Avoid Managed Care Benefit Denial

Harold J. Bursztajn

Patients, and where clinically indicated their families, need to be encouraged to become informed of the benefits they are entitled to by contract or state mandate.

Whenever possible, clinician communication with managed care should be not only with the patient's consent but with his or her active participation.

Such communication should be integrated into the patient's treatment program rather than treated as simply "business" or "administration." While those dimensions need to be acknowledged, helping the hospitalized patient relearn how to conduct business or administrate can be an important component of supportive psychotherapy.

Documentation needs to follow discussion with the patient. This includes not only documentation of short-term goals (for example, restoration of self-care behavior) but also consideration bearing on intermediate-term outcomes (for example, education in self-observation for early detection and reporting of symptoms consistent with relapse) and on long-term outcomes (for example, increased insight leading to a greater degree of autonomous function under conditions of stress). Where there are trade-offs among goals, those trade-offs need to be acknowledged.

Where treatment options are limited by economic or administrative consideration, the patient must be informed of this in as supportive a manner as possible as soon as it is clinically feasible.

Where the initial managed care review denies benefits, patients should be supported in the appeals process.

Where the appeals process appears to be unfair, patients should be supported in obtaining their own consultations for second opinions from clinicians not directly affiliated with the treating institution.

Where such a consultation supports the treatment program agreed to by the clinician and the patient, and where benefits exist but have been denied by the managed care organization, such an external consultation can be the last resort before court. When the managed care organization refuses to recognize such an external consultation, there are a variety of legal options that the patient and family can exercise.