Who Will Review Information? The position of the American Psychiatric Association (APA) is that, when an MCO wants to question the quality or appropriateness of care, one qualified, independent clinician should review the case. Several provider respondents support this idea and commented that, to support such a review, sharing the patient’s entire record with the reviewer is acceptable. This process is currently the law in New Jersey and the District of Columbia. However, in New Jersey there have been no such independent reviews in many years. 2
Absent a review process involving only one, and some specified “independent” clinician, 3 many provider and advocate respondents object to requests for the full record in order to justify treatment, although they sometimes provide full records to MCOs because this is usually the only way to appeal a denial. In theory, all respondents, including the MCOs, agreed with the concept that sensitive, highly personal information (names of family members with drinking problems, names of perpetrators of abuse) does not need to be included in the record. However, such details are often included in practice because maintaining a set of records for this information that is separate from the patient’s medical record would add considerable administrative burden to the provider’s practice. A couple of providers simply do not record details that would be inappropriate to share, but they acknowledged that it is likely that many providers do record such information for the benefit of any future treating provider to whom the records may be transferred.
Patient’s Explicit Consent. One provider respondent explained that she does not mind sharing information with MCOs about the problem, goals, treatment plan, and progress as long as the patient consents to this. While our sense is that mental health treatment providers often rely on the patient’s general consent to share information with payers, this provider told us she has specific conversations with all her patients about what information their insurer needs. She also said this practice of discussing the shared information has neither interfered with her relationship with her patients nor discouraged patients from treatment. We suspect that both patient and provider factors may contribute to this success in her practice. That is, other providers told us that patients in certain occupations, such as law or teaching, or with a high profile in the community are extremely sensitive about sharing any information. So, this provider may have fewer “high-visibility” patients, and/or she may be particularly skilled at explaining the rationale for sharing the information. Also, this particular provider was not aware of any problems in the MCOs’ handling of the information that she sends and generally maintains good working relationships with the MCOs in her area.
 In the District, there is no one responsible for tracking the frequency with which such reviews have taken place.
 Note that whether a clinician is independent or affiliated with the MCO is irrelevant from a privacy perspective, assuming that in each case there is only a single person reviewing the file.
"MHPrivacy.pdf" (pdf, 768.25Kb)
"appen-b.pdf" (pdf, 224.4Kb)