Things I Didn't Learn in School: Utilization Review

Utilization Review (or UR) is a fancy way of saying insurance review - it is the process health care providers have to go through to get health insurance companies to pay for treatment. While some internships provide an opportunity for students to learn this process, many don't (mine didn't), and it is certainly not covered in class curricula (which foster the illusion that being clinically correct is the only thing that matters). I imagine I'm not the first to tell you this illusion is false: clinical correctness matters...but only if you can convince a client's insurance company to pay for the treatment they need. If you can't convince the insurer, you won't be able to provide treatment, regardless of what your client needs (unless you happen to work with folks who are independently wealthy...).

While insurance companies claim that the purpose of UR is to ensure that their "members" receive the best care possible, we all know that a primary goal for the company is to contain costs. While they have an obligation to cover necessary services, they want to avoid paying for anything unnecessary, or ineffective. As a result, a primary focus of UR is the medical necessity of treatment. Most basically, you have to demonstrate that there is a clinical condition that is impairing the client's functioning and requires the recommended treatment (rather than a less-costly alternative). 

Classes address level of care from the perspective of ethical mandates to preserve clients' self-determination by providing treatment in the "least-restrictive environment" that allows for client safety and treatment effectiveness. In the UR process, however, level of care translates into cost: higher levels of care are more expensive. As a result, we have to make the case that the client would be unsafe, decompensate, or at least fail to improve at a lower level of care than whatever we're recommending. Even with a solid argument against lower levels of care, however, insurance may push back if the client has already exceeded expected/average duration of treatment at that level of care. 

That brings us to the trajectory of UR over the course of treatment. For most insurers, UR begins with prior authorization (also called pre-authorization, or pre-certification). Clinicians have to provide a diagnosis with supporting clinical evidence, make an argument for the medical necessity of the recommended level of care, and identify concrete treatment goals that cannot be achieved at a lower level of care. If the clinician has made a good case, the insurance company authorizes an initial number of days/units/sessions, depending on the level of care (e.g., days for inpatient, sessions for outpatient). Typically, the more expensive the treatment, the smaller the duration of treatment covered by the initial authorization; for example, I've seen an average of 3 days inpatient, 1 week partial hospitalization, and 8-12 sessions in intensive or standard outpatient.

Once the initial authorization has been used (or expires - they also have time limits), the clinician calls back to request additional time if necessary. They still have to demonstrate the medical necessity of this level of care, but also have to summarize what treatment has been provided, the client's response, goals for continued treatment, and the plan for discharge (e.g., a transition to a lower level of care). Obviously each concurrent review should show that the goals identified in previous reviews have been addressed, whether or not they have been met; if a goal has not been addressed, a solid reason should be provided. If medical necessity is unclear, or the client has already exceeded an average length of treatment, the insurance company may require a "doc-to-doc," where a physician employed by the insurer reviews the case with a physician or other licensed provider at the treating facility, and then makes a determination.

Once a client is able to be treated at a lower level of care, another call is made to the insurance company, summarizing the client's condition at discharge, verifying the total amount of treatment provided, and outlining the aftercare plan - what treatment will follow. This includes any outpatient appointments that have been scheduled, and in the case of a transition to any level of care other than standard outpatient, obtaining an initial authorization for that treatment.

Finally, some insurance companies will occasionally perform random audits of medical records to verify that treatment they've paid for was provided as described by clinicians, and was consistent with the contact between insurer and treatment facility. Medicare and Medicaid are most known for such audits, which are particularly crucial for Medicare because it does not conduct UR before or during treatment. Documentation is crucial to avoid owing money back to the insurer!

What tips do you follow for successful UR?

Nuances in Countertransference

In school, we learn a little about countertransference - basically, enough to know that it's normal for therapists to have emotional reactions to clients, which are called countertransference, and that these reactions can provide us with important information about the client's internal experience, and how others may relate to him/her. While that's useful knowledge for beginning therapists, countertransference is actually much more complex.

