Negotiating Managed Care: A Manual for Clinicians / Edition 1

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Overview

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.

American Psychiatric Publishing

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Editorial Reviews

Jay M. Pmerantz
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.

(M.D., Psychiatric Services)

Doody's Review Service
Reviewer: Raj Tummala, MD (Wyeth Pharmaceuticals)
Description: This is an interesting new book for mental health professionals and administrators about negotiating with managed care reviewers for approval of patient care.
Purpose: The purpose is to review clinical monitoring standards and educate the trained clinician on how to present cases to managed care reviewers in various psychiatric settings.The book also details the fundamentals of clinical documentation for accurate presentation. This useful and timely book largely meets its overall objective.
Audience: This book is targeted towards residents, psychiatrists, and other trained mental health professionals. The author is very solid and credible in the area of managed care.
Features: The book starts with a review of criteria and clinical monitoring standards and goes on to detail presenting a case to a reviewer. The author describes presenting cases to reviewers in various psychiatric settings such as inpatient, outpatient, partial hospital and substance abuse. He also details clinical documentation standards for better negotiation with the managed care. Some of the appendixes are especially useful for quick references.
Assessment: This is a useful and easy to read book about negotiating with managed care reviewers.

3 Stars from Doody
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Product Details

  • ISBN-13: 9781585620425
  • Publisher: American Psychiatric Publishing, Incorporated
  • Publication date: 2/28/2001
  • Edition description: New Edition
  • Edition number: 1
  • Pages: 128
  • Product dimensions: 6.00 (w) x 9.00 (h) x 0.25 (d)

Meet the Author

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.

American Psychiatric Publishing

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Table of Contents

Introduction. Clinical monitoring, standards, and liability. Presenting your case to a reviewer. Presenting an inpatient case. Presenting a partial hospital case. Presenting a substance abuse case. Fundamentals of clinical documentation. Documenting an individual patient's care. Index.

American Psychiatric Publishing

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