Many respondents, including clinicians and consumer advocates in the mental health and substance abuse fields, believe that it is acceptable for managed care plans to routinely collect additional summary information specifically for outpatient care pre-authorization, that is, after the first set of sessions, which typically do not require review. The specific types of information mentioned by respondents as acceptable vary, as described below.
The Problem, Goals, Treatment Plan, and Progress. One consumer advocate simply stated that it is reasonable and appropriate for insurers to know about the patient’s diagnosis and progress before continuing to pay. “We think payers should be able to know more than a bunch of check-boxes about a case. Consumers generally make a distinction between confidentiality within the health care system and the rest of the world.” Another respondent believes it is reasonable to submit a summary of the presenting problem, goals, treatment plan, progress made towards the goals, and future expectations (provider association representative speaking off the record). Similarly, a clinician said that it is not unreasonable for an MCO to want to know what problem the clinician is trying to address and what the treatment plan and goals are. Another said that MCOs generally need to know the diagnosis, level of impairment, and level of treatment appropriate to the condition, and that the Maryland Uniform Treatment Plan Form (Appendix B) is an appropriate vehicle for providing this information.
Same Items Typically Required by Indemnity Insurance. One clinician said it is reasonable to share a summary of a few lines that describes a patient’s condition, history, and prognosis. The same respondent believes it is acceptable to be asked to indicate something about the initial contact with the patient, whether the provider previously treated the patient, whether the client is on medication, how often the provider sees the patient, and what the provider recommends (for example, continuing treatment twice a month for three months). She said that, in her experience, these items were typically required under indemnity insurance.
Information Similar to That Required for Approving Physical Health Services. One expert on privacy issues from the advocacy community would not comment on what information is acceptable but said the test should be whether MCOs require similar information to pre-approve physical health services.
"MHPrivacy.pdf" (pdf, 768.25Kb)
"appen-b.pdf" (pdf, 224.4Kb)