Practical Tips to Working with Managed Care

With the changes to managed Medicaid, it is important for therapists to be ready to advocate for their clients and for the care they deserve. After over sixteen years of dealing with managed care, there are certain tips that might be helpful if you are new to the process of calling companies. Often this is a counselor’s least favorite part of the job and making it easier can be useful.

  1. When calling a managed care company, it is important to have an angle when asking for more visits. Calling managed care does help you define your goals concretely so that you can present them and also verbalize the progress the client has made. The therapist should be concrete and explicit about these goals (e.g., identifying certain triggers). If you speak in vague terms (e.g., client is struggling), the person you are speaking to may not have a sense of what you are working on with the client.
  2. In general, the ideal scenario for getting more sessions is that the client is doing well, and they are engaged in treatment but not well enough that they don’t need further treatment at a certain level of care. This way the treatment is working but there is also a need for more contact and ongoing care.
  3. Often clinicians are advocating for a certain level of care (e.g., intensive outpatient, outpatient rehab, etc). So, it is important to understand why someone needs outpatient rehab as opposed to a twice a week recovery support group. Be clear why this is so and make a case for a certain amount of structure and support the person needs.
  4. Involve the client. Clients should know what the implications are of their insurance company. For example, insurance companies tend to be “unforgiving” of poor attendance and clients should know that this jeopardizes their treatment on multiple levels. There are times where clients may feel blindsided by the decisions of their managed care company. Therefore, they should be informed of the process as it unfolds so that if treatment gets cut off, they will not be surprised or not prepared. If you feel a company is getting tighter about giving you more visits, it might be helpful for the client to know so that when they do need to end or transition to another level of care, they are ready. Companies may give you some time to terminate but at times it might just be a session.
  5. Try to understand the criteria for levels of care. There are some companies that you learn will only give you a certain amount of IOP visits (20-30) for example and it’s good to know that beforehand. If a company has a certain rigid criteria, I have not found that challenging this has been helpful. For example, I recently found that a company did not accept someone into inpatient rehab unless they had serious psychiatric or medical issues (though not serious enough to warrant inpatient psych or a medical unit). The former criteria of “failing IOP” which many companies use was not acceptable. When companies have very fixed timelines for more intensive outpatient treatment, they usually don’t go beyond the number of sessions allotted by the company.
  6. Be prepared. If you aren’t, it sounds bad. You should have access to very concrete information that you unfortunately may have to repeat over and over to different providers such as policy number, your facility tax ID, date of birth of client, etc. Clinically, a counselor may be asked to talk about how care will progress over time in the long term. While they often will not be held to this criteria, they need to know what their discharge plan may be down the road.
  7. So much has changed about inpatient substance abuse care. Many clients have a preconceived notion that they have to have inpatient to get better. However, it has gotten harder and harder for people to go inpatient. Clients can enter detox but only certain substances warrant this such as alcohol or benzodiazepines. With these substances, a medical professional needs to get vitals and the detox needs to be medically warranted. Often clients and family members feel they need it but should be prepared for a possible rejection.
  8. Rehab stays are very difficult to get when using managed care. They are often time limited and do not go up to 28 days. A client does not tend to get approved for rehab if they have not tried outpatient first. There is some good reason for this because the client may stabilize with outpatient care. However once again clients and their families may be very disappointed by this.
  9. Think long term. There are times where counselors may precert intensive outpatient treatment and exhaust benefits for ongoing care in the long term. While intensive care may help, clients may need to be in treatment over the course of a year and you want to make sure they can go to a recovery support group after intensive. A counselor needs to look at the long-term trajectory for a client and recognize that their client will get better over time given the support.
  10. Educate your client. Clients often will say, for example, I have 30 days inpatient benefits, but they don’t understand that these visits are granted if they are seen as medically necessary by the insurance company.
  11. As clinicians and as supervisors we need to make our programs as flexible and realistic as possible to provide good care given the restrictions we are faced with. Clients for example may need to come part time for some of our day programs where their insurance is being tight. They may not be able to come as often but they will keep the continuity of working with their specific therapist.
  12. There are times when managed care may ask for specific interventions such as involvement of family. It is important to make sure that this gets addressed because the next time a call gets made, there will be follow up.

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