Psycho-Babble Medication Thread 6242

Shown: posts 1 to 7 of 7. This is the beginning of the thread.

 

Med-Checks/Insurance

Posted by SJ on May 18, 1999, at 22:43:01

My insurance company requires that I get mental health referrals from a separate company, the name of which I guess I shouldn't mention (but it was called Greensprings just a few weeks ago). These people are not exactly pleasant to have to deal with, especially when one feels so bad. I'm pretty sure that one of the methods they use to limit claims is to make you so frustrated at dealing with them, that you just give up.

I'm confused about how much I have a right to expect as far as treatment goes. The only language used to describe my mental health benefit from the primary insurance company is that it's covered at 50%, with up to 20 outpatient visits per year. However, this outfit will only authorize 5 or 6 visits, and only for "med-checks". This is demoralizing, considering they are aware that I'm suicidally depressed often times. I'm not interested in med-check only treatment, either. I can get THAT from my primary care doctor. Many of us here know more about the meds we take than our doctors do.

What is it with this "med-check" method of treating depression? While medicine is certainly a big part of the picture, I thought that talk therapy had significant value as well (it does for me). I've received treatment from a nurse-practioner whose fee I was able to afford without getting insurance involved, but psychiatrists are nearly triple the cost. Ironically, the nurse wasn't covered by my insurance!

How do others approach this problem of having insurance companies (and their 3rd party administrators) dictating what kind of treatment you receive?

 

Re: Med-Checks/Insurance

Posted by friend on May 19, 1999, at 12:55:47

In reply to Med-Checks/Insurance , posted by SJ on May 18, 1999, at 22:43:01

> My insurance company requires that I get mental health referrals from a separate company, the name of which I guess I shouldn't mention (but it was called Greensprings just a few weeks ago). These people are not exactly pleasant to have to deal with, especially when one feels so bad. I'm pretty sure that one of the methods they use to limit claims is to make you so frustrated at dealing with them, that you just give up.
>
> I'm confused about how much I have a right to expect as far as treatment goes. The only language used to describe my mental health benefit from the primary insurance company is that it's covered at 50%, with up to 20 outpatient visits per year. However, this outfit will only authorize 5 or 6 visits, and only for "med-checks". This is demoralizing, considering they are aware that I'm suicidally depressed often times. I'm not interested in med-check only treatment, either. I can get THAT from my primary care doctor. Many of us here know more about the meds we take than our doctors do.
>
SJ---
Sorry - i can't answer your specific questions,
but here are some important facts to find out:
Each state has different legislation regarding
mandatory requirements for insurance companies regarding coverage. Hopefully, included in that
legislation, are specifics on Mental Health coverage. DO NOT ASSUME that all insurance companies know or comply with your state's legislation. Contact a state delegate in your state, and they can tell you what or where to find the legislation on STATE mental health.
One other point, it gets rather confusing on WHICH state covers you if you live in one state and work for a company in another state - so be sure to check out THAT part of the insurance law also.
Sorry I can't be of more help. I had to know these facts in order to fight for coverage.
good luck.

 

Re: Med-Checks/Insurance

Posted by Elaine on May 19, 1999, at 23:16:25

In reply to Re: Med-Checks/Insurance , posted by friend on May 19, 1999, at 12:55:47

Hi, I used to be with an HMO that covered mental health 50% up to 20 visits. Between weekly therapy sessions and periodic med checks with my pdoc, I far exceeded 20 visits in a year so I just used it as wisely as could, against the hour long therapy sessions rather than the 20 minute med checks. If you are forced into this restricted plan, the best you may be able to do is pay for your therapy and get whatever they will pay for med checks (having pdoc talk to you for 20-30 minutes so s/he can see if the medications are still appropriate). No medical plan is required to provide mental health benefits, my present one doesn't, but I don't understand how a referral service (and I'm not quite clear on how that works) can be more limiting than your actual health care provider. If they are being more restrictive (and do you have that in writing?), I might contact the Insurance Commissioner's office and check it out. You, your employer or whoever is paying the premium is paying for a certain amount of services, BY CONTRACT with the insurance company. I don't see how a referral service can legally step in and give you less than what you're paying for. I know why they do it - to show the insurance company how much they are saving in benefits - but I'm not sure of the legality, unless they're being sly and not putting it down as written policy. Anyway, my best suggestion is to check with the Office of the Insurance Commissioner, probably in your state capitol. Good luck!

