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I recently received a quite unusual denial of outpatient services from a managed care organization. Since I was not a panel member of this organization, I fully expected to have my services denied on this basis. However, there was another reason included in the denial-a reason that I find quite serious, and, if this type of denial is standard for this insurance company and psychiatric managed care carveout, it presents very serious implications for my professional organization and my professional future. The added denial was as follows:
"Individual psychotherapy with a psychiatrist is not a benefit included in the patient's insurance coverage."
I find this statement of unequivocal exclusion very disturbing. Since this company is one of the major players in managed care and controls a large share of the mental health market, the implications of this position for psychiatry are quite serious. The company's "alternative plan" was even more troubling. It suggested that the individual call the company to "identify a credentialed psychotherapist for continued therapy."
At this point, the company has made a medical and market decision for my patient, as well as excluded me and other psychiatrists from providing any psychotherapeutic services to their members, regardless of whether I am a member of their panel. Further, the company has defined individual psychotherapy as a nonmedical procedure and, in all likelihood, has limited the function of a psychiatrist to being simply a provider of a signature to a prescription.
Who is restraining whose trade! Has the company not made a medical decision for patients with this type of coverage and is now redefining what a psychiatrist is? I had assumed that my professional organization defined what a psychiatrist is.
I would certainly hope that my professional organization would give this matter very serious scrutiny.
Chester M. Berschling, M.D.
Pittsburgh, Pa.