Archive for the ‘insurance’ Category

Consumer, Client, Patient, Analysand: What’s in a Name?

Thursday, April 28th, 2011

Willy Shakes asked the question in Queen Lizzie’s time (the first one, not the current monarch.) At that time he was asking because, to the questioner, a name was something that made no difference in the person to whom it was attached but made lots of difference as to how the person was perceived and accepted by others.

Insurance companies have renamed everyone who is receiving health care services. No longer are we “patients,” “clients”or, in the case of psychoanalysis and or psychotherapy “analysands.” We’re now “consumers,” according to the insurance companies. Those of us who are delivering health care services are no longer “doctors,” “analysts,” or “psychotherapists.” We’re all lumped under the title”provider,” again by the insurance companies. What does this mean? Don’t we still get treated the same as we did when we were patients and therapists, Analysts and analysands, etc?

Well, no. Not really and, on top of that, I don’t like being called a consumer when I’m on the receiving end of health care, nor do I much care for being called a provider when I’m on the giving end. Why? I’m gonna tell ya (with a nod to Dino. RIP.)

A consumer is someone who uses/purchases a good or service, which is considered a consumable. Very general. Doesn’t separate someone who is in treatment from someone who’d buying a toaster. Are you using my service? Yes. Does that make you a consumer? No. Our relationship is more personal than that, or, at least, is intended to be more personal than the relationship between someone buying a toaster and the salesman at an appliance store.

“OK. So I’m not a consumer,” you say. “Then I’m your client, right?” I’m not so sure. The dictionary on my e-reader says that a client is “a person…using the services of a lawyer or other professional person or company” (New Oxford American Dictionary.) I guess that sounds closer to the mark. I am a professional. Are you “using” my services? Well, yes and no. You have engaged me in my professional capacity. Maybe client does work but it seems to me that it misses something. It’s like chicken soup without the parsnip and dill weed. It’s may be good but it’s missing that geschmeck that makes it delicious.

What’s missing? You got it? No? Sure you do. The helping relationship. The (hopefully) healing relationship. So what’s the word now? Patient, right? Same dictionary gives the first use of the word patient as a noun to be “…a person receiving or registered to receive medical treatment.” Woah! Shazaam!, as Gomer was wont to say.) Shazoom!, as Captain Marbles said. “That’s it,” I hear you say. Well, yea and nay. Far better than consumer,  more better than client but still….

Analysand? What the hell is that? A person undergoing the process of psychoanalysis with a trained psychoanalyst. A very specific word that honors the relationship that exists in the room between us.

As for “provider….” Dad (in the stories of how family life used to be) is the “provider.” “Your father’s a good provider.” Can we talk about transference and countertransference here? I thought so.

So, what do you prefer to be called? What do the implications of “consumer” and “provider” mean to you? Add a comment and let us know. Keep those ol’ cards & letters rollin’ in (Dino, we miss you. Lots.)


You, Your Insurance and Privacy of Our Work, Pt III

Wednesday, October 13th, 2010

OK, now for the kicker. The something more. This information that lives with your insurer and their insurers isn’t finished yet. What happens if you apply for life insurance? An auto loan? Change jobs and need to sign up for other health insurance? Apply for a credit card? Have you guessed yet?

That’s right. These worthies will often turn to an agency that they hire to collect your information, your protected health information, and that agency will then turn to me and request the records of your treatment. They will sometimes accept a summary but I have to tell them that’s what they’re going to get. What you’ve signed, after you first told them that you had this treatment (if they ask, and for life insurance they sure will,) is a consent for release of information for your medical records. That means they are going to be requesting my session notes (which are part of your official medical record.) This also means that this 4th party outside of the triangle of you, me & your insurance company (and their backers, but I included them in the triangle – so what if it’s got 4 sides? I’m a psychotherapist not a geometer) has your protected health information in its data bank. Yes, the release you signed is HIPAA compliant. They know the law & know that that’s what they have to give you. It doesn’t mean that they are as careful about disclosures as your psychotherapist (me, in this case.)

Does this chill you a bit? If it doesn’t then you’re not following the flow of your information. Wider and wider circles of dissemination.

Now, I’m not saying that if you and I keep things between us and you leave your insurance out of our relationship that you won’t at some point decide that you want life insurance and they won’t ask about treatments you’ve received. If you do they will. I won’t tell you not to tell them about treatments. That would be telling you to commit fraud and I won’t do that. I won’t tell you to lie on the application. I will tell you that, unless you are asked about treatments, in most cases (within the limits of the laws about confidentiality) it stays between you and me (maybe your accountant and Uncle Sugar if you claim it on your taxes, but I’m not going to go there.) There are limits imposed on confidentiality by law, such as if I think you are an immediate danger of committing harm to yourself or somebody else, or in case of suspected cases of child abuse but within the law what’s between you and me stays between you and me. Personally, I like it that way.

Another time I’ll tell you why I don’t like “diagnosis” as used in the DSM (or ICD,) but that’s not part of this. Let’s call it a day and I’ll go back to enjoying my cup of tea.

You, Your Insurance and Privacy of Our Work, Pt II

Wednesday, October 13th, 2010

OK, where was I before I started brewing my tea – a nice Oolong with lots of flavor, good aroma & gentle bite? Oh, yeah, about codes and privacy. This section gets a little technical but hang in there, fans – it’s worth it.

