Using the DSM-5 Legally and Ethically: A Clinician s Guide Section C Insurance Fraud Considering Culture in the DSM Presented by Pamela H. Harmell, Ph.D. C-1 Parity Diagnoses http://www.dol.gov/ebsa/newsroom/fsmhpaea.html U.S. Department of Labor Employee Benefits Security Administration January 29, 2010 The Mental Health Parity and Addiction Equity Act of 2008 requires group health plans and health insurance issuers to ensure that financial requirements (such as co-pays, deductibles) and treatment limitations (such as visit limits) applicable to mental health or substance use disorder benefits are no more restrictive than the predominant requirements or limitations applied to substantially all medical/surgical benefits. C-2 Accuracy in Diagnosis Parity Diagnoses Mental Health Insurance Coverage Stretching for parity is very tempting Sometimes called INSURANCE DIAGNOSIS Same benefits & limits as medical diseases Tempting to help client receive better reimbursement 1996 Federal Legislation enacted 1998 Federal Legislation implemented C-3 P. Harmell, Copyright, 2014 Section C -1-
Accuracy in Diagnosis Parity Diagnoses http://www.millsconsulting.com/start/parity.html Actual Diagnoses Vary by State IN GENERAL, CALIFORNIA PARITY INCLUDES: Anorexia Bipolar Disorder Bulimia Major Depression Obsessive-Compulsive Disorder Panic Disorder Pervasive Developmental Disorder Schizoaffective Disorder Schizophrenia C-4 Accuracy in Diagnosing Erikson & Kress, 2005 Many practitioners see the DSM as a game to be played and misinterpret their work to 3 rd parties (p. 24) Socioeconomic level impacts diagnosis Ability to pay out of pocket lessens insurance game playing C-5 Accuracy in Diagnosing Erikson & Kress, 2005 Managed Care May Not Reimburse Medically necessary treatment is required Pragmatic reasons encourage inaccurate Dx Sometimes called INSURANCE DIAGNOSIS Clinic and HMO clients stimulate misrepresentation Diagnostic discrimination Worse diagnoses assigned to insurance clients Lower SES clients receive parity diagnoses Appear in research to have higher levels of serious mental illness C-6 P. Harmell, Copyright, 2014 Section C -2-
Accuracy in Diagnosing Erikson & Kress, 2005 Managed Care May Not Reimburse Provision of parity diagnosis for Couple & Family therapy Accurate diagnosis = Z-Code NO insurance reimbursement for Z-Codes Illegal solution: Assignation of parity diagnosis Identified Patient (IP) for insurance billing C-7 Accuracy in Diagnosing Erikson & Kress, 2005 Assigning Inappropriate Diagnosis Constitutes insurance fraud Survey research: 44% respondents Changed Or would change A client s diagnosis to qualify for HMO reimbursements C-8 Intentional Misdiagnosis Braun & Cox, 2005 Managed Care and Ethical Issues DSM Ethical and Legal Concerns Therapists are not honoring DSM codes Patient-therapist agreement Submit inaccurate codes Diagnosing for Dollars C-9 P. Harmell, Copyright, 2014 Section C -3-
Intentional Misdiagnosis Braun & Cox, 2005 Managed Care and Ethical Issues DSM Ethical and Legal Concerns Temptation to intentionally misdiagnose Clients receive reimbursement Clients receive more treatment C-10 Intentional Misdiagnosis Braun & Cox, 2005 Managed Care and Ethical Issues DSM Ethical and Legal Concerns Why use DSM diagnoses? Proper billing and reimbursement Meeting agency and licensing requirements Record keeping, data collection, research Demonstrating need for services Providing livelihood for clinician 85% of private practice psychologists reported MCO provided majority of their income C-11 Ethics and Multiculturalism Sue & Sue, 2007; Welfel, 2013 Diversity as centerpiece of ethics Needs further attention in DSM Competence and skill not yet achieved A factor in every aspect of professional practice C-12 P. Harmell, Copyright, 2014 Section C -4-
Ethnic and Cultural Sensitivity DSM: The Impact of Cultural Differences Cultures exhibit symptoms differently Understanding distinctions helps aids proper diagnosis Increases effective treatment C-13 Ethnic and Cultural Sensitivity ETHNIC & CULTURAL SENSITIVITY TWO METHODS TO ADDRESS INTEXT DISCUSSION Outline for Cultural Formulation Cultural Formulation Interview (CFI) Cultural Concepts of Distress C-14 (2) Outline for Cultural Formulation Five elements for assessment C-15 P. Harmell, Copyright, 2014 Section C -5-
