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Overview
For many psychiatrists and other mental health professionals, the clinical review is the most burdensome and disagreeable part of managed care. In that review clinicians are asked by a representative of the managed care company to justify their patient's need for care and to defend the treatment they are providing. Clinicians usually feel at a disadvantage in these discussions because they are never quite sure what information will convince the reviewer to approve the patient's care. This does not have to be the case.
The goal of this book is to teach psychiatrists, mental health professionals, and administrators how reviewers think and how to present a case in a manner that greatly increases the likelihood that a reviewer will approve the request for care. Beginning with five questions that must be answered in every managed care review, the author shows you how to • Present effective requests for inpatient, partial hospital, and substance abuse care• Negotiate with a reviewer to get approval for your patient's care• Write effective clinical notes that substantiate your request for care • Deal with unethical reviewers and managed care companies• Appeal denials of care
These and many other important issues are highlighted in brief vignettes illustrating a clinician's presentation of a patient's case and a typical reviewer's comments. This tremendously useful volume will be welcomed by every mental health care practitioner who must negotiate the current managed care landscape.
American Psychiatric Publishing
Editorials
Jay M. Pmerantz
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.
From The Critics
Reviewer: Raj Tummala, MD(Wyeth Pharmaceuticals)Description: This is an interesting new book for mental health professionals and administrators about negotiating with managed care reviewers for approval of patient care.
Purpose: The purpose is to review clinical monitoring standards and educate the trained clinician on how to present cases to managed care reviewers in various psychiatric settings.The book also details the fundamentals of clinical documentation for accurate presentation. This useful and timely book largely meets its overall objective.
Audience: This book is targeted towards residents, psychiatrists, and other trained mental health professionals. The author is very solid and credible in the area of managed care.
Features: The book starts with a review of criteria and clinical monitoring standards and goes on to detail presenting a case to a reviewer. The author describes presenting cases to reviewers in various psychiatric settings such as inpatient, outpatient, partial hospital and substance abuse. He also details clinical documentation standards for better negotiation with the managed care. Some of the appendixes are especially useful for quick references.
Assessment: This is a useful and easy to read book about negotiating with managed care reviewers.
3 Stars from Doody