Negotiating Managed Care: A Manual for Clinicians

Michael Fauman's little book is a pleasant surprise. It presents a realistic and balanced view of managed behavioral health care from the perspective of an insider, currently the medical director and vice-president for medical services of Magellan Behavioral of Michigan, Inc. Although I approached the book with hesitation—fearing that my clinician self was about to be lectured on how to dance to managed care's tune—that did not happen. Instead, I found a series of patient vignettes that served to illustrate the proper roles of clinician and reviewer in today's managed behavioral health world.

According to Fauman, rancor between reviewers and clinicians is avoidable, provided that each is respectful of the other's legitimate function. Mental health practitioners should be able to conceptualize, present, and document clinical care so that the necessity and cost-effectiveness of that care are readily apparent to reviewers. The reviewer's job is to use the information presented to evaluate the patient's need for help and to make sure that it is matched with treatment intensity.

Both practitioners and reviewers need to understand where the other is coming from. The key is the proper sharing and documentation of appropriate information in a concise, articulate fashion. Many examples of how to present different kinds of patients—such as inpatients, partial hospital patients, substance abusers, and outpatients—take up most of the book. Clear thinking leads not only to economically sustainable treatment but to better treatment, Fauman argues. A chart that is well documented to allow for the possibility of a retrospective utilization review would also help in any malpractice defense, should there be a bad clinical outcome.

As the author makes clear, one of the book's fundamental assumptions is that many of the disagreements between reviewers and providers are caused by honest differences in clinical judgment about the severity of a patient's illness and the type of care the patient needs. Yet Fauman acknowledges that the possibility exists for unethical reviews by reviewers working for managed care companies who have underbid the contract or otherwise need to save money by curtailing needed care. Recognizing such a situation from the nature of the review and knowing how to deal with that situation is one of the best pieces of information imparted by this book.

Another thing that won me over to this book was the short but frank discussion of the unequal malpractice liability situation that prevails because of the Employee Retirement Income Security Act (ERISA). This federal law provides de facto legal immunity for managed care reviewers. That makes for an unequal liability situation, because the courts generally find that a provider's clinical obligations to a patient supersede financial considerations.

Although it is addressed to clinicians, this book will also be a good primer for managed care reviewers. Proper and improper reviewer responses to clinicians are illustrated and discussed. Interspersed with the cases are handy tables that outline the generally accepted medical necessity criteria that apply at different levels of care.

Overall, this short book is worth the two hours or so that it takes to read.