentiality of this information cannot be guaranteed once disclosed. Some insurers submit medical data to national data banks - where the material then becomes accessible to other insurers and, potentially, to other parties.
When You Pay Yourself
When you pay for treatment yourself, full confidentiality is observed. Confidentiality is protected within the limits of state law for all licensed mental health providers.
What are my therapist's responsibilities to my insurance company? What if my personal wishes and goals are different from the insurance company's guidelines and requirements?
With a Traditional Plan
In most cases, the therapist's only obligation to the insurer is to provide information about diagnosis and date and type of sessions. Beyond that, your therapist is free to work with you to design a treatment plan that best meets you needs.
With a Managed Care Plan
When therapists contract with managed care companies, they agree to work within the company's guidelines and review procedures. The therapist also contracts to work with you to develop a plan to meet your goals. At times, your goals may differ from the insurer's guidelines or from the case reviewer's decisions. In that case, you may choose to appeal the plan's decision or to continue therapy privately.
When You Pay Yourself
The therapist's sole responsibility
is to you, within the limits of the law.
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(last edit 1/28/03)