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As I have noted previously, managed care organizations (MCOs) determine if services are medically necessary and therefore payable based on various indicators of the focus, appropriateness and length of treatment. Provider organizations are most likely to be reimbursed for behavioral health services to managed care patients when their clinicians can validate that treatment is focused on measurable reduction of current symptoms and functional impairments within a time-limited framework.
In addition to the various indicators of medical necessity that I have addressed, organizations that provide outpatient behavioral health services to patients whose care is managed by MCOs should be aware of a number of pitfalls that can lead to not getting paid. The leadership of provider organizations should ensure that all clinicians doing managed care work understand and avoid these pitfalls:
* GAF of 70 or above.
Many MCOs require that clinicians note a patient's Global Assessment of Functioning (GAF) score. Clinicians must be honest in their assessment of the GAF, but also need to understand that most MCOs consider a GAF of 70 or higher to indicate that even if still symptomatic, a patient is capable of managing his or her difficulties without professional services, either independently or with community or self-help resources.
Once the GAF reaches 70, treatment should be in the termination phase, or transitioning to once-monthly maintenance for bona fide chronic conditions. …