106. What are the disadvantages of a managed care plan?

  • Pre-approval is required before starting treatment.
  • You must tell an insurance company representative about your problem to be approved, no matter how embarassed you are to talk about it.
  • You are limited to panel or network providers, and sometimes have no choice at all. Often there are many more therapists with less training and experience.
  • Network providers may not be conveniently located.
  • Network providers may not have appointment times available that fit your schedule.
  • You may have to wait weeks for an appointment.
  • Network providers may not have expertise in treating your problem.
  • Network providers may have less education and experience than other local professionals.
  • There is limited confidentiality. The managed care company receives treatment summaries with details of your problem and treatment.
  • Treatment is usually more time-limited than in POS coverage.
  • You must receive authorization for all treatment.
  • The provider may be reluctant to ask for more treatment sessions because it is a "hassle."
  • Non-authorized or non-approved treatment will not be covered. 
  • Type of treatment and length of treatment must be approved by managed care.
  • If you appeal managed care limits, coverage (and treatment) must wait for the appeal.

The way managed care works, professionals join a panel by agreeing to accept a discounted fee as payment in full for services, and by agreeing to follow the procedures established by the managed care company for authorizing and continuing treatment. The managed care company agrees to send clients/patients to the professional. If the fees are reasonable, and the managed care procedures are consistent with good clinical treatment, the arrangement works fine. You call the managed care company, they refer you to a few professionals with expertise in treating your problem, and the professional provides treatment to you at a discounted fee. In theory, everyone benefits.

In practice, the vast majority of managed care companies never provide cost of living increases in their fees (I personally know of none who do this, but I assume there might be a managed care company that does.) Worse, many managed care companies have routinely reduced their fees over the years. Obviously, this causes many professionls to quit panels, and is more likely to cause more experienced professionals to quit, because they can survive without the managed care referrals. (After all, how would you feel if your boss cut your salary every year, and never gave you a raise? Would you look for another job?)

But many professionals also complain that managed care companies limit treatment, or even have their non-clinical employees recommending less expensive treatment as “better” than the treatment plan developed by the professional. For example, a managed care plan may insist that medication is all that is needed to treat depression, even if you do not want to take medication. If the professional does not agree with the managed care recommendations, either the treatment will not be approved, or the professional will be labeled as noncompliant and dropped by the managed care panel, or will simply stop receiving referrals.

All managed care plans do not have all the problems listed above. Some provide very good, appropriate treatment. But, the limitations listed above have caused many experienced professionals to discontinue doing business with managed care companies, and this certainly limtis your access to quality treatment within manage care.

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