Psychiatric Medical Necessity Disputes
Managed care has made great inroads in the past 10 – 20 years in cutting back the payments made for medical care. Nowhere has this been more significant than in cases involving mental health. You can say that is a good or a bad thing; I’m not here to take a position on that. But the question remains: for purposes of determining the extent of a patient’s insurance coverage, should the opinions of reviewing physicians, doctors who are only reviewing a patient’s medical records for a payer, be given equal weight as the opinions of the treating physician? If they are, the payer really has the upper hand in limiting the reimbursement it sends to a provider of care.
Out of the federal district court in Buffalo, New York, comes an important case last month regarding how judges should evaluate medical necessity disputes in psychiatric cases. Westphal v. Eastman Kodak Co, 2006 U.S. Dist. LEXIS 41494, a copy of which you can access in the library here, contains a thorough analysis of the advantages the treating physician has over the reviewing physician in evaluating a patient’s condition. For psychiatric cases, an important aspect of the assessment of the patient’s condition comes from observation of the patient’s demeanor, watching affect, evaluating nuances of speech, etc. These types of things, and there are many of them, simply cannot be recorded in written medical records. In addition, the ethics code of the American Psychiatric Association prohibits an M.D. from offering a professional opinion unless he or she has examined the patient.
In Westphal the court determined that the payer acted in an arbitrary and capricious manner by relying on the opinions of non-treating, non-examining doctors to override the prescription of care offered by the treating physician. This rationale of this opinion could go a long way toward tipping relatively balanced scales in close cases in the provider’s and patient’s favor.