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The article reports on the reimbursement for telephone sessions conducted by managed care organizations (MCOs) and commercial health plans with patients. Providers and provider organizations believe that they should be reimbursed for telephone sessions with patients, however, this article presents the reasons why MCOs and health plans will not pay for telephonic sessions.

The article discusses the concept of administrative denials in health insurance reimbursement. An administrative denial is the findings from a managed care organization or an insurance company in which due to certain provisions of a patient's health plan, a service is not covered under the health plan despite clinical merit. Insurance companies and managed care organizations can still issue administrative denials even if the service is medically necessary.

Reports on the role of managed care organizations in determining whether services are medically necessary in the U.S. Likelihood of provider organizations to be reimbursed for behavioral health services to managed care patients; Requirement that clinicians note a patient's Global Assessment of Functioning score; Consideration of the endpoint of treatment to be when a patient is capable of tolerating his or her symptoms.

The article reports on the likelihood for behavioral health providers and provider organizations in the U.S. to receive denials from managed care organizations and insurance companies. Prevention is a better approach to denials. When denials do happen, the appeal process is a nice approach to reverse them and get reimbursed.

Behavioral health clinicians tend to believe that all services that they provide to patients should be reimbursed when publicly funded or commercial health plans are involved. The reality, however, is that many services are not covered, which can result in a significant number of hours of clinical work for which provider organizations are not reimbursed. Few provider organizations can afford that, especially in the current economic climate. Some organization leaders may actually not be aware of the full extent of non-covered services being provided by their clinicians. To minimize the adverse financial impact of providing an excessive volume of non-reimbursed services, leaders of behavioral health provider organizations need to establish a culture that actively discourages the common clinician attitude of, "If I say it should be covered, then it should be covered." Clinicians need to learn that health plans decide what services are covered and not covered, and that clinicians are responsible for minimizing the provision of non-covered services.