 

Re: Med-Checks/Insurance for Elaine

Posted by anne on May 19, 1999, at 23:55:36

In reply to Re: Med-Checks/Insurance , posted by Elaine on May 19, 1999, at 23:16:25

Managed care organizations have found it less expensive to contract with agencies that specialize in providing mental health services. The advantages to both the pt and MCO are that they have 24 hour/day services available and they have better control of utilization, particularly in the inpatient setting. It is thought that in some teaching hospitals, patients admitted on the week-end don't get much treatment until Monday. These contracted agencies specialize in getting the most bang for the buck. They feel it best not to have the primary care doctor managing psych patients; their time is best used elsewhere. BTW these companies take triage seriously and utilize different types of practitioners depending on what is needed. I'm not saying this is a great system but it is becoming more common.

 

Re: Med-Checks/Insurance for anne

Posted by Elaine on May 20, 1999, at 23:31:34

In reply to Re: Med-Checks/Insurance for Elaine, posted by anne on May 19, 1999, at 23:55:36

Thanks for the info. I can see how it would work for inpatient care, and I am glad to hear that patients in crisis are well taken care of. But what about the scenario above, if I am reading it right, limiting outpatient benefits to medchecks when the insurance contract may read differently?

 

Re: Effective Utilization?

Posted by SJ on May 21, 1999, at 2:11:16

In reply to Re: Med-Checks/Insurance for Elaine, posted by anne on May 19, 1999, at 23:55:36

Excuse my cynicism, Anne, but something tells me that these 3rd party administrators are mainly in the business of pleasing the folks paying the bills: the insurance companies. I'm not buying the idea that they are only looking out for those poor souls who have only a primary care doctor that doesn't work weekends on their side.

I'm with Elaine: If I'm not satisfied with the response I get from Greensprings, I'll be contacting the Washington Health Care Authority. This is (just) my opinion, buy I think the more vocal we are about the crap these ins. cos. force upon us in the name of "effective utilization", the greater the liklihood we might actually see some positive changes in the mental health care arena. I think I can say with confidence that not many here are very happy with the direction that managed care has taken us, particularly regarding mental health care.

 

Re: Med-Checks

Posted by anne on May 21, 1999, at 16:45:57

In reply to Re: Med-Checks/Insurance for anne, posted by Elaine on May 20, 1999, at 23:31:34

Elaine,

If your policy provides for something more than med-checks, I wouldn't give up until you get what you are paying for. I seemed to have touched a raw nerve here. My point is not that this is the *best* medical care, but this is the kind of medical care middle-class people will be getting more of in the future. We have a 3-tiered system in the U.S. (the uninsured poor and near poor, employed middle class and relatively wealthy). Managed care arose because there were no gatekeepers with the old 80/20 insurance and having insurance increases demand for services. There were no incentives for docs to keep prices down or control utilization so we are now at the point where health care consumes about 14% of the gross national product. No other industrialized country comes close to this figure. Canada is closest to us at 9%, but Japan, Australia and the U.K. are in the 6-7% range. And they have universal coverage. Yes they have rationing in some form but we do too with managed care. That's all managed care is - a way to ration health care to keep it more affordable. Soon Medicare will go from a defined benefits plan to a defined contribution plan where everybody receives a fixed annual voucher with which they could purchase insurance or elect to stay with Medicare. But Medicare would be constrained by a fixed budget cap which would be maintained by cutting fees to providers when necessary. Thus, the risk of health care cost inflation would be transferred from the taxpayer to the Medicare beneficiary. This will segregate health care among seniors the way it is for working people.

Americans do not perceive health care as a social good the way Europeans do (implies available to all regardless of ability to pay). In the U.S. health care is seen as a private good (you get what you can afford) and this is unlikely to change.


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