There are two ways of distinguishing various countertransference reactions that I find helpful. The first is subjective vs. objective. Subjective countertransference comes out of our own issues and histories, rather than the client's. One possible source of subjective countertransference is our past relationships - for example, when a client reminds us of our mother or daughter, a childhood friend or bully, and therefore elicits feelings from these relationships. Another source of subjective countertransference is emotional difficulties, traumas, or other vulnerabilities we've experienced. For example, someone who has had depression may find the experience of treating a client with depression more distressing due to fear of being sucked back into that state, or someone who has experienced rape may have strong reactions to a client describing a rape, let alone a client who has been a perpetrator, or even makes general comments that seem to justify sexual aggression.

While these kinds of subjective countertransference are normal, they do not give us information about the client, and can hinder rather than help therapeutic work. As a result, it's important for us to learn to recognize, manage, and contain our subjective countertransference, to keep it from negatively influencing the work. If we are unable to contain it, the ethical decision would be to transfer the case to someone who might be more objective, and if the reaction is to a certain client population (e.g., perpetrators of sexual abuse) we should seek out a field of practice or practice setting where we won't be working with that population.

Objective countertransference is elicited by the client, out of their own issues and histories. It gives us information about their emotional state, unconscious material, and/or how they may be experienced by others. For example, if we become irritated by a client, they may be experiencing irritation - even if they are not expressing it. If we feel distanced or dismissed by the client, they may also distance or dismiss others, or feel distanced and dismissed by others. Awareness of objective countertransference can be a useful tool in therapy, both by informing our own clinical hypotheses, and through carefully constructed comments sharing our observations, make implicit clinical material explicit.

The other useful distinction between types of countertransference is common vs. idiosyncratic. Common countertransference refers to the reactions that we always or usually have to a particular clinical situation. For example, sitting with someone who is depressed makes me feel like I'm in a black hole, and the feeling is so consistent that I can use it as a diagnostic tool. These reactions can be helpful (e.g., when they are a diagnostic tool), or unhelpful (e.g., if my lethargy when sitting with a depressed client interfered with effective intervention), depending on how we manage and use them.

Idiosyncratic countertransference is the unique reaction we have to a particular client and/or a particular clinical encounter. For example, experiencing a surge of anger toward a client with whom we have not felt angry in the past can point to their own anger, and/or to how they might elicit antagonism from others, while anxiety without a known cause likely reflects the client's level of anxiety. Such idiosyncratic reactions are the most informative kind of countertransference because they provide a window into this client at this moment in time, and may even reveal things that client is not yet consciously aware of. Of course, like all forms of countertransference, the utility of such reactions depends upon our being aware of them and managing them effectively so that we reflect on, rather than enacting, them.

How do you understand, manage, and use countertransference in your work?

Things I Didn't Learn in School: Paid Time Off

Today is President's Day, a Federal holiday in the U.S. recognizing the birthdays of Washington and Lincoln. Government offices, schools, and many other workplaces, have the day off.

This is the first year I have to work on President's Day - a fact that has led me to reflect on how agencies determine holidays, and other so-called "fringe benefits."

Let's start with where I'm working now: it's a for-profit company focused on the more acute levels of care (inpatient, residential, partial hospitalization, and intensive outpatient). As a result, 1) at least some of the programs have to run 24/7, and 2) there is concern about lost profits whenever programs are closed for a day. It's no surprise, then, that we're open on lesser National holidays (President's Day, for example, vs. Thanksgiving, when we're closed). We also don't get "holiday pay" - in other words, we don't make more for working a holiday than for working any other day.

I'm actually ok with not having the holiday off, because of another quirk of the for-profit world: "Paid Time Off," or PTO. Companies that use the PTO model don't separate out vacation, sick time, personal time, and holidays. Instead, it's all lumped together into one pool (called PTO). The employee has more flexibility about how this PTO is used. For example, if you have surgery you might use more of it as sick time, but if you never get sick, you have more time available for vacation. That's very different than the non-profits I've worked for, where sick time was treated separately, and was not seen as "earned time." In other words, you weren't entitled to that time, and how you used it was subject to scrutiny. But, back to the holiday: instead of using a PTO day today to get the holiday off, I can use that PTO day as part of my vacation time later in the year. In part as a result, I get more vacation in my first year than many other agencies would offer.

