The Insurance Mole

I have a secret I’m going to confess to the world right now- I was trained as a peer reviewer for insurance companies. That’s right. Those people (commonly known as a care manager or peer reviewer) who call you to talk about why your client needs more sessions.

Don’t hate me!

The truth is, I was trained but then I never got any peer review cases and the job just sort of fell off. So no, I never actually questioned why a therapist hadn’t justified medical necessity or denied sessions to anyone. But through that process and my experience working as a Quality Assurance Manager I’ve learned quite a bit about documenting for insurance.

Contrary to popular belief, insurance isn’t always out to get us and refuse paying for services (not all the time, anyway!). Think of insurance companies as a slightly OCD relative who maintains a very strict schedule and throws a tantrum when you want to make changes to vacation plans on the fly. They like their schedule and they’re sticking to it… unless you give them a good reason not to. 

You see, insurance companies work with millions of customers, so they have a lot of data. They’re able to see the average number of sessions people normally attend to deal with various problems or to work with certain diagnoses. 

They also rely on research. They know what type of treatment is proven to alleviate certain symptoms and what treatments work more quickly or have longer lasting results.  

Insurance companies then use that information to determine medical necessity, essentially,  whether or not a treatment is needed for a specific client, appropriate to the diagnosis/symptoms, and determine it’s effectiveness over time. (To learn more about medical necessity, read this past blog) They have a game plan. And when you sign that form to contract with an insurance company, you agree to play the game.  

So, the big question is whether or not you can all (therapist, client, insurance company) play the game and achieve a win-win-win. My answer is a modest yes… if you play by the rules and learn to woo peer reviewers every once in a while.

First, know the insurance company’s definition of medical necessity. As a peer reviewer, that was the first thing I looked at. Look at how your treatment fits into that definition. Write it out in a simple sentence or two, like a mini treatment plan. If you need more than two sentences, you’re getting too in depth for (most) insurance. Use concise language and be direct.

Second, evaluate the two biggest concerns of every insurance company- cost and effectiveness. Show the insurance company you’re not trying to squeeze every last penny out of them. You just want to do what’s best for your client. When talking with a peer reviewer, identify the progress you’ve already made. This highlights the effectiveness of your treatment. Then identify a clear plan for completing treatment. That may be two weeks or two years from now, but you need to show you’re thinking about the end result.

Ultimately, I was told that if a therapist could explain to me how the services were medically necessary and would help the client, I could recommend they were approved. However, I was only supposed to give a therapist about 15 minutes to do this, ask follow-up questions and make my recommendation, which is why I emphasize learning to be concise. 

Insurance companies feel like big bullies sometimes but remember that when you’re on the phone with a representative, care manager or a peer reviewer you’re just talking to another person. Treat them with respect, listen to their questions, ask them to clarify and know that they are working within the rules of the game as well. And the goal of the game is to get your client the best treatment they need and get them well as soon as possible. Hopefully, that’s something we can all agree on!

Still have questions about documentation and insurance? Check out Barbara Griswold's website. She has a regular newsletter and fantastic resources.