Understanding health plans to provide care and anticipate risks
Psychiatrists should be knowledgeable about the benefits provided under their patients’ health care plans. There are significant differences among plans, whether they are private or government-sponsored organizations. Most health care plans, including HMOs and PPOs, use evidence-based guidelines as a road map to decide what treatments are approved and in their review of physicians’ recommendations. Understanding the basics of each plan, such as the recommended formularies and approved treatment, will allow you and your patients to make more informed decisions.
Plans list certain mental illnesses as “coverable.” For each illness, plans specify approved treatments and the contexts in which those treatments can be prescribed. Although medication may be covered, many brand-name medications will not be approved until there have been trials of generic alternatives. A patient may not be able to continue to take certain brand-name medications started as an inpatient when outpatient use of those medications is not covered by his plan. In this situation, switching to a generic or other alternative treatment may lead to the loss of any short-term gain as the patient transitions to outpatient care. That is, such transitions may involve hidden transaction costs, such as when the patient is uninformed of the potential consequences of switching from a brand-name to a generic medication. For example, patients may be left without medications for awhile until they can see their outpatient provider. Also, alternative treatments may not be as effective as the inpatient treatment. In both of these cases, the transaction cost is the increased risk of decompensation of the patient. Therefore, a lack of planning, information, and communication increases the risk of an eventual negative outcome, including possible rehospitalization.
In light of third-party administration and the need for more efficiency amid limited resources, respect for patient autonomy has become increasingly important in clinical practice. Encouraging patients to learn about their illness, to reduce stress, to take responsibility for avoidance of substance use, and to understand their plan promotes thoughtful patient decisions about where to access care.8 This also allows patients to make more informed decisions about treatment, including when they may be required, or even elect to pay for services out-of-pocket.
If benefits are denied by a health care plan, psychiatrists may appeal on behalf of patients or, alternatively, educate patients about their rights so that patients can pursue their own appeals. This is especially important in cases where there is no adequate alternative to care. However, the likelihood of a successful appeal must be considered in light of information such as that from the New York Insurance Department, which indicates that of 11,179 appealed decisions to 15 HMOs, only 38% were successful.9
Even in cases where an insurance company acts egregiously, such as by denying standard care, patients who sue their health care plan providers may be limited to recovering only the benefit itself or a monetary equivalent under the Employee Retirement Income Security Act of 1974 (ERISA).10 Recovery cannot be gained from plans covered under ERISA for expenses lost and personal injury, including pain and suffering, because of an inappropriate denial of benefits.10
Administrative guidelines may protect the managed care organization when benefits are denied but may not protect the clinician. In sum, understanding covered conditions and treatment allows both psychiatrists and patients to better understand the most cost-effective ways to proceed with treatment. This also allows psychiatrists and patients to anticipate any potential denial of benefits and, therefore, prospectively plan for potential alternatives to care.
How to provide for continuity of care when leaving an insurance panel
Psychiatrists occasionally choose to leave a third-party insurance panel. When this occurs, the psychiatrist must continue to address issues, such as limited resources available to provide continued mental health treatment; obligations to patients, including guarding against actual and perceived abandonment; and following contractual specifications and ethical guidelines in providing a smooth transition to another mental health provider.
When psychiatrists leave insurance panels, patients must receive adequate notification and continuity of care to reduce the risk that a patient will decompensate or “be lost to follow-up.” More planning and assistance during transitions of care may be required for patients in crisis. Some insurance panels require that treating psychiatrists continue to care for a patient in crisis even if the psychiatrist leaves the panel. Therefore, if a psychiatrist leaves a panel while a patient is in crisis, he may need to refer to the initial insurance panel contract or review the contract with a lawyer to determine his obligation to the patient and the steps required for the patient’s transition. The following recommendations assume a “stable” patient population.
Many of the notification steps that a medical practitioner should take when leaving a panel are similar to those that psychiatrists take when retiring from practice. For example, when psychiatrists retire, they need to notify their patients of the closure of their practice, help patients find a new psychiatrist, offer to forward records to the new treating psychiatrist and, if possible, be available for emergencies for a reasonable period while the patient is transitioning to a new therapist.11The difference between retiring from practice and leaving a panel is that in the latter case a patient may choose to continue to be treated by the psychiatrist, but the patient needs to be notified of the change and how it may affect the doctor-patient relationship.12,13
Patients can be notified that a physician has retired or has left an insurance panel via letter, by informing patients during a session, or by posting an announcement in the office. The last 2 methods can be problematic. In terms of risk management, it may be helpful to inform patients in writing with a letter to ensure that the patient has been notified. It is advisable to send patients at high risk for adverse transition-of-care events a certified letter at least 30-days before leaving the panel to ensure its receipt. The letter should inform the patient that:
• The psychiatrist is leaving the panel.
• The patient may continue to be seen at the office but may be subject to a different fee schedule.
• If the patient does not express an intention to continue at the office, then his file will be closed.
• The patient can contact the insurance company for a list of available psychiatrists still in the panel.
• Records will be sent to the patient’s new doctor on request.
The earlier the notification before the actual termination the better, because it allows the patient more time to decide whether he wishes to continue with the psychiatrist or find a new one. It can be a lengthy process to find a new therapist (depending on the availability of psychiatrists in the community). While it may be therapeutic to inform a patient during a session, oral communication does not provide sufficient documentation to prevent a malpractice suit (since it may become a “he said, she said” issue). It is not enough to inform patients merely with an announcement in the office because patients can legitimately claim not to have noticed the announcement.
Electronic means such as e-mails, instant messaging, blogs, or Web sites may soon become an acceptable way to notify patients. However, from a risk management stance, electronic communication is not currently the best means of communication because of potential confidentiality issues and Health Insurance Portability and Accountability Act (HIPAA) concerns.14-17 Also, if a psychiatrist corresponds electronically, he needs to respond as quickly to an e-mail as to a telephone call. For some psychiatrists, this means of communication is less practical or less efficient.16,17
If a patient “chooses” to terminate his relationship with a psychiatrist when the psychiatrist leaves the panel, the patient may be asked to sign a “voluntary termination of treatment” form during the final visit. This form should clearly indicate that the patient:
• Is choosing to leave treatment.
• Has been given a list of referrals or has been referred to the insurance provider to obtain a list.
• Understands that the psychiatrist with whom he is terminating will be available for emergencies for at least 30 days or until the patient finds a new psychiatrist.
This practice encourages sound documentation for rebuttal for any subsequent allegation of abandonment made by the patient.
It is not a psychiatrist’s obligation to find a new psychiatrist for the patient but rather to “assist” the patient in doing so. This is usually accomplished by providing names and numbers of other practitioners or contact information for the local mental health department. It is important to provide patients with as much forewarning as possible because in some locations it may take 6 to 8 weeks to obtain an appointment with a new therapist.
