Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Sunday, March 2, 2014

Insurance-Speak, a Mini Book Review

Language is a funny thing. Sometimes literally.

In preparing for this post, I've been using these little sticky notes that were given to me by a friend, a few months ago. They're these cute, cold-weather animals-penguins, otters, seals-and they're made by some Asian company. The mangled-English description on the back reads:

Composure creates time to the full.
It is convenient to carry.
It can be used as prompts, footnote to use, convenient recording and reading.

If anybody has a clue about what "composure creates time to the full" means, please do comment.

I got a book from the library, Psychodynamic Practice in a Managed Care Environment, by Sperling, Sack and Field. It was published in 2000, but it's surprisingly less out-of-date than I would have expected. I found it useful in trying to understand the concept of medical necessity, which it breaks down into "the notions of (1) treatment need (i.e. the patient presents a diagnosis and symptom picture that are reasonably treatable), (2) clinical efficacy (i.e. a given treatment has demonstrated results), and (3) cost efficacy (i.e. a given treatment is less costly in comparison to other equivalent treatments)."p. 30

With respect to the confidentiality issues that come up around working with insurance companies, it makes what I think is an interesting point, when considered in light of today's mandatory insurance coverage. "Managed care organizations would argue that third party reimbursement is not a mandatory enterprise and that if an individual is contracting with a company for health care payments, he/she needs to abide by that company's rules for exchange of information." p.27

But what I found most useful were the suggestions for how to communicate with insurance companies to get approval for care.

The book claims that insurance companies are not interested in psychodynamic formulations, and that, in fact, the language of psychoanalysis will be confusing to reviewers, who are more comfortable with clinical language that "draws particularly from those bodies of theory that can be construed as supporting time-limited, and therefore purportedly cost-contained, psychotherapy."p. 41 

"Such descriptors as psychoanalytic, transference-based, interpretive, and insight-oriented are red flags that can scare off the managed care organization. Alternative and roughly similar descriptors such as, respectively, interpersonal, relationship history, cognitive reappraisal, and promoting reality testing would be more understandable..."p. 25

In fact, the book goes so far as to recommend always using "interpersonal", when you mean "psychoanalytic" or "psychodynamic".

The bottom line, though, is function. Insurance companies don't think treatment for intrapsychic difficulties that cause suffering is necessary, unless the suffering individual has trouble with work or relationships. So you need to speak to them in a language that emphasizes function and symptoms. "Such a language is rooted in the principles of mental status examination and the various symptom- and observation- based descriptors that it engages." p.42

The following are from Table 1. Psychodynamic Concepts and Their Behavioral or Cognitive Parallels p. 43

Psychodynamic                                          CBT/Functional

Intrapsychic Process                                 Underlying Psychological State

Transference                                              Cognitive Schema; graduated exposure (in vivo
                                                                    and imaginal) to earlier relational experience

Therapeutic Alliance                                 Positive Attribution; modeling

Working Through                                      Self-efficacy; stimulus control; contingency                                                                                                management; cognitive self-monitoring

Rationalization                                           Cognitive reconstrual

Projection                                                     External attribution

Suppression                                                 Avoidance

Repression                                                   Exclusion of information

Clarification                                                 Distancing

Confrontation                                             Decentering

Interpretation proper                              Reattribution; shaping; identifying alternative                                                                                         cognitive patterns

The idea is not that these concepts are the same. Just that they are parallel, and that the right-hand column is more easily understood by insurance companies.

To me, that means, "dumb it down, so you can give them what they want, because they can't understand what you're doing, anyway." This may be my interpretation of the authors' views on the sophistication of function- and symptom- based treatments.

There are other interesting topics in the book, and good explanations of various types of managed care. Some of these may no longer exist, but it's useful to have a history. And there's an almost comical paragraph about a future trend, "Focus on Quality of Care":

"...in addition to controlling costs, employers, health insurers, and consumers are all realizing that saving money is not worth much if the quality of care stinks. this seemingly obvious realization is a welcome addition to the prevailing zeitgeist in the managed care industry, and we hope it will increasingly filter into the review and credentialing practices of managed care organizations." p. 116

Little did they imagine how "quality of care" could be used to limit actual care.

The final language-related admonition has to do with the use of the term, "long-term treatment".
"Unless there is compelling reason to [use it], the phrase long-term treatment should be erased from your communicational vocabulary with managed care. It is simply anathema to their way of doing business. When managed care patients need long-term treatment, it is best to present the work initially as moderate term, and keep justifying on subsequent communications why the targeted treatment closing date needs to [be] extended." p. 113

I don't know how well the authors' advice translates to current day interactions with insurance companies. Will altering my language be the reimbursement difference for my patients? Maybe, maybe not. But it's interesting to note that not all that much has changed since the book was written.

And because I couldn't resist, here's the ultimate example of mangled English, from South Park's ninja episode, Good Times With Weapons. The song is called, "Let's Fighting Love".


  1. I have some parallel insurance company jargon that the author refers to as the Hot Air Index:


    1. Great Link. Made me laugh and scowl at the same time.