In my experience as both mental health practitioner and as managed care Agent of Evil (c'mon psyclops- you know I have a sense of humor about that!), you most definitely CAN get treatment for borderline PD authorized, but there are a few tricks I'd recommend to facilitate the process.
fyi, MBHO= managed behavioral health organization
1. Most of the losses incurred by the MBHOs (
hahahahahaha... but I digress...) come from inpatient admissions. Trust me, they will have a list of frequent flyers, and a good chunk of that list will have a significant Axis II disorder. These members are very expensive for them, and they will likely be looking for ways to decrease these costs. Pick a frequently admitted patient, have either UR, the inpatient therapist, or the psychiatrist contact the insurance and say "We both know this isn't a good situation, what can we do to work together to prevent readmission?" Make them work with you.
2. Many MBHOs will have a case manager designated to follow high-risk patients. This may be risk= high financial cost or risk= clinical risk. People we had flagged as high-risk were chronically non-compliant with outpatient follow-up, or had suicide attempts which resulted in ICU stays, had frequent readmissions, pregnant women... other categories, I'm sure. The case manager's job is to follow up with the member (read: nag) on a regular basis to encourage compliance with outpatient care, medications, and be a contact person if the member needs community resources, new referrals, etc., and can get the member into the habit of contacting the insurance BEFORE going to the ED. Psychiatrists could ask the UR staff to inquire if this is available through the BPD patient's insurance.
3. It would be really helpful if psychiatrists actually documented the diagnosis. If it looks, walks, and quacks like a duck, it probably is one. At a minimum, "Personality DO NOS with cluster B traits" would be good. It irks me when I talk with a psychiatrist about a mutual patient and we both verbally agree the patient is BPD and the doc refuses to put it in writing "because of the stigma". Hard to get someone into a DBT group if the doc won't document the diagnosis!
4. DBT groups are wonderful. They really are. Too bad managed care is just finding out they exist. And the statistics so far have proven that they're very cost-effective in reducing inpatient costs. However, there will be a slight increase to the MBHO in outpatient costs, as they'd be paying for both group and individual therapies now. So a stingy company will balk at that.... plus, depending on how closely they manage things, they will want to know lots of questions about the type of group, as only "medically necessary" treatment is covered, not support groups. Ultimately, it's in their favor to authorize more outpatient- it takes a LOT of outpatient sessions to equal one inpatient day.
So to get it covered..... when I worked at a CMHC, we had DBT groups and I referred an individual client of mine. I called her MBHO (conveniently, the one I later worked for) and explained about the fact that it's a didactic group, expected to reduce inpatient costs, time-limited (20 weeks at our place), that it's targeted toward a specific diagnosis, and gave specific symptoms to justify the client's diagnosis. They agreed to continue covering me for individual, and authed 10 sessions of group. Group therapist had to call after 10 and confirm attendance and compliance and was immediately given the other 10. When I started working there, I was able to educate my boss more about it, gave him the group manual so he could see what it involved, and he started to change his thinking on it.
5. Capitated benefits suck- the "20 sessions per calendar year" thing. All of the benefits for the plans I worked with were "unlimited visits per year based on medical necessity", which can mean different things. At my company, it meant we were completely nit-picky and intrusive. At my friend's company, it means they're hands-off unless they see something that looks abusive (ie, 70+ sessions/year). But LM's right- if it's capitated, they are under no obligation to pay. Start looking into CMHC referrals, as they will likely be able to continue services through state funding.
6. Check if the patient has a comorbid Axis I affective DO and is on disability, which often means Medicare. Medicare benefits are fairly loosely managed and grant more access to treatment than many private MBHOs. Caveats are that a) it may be difficult to find Medicare providers b/c of poor reimbursement rates if they don't have Medicaid or another supplement and b) Medicare will only reimburse psychologists and clinical social workers, not professional counselors. I have a Medicare/private supplement patient who I've seen now for 11 months, and I think I just added up that it's been 45 sessions to date (God help me) and no one has blinked. (Although to be honest, to meet her is to understand that she meets medical necessity criteria....)
7. Because of stigma, it might be hard to find a practitioner who is willing to take on clients with BPD. That may account for some of the resistance to psychiatrists referring. Who will take this person? The MBHOs may have a list of therapists who will... again, the CMHCs are a good resource... or talk to your colleagues about who they use. I got the above-mentioned client from a psychiatrist who works PT at a CMHC where one of my office-mates used to work. This is one of his private patients, and my friend is not a Medicare provider, so she referred him to me. That has led to him having one of his partners refer a patient to me as well. It's all about the networking, I tell ya.
Good topic for discussion, whopper.
psyclops- revenge is a dish best served cold.
