The Hidden Crisis in Health and Mental Health Care
In the evolving landscape of health care, the term medically necessary carries significant weight. For social workers, mental health providers, and physicians, this phrase determines whether clients receive the critical services they need. Yet, as the barriers to care mount, there’s an unsettling trend – more services deemed essential by health professionals are dismissed by insurance companies as not medically necessary.
The Disconnect Between Providers and Payers
As a practicing physician or therapist, determining whether something is medically necessary involves careful review. It means examining records, seeing the patient, conducting thorough assessments, and drawing conclusions grounded in years of education and clinical experience. Yet, insurance companies wield the power to override these decisions without ever speaking to or examining the patient.
One can’t help but ask – are they just that good? Or are they leveraging algorithms and AI to systematically deny care, regardless of the human cost?
Social Work as Medically Necessary Care
For social workers, the medically necessary debate extends beyond physical health. Housing, mental health counseling, transportation, and food security all fall under the umbrella of health determinants. If a social worker recommends community habilitation for a high-functioning client to prevent relapse, it should be seen as essential to their recovery. However, insurers often reject these interventions as not medically necessary – a dangerous misunderstanding of what comprehensive care truly involves.
Take for instance a mental health client facing eviction. A social worker steps in to advocate for housing stability, recognizing that homelessness could exacerbate psychiatric symptoms, lead to hospitalization, or worse. From a social work perspective, this intervention is undeniably necessary. From an insurance standpoint? It might just be labeled as an ancillary service, leaving the client vulnerable to catastrophic outcomes.
The Liability Divide
Here lies the critical inequity – if a physician or therapist gets a diagnosis or treatment plan wrong, they face medical liability. If a social worker overlooks a housing barrier that leads to client deterioration, they are held accountable. But when an insurance company denies care, even when it results in severe harm or death, they bear no medical liability.
Shouldn’t insurers carry the same malpractice exposure as any other health professional when making decisions that directly affect someone’s well-being? After all, their denial of services often results in life-altering consequences – consequences no different than those resulting from a misstep by a provider.
The Real-World Impact of Denials
Insurance companies may argue that denying care doesn’t directly harm patients, but this is a flawed and dangerous narrative. When treatment is labeled not medically necessary, patients are left stranded – sometimes unable to access critical mental health care, medications, or social services.
A social worker advocating for therapy coverage for a suicidal client might find themselves in a bureaucratic tug-of-war, forced to justify care that should be self-evident. This administrative burden not only delays treatment but places unnecessary strain on practitioners who already operate in high-pressure environments.
Advocating for Change
To shift this dynamic, social workers, physicians, and mental health advocates must collectively demand greater accountability from insurance companies. This means:
•Pushing for legislative reform that holds insurers legally accountable for wrongful denials.
•Amplifying patient stories that highlight the devastating effects of denied care.
•Continuing to emphasize the holistic nature of health care – mental health and social services are as medically necessary as physical interventions.
A Call to Action
Health care providers don’t have the luxury of practicing medicine through algorithms alone. We engage with patients, listen to their concerns, and apply nuanced judgment that no AI can replicate. If insurers want to dictate care by deeming services not medically necessary, they should share the risk – and the liability – when things go wrong.
In the end, denying medically necessary care isn’t just an administrative decision. It’s a life-or-death calculation, and until insurance companies are held accountable, the scales will remain unfairly tilted – to the detriment of patients and providers alike.
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Author Info:
Max E. Guttman
Max E. Guttman is the owner of Mindful Living LCSW, PLLC, a private mental health practice in Yonkers, New York.
