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Managing Risks When Practicing in Three-Party Care Settings

How to provide for continuity of care when leaving an insurance panel

Psychiatrists occasionally choose to leave a third-party insurance panel. When this occurs, the psychiatrist must continue to address issues such as limited resources available to provide continued mental health treatment; obligations to patients, including guarding against actual and perceived abandonment; and following contractual specifications and ethical guidelines in providing a smooth transition to another mental health provider.

When psychiatrists leave insurance panels, patients must receive adequate notification and continuity of care to reduce the risk that a patient will decompensate or “be lost to follow-up.” More planning and assistance during transitions of care may be required for patients in crisis. Some insurance panels require that treating psychiatrists continue to care for a patient in crisis even if the psychiatrist leaves the panel. Therefore, if a psychiatrist leaves a panel while a patient is in crisis, he may need to refer to the initial insurance panel contract or review the contract with a lawyer to determine his obligation to the patient and the steps required for the patient’s transition. The following recommendations assume a “stable” patient population.

Many of the notification steps that a medical practitioner should take when leaving a panel are similar to those that psychiatrists take when retiring from practice. For example, when psychiatrists retire, they need to notify their patients of the closure of their practice, help patients find a new psychiatrist, offer to forward records to the new treating psychiatrist and, if possible, be available for emergencies for a reasonable period while the patient is transitioning to a new therapist.11 The difference between retiring from practice and leaving a panel is that in the latter case a patient may choose to continue to be treated by the psychiatrist, but the patient needs to be notified of the change and how it may affect the doctor-patient relationship.12,13

Patients can be notified that a physician has retired or has left an insurance panel via letter, by informing patients during a session, or by posting an announcement in the office. The last 2 methods can be problematic. In terms of risk management, it may be helpful to inform patients in writing with a letter to ensure that the patient has been notified. It is advisable to send patients at high risk for adverse transition-of-care events a certified letter at least 30 days before leaving the panel to ensure its receipt. The letter should inform the patient that:

• The psychiatrist is leaving the panel.

• The patient may continue to be seen at the office but may be subject to a different fee schedule.

• If the patient does not express an intention to continue at the office, then his file will be closed.

• The patient can contact the insurance company for a list of available psychiatrists still in the panel.

• Records will be sent to the patient’s new doctor on request.

The earlier the notification before the actual termination the better, because it allows the patient more time to decide whether he wishes to continue with the psychiatrist or find a new one. It can be a lengthy process to find a new therapist (depending on the availability of psychiatrists in the community). While it may be therapeutic to inform a patient during a session, oral communication does not provide sufficient documentation to prevent a malpractice suit (since it may become a “he said, she said” issue). It is not enough to inform patients merely with an announcement in the office because patients can legitimately claim not to have noticed the announcement.

Electronic means such as e-mails, instant messaging, blogs, or Web sites may soon become an acceptable way to notify patients. However, from a risk management stance, electronic communication is not currently the best means of communication because of potential confidentiality issues and Health Insurance Portabil-ity and Accountability Act (HIPAA) concerns.14-17 Also, if a psychiatrist corresponds electronically, he needs to respond as quickly to an e-mail as to a telephone call. For some psychiatrists, this means of communication is less practical or less efficient.16,17

If a patient “chooses” to terminate his relationship with a psychiatrist when the psychiatrist leaves the panel, the patient may be asked to sign a “voluntary termination of treatment” form during the final visit. This form should clearly indicate that the patient:

• Is choosing to leave treatment.

• Has been given a list of referrals or has been referred to the insurance provider to obtain a list.

• Understands that the psychiatrist with whom he is terminating will be available for emergencies for at least 30 days or until he finds a new psychiatrist.

This practice encourages sound documentation for rebuttal for any subsequent allegation of abandonment made by the patient.

It is not a psychiatrist’s obligation to find a new psychiatrist for the patient but rather to “assist” the patient in doing so. This is usually accomplished by providing names and numbers of other practitioners or contact information for the local mental health department. It is important to provide patients with as much forewarning as possible because in some locations it may take 6 to 8 weeks to obtain an appointment with a new therapist.

Summary

In third-party, resource-administered, time-limited environments, it is vital to be mindful of fundamental principles, particularly in the midst of the stress of decision making under conditions of uncertainty.7 This includes recognizing that clinical decision making in real time contains elements of uncertainty, and thus shared responsibility expressed as a respect for patients’ autonomy is crucial. When clinical time or resources are limited, it is vital to distinguish between patients who want to take responsibility and pseudopatients who are not interested in treatment by reason of character or motive. The psychiatrist who respects a patient’s autonomy is in the best position to provide wise, effective, nondefensive clinical care while also being able to manage the risks for the practice in resource-constrained third-party treatment environments.

[At the time of writing]:Dr Paul is board-certified in psychiatry and is a forensic psychiatrist in practice in San Diego. He completed a fellowship in forensic psychiatry at Case Western Reserve University in Cleveland and is a past GlaxoSmithKline and Rappeport Fellow. Dr Lockey is assistant professor of psychiatry at Oregon Health and Science University in Portland. He completed a fellowship in forensic psychiatry at Case Western Reserve University. Dr Hall is an affiliate instructor of psychiatry at the University of South Florida and a past Rappeport Fellow of the American Academy of Psychiatry and the Law. Dr Bursztajn is cofounder of the Program in Psychiatry and the Law at Beth Israel Deaconess Medical Center, department of psychiatry, Harvard Medical School, Boston. He has an active clinical and forensic neuropsychiatric practice. He has been a consulting and testifying expert for attorneys representing physicians, patients, and third-party organizations and is a consultant for independent peer-review organizations. He is a recipient of the Clifford A. Barger Excellence in Mentoring Award from Harvard Medical School.

References

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9. State of New York Department of Insurance. 2008 New York Consumer Guide to Health Insurers. http://www.ins.state.ny.us/hgintro.htm. Accessed January 21, 2009.
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13. Health and Ethics Policies of the AMA House of Delegates. E-9.06 Free Choice. http://www.ama-assn.org/ad-com/polfind/Hlth-Ethics.pdf. Accessed January 22, 2009.
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Managing Risks When Practicing in Three-Party Care Settings

This article originally appeared in:

Psychiatric Times

It is reprinted here with permission.