Now, it's definitely NOT true that all for-profit companies are open today. I think there are two other factors that play into it. The first is, will the company be able to get any work done? Any company that relies heavily on shipping, or involves government agencies (e.g., the courts), or schools, or other places that are closed, might as well close because not much will be accomplished anyway (they'd be paying people to come to work but not actually work much). The second factor is, is the agency unionized? Whenever unions get involved, there seem to be a greater number of guaranteed holidays. My second job is unionized and I think they recognize 12 holidays a year, vs. 10 at other non-profits I've worked for, and 6 at the for-profit I work for now (note that this is Massachusetts, and we have some additional holidays that bring the number up to 12).

There may be additional factors that play into an agency's decisions about holidays, sick time and vacations. If you are aware of others (or if my theories are wrong), please leave a comment below. The bottom line, though, is that you should definitely ask questions about the various kinds of paid time off when you're thinking about accepting a job. It would not have occurred to me to ask about holidays, but it's definitely something worth considering. While I prefer having the day available when I want to have time off (rather than a random Monday in February), it would be really inconvenient to have to work holidays if I had a child in school who would have the day off!

I'm Skeptical

This is probably one of the most frequent phrases i find myself saying: "I'm skeptical." It's true - I take just about everything with a grain...or sometimes a shaker...of salt.

I haven't always been this way. In fact, I was exceptionally gullible as a child (and was frequently tricked by my father, perhaps contributing to my eventual skepticism). I attribute the majority of my skepticism to two other sources, however.

The first is endemic to the information age. We have almost limitless information at our disposal, some of it from legitimate sources, and some of it...not. It's much easier for anyone to get their ideas out there (take this blog, for instance!). As a result, my first year curriculum at college emphasized making us "critical consumers of information." Where it was enough for our parents to try to find relevant sources for research projects, we were up to our eyeballs in sources and needed to know how to scrutinize the quality of available information.

We're also connected to one another in new ways, through digital access points that also introduce new security issues: cell phones, email, social networking, etc. We have therefore had to learn to be cautious about how we're presenting - and protecting - ourselves, while also paying attention to how we're connecting and with whom. In the last week, news stories have reported teens having pictures taken from the facebook pages and posted on a porn site, as well as an extortion attempt against another teen based on information revealed online. In the same period, I've gotten multiple emails "pretending" to be from a friend, and Paypal, both of wanted me to click a link to enter information. I've also gotten phone calls telling me I've won a prize and just need to enter information. Skepticism is both a natural outcome of, and much-needed defense from, this kind of environment.

The second reason I'm as skeptical as I am is because of the work I do. Yep, I said it. Call me jaded, if you will, but being a therapist has rid me of whatever naivete I  had left. I have learned not to equate what someone says with "the truth," both because everyone sees the world through their own (often distorted) lens, and because sometimes people don't tell the truth, even (especially?) to therapists! Defense mechanisms, transference, addiction, delusion, shame, anger, fear, etc., can all lead a client to say things that are distorted, or downright lies. We sometimes euphemistically say that the worst offenders are "poor historians." But, to recognize when things aren't adding up, we have to have our antennae up. We have to be skeptical to be effective. Gullibility can interfere with effective treatment.

That's been my experience at least. As a result, I'm almost always at least a little skeptical. Do you agree? Disagree? How do we strike the right balance of respecting our clients, while also respecting their treatment enough to be...skeptical?

The Continuum of Care

The continuum of care - I'd put this topic in the category of Things I Didn't Learn in School, but which is vital to (responsible) practice as a mental health provider. It goes along with the ethical principle of providing treatment in the least restrictive environment where the client's safety can be maintained.

At the one extreme are those clients who have difficulty with some area of functioning, but are able to continue self-care and maintain safety, and experience a restoration of functioning with standard outpatient therapy and/or psychopharmacology. At the other extreme are individuals whose functioning is so impaired that they require long-term institutionalization for 24-hour a day supervised care; these individuals are usually either unable to meet their own basic needs, and/or present a safety threat to themselves or others.

