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For many psychiatrists and other mental health professionals, the clinical review is the most burdensome and disagreeable part of managed care. In that review they are asked, by a representative of the managed care company, to justify their patient's need for care and to defend the treatment they are providing. Clinicians usually feel at a disadvantage in these discussions because they are never quite sure what information the reviewer needs to approve the patient's care. This does not have to be the case.
The goal of this book is to teach psychiatrists, mental health professionals, and administrators how reviewers think and how to conceptualize, present, and document clinical care in a manner that greatly increases the likelihood that reviewers will approve their request for care. Beginning with five questions that must be answered in every managed care review, the author discusses the following key topics and many others.
• Presenting your case to a reviewer—How to effectively present requests for inpatient, partial hospital, and substance abuse care and avoid common mistakes that decrease the likelihood that your request will be approved. How to answer the four clinical questions that must be addressed in every review even if they are not asked by the reviewer.
• Negotiating with the reviewer—How to negotiate with a reviewer who is reluctant to approve the care you request.
• Writing effective notes—How to write effective clinical notes in the patient's record that substantiate your request for care and increase the likelihood that it will be approved.
• Dealing with unethical reviewers—How to identify and take action against unethical reviewers and managed care companies that are insensitive to your patient's clinical needs.
• Appealing denials of care—How to appeal denials of care when you do not agree with the reviewer's decision.
These and many other important issues are highlighted in brief vignettes illustrating a clinician's presentation of a patient's case and a typical reviewer's comments. This tremendously useful volume will be welcomed by every mental health care practitioner who must negotiate the current managed care landscape.
Although it is addressed to clinicians, this book will also be a good primer for managed care reviewers. Proper and improper reviewer responses to clinicians are illustrated and discussed. Interspersed with the cases are handy tables that outline the generally accepted medical necessity criteria that apply at different levels of care. Overall, this short book is worth the two hours or so that it takes to read.
— Jay M. Pmerantz, M.D.
Michael A. Fauman, Ph.D., M.D., is Clinical Associate Professor of Psychiatry at the University of Michigan School of Medicine in Ann Arbor, Michigan. He is also Medical Director and Vice President for Medical Services at Magellan Behavioral of Michigan, Inc. in Farmington Hills, Michigan.
Chapter 1. Introduction
Chapter 2. Clinical monitoring, standards, and liability
Chapter 3. Presenting your case to a reviewer
Chapter 4. Presenting an inpatient case
Chapter 5. Presenting a partial hospital case
Chapter 6. Presenting a substance abuse case
Chapter 7. Fundamentals of clinical documentation
Chapter 8. Documenting an individual patient's care
Index