Get Psyched On This Problem

As if people with mental problems didn’t have enough headaches, a recent change in psychotherapy treatment codes has dumped a whole new layer of complexity on the plates of those needing treatment.

According to a recent story in the Wall Street Journal, mental health professionals providing treatment are not being paid since the change because insurance companies claim that the changes are bigger and more complicated than was expected and companies are having difficulty setting up their systems to accommodate the code changes . 

And all of this is happening when there is a growing public demand for better mental health intervention.

Millions of mentally ill people are facing diminished care because their mental health providers are not being paid for their services.

The American Medical Association updates the codes annually.  Only 30 codes out of 8,000 or 9,000 were changed this time.  But those 30 changes, which had to do with mental health services and hadn’t been modified since1998, threw a monkey wrench into the system.

Worst of all, many of those who are hurt can ill-afford the stress and uncertainty of having their treatment affected.

With about 11.5 million Americans suffering from serious mental conditions, according to the WSJ article, and public demand growing for more and better interventions with the mentally ill since the recent spate of shooting massacres, these coding problems could not have come at a worse time.

The biggest worry of mental disability providers is that this coding chaos will affect care for their vulnerable patients.  With many insurance companies being unable to estimate when the coding problems will be fixed, it is anybody’s guess when some order will be restored to the mental health system.

In a field of treatment where one missed appointment may undo months of intense work, it is hard to foresee how far this glitch will set things back.

With a so much hanging in the balance, we urge everyone involved to get the lead out and get the mental health system working again.

Disability Attorneys Must Be Prepared

As if people with mental problems didn’t have enough headaches, America’s psychiatrists are changing their mental disorder guidebook, according to a recent article by the Associated Press.

This would be the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), published by the American Psychiatric Association. The revision has been in the works for several years.

Many people might not consider this announcement earth-shaking. But the DSM’s definitions define the clinical characterization and treatment of mental problems. Disability insurance companies and school systems usually base their decisions on benefits on how the DSM defines mental conditions and the treatments recommended.

Scheduled for publication next May, the new DSM seeks to capture the current state of knowledge of psychiatric disorders, according to the Association.

Just what effect the new DSM will have on the care and treatment of people with mental disorders will have to await publication of the manual and digestion of its contents by the lay, medical and insurance communities.

One thing we are sure of, insurance people will be all over the manual with a fine tooth comb, looking for new excuses not to pay mental disability claimants, or how to stop payments to some already being paid benefits. How do we know this? Because we fight with these companies every day over claims that are as plain as the nose on your face to everybody, except insurers.

Any attorney involved in a mental disability claim must be familiar with the new DSM and study it. Disability and ERISA lawyers must follow comments on the Guide which are bound to be published shortly after it is published so as to be up on the latest thinking in this field of claims law.

Knowing as much or more about the DSM changes than insurance company’s minions is an absolute must. Disability income insurance attorneys are bound to be bombarded with calls from beneficiaries who are being threatened by insurers with a loss of benefits because of how insurance companies interpret the new DSM.

Like the Boy Scouts, these attorneys must “Be Prepared”.




Insurers Like Psych

The question of why mental illness is treated differently from physical illness was raised in a recent California case, Harlick v. Blue Shield , 656 3d 832 (9th Cir. 2011).   The case turned on the wording of a California statute which is not relevant to the purpose of this post.

What is most relevant is the reasoning behind the insurance industry’s effort to save itself money by classifying mental illness as less than physical illness.  Those who have had first-hand acquaintance with mental illness know that there is very little, if any,  difference in the disabling factor between the two.  If your mind can’t cope with the duties of your occupation, it is as if you have a physical disability which prevents you from performing.

Psychiatric disabilities can sometimes be cured in weeks or months and sometimes not for years.  The same is true of physical disabilities.

Yet, insurance companies frequently limit their obligation to pay LTD benefits to two years while physical disabilities will be paid for the term set forth in the policy. 

This has led to insurance companies developing a new tactic – all employment disabilities are caused by psychiatric problems rather than psychiatric problems being triggered by physical disabilities.  Now that the 2-year limit on paying for disabilities in disability income policies has become more or less standard, it has become the preferred denial “go to” for insurers when nothing else jumps right out at them.

If there is any psychiatric involvement at all in a disability income claim, you can bet your bottom dollar that the insurance company will be doing its darndest to say it was based upon a psychiatric disorder.  These days, it has become almost a knee jerk reaction.

So, if you are hit with this defense, whether as a claimant or a lawyer, don’t accept it without scrutiny.  The stakes are too high to take the carrier at its word. 

Insurance companies are not all the same and don’t act the same, except in one regard:

They hate to pay claims!

Easing The Psychiatric Burden

Anyone who has ever handled a psychiatric disability claim knows they are tough enough to prove. Establishing the existence of a mental condition, which is not easily shown by objective medical evidence (X-ray or MRI), makes experienced and knowledgeable advocacy a must.

Add the burden of showing the disability prevents the claimant from performing employment obligations, as required in any disability income claim, and the matter really gets complicated.

Unless an advocate has had a great deal of experience in proving psychiatric disability claims, insurance carriers are sure to lead them on a merry chase while the client is unable to work or earn money for themselves and their family.

A psychiatric disability claim, is a Perfect Storm favoring the insurance company:

* The claimant is ill.
* The claimant is earning no income to live on.
* The insurance company has the experience, the money and the lawyers to fight on and on and on.
* The claimant has a psychiatric impediment which may affect his or her mental acuity, concentration, or ability to stand up to the pressures of a long-term litigation.

Can you think of a worst case scenario? What better potpourri of negative circumstances could an insurance company ask for in fighting a claim?

Psychiatrists and psychologists treating patients with disability claims should be sensitive to the added problems such claims can cause their patients. No one has to tell these professionals that such basic threats to the patient’s wellbeing have to be dealt with successfully to treat the patient.

The problem is that psychiatrists and psychologists don’t have the training and experience to handle the legal aspects of a successful psychiatric disability claim. They know the client’s medical condition, but have no experience in presenting the claim in the way the insurance company or the law requires, nor can they anticipate the legal impediments which may affect the success or failure of such a claim.

Moreover, the psychologist or psychiatrist faces special ethical constraints when donning the mantle of “advocate” while also trying to heal an ailing patient, given the prohibition against “multiple relationships”. The two roles can easily lead to a conflict, causing failure in both. See, e.g., “Ethical Principles of Psychologists and Code of Conduct”, American Psychological Association, at Sec. 3.05.

As part of the treatment in such a case, the treating professional should try to see to it that the patient obtains independent, competent legal help to properly pursue the claim. Neither uncertainty in a patient nor diffusion in a professional’s treatment goal is helpful in a patient’s treatment.

Ideally, the claimant’s disability lawyer should have extensive experience succeeding with psychiatric claims. Through this experience, they will have learned that psychiatric claimants and their treating professionals require the utmost in patience, cooperation and understanding.

On the other hand, insurance companies require just the opposite type of treatment. Attorneys who know the ropes of psychiatric disability insurance claims and aggressively pursue such claims must fight hard, including keeping the insurance company’s hands off patient records they have no right to see.  Hands Off My Info.

The point is that a good, competent, understanding disability lawyer can be an important part of the treatment of a patient with a psychiatric income claim.

Easing claimant anxiety levels is a good thing, especially when the claim involves a psychiatric disability. Having a competent disability advocate with long experience “in the trenches” should help lower a patient’s anxiety level, and makes it easier for the treatment provider to focus on treating the patient’s ailment.