Psychiatrist liability and treatment planning in outpatient clinic services: commentary.

In many community mental health clinics the medical director and other psychiatrists on staff find significant amounts of their time applied to ‘‘signing off’’ on treatment plans for patients/clients who might also be or might only be under the direct care of other mental health professionals. The volume of such paperwork tests the mettle of any clinician in such settings. In an era of constrained finances, when a psychiatrist has a prime opportunity and responsibility to see that medical care dollars are being spent wisely, the signing of a treatment plan affords the physician an opportunity to change the chore of overwhelming paperwork into a constructive role in the national management of health care. To our knowledge there has been minimal published discussion to date about liability and treatment planning in outpatient psychiatric treatment and ‘‘mental health services’’. In this article we shall explore the state of the field in terms of requirements and behaviors of psychiatrists in signing treatment plans in community mental health settings. The Medicaid requirements of an outpatient mental health clinic are described in the Code of Federal Regulations (42 CFR 440.90 Rev. 15, 4221) and demand an individual plan of care (PoC) for each Medicaid patient. Each state also has Medicaid regulations through which these guidelines are implemented. The PoC consists of a written, individualized plan to improve the patient’s condition to the point where the patient’s continued participation (beyond occasional maintenance visits) is no longer necessary. It describes the objective of treatment, the treatment regimen, the schedule of service delivery (including the expected frequency and duration of each therapeutic session), the type of personnel to furnish the treatment, and a projected schedule for reevaluating the patient and updating the PoC. The regular signing of outpatient clinic treatment plans in community mental health centers is, in large part, driven by Federal Medicaid regulations that require treatment plan updates on a regular schedule, usually at least every 3 months, though some states only require 6 month updates. Although it is not clearly spelled out in the Code of Federal Regulations, by tradition or by regulatory zealousness, a physician’s signature on these plans is required. This signature attests to the appropriateness of the care proposed and conducted and to the medical necessity of taxpayer-paid interventions. In practice, many community mental health psychiatrists may be asked to sign off on treatment plans even more frequently in order to comply with state-mandated regulations for some of their patients. Furthermore, to assure that no patients requiring treatment plans are accidentally overlooked, even non-Medicaid covered patients may have their plans reviewed and signed as frequently. Because of harsh reimbursement penalties that can be assessed if a Medicaid audit uncovers billed treatments conducted without signed treatment plans, clinics may well choose to be overinclusive in making sure their patients have timely signed treatment plans. In our experience, little if any attention is paid in psychiatric training or ongoing education to this aspect of the D. A. Oren (&) Birmingham Group Health Services, P.O. Box 658, Ansonia, CT 06401, USA e-mail: doren@aya.yale.edu