The Medical Necessity Catch-22

Last month, I expressed frustration with insurance companies' reluctance to cover medically necessary treatment just because the client was experiencing (normal) ambivalence about behavior change. This week, I am (yet again) frustrated with an insurance company's initial refusal to cover treatment, this time for the opposite reason.

To be fair, they did pay for 7 weeks of inpatient and residential treatment thus far - due to the severity of the client's anorexia and the risk of death or medical complications as a result of very low weight. She was one of several patients discharged from residential last week because of contagious illnesses, with the understanding that she would re-admit once she was feeling better. Still at a dangerously low weight, with abnormal labs - but miraculously not having lost weight since discharge, in spite of illness - the insurance initially declined to authorize her readmission. Their rationale? She IS motivated for recovery, didn't lose weight and her electrolytes were within normal limits. 

Wait, didn't they just tell me they only wanted to pay for treatment for motivated clients? 

This client had gone to some pains to prevent weight loss and normalize labs because she was afraid she'd wide up inpatient instead of residential. Had her hard work basically undermined her ability to qualify for treatment at the appropriate level of care (i.e., residential)? What message does that send to clients, and at what risk?

Thankfully, when I appealed the decision, they did ultimately approve her readmission to residential. However, I'm still frustrated. Refusing to pay for treatment because clients are too motivated (in this case, claiming she could recover with less intensive treatment because she was motivated), or because clients aren't motivated enough, puts clients and clinicians in an uncomfortable catch-22. Whatever the client does, s/he gets the short end of the stick. 

For clinicians, we're faced with the daunting task of walking the tightrope in advocating for our clients: we need to frame the clinical information we provide to insurers to highlight just the right degree of motivation and progress. Too far in either direction, and our clients could be refused treatment. For clients, the danger is that those who are denied treatment for being too motivated or working too hard on recovery will learn that they need to be more symptomatic to get the treatment they want and need. When the symptom could be deadly, that's a serious concern. 

Yet another reason why healthcare reform should be a significant priority!