psychgeek said:
I don't think he objected to the question; he objected to having his clinical judgment questioned by an insurance rep. He had a pretty adversarial relationship with insurance companies in general and encouraged the same in his trainings.
He reminded me of another supervisior who told me that when she requests inpatient authorization she immediately gets p***** off and asks to speak to the insurance reps supervisor. She said she knows this is what is going to happen eventually and this approach saves everyone 20 minutes.
Too bad things got so adversarial in those cases. On the insurance side, my coworker and I were put to work as an intake CMs because of our prior hospital intake experience. This helped so much in knowing a) what a "good" assessment is and b) the pressures that an intake assessor is under- from the ED, the patient, the family, the floor, the psychiatrist, etc etc etc. I also covered inpatient cases for a while.
I worked at a regional office of a national company, so most of our hospitals were in our metro/state area and neighboring states. It's an incestuous mental health community around here- kind of like 3 degrees of separation, so you have to be VERY careful about not burning bridges. We were able to reduce (not eliminate- it will never happen) the amount of tension between ourselves and our facilities because of previous professional/personal relationships, and by improving interrater reliability on our end. Amazing what consistency can do. And humor. I don't see how people can do either side of that job without a great sense of humor. I was also surprised to find out how many UR and intake people took our statements so personally. Someone started crying on my buddy once when he said he couldn't authorize something and suggested an alternative. Crying???? Seriously???
Quality of assessment was so variable, that sometimes we had no choice but to question judgment. Most of the assessors we worked with were masters-level, a few doctoral-level folks. Some we learned we could rely on to consistently provide thorough and accurate information. They usually got what they wanted, b/c they came to "battle" prepared. Then there were the lazy people who didn't bring any ammo. I recall telling someone from my old hospital, "You KNOW I used to work there. I know what's on your form- how come you haven't asked those questions???????" I made him go get the answers and call me back. Bitchy? Sure. But he never called me again without a finished assessment. And then there were a few genuinely incompetent folks. A 20-minute anger outburst by a 14 y/o who did not get his way, in the absence of any affective symptoms, does NOT qualify as "bipolar I, most recent episode manic", people.
We had a few facilities who used psychiatry residents or fellows to call in clinical. Man I loved those facilities. Bar none, the best assessments I could possibly get. I had one guy who would tell me the diagnosis and then give me every DSM-IV criteria which the patient met. This made my job so much easier. Actually, now that I think about it, there was one exception.... but those were part of the next group.....
There were a few rural free-standing psych hospitals. During the day, the assessments were called in by an LPN. At night, by the switchboard operator. I wish I were kidding. These places offered transportation services (would send a van to the patient's house to pick them up and bring them in), so they were requesting pre-cert based off of a phone conversation with an upset parent of a belligerent 8 y/o. These were our nightmare cases, usually involving one of us having to call the family, and do an assessment ourselves. If a child was admitted, the ELOS was 10 days, no matter clinical presentation, diagnosis, or prognosis during treatment.
One thing I could never abide by that I heard a (horrible) coworker say- "Why am I recommending a denial? Because I can." Or how about "Because it's day 4 of the inpatient stay." F*** that. If I was going to question someone's clinical judgment, I needed to back up my statements with a clinical rationale of my own. Turnabout's fair play, and more often than not, it allowed us to have a clinical discussion and come to an agreement, rather than having an argument that accomplished nothing but perpetuating ill will.
jk
