Patients in a catch-22
Although most insurance plans make 20 to 30 annual mental health visits available in their contracts with employers, they may deny coverage after approximately eight to 10 visits due to their determination of "medical necessity." The companies typically ask for an outpatient treatment report, or OTR, after several visits.
"If we state on the OTR that the patient is making progress, the company may deny further payment because the patient is getting better and treatment is no longer a 'medical necessity.' On the other hand, if we report that the patient is making little progress, the company often denies additional treatment because it doesn't seem to be doing any good," says Goldberg. The concept of "medical necessity" is particularly vexing for patients and therapists because health insurance companies can define it any way they like, and the definition often changes from year to year.
If the insurance company won't authorize payment for services or therapy sessions that you and your therapist think you need, your therapist is ethically obligated to call the insurance company on your behalf. The first person the therapist speaks with is usually a utilization reviewer or care coordinator. This person typically has no special mental health training and is unlikely to be much help. Your health-care provider should ask to speak to that person's supervisor who should be a "like professional," or another psychologist or doctor.