Association News
Help Line Mediates Dispute Between Psychiatrist, Carveout
Psychiatric News
Volume 36 Number 10 page 2-24

Psychiatrist Arthur L. (Gus) Smith, M.D., had reached his tolerance limit in trying to convince a managed care carveout firm that its staff was erroneously interpreting its authorization rules when it refused to reimburse him for consultation services.

So after a series of unsatisfactory communications with the company, Smith, a private practitioner in Tucker, Ga., decided to turn to APA’s Managed Care Help Line to see whether it could deliver the assistance he was hoping for. He says it met the test with flying colors.

"It has been a real comfort for me to know that there is someone. . .at the American Psychiatric Association advocating for both psychiatrists and patients alike," he said in a letter thanking Help Line Manager Karen Sanders.

He told Psychiatric News that the help line turned out to be "a great resource. It was important to know that I wasn’t alone in this battle—that I wasn’t just David taking on Goliath."

Smith was angry that clinical service personnel at Magellan Behavioral Health, which manages mental health care for Blue Cross/Blue Shield of Georgia, denied his reimbursement claims for patient visits that were follow-ups to consultation services he had provided.

Smith’s saga began after a primary care physician called him to a local hospital to provide a consultation on an elderly patient on a medical/surgical floor who had become delirious and agitated. It was an emergency consultation request that he received at 6 a.m. on a Saturday in December 1999.

When the information about the consultation visit and a follow-up visit two days later got to Magellan Behavioral Health, which had a contract with Blue Cross/Blue Shield of Georgia for the patient’s mental health care, a utilization reviewer contacted Smith and told him that he would not be paid because he had not gotten prior authorization for the emergency consult visit. The reviewer, who was not a physician, also challenged the psychiatrist’s decisions about diagnosis, medication choice, and dosages, Smith told Psychiatric News.

The reviewer did eventually authorize the initial consultation, but Smith said the reviewer made a point of telling him that the case might have been handled without medication, and in that case, it would have required only a social worker, not a psychiatrist. Apparently, he pointed out, the reviewer was not even aware that social workers are not on the hospital staff, let alone trained to consult on a case of an agitated, delirious patient.

Also troubling, Smith said, was the reviewer’s contention that Magellan was disallowing the follow-up consultation because its policies state that such a visit is not reimbursable. He said that he informed the reviewer in no uncertain terms, "That’s what doctors do! They follow-up with seriously ill patients!" He added that he got no response when he asked if the company expects cardiologists, for example, to forego follow-up visits. He pointed out that the patient’s rapid response to medication he had recommended ended up saving Magellan money it would have spent on a prolonged hospitalization for this patient. The written response he eventually did get indicated that the carveout reviewers were just following a policy handed down from Blue Cross.

Particularly galling, Smith said, was that he got the same responses when he demanded to speak with the reviewer’s supervisor. He recounted that he later learned in a telephone conversation with one of Magellan’s regional medical directors in Georgia, Andrea Bradford, M.D., that the so-called supervisor was in fact just another reviewer to whom the original one had passed the phone, a practice Sanders, the APA help line manager, suspects is common. (Bradford did not respond to an interview request with Psychiatric News by press time.)

When he took his complaints to Blue Cross/Blue Shield, since Smith said the carveout reviewers told him they were following the Blues’ policy, an official told him that "that’s baloney. We don’t have any such policy."

Smith maintains that Magellan’s attempt to bar reimbursement for consultation follow-ups is a "blatant form of discrimination against psychiatry." The process the company suggested he follow of seeing the patient, gathering data, and then calling the company each day for authorization shows how biased the policies are, he said.

Smith said it took about a year of phone calls, letters (including an unproductive one to the state insurance commissioner), and intervention from Sanders at APA before he was finally reimbursed for the consultations. Sanders’ involvement, Smith told Psychiatric News, resulted in Magellan’s retraining its Georgia staff about the rules concerning authorization and payment for initial and follow-up consultation visits.

Also in response to Smith’s complaints, Bradford sent a letter to Magellan’s "care management" staff that clarifies the company’s policy on psychiatric consultations in which she notes that "it is justified and appropriate to authorize, at a minimum, the initial consultation. If a physician is requesting a psychiatrist to assist in medical management of an inpatient, I fully support an authorization for the evaluation and recommendations to the attending to be completed. . . . If additional visits for follow-up consultation are requested, please obtain additional clinical information to ensure that continued consultative issues (e.g., medication management) require additional visits by the psychiatrist." She also told the staff that it would be "inappropriate" for a psychiatrist to use a consultation visit "to form a treatment relationship or initiate psychotherapy."

Despite assurances of improvements in the way Magellan handles psychiatric consultations, Smith said that the company is still "dragging its feet" about approving and paying for his consultation visits. The lesson in this episode, he emphasized, is that "psychiatrists still have to stand up for patients, themselves, and good medical practice in the face of arbitrary and capricious denials of care." ▪

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