A managed care clinician completed a utilization review and has just denied auth

Question

A managed care clinician completed a utilization review and has just denied authorization for you to continue treating a client. You believe that the client could benefit from four additional sessions. At the same time, you understand that the managed care clinician must apply criteria of medical necessity to justify continued treatment, and you are aware that many of your agency's clients have problems much more severe than your client's. Make a list of all of the ways that you could try to ensure that the managed care system does not prevent you from giving your client the type and duration of treatment services that he or she needs. Categorize each of the items into two groups reflecting those that would be considered professionally appropriate and ethical, and those that would be considered to be a violation of professional ethical standards.

Explanation / Answer

1. Professionally ethical reasons:

- beneficence to the patient

- non maleficence

- as well as giving the patient the right amount of care that they deserve.

Hence, ethically I should be treating the patient with the treatment that they deserve.

- I could persuade the management by mentioning the ethical principles and emphasising on how much care the patient requires. - ethical way of persuasion

- I could persuade the managed care system to appoint some other nurse for taking care of the other patients, so that complete care could be provided to this patient. - unethical as that might fall in denial of duty.

- Also, I could persuade them by saying that it is necessary to provide complete care to the patient, if not the patient could report or sue us. - unethical as this might fall in blackmailing the higher authorities.

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