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 reviewerAHow 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 reviewerAHow to negotiate with a reviewer who is reluctant to approve the care you request. -Writing effective notesAHow 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 reviewersAHow to identify and take action against unethical reviewers and managed care companies that are insensitive to your patient's clinical needs. -Appealing denials of careAHow 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 clinicianAs presentation of a patientAs case and a typical reviewerAs comments. This tremendously useful volume will be welcomed by every mental health care practitioner who must negotiate the current managed care landscape.
Author(s): Michael A. Fauman
Edition: 1
Year: 2002
Language: English
Pages: 128
Contents......Page 8
1 Introduction......Page 10
2 Clinical Monitoring, Standards, and Liability......Page 16
3 Presenting Your Case to a Reviewer......Page 34
4 Presenting an Inpatient Case......Page 48
5 Presenting a Partial Hospital Case......Page 62
6 Presenting a Substance Abuse Case......Page 76
7 Fundamentals of Clinical Documentation......Page 100
8 Documenting an Individual Patient’s Care......Page 114
D......Page 126
O......Page 127
R......Page 128
U......Page 129
