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Saturday, January 1

Letter to the Editor

Terri Schmidt, LCSW

The following is a “letter to the editor” in response to an article that appeared in the November 2004 Networker titled “The Managed Care Mess” by Lisa Daujotas.

 Lisa Daujotas is absolutely right in her view that managed care is not the choice for every social worker in private practice. However, it can be the right choice for others. This view will look at some of the positive aspects of managed care in order to give NASW members in private practice the ability to make an informed decision about the best way to structure their practices.

 A brief historical review is in order here. In 1993, the Illinois Chapter recognized the need to educate members about managed care issues, and initiated the Managed Care Task Force. I was one of the initial task force members, representing the views of private practitioners. Other members represented schools of social work, public and nonprofit agencies, employee assistance firms and managed care companies. Carol Goldbaum was our liaison to NASW’s Board of Directors. During its seven year tenure, the task force held a number of educational forums around the state in response to focus groups that determined members’ needs. We also published and sold a managed care directory with information about joining panels. Around 1995, the Illinois Dept. of Public Aid was considering a managed care format for recipients – Mediplan Plus. Many behavioral health professionals were concerned that behavioral health would not have parity with physical health. NASW’s task force took the initiative in organizing a coalition of professional associations, including the Society of Clinical Social Work, the American Psychological Association and the Illinois Hospital Association, among others, to craft a list of behavioral health criteria that needed to be included in any insurance options offered to public aid recipients, and met with the governor to discuss it. Members of the task force testified in the Illinois legislature regarding consumer protection in managed care. NASW also was represented on the Medicaid Advisory Committee regarding the design of Kidcare, ensuring that behavioral health was included in screening and provision of services. The task force was discontinued several years ago because it had fulfilled its original mission of education and advocacy.

A common complaint among all health care providers, including physicians, dentists, therapists, etc. is the increased amount of time needed on billing procedures. Currently, there are 45 million uninsured Americans and the rate of increased health care costs is greater than the rate of inflation. Managed care was introduced as a way of attempting to manage the rate of increase. It is not specific to behavioral health, but applies to all aspects of health care.

 Not all managed care plans are created equal; some are clearly better than others. The past decade has seen a great number of mergers and acquisitions in the field with the result that policies and procedures can also rapidly change within companies. The fact that few social workers are trained to have a “business mindset” can result in considerable difficulty in running a private practice which ultimately is a small business. Like any successful small business owner, it’s important to read the small print in contracts, determine if pre-authorization is required, verify benefits before seeing a client and making a copies of insurance cards for the client’s file.

 Here is a quick example of some of the interacting factors: The standard managed care reimbursement for an MSW ranges from $60 to $75 depending upon the company. Each insurance company has many contracts with different companies; each company may offer their employees a choice of several plans, such as PPO, HMO and POS. Each plan may have different deductibles and different co-pays, which in turn affects the out-of –pocket costs and monthly premiums. Typically, the higher the deductible and co-pay, the lower the monthly premium, and viceversa; the more choice in providers, the higher the premium, etc. So if a client has a $10 co-pay, and $1800 deductible, and the therapist is reimbursed at $60/hour, the client will need to pay the first 30 sessions of $60 each($1800 divided by $60) before paying the therapist only the co-pay. If the therapist doesn’t know this, and collects only $10 at the appointment, the therapist will not be paid the $50 balance. Furthermore, if the therapist bills the insurance company at $90/hr., only $60 will be applied toward the deductible, and $30 will be considered over the usual and customary fee.

Two clients working for the same company and having the same insurance company may have different deductibles and co-pays, depending on whether they chose a PPO or an HMO product. It is very important to include the client as being responsible for their portion of the bill and to involve them in helping to resolve problems with collecting money due. In a worst case scenario, the client may need to contact their human resource department to put pressure on an insurance company who is delaying the payment process.

Billing issues can be overwhelming to those practitioners who choose to use a professional billing service and sidestep this issue altogether. Typically, billing services charge a percentage of what they successfully collect from both clients and insurance companies. However, using a service enables therapists to remain on panels without being driven to distraction by billing problems.

Each managed care company may offer a number of products to their customers beyond health insurance, including wellness seminars, health fairs, employee assistance programs, and elder care resources among others. Each product may have reimbursement rates for providers that differ from rates for standard therapy. Some practitioners may receive a higher reimbursement rate for providing special services that are in high demand, such as counseling in a language other than English, biofeedback for pain control or training in providing SAP (Substance Abuse Professional) evaluations for companies contracted with the Dept. of Transportation (DOT). Usually, a clinician is asked to specify specialties and produce evidence of training during the annual or biennial credentialing.

The good news – bad news of behavioral health is that there is much less stigma surrounding mental illness. Witness the TV commercials for anti-depressants! Mental health and physical health are becoming much more integrated, which is the good news. The bad news is that behavioral health providers are obliged to follow a medical model which uses standard protocols for treatment and requires outcome measurements in much the same way that physical ailments are treated. Some practitioners think this is an infringement on their therapy. Others feel more comfortable using an evidence based medicine model for their practice. This is a very personal decision that each private practitioner must make. I believe managed care allows more people to get at least some of the help that they need in a very restrictive health care environment and that some is better than none. I also enjoy the fact that I have a full practice and a steady stream of referrals rather than relying on private-pay clients in a down economy. Finally, I find a diversified caseload much more satisfying professionally than a “boutique practice.”

While Ms. Daujotas recommends that NASW become involved in managed care issues once again, my opinion is that those members who choose to become private practitioners need to become better trained in small business operations. There are several newsletters designed for the business of private practice, notable “Psychotherapy Finances” and “Open Minds.”

If members’ responding to these two articles indicate a need to revive the managed care task force, then it will be important to be very specific about what the targeted problem is and how we will know when we have achieved a solution. That’s a lesson I have learned from managed care.

Posted on 01/01/05 at 02:35 PM (0) Comments

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