Case+of+Ethical+Pitfalls+in+Managed+Care

__Case of Ethical Pitfalls in Managed Care __ Taylor Woodruff, Amaris Williams, Faye Fleming media type="youtube" key="ThMdtEq9dk4" width="448" height="251" __ Case Study Summary __ Martin is a newly licensed professional counselor, and he has just opened his own independent private practice. Initially, Martin was not certified as an approved provider by any insurance company. Martin was actually not even aware of how significantly managed care companies impact counselors and counseling services. Although he employed various strategies for finding new clients and promoting his business, Martin did not have much success in gaining referrals.

Eventually, Martin decided to go through the process of becoming a network provider with HealthCo, a managed care company. Martin accepted the HealthCo hourly payment of $50, even though it was lower than his usual fee. He agreed to abide by HealthCo’s approach to managed care, and soon the referrals from HealthCo were coming regularly. Martin was happy about the steady new business, but there were some aspects of the relationship with HealthCo that concerned Martin.

Martin was required to get telephone authorization for client sessions, but it seemed to him that he was always connected to a different case manager who identified him- or herself only by first name. Before he began to work with HealthCo, Martin had been required to give a diagnosis when completing paperwork for third-party payers, and he was comfortable with giving that information. But these case mangers insisted if they were to manage, they needed much more information. They inquired about clients’ childhood traumas, marital problems, addictions, and other matters. Martin understood that this questioning was legal because the clients had signed HealthCo’s disclosure form, but he wondered if it was ethical. Martin was concerned about what happened to the information he disclosed over the phone, and whether or not the case managers were bound by the same parameters of confidentiality that he was required to uphold.

Soon after these concerns began to emerge, one of Martin’s clients ran out of insurance benefits. The case managers suggested that Martin space out the last 3 of the 20 allocated visits over a period of several months or arrange a referral to a community mental health center. In Martin’s professional opinion, these options were not acceptable. The client needed weekly sessions, and considerably more than the 3 that remained. Martin also believed that continuity of care was very important to this particular client, so a transfer to a new counselor would not be in her best interest. Martin attempted to explain his concerns to the case manager but was unsuccessful in convincing her to alter her decision. Because he could not consider abandoning a client and would not agree to make a referral, Martin decided to continue to see the client pro bono. Martin felt some resentment toward HealthCo, since he felt that they were not concerned about the best interests of the client. He also began to wonder about the professional credentials required to be a HealthCo case manager. Did they have any sort of mental health education or licensure? Were they even qualified to make decisions about psychotherapy?

Soon thereafter, an 11-year-old boy named Joshua was referred to Martin under the boy’s father’s company insurance plan administered by HealthCo. Joshua was getting in fights at school. It quickly became clear to Martin that Joshua’s parents were in conflict, so Martin recommended martial counseling. However, this particular HealthCo plan didn’t cover marital counseling. Because Martin was already feeling frustrated with managed care, he decided to see the parents in counseling and billed the sessions under Joshua’s name. He justified his decision to himself by reasoning that any gains made in the marital relationship would surely yield benefits for Joshua.



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