As with most continua, the vast majority of clients fall somewhere between these two extremes: many will at some point require more support than weekly therapy, but most will never require long-term institutionalization. Enter the Continuum of Care - a sequence of progressively less (or more, depending which way you go) restrictive treatment settings that allow a client to avoid unnecessary restrictions on their liberty, while also maintaining safety. Moving from most to least restrictive, the continuum of care goes as follows:

1) Long-term Hospitalization, often a State Hospital
Individuals are only admitted to a long-term hospital after conventional inpatient treatment (see below) has been ineffective. They typically have had multiple acute hospitalizations, and may have been on an acute inpatient unit for several months without showing improvement in functioning (or at least insufficient improvement that they can maintain safety out of the hospital). These individuals are typically moved to a long-term facility after they have been "committed" to the hospital by the courts for a period of several months.

2) Inpatient treatment
"Regular" inpatient units (in contrast to their long-term cousins, described above), are intended to provide "acute" care - in other words, they are designed for the short-term treatment and stabilization of individuals experiencing psychiatric crises. Inpatient treatment provides 24-hour a day supervision, aggressive psychopharmacological intervention (up to and including ECT when warranted), and case management in preparation for speedy discharge (admissions are often shorter than one week in duration).

3) Partial Hospitalization
Given the speed with which people are discharged from inpatient units following a crisis, there is often a need for more support than standard outpatient services. So, once individuals can maintain safety and self-care during the overnight hours (i.e., they no longer need 24-hour a day supervision), they are often transitioned to something called a "partial" hospital program. "Partial" (rather than full) refers to the fact that these programs are day programs (typically only about 6 hours per day, 5 days per week), and allow clients to return to their homes for evenings and weekends. Treatment includes some combination of group therapy, psychopharmacology, brief individual and family interventions, and case management.

4) Intensive Outpatient Programs (IOP)
When individuals are able to maintain safety and self-care without the need for such a structured program, they are often referred to an IOP as a transition between partial hospitalization and standard outpatient treatment. IOPs typically run between 3-5 days per week, for three hours each day. They provide group therapy, brief intervention with individuals and families, and case management. IOP may last from a week to several months, depending on the program, the client, and whether IOP is being used as a step-down from higher levels of care (where much work has already been done), or to prevent the need for higher levels of care (meaning there may be more work that needs to be done for the individual to stabilize). The presenting problem and insurance requirements also play a role.

5) Standard Outpatient
Not to be forgotten, standard outpatient treatment is the backbone of mental health services, in spite of its location at the far end of the continuum of care. After all, we hope that most patients can be maintained in outpatient treatment, and will ultimately no longer need treatment to maintain a satisfactory quality of life. This level of care is quite flexible, with the ability to titrate the frequency of counseling and psychopharmacology appointments to meet the client's needs.

Of course, this continuum can also progress in the other direction - individuals who are struggling in outpatient services can step up to IOP or partial, before needing to be admitted to an inpatient unit, and often patients are transitioned to IOP or partial who ultimately need a higher (inpatient) level of care. The existance of multiple levels, and the flexibility to move  between them are what make the whole system "work."

So, what do you think about the so-called Continuum of Care? Is it effective? The best way to ensure the least restrictive environment for clients? Or could we be doing things differently?

Things I Didn't Learn in School: The Numbers Game

An important skill to have if you want to do therapy for a living is getting clients to show up. As I discussed in a previous post, most salaried positions require a minimum number of "billable hours" per week (usually around 65% of the total hours worked), and both fee-for-service jobs and private practice only pay for billable hours. For all of us, there is a definite incentive to get clients in the door!

How hard that is depends in part on the population. With privately-insured populations, you or your agency may bill the client for no-shows or late cancellations (i.e., less than 24 hours notice). That puts some of the financial risk and incentive on the client - sharing the financial burden of no-shows. Of course, it's important to check the provider contract to make sure there isn't a clause barring this practice, and remember to bill the client rather than the insurance company (which won't pay for a service that wasn't provided!)

