Now the reviewer is a person who is at least conversant with the field, but still omeone whose job consists of making money for the company by denying benefits. Then there is the in-house grievance process. It would be useful to know the number of grievances filed and the rates of denials overturned. This information is usually held as proprietary, but from what we see, the rates of reversals, predictably, are extremely low. The whole process can eat up months of waiting time.
People give up, go away, and suffer.
The company makes money. There needs to be an entity independent of the managed care company to which patients can turn for a review that has some integrity, and it needs to be accessible with minimum delays. Reviewers in all settings should be licensed mental health professionals whose licensure binds them to responsible clinical decision-making as reviewers just as such licensure does for practitioners. Plans differ in their philosophy about what is necessary. They may define it broadly in terms of a deficit in the quality of life that has the potential for improvement through treatment.