Cultural Formulation ApA, 2013; Lewis-Fernandez & Diaz, 2002 DSM-5 FIVE CULTURAL CATEGORIES FOR EXAMINATION (1) Cultural Identity of Individual C-16 Cultural Formulation ApA, 2013; Lewis-Fernandez & Diaz, 2002 DSM-5 FIVE CULTURAL CATEGORIES FOR EXAMINATION (2) Cultural Conceptualizations of Distress C-17 Cultural Formulation ApA, 2013; Lewis-Fernandez & Diaz, 2002 DSM-5 FIVE CULTURAL CATEGORIES FOR EXAMINATION (3) Psychosocial Stressors & Cultural Features of Vulnerability & Resilience C-18 P. Harmell, Copyright, 2014 Section C -6-
Cultural Formulation ApA, 2013; Lewis-Fernandez & Diaz, 2002 DSM-5 FIVE CULTURAL CATEGORIES FOR EXAMINATION (4) Cultural Features of the Relationship Between Individual and Clinician C-19 Cultural Formulation ApA, 2013; Lewis-Fernandez & Diaz, 2002 DSM-5 FIVE CULTURAL CATEGORIES FOR EXAMINATION (5) Overall Cultural Assessment C-20 (3) Cultural Formulation Interview (CFI) ApA, 2013 Third element of Assessment Set of 16 questions Impact of culture on presentation A mental health assessment Use in entirety or specific components C-21 P. Harmell, Copyright, 2014 Section C -7-
Cultural Formulation Interview (CFI) ApA, 2013 Emphasizes four domains 1. Cultural definition of the problem - Questions 1-3 2. Cultural perceptions of cause, context, and support - Questions 4-10 C-22 Cultural Formulation Interview (CFI) ApA, 2013 Emphasizes four domains 3. Cultural factors affecting self-coping and past help seeking - Questions 11-13 4. Cultural factors affecting current help seeking - Questions 14-16 C-23 (4) Cultural Concepts of Distress ApA, 2013 Current formulation: Acknowledges distress is locally shaped From this perspective, many DSM diagnoses can be understood as operationalized prototypes that started out as cultural syndromes, and became widely accepted as a result of their clinical and research utility. (p. 758) C-24 P. Harmell, Copyright, 2014 Section C -8-
Cultural Concepts of Distress ApA, 2013 Glossary of Cultural Concepts of Distress Glossary Located in Appendix Well-studied cultural concepts of distress Guideline for interrelationships among cultural syndromes C-25 Sum Up Questions LEGAL / ETHICAL ISSUE: Why are clinicians tempted to inflate a diagnosis and give an insurance diagnosis? Answer: Harmell, D-26 copyright, 2014 Sum Up Questions LEGAL / ETHICAL ISSUE: Which population is most adversely effected by misdiagnosis of a parity diagnosis? Answer: Harmell, D-27 copyright, 2014 P. Harmell, Copyright, 2014 Section C -9-
Sum Up Questions LEGAL / ETHICAL ISSUE: Why are individuals with parity diagnoses at more risk for potential negative consequences related to being diagnosed with a parity diagnosis? Answer: Harmell, D-28 copyright, 2014 Sum Up Questions In which section are the cultural sensitivity assessment measures located? Answer: Harmell, D-29 copyright, 2014 References Bartoli, E., & Pyati, A. (2009). Addressing clients racism and racial prejudice in individual psychotherapy: Therapeutic considerations. Psychotherapy: Theory, Research, Practice, Training, 46(2), 145-157. Braun, S.,& Cox, J. (2005). Managed mental health care: Intentional misdiagnosis of mental disorders, J of Couns & Development, 83, 425-433. DeAngelis, T. (2009). Unmasking racial micro aggressions. American Psychologist, 40(2), 42. C-30 P. Harmell, Copyright, 2014 Section C -10-
References Frame, M., & Williams, C. (2005). A model of ethical decision making from a multicultural perspective, Counseling and Values, 49, 165-178. Gallardo,M., Johnson, J., Parhan, T., & Carter, J. (2009). Ethics and multiculturalism: Advancing cultural and clinical responsiveness, Professional Psychology: Research and Practice, 40 (5), 425-435. Laungani, P. (2002) Mindless psychiatry ands dubious ethics. Counseling Psychology Quarterly, 15(1), 23-34. C-31 Bibliography Sue, D., & Sue, D. (2008). Counseling the culturally diverse: Theory and practice (5 th ed.). NY: Wiley. Van der Zee, K. van Oudenhoen, J, Ponterotto, & Fietzer, W. (2013). Multicultral personality questionnaire: Development of a short form. Journal of Personality Assessment, 95(1), 118-124. Zhang, N., & Burkard, A. (2008). Client and counselor discussions of racial and ethnic differences in counseling: An exploratory investigation. Multicultural Counseling and Development, 36, 77-87. C-32 P. Harmell, Copyright, 2014 Section C -11-