Lecture on Chapters 8/9: Managed Care

Question 1

What are the goals of Managed Care?

Answer 1

1. Increase quality of care

2. Decrease healthcare costs

Question 2

What is an HMO?

Answer 2

Healthcare Maintenance Organization:

- Counselor joins a network of providers

Question 3

What is a benefit for a counselor in joining an HMO?

Answer 3

Get steady stream of referrals from PCP

Question 4

In an HMO, the ____ acts as the gatekeeper

Answer 4

PCP (primary care provider)

Question 5

What is the most limited type of healthcare coverage?

Answer 5

HMO

Question 6

What is the ultimate purpose of an HMO?

Answer 6

Provide the most cost-effective care

Question 7

What is a PPO?

Answer 7

Preferred providers organization

- still have incentive to use provider within network, but you can opt to see someone outside network for higher cost

Question 8

What is a POS?

Answer 8

Point of Service plan

• select whether you are using HMO or PPO model
• more expensive, but more choices
• from Google: has some of the qualities of HMO and PPO plans with benefit levels varying depending on whether you receive your care in or out of the health insurance company’s network of providers

Question 9

What is an EAP?

Answer 9

Employee Assistance Program

- often covers mental health, but allows limited number of sessions

Question 10

What did the Mental Health Parody Act of 2008 do?

Answer 10

Told insurance companies: IF you DO cover mental health, then you have to cover it at the same level as other health services.

• insurance companies can still refuse to cover mental health, yet cover other services
• only applies to companies with 50+ employees

Question 11

What is HIPAA, and what is its purpose?

Answer 11

Health Insurance Portability and Accountability Act, 1996

- Purpose: protect client’s information

Question 12

True/False: If you are a facility that is NOT governed by HIPAA, is client information sent electronically still exempt from HIPAA regulations?

Answer 12

NO. Anything sent electronically, anywhere, is not HIPAA-exempt, even if you are at a facility that is not governed by HIPAA.

Question 13

Do psychotherapy notes fall under the Privacy Rule of HIPAA?

Answer 13

No, psychotherapy notes are exempt from the HIPAA Privacy Rule. Traditionally handwritten notes are not part of the client record (however, you wouldn’t share them anyways because that’s against our Ethics Code!).

Question 14

Does Managed Care value short-term or long-term care? Why?

Answer 14

Short-term care, because:

• Financial incentives to use brief treatments
• Encourages counselor and client to quickly come up with well-articulated and specific treatment goals
• Encourages counselors to be more directive, with the thought that treatment will be brief if counselor is directing treatment.

Question 15

What is a Utilization Review?

Answer 15

A review of how you and your client are utilizing treatment

- you literally call someone on the phone, and they decide whether the client gets more sessions

Question 16

When do you do a Utilization Review?

Answer 16

In the beginning and middle of treatment

Question 17

Does managed care reimburse for all mental health diagnoses and medications?

Answer 17

No, they limit diagnoses and medications they will reimburse for. Phone sessions are usually not covered.

Question 18

Managed Care companies will often ask you to have your client sign a ______ before starting treatment.

Answer 18

Release of Information

- make sure you and your client both understand what’s in the release of information (informed consent!)

Question 19

What should a counselor include in their clients’ notes (use acronym: SOAP)?

Answer 19

S - subjective (what client says is going on)
O - what you observe
A - assessment
P - plan