I said that those codes don’t leave much of an artifact (footprint, trace, record) that’s going to make any difference, right? Wrong! There’s a procedural code for every procedure that goes on a claim form, whether it’s medical, dental, surgical, psychotherapeutic, etc. The procedure performed becomes part of your permanent medical record in your insurer’s database. “So what” I hear you say. So this: it’s not just in your insurer’s database. It’s in their insurer’s database. They’ve gotta lay their bets off somewhere. That’s with a meta-insurer (think AIG or similar.) Someone who does risk-management and determines how much they can back the bets your insurers make. Think of it as the insurance company has sold your marker to someone. You said it was Jake for them to do that when you signed the line that said that your information could be disclosed for the purpose of obtaining payment. And you thought it was just between you, me, and your insurance company. Have another thunk because there’s more.

Anytime there’s a procedure code there’s a diagnosis. Again, this is whether the work is medical, dental, surgical, psychotherapeutic, or whatever. Now we’re beginning to where it gets sticky. Diagnosis is a serious word. It means that, based on criteria established by the Taskforce that created the Diagnostic and Statistical Manual of Mental Disorders-IV TR, you get labled with a disorder. You are no longer “the worried well,” or someone who just feels anxious. You now have a recorded disorder. This is part of that marker. The fun doesn’t stop there….

Anything that is contained in the DSM-IV is contained in a book called the ICD-9 (going on ICD-10) – “The International Classification of Diseases” published by varoius publishers all putting out the same book (it’s used world wide – International, right?) This means that where ever your record is read they all read the same diagnosis. Great, right? Maybe if the people reading that record were also psychotherapists, psychiatrists, or some kind of mental health professionals, but they may not be. Yes, some insurance companies do utilize us for review but not all the reviewers are. This means that your case is being reviewed by a clerk of some sort. This clerk gets to decide (among other things) how many sessions we can have during a given year for a particular disorder, if any at all. They can also decide that treatment has gone on long enough based on the tables they have and what instructions they’ve been given. At this point it involves more work; usually for me and for which I don’t get paid but, again, even though I mention the do-re-me it’s not about the bucks. It’s about the time it takes to appeal the decision & meanwhile the treatment and who’s going to pay for it is in Limbo (which is often somehow contiguous with Hartford, CT or someplace in Texas, maybe offshore. Who knows?)

These clerks aren’t under the same constraints about the privacy of your information (remember, that’s what this is about) as I am. They are allowed to bundle it for research as well as developing their actuarial tables and other statistical purposes. Your personal information (PHI – Protected Health Information) is not as protected anymore.

But wait, as they say on the infomercials, there’s more. See part III, coming up shortly….

You, Your Insurance And Privacy of Our Work Together

Wednesday, October 13th, 2010

“Do you take insurance?” Yeah. I’m in-network (“par,” in insurance terms – participating) with several plans and take assignment. I’m not in-network (“non-par” – I don’t par…never mind. You get the idea) with many more than I’m in with. There’s various reasons for that, none of which really matter here. Feel free to email me if you really need to know but, trust me, that’ not what this is about.

Personally, I’d rather you not use your insurance. That way we can keep things just between us (the two of us, not the two of us and a lot of other people.) I know that you want to have your insurance company pay me (“par”) for part of your treatment or reimburse you (“non-par”) for some of what you paid me. It makes absolute cents. Dollars and cents. Unless you work for the exceedingly rare, and growing rarer all the time, companies that pay your entire premium, you pay a lot for your share of the premium on your health insurance. You want to get something for that hard earned cash that’s not going into your paycheck. Even if your policy doesn’t cover “behavioral health,” you may have a flex or cafeteria plan that you can use to cover some of the period of treatment, some sessions, something.

I get it. I feel the same way about my health insurance. I want to get something back for the money that’s paid in. It’s why we have insurance, right, so that we don’t have to pay the whole ginormous cost of examinations, treatments, medications, devices, etc., etc? Yeah, that’s all real swell but there’s a good reason, maybe several, why you should consider not using your insurance for your psychotherapy/psychoanalysis/mental health treatment. Can you guess what it is?

Money? No. That’s not it. Yeah, sure, I can ask for more money from you if you pay out-of pocket than the fees that the insurance companies “negotiated” in the contract for “par” situations. Even if I can charge you more if I’m non-par because I don’t have to accept the rate the insurance company wants to pay, it’s still not about the money.Please believe me on this.

OK, I’ll give you a hint: look at the title again. The part that says “…Privacy of Our Work Together.” That’s my big concern and needs consideration on your part before you simply say “I pay for the insurance and I want to use it where ever I can.”

Have you stopped to think about how I get paid or you get reimbursed? Of course you have. I do something that goes to the insurance company and they send me a check (or deposit to my account) or I give you something, you combine that with something else, send it to the insurance company and they send you money. Simple. As easy as 3.1416.

Not so fast, Kimosabee. What’s on that claim form that goes to them? The CPT code (that tells them what procedure was performed, e.g., 90806= O(ut)P(atient) psychotherapy, 45-50″ (minutes,) no med(ication) eval(uation.) That tells them how much they pay out for what went on in the room. We can all agree that this is pretty harmless and doesn’t really do much in the way of leaving an artifact, right? Wrongo! Let’s move on to part II of this and I’ll explain more. For now my tea is ready to brew. See you in a bit!