In contrast to the previous models, which proposed ways MCOs might protect patient information after they collect it, several providers have put forward models for reforming the payment review system that would minimize the physician's obligation to disclose treatment information in order to receive payment.
Kevin Corcoran and William Winslade propose that the patient-therapist privilege, which currently protects the confidentiality of information disclosed by the patient in the course of treatment, be extended to include the managed care payer. The managed care plan would have access to patient data needed to authorize services, but would have the same ethical obligation as the provider to protect the data (Corcoran & Winslade, 1994). Whenever possible, the client, rather than the provider, should disclose the information to the managed care representative directly. The authors argue that this will help to create a stronger relationship between the client and the MCO, giving the client a greater understanding of why the payer needs certain information and how the information is to be used. This would also give the insurer a legal and ethical liability for maintaining client confidentiality.
The American Psychoanalytic Association, a membership organization of therapists conducting psychoanalysis, advocates for the adoption of a peer-review model for third-party reviews. In a peer-review model, when a payer requests an external review before paying a claim, the patient is referred to a second therapist who evaluates the patient and issues a recommendation as to whether continued treatment is justified or not (American Psychoanalytic Association, 1999). The reviewing clinician is under the same patient-therapist privilege as the treating therapist. In this model, the managed care company accepts the reviewer's assessment of whether or not to continue treatment, and no confidential patient information is disclosed to the insurer in order to secure payment.
Jay Pomerantz and colleagues (1998) designed a new behavioral health managed care system when their program was about to be carved-out to a managed behavioral health care organization. To prevent this, the mental health clinicians designed a new type of program to control behavioral health care costs that also resulted in less information being transferred to the third party insurer. Under this system, behavioral health clinicians have merged into Professional Affiliation Groups (PAGs), with a psychiatrist designated as the leader. While each clinician retains responsibility for his or her own patients, the head psychiatrist approves all inpatient stays and all outpatient treatment over six visits. In the event of a dispute between the head psychiatrist and the treating clinician, the case is reviewed by all clinicians in the PAG. Because level of care determinations are made within the PAG, all sensitive patient information is retained within the PAG, where all clinicians are held to the patient-therapist privilege. The only clinical information relayed to the managed care organization is the patient's diagnosis, date and type of session, short-term treatment goals, and Global Assessment of Functioning.
"MHPrivacy.pdf" (pdf, 768.25Kb)
"appen-b.pdf" (pdf, 224.4Kb)