Managed care settings may terminate payment for treatment before it is clinically indicated because of policy limitations or because a reviewer considers the treatment as medically unnecessary. Psychologists who treat managed care patients need to anticipate coverage ending for some patients who continue to need treatment. Informed consent procedures require psychologists to make patients aware of that possibility at the start of treatment or as soon as feasible.
Psychologists have a number of available options.
First, if the managed care organization refuses to approve treatment that the clinician believes is necessary, the clinician should pursue the case through all the possible appeal steps. A second option is for the patient to continue in therapy with the same provider after the insurance benefits are no longer available. If the managed care contract permits, the patient and provider can establish fees as would be done with any new patient, either at the provider's usual rate or on a sliding scale basis if the provider is willing. However, the cost of treatment may still be beyond what the patient is able to afford. It is also always an option to continue service on a reduced fee or a pro-bono basis.