On the Lighter Side

Useful Managed Care Treatment Guidelines

By Martin H.Williams, Ph.D.

I have an old friend named Clem who has knocked around from job to job. Sometimes he rides the rails, and occasionally he ends up in jail.

He’s never gotten much of an education, and I last heard that he was working in a muffler shop. I always felt his days were numbered at the muffler shop, since he had a tendency to weld together whatever “looked like they should go together.”

I also dropped in once to have my shocks checked, and observed Clem to be welding rather close to a full gas tank. Clem, you see, was never long on smarts. Sometimes Clem gets distracted by the illumination from the welding torch. He says it reminds him of a glow he used to see after taking “some really good acid.”

Well, you can imagine my surprise when he E-mailed me that he is now a Case Manager for Efficiency Incorporated, a managed care company.

Clem wrote that he liked the work, but that it hardly paid more than installing mufflers and shocks. He said he would probably keep the job for a while because, as Clem put it, “you don’t get your hands dirty,” an ironic choice of words that went well over Clem’s head.

Clem tells me he has a certain fondness for the psychologists he speaks with on the phone. He said they seem to be very nice people, and cooperative, too. He said, “I feel so great. I can literally control their lives—me, the guy who dropped out of eighth grade.”

The reason Clem wrote to me was to share the guidelines he uses as a Case Manager. He said these guidelines are supposed to be top secret, but not being an honest man anyway, Clem felt comfortable sharing them with me.

Clem found these guidelines to be so helpful, he wanted me to share them with all of you, thinking that if you knew these guidelines, you would save a lot of time on the phone when you call for treatment authorization.

Please do not be distracted by the asterisks. Clem has an old habit, dating from his school days, that has him place an asterisk next to any word he does not understand. He intends to look them up later, but never does.

Efficieny, Inc. Treatment Guidelines for Common Mental Health Conditions

Condition, followed by Number of Approved Visits and Treatment Focus

Borderline* Personality* Disorder 2 (Note: This is the only condition that is approved for long term treatment. Hence, two visits are permitted.) Firmly inform the patient not to continually overreact* to situations. Take a firm, paternal or maternal tone and say, “Now what good does it do to cut on yourself?”

Major Depression* 1 Patient needs to learn to “get over it” and to “think good thoughts.” Advise care provider to advocate “being a positive person.”

Panic Disorder 1 Patient needs to be told to “relax.” Patients who cannot relax are resistant and unsuitable for treatment*. Also, tell patient, “It’s not like you’re going to die or anything.”

Marital Problem 1 Patient needs to gain perspective. Firmly insist that no one has a “perfect marriage.” Offer list of attorneys.

Schizophrenia* 0 This is a medical condition. No psychotherapy visits are covered.

Bipolar* disorder 0 See above regarding schizophrenia.

Schizoid Personality Disorder 1 Encourage patient to seek technical training. Message is “who needs people.”

Sex problems 1 Viagra or vibrator. Anything else is long term, non-covered treatment.

Clem wanted me to know that the only really hard part of the job is dealing with the few psychologists who think they know better than Clem how to treat patients. Clem feels that the time he has spent in various county jails has hardened him to the point that he can handle the few difficult psychologists. He also forwarded me an in-house chart that dictates how Clem should handle troublesome psychologists.

Efficiency, Inc., Guidelines for Managing Provider Conflict; 1)Nature of Conflict; 2)Remedy; 3)Disposition

1) Psychologist “talks back.”
2) Immediately threaten to remove provider from panel. Inform provider that there are 27 other providers in your same zip code, and that it would be very convenient for us to simply skip you if you keep this up.
3) Provider is removed from panel, even if he or she promises never to “talk back” again.

1) Psychologist requests additional visits.
2) Immediately ask the psychologist where he or she got trained, with the implication that someone with any decent training at all would not need extra visits for treating this condition. Really pour it on: Ask about each and every internship or fellowship placement the psychologist ever completed and for the names of each of his or her prior clinical supervisors. Not that the supervisors will be contacted, but it’s fun to intimidate psychologists.
3) Provider is removed from panel with one exception: If provider starts to cry and begs for guidance regarding how to treat the patient within the allotted number of visits, provider is considered rehabilitatable and will get repeat referrals.

1) Psychologist asks for approval of additional visits after the fact (the visits have already occurred).
2) No problem. Visits not covered and will not be paid.
3) No action taken if provider quickly hangs up the phone and gets out of your hair. If provider talks back, see above under “Psychologist talks back.”

1) Provider is not a psychologist and has a masters level degree
2) Great. This is who we like.
3) Offer reimbursement at 1/2 the psychologist rate. If masters level provider acts truly grateful, add name to panel. If any resentment is shown regarding the reduced level of reimbursement, remind provider of how many hundreds of thousands of masters level counselors are out there and drop provider’s name from panel.

1) Provider has a sob story about a suicidal patient.
2) Carefully gather information while implying that putting the patient in the hospital will result in the provider being dropped from this panel and from every managed care panel that ever existed or ever will exist. As soon as provider gives any indication that an outpatient treatment strategy might be feasible for a little while longer, document provider’s exact words. This documented quotation will be used to establish liability once provider becomes a defendant. Be prepared to testify that you would have immediately authorized inpatient admission but that the psychologist did not think that was necessary. Quote provider’s exact words to that effect (leaving out, of course, that you had threatened him or her with utter economic ruin in order to extract that quote).
3) As soon as provider gives any indication that an outpatient treatment strategy might be feasible for a little while longer, document provider’s exact words. This documented quotation will be used to establish liability once provider becomes a defendant. Be prepared to testify that you would have immediately authorized inpatient admission but that the psychologist did not think that was necessary. Quote provider’s exact words to that effect (leaving out, of course, that you had threatened him or her with utter economic ruin in order to extract that quote).

1) Provider has publicly criticized managed care
2) Act like there is a bad connection and neither authorize nor refuse requested visits.
3) Drop provider from panel. Also drop all provider’s friends and anyone who has ever talked with provider from panel.

1) Provider calls seeking authorization for treatment of high-up executive who works for our managed care company
2) Immediately authorize unlimited visits. Psychologist offering psychodynamic orientation is preferred.
3) Hey, unless we take care of our own key people with high quality psychotherapy our productivity could suffer.

1) Ivan Miller or Karen Shore calls
2) All visits authorized as well as full inpatient benefits.
3) Hey, it’s well worth it just for the fun of messing with their heads.

After Clem and I discussed the chart, Clem felt compelled to share a personal confession with me. He said that he usually does not even look at the chart. Instead, he has a daily number of visits that he knows he can authorize while staying within his quota. To keep himself entertained, he authorizes those visits in various ways.

For example, one day he might come into work and authorize every call that comes in until he uses up all his visits for that day. Calls that come in after that point, will get no authorized visits. Sometimes, Clem with authorize every other call, meaning that he alternates yes and no from call to call. Other times, Clem will authorize a few visits early in the day and then see if he can deny enough visits so that, just for fun, he can authorize whoever calls at precisely 4:59PM for fifteen visits.

Clem said he really likes working there, that it is lots of fun, and that he has made use of his health coverage to get some badly needed psychotherapy. By the way, he said, we get really good health coverage with this job, “It’s not like they just give us managed care or anything,” he added.

Clem then had to go to see his psychologist. It seems that he has gotten into psychotherapy to deal with his self-defeating lifestyle. Maybe that’s why he has kept this decent job for so long and hasn’t gotten drunk or fired. He said he didn’t trust this psychologist for the first fifteen or so visits but is really making progress now.

“Thank God,” Clem said, “that my psychologist didn’t have to call to get authorization after the first few visits.”