However, Medicaid does not allow its clients to be billed for no-shows. And since policies have to be applied uniformly to avoid discrimination, that means practices who treat anyone with Medicaid insurance can't bill any of their clients for no-shows. Except for private practices and very affluent communities, the majority of clinics fall into this category. Furthermore, clients dealing with poverty may face difficulty arranging reliable transportation, childcare, and phone service - all of which can interfere with attendance. 

The end result, at least where I work, is an average show-rate around 70%. If the productivity requirement is 65%, that means you have to have someone scheduled every hour just to meet the minimum! There go those bonuses, or that pay differential for fee-for-service staff, right? Not necessarily!

First, there are things you can do to get your show-rate up. Start by communicating to clients that you're reserving a time just for them, so it's important for them to be there, or cancel so that someone else can have the time. Reminders help - appointment cards, phone calls, postcards. So does a prompt follow-up by phone (or failing that, letter) to find out what happened and reschedule when someone no-shows. 

Then, you can hedge your bets by scheduling more people. Since a "billable hour" is really 45-50 minutes, you can schedule using 45-minute increments. That adds up to 10 clients in an 8 hour shift, with 30 minutes for lunch.

Those who are more daring can consider overlapping sessions - a form of double-booking. You would schedule the second session for around 15 minutes sooner than the first session would end, with subsequent sessions starting the full session length after than second session. So, for example, using 45 minute sessions: 9:00, 9:30, 10:15, 11:00.... Or using 60 minute sessions: 9:00, 9:45, 10:45, 11:45. Using this system, clients wait no more than 15 minutes (and only if everyone before them shows up, so it's best to schedule frequent no-showers early in the day), but you lose no more than 30 of 45, or 45 of 60 minutes.

It's important to think about your goals - both for productivity/income AND keeping your job manageable. It's possible to err on either side - too little productivity makes it hard to pay the bills, but too much can quickly become overwhelming, and make you less effective as a therapist!

Things I Didn't Learn in School: Medical Necessity

Periodically, I will be posting on elements of practice that are important to functioning as a clinician, but weren't covered in my graduate school training. The first of these is: Medical Necessity.

For those lucky few who do not work with third party payors (i.e., health insurance companies), medical necessity may be a foreign concept. For anyone who hopes to receive third party payment, it's a vital part of case documentation. Basically, insurers will only pay for treatment that is deemed medically necessary. If you get audited and have not adequately documented the medical necessity of your services, the insurance company can refuse payment or require you to give them money back. Not a good thing!

So, what criteria determine medical necessity?

1. There must be a documented mental disorder - a DSM diagnosis with supporting evidence. For example: "Tim suffers from Major Depressive Disorder, with symptoms including increased sleep and appetite, loss of interest in his usual activities, isolation, loss of motivation, and feelings of hopelessness and worthlessness."
2. The mental disorder must cause significant functional impairment (if you check the DSM, you'll note that all diagnoses actually include "clinically significant" impairment in functioning as a diagnostic criterion). Possible functional impairments include educational, occupational and social functioning, judgment, and self-care or safety. For example: "As a result of these symptoms, Tim's occupational functioning is impaired and he is in danger of losing his job."

But, it's not enough to just document that the person needs treatment, based on the two criteria listed above. You also need to demonstrate that you're providing appropriate treatment:

1. Treatment provided must be consistent with accepted standards for the diagnosis and degree of impairment (e.g., someone with mild occupational impairment doesn't need an intensive outpatient program)
2. There needs to be a treatment plan showing how treatment will address the mental disorder and functional impairments, as well as behaviorally-worded discharge criteria.
3. Progress notes should demonstrate that the treatment plan is being applied. There should be evidence of both progress as a result of treatment (based on what is reasonable for the diagnosis), and continuing impairment to warrant continuing treatment.

Medical necessity can feel like busy work, or one of those annoyingly inconsequential things managers nag about. On the other hand, it can be an important systems of checks and balances to prevent abuse of the healthcare system. How do you see it in your own practice?

Reference: Wiger (2005) The Psychotherapy Documentation Primer (PracticePlanners)