Getting More Sessions: Successful Treatment Requests
By Barbara Griswold, LMFT
(April 15, 2012)
So if you have been reading my newsletter, you know the 2010 federal parity law delighted therapists by granting unlimited sessions for most clients. But you also know that insurance plans (who were not so delighted) have sought to take advantage of the loophole that allows them to deny coverage for any service they deem not “medically necessary.” So we all need to learn to speak in a new way about our work, and be ready to defend the medical necessity of our treatment (to read my article on medical necessity, click here).
However, I got a lot of e-mails in response to the article, saying, “Hey Barbara, can you give us some examples?” So here are some examples of good and not-so-good responses when a plan asks about your treatment.
But first, let’s review: Medical necessity criteria usually requires that treatment: 1) relieve some DSM diagnosis (not just V-code), 2) be necessary for medical symptom reduction, 3) reduce impairment, 4) not just be for personal growth, 5) be the most cost-effective, 6) is provided to a client who is engaged and progressing, and 7) is the standard of care.
SO…..IF ASKED ABOUT SYMPTOMS:
- GOOD: “Client has symptoms of Major Depression including insomnia, isolation, social withdrawal, decreased appetite, suicidal ideation, and poor concentration, which interferes with daily functioning, most notably work productivity” (specific, identifies diagnosis, measurable symptoms, and impairment).
- GOOD: “Since rape 3 months ago, client has demonstrated symptoms of Post-Traumatic Stress Disorder, including flashbacks 3x daily, insomnia, hypervigilance, nightmares of the event 3x weekly, distressing and intrusive recollections of the rape, intense anxiety when alone, reports complete avoidance of being home alone.”
- POOR: “Client has symptoms of major depressive disorder” (symptoms missing).
- POOR: “Client has poor communication, poor self-esteem and is unable to identify feelings” (These are not medical symptoms – sounds like growth-oriented treatment).
IF ASKED ABOUT TREATMENT GOALS (Remember, they should be specific, observable, and/or measurable):
- GOOD: “Reduce panic attacks from 1x per day to no more than 1x per week. Client will take medications as prescribed and attend Mindfulness-Based Stress Reduction class to learn techniques to cope with anxiety.”
- GOOD: “Reduce oppositional and defiant behavior by following adult directions from 0x/day to 3x/day; Decrease fighting at school from average 2x/week to 2x/month. Increase attendance at school from 0 days to at least 3 days per week.”
- GOOD: “Symptoms of depression will be reduced, will no longer interfere with functioning, and will be measured by a t-score of 60 or below on the YSR Withdrawn/Depressed scale.”
- POOR: “Reduce anxiety.” (lacks numbers and frequency related to specific symptoms and is too vague).
- POOR: “Client and husband have been separated for 6 months but are still working on relationship. Communication is poor.” (In the first place, these are not goals. Client must be single person, not relationship, even in couples work. Identify: What MEDICAL symptom will be reduced for your identified client, and how will you measure the reduction?)
- POOR: “Help clients communicate better.” (vague and non-medical, and may sound like personal growth).
ANOTHER EXAMPLE: While this link is far more detailed than anything you might ever be asked for, check out this sample treatment plan for more tips.
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Barbara Griswold, LMFT, is the author of Navigating the Insurance Maze: The Therapist’s Complete Guide to Working with Insurance – And Whether You Should. To purchase the book or other resources for therapists, click here. Contact Barbara at firstname.lastname@example.org to get answers to your insurance questions.
Copyright 2008-, Barbara Griswold, LMFT. No part may be reproduced without written permission of the author.