Managing Managed Care's Outpatient Review Process: Insights and Recommendations From Peer Reviewers at a Health Services Company.

Many psychotherapists may not remember an age when the landscape of clinical practice did not include managed care organizations (MCOs). As peer reviewers for a large health services company, we have found that utilization review is still perceived as onerously as it once actually was. To help practitioners save time and advocate more effectively for mental health outpatients, we provide guidance on the peer review process for psychotherapists who interact with MCOs, either as members of insurance networks or as psychotherapists for self-pay patients who, in turn, must justify to third-party payers the medical necessity of treatment in order to obtain reimbursement themselves. We describe the process of utilization review, the peer review being a central component, followed by the specific elements of medical necessity that pertain to outpatient care. Finally, we discuss specific case examples to highlight how providers can advocate most effectively for treatment that is medically necessary. [ABSTRACT FROM AUTHOR]