Am I about to say something pro-insurance? Maybe
There’s nothing like insurance to get me back into blogging after being absent for awhile. This week, local therapists received a letter from a very reputable local insurance company about their plan to begin limiting mental health sessions without prior authorization, starting in 2024. If you’ve ever read my writings on insurance companies, you’ll probably expect an angry rant from me but I’m weirdly relieved.
You know that counterintuitive concept that kids feel safer and happier with clear rules? So do adults. I feel really happy to have clear parameters about how to work with this insurer.
Insurance coverage for mental health has evolved over the years. Once upon a time, it wasn’t covered at all. Then we got 12 sessions (or so). When parity went into effect, it was the Wild West with a vague threat that treatment must be “medially necessary” without a heck of a lot of guidance as to what that meant.
Finally, an insurer is giving me clear information: Each member gets 26 sessions with little review but if they’re not done by that point, we need an argument for covering continued therapy. Here is EXACTLY the documentation we need to have to review the case. We will approve medically necessary services.
The proof will be in the implementation, of course. But I can operationalize those requirements in my EHR using the tools I have. I can print the required pages in five minutes. And 90% of my clients don’t need more than 26 sessions per year. I can tell my clients what the rules are and we can plan collaboratively using clear parameters.
Here is the letter I sent my clients today and I hope it provides some guidance for anyone who need it:
Dear clients:
This week, one of the three insurance carriers I’m paneled with sent out an announcement about new session limits for mental health care. I’d be happy to share an unabridged version of the history of mental health care coverage, if you want to hear it. In short, insurers have lost COVID funding and mandates and are therefore working hard to reduce costs and increase access by moving people “through” therapy faster.
What happened this week?
One of the insurers I’m contracted with sent out an announcement that beginning January 1, 2024, they are setting an annual limit of 26 therapy sessions for each member/client/patient. For clients with medical necessity, we can request additional sessions using a prior authorization request but that will require a review of the most recent annual assessment, treatment plan and most recent five sessions of progress notes.
This is information that insurers have always been entitled to review but rarely request. This is information I’ve always maintained in your electronic record but now must insure is perpetually organized and ready for review.
What changes should you expect?
In the simplest terms, I will be including you more in the record keeping of your file. You will see me send you a (new) treatment plan for your review. If you think I’ve captured our work well, you can review and sign it. BUT I encourage your edits and input and we can use what I send you as a starting point for a plan we create together (that’s the best kind of plan, right?).
Insurers want outcome measures. The WHODAS survey that the EHR asks you to fill out once or twice a month is a global measure of functioning and the impacts that your symptoms have on daily life. I appreciate it if you can complete that survey when it comes up because it helps me justify services if we need to ask for authorization from your insurer.
If I am concerned that our frequency or duration of sessions or overall treatment would not pass a medical necessity review, I will need to discuss that with you. I cannot bill insurers I’m paneled with or not paneled with if I can’t make a medical necessity case. That doesn’t mean that the moment your distress is lower, we end services. It’s always justifiable to spend some time on relapse prevention efforts.
If we are not billing your insurance or coding you invoices, medical necessity doesn’t matter and while I still do keep session notes and plans, they do not have to be as formal. Of course, we always should agree that our work together is giving you a good return on your investment but that’s decided by you rather than your insurer.
Following up
I know that I will get a lot of questions about medical necessity once I send this out. The truth is that it’s not black-and-white. I will talk with you at our next session about the WHODAS measure, your current and historical scores, and when I start to worry that the insurer will question medical necessity.
The idea of review can be really scary or creepy for some people and I want you to know that I do not send your notes to an insurer without contacting you first. If I am in network with that insurer, I am REQUIRED to send them your notes upon request but I will notify you of the request. If I am not in network with your insurer, you can decide whether I send those documents and we can talk about risks and benefits of responding vs. not. If your insurance company doesn’t know about our work together and hasn’t been paying for it, they’re entitled to nothing.
I hope this answers some of the questions I anticipate and I’m happy to answer any remaining questions at any time.
Sincerely,
Katie