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Ethical Violations

Case Study

Ethical Pitfalls in Managed Care

After completing his master's degree in counseling, Martin worked at the Family Service Center, an agency where he received 3,000 hours of supervised practice required for licensure in his state. He passed the state board examination and became a licensed professional counselor. Only then, in accordance with state licensing regulations, did Martin hang out his shingle and open his independent private practice
Martin wanted to provide the best possible counseling services to his clients. He also wanted "and needed- to earn a good living. During the first few months he struggled, unaware of the extent to which managed care had affected the private practice of counseling. He placed ads in the yellow pages and local telephone directories, gave free talks at PTA meetings and to various civic clubs, invited referral sources out to lunch, and attempted several other strategies to build a client base. Very few referrals came.
Martin pursued an opportunity to become a network provider with HealthCo, a managed care company. He accepted the company's $50 per hour payment, although it was considerably less than his usual fee, and agreed to comply with HealthCo's approach to managed care. He was delighted when HealthCo referrals began to come in on a regular basis.
In some respects, Martin was pleased with the service provided by the managed care company. When he ascertained that a client who presented with depression was also suffering from anorexia, he realized that he needed to refer clients because he lacked training and supervised experience with this disorder. He called his HealtCo case manager, who arranged a psychiatrist in the network who specialized in eating disorder.
However, there were some aspect of the relationship with HealthCo that worried Martin. He was required to get telephone authorization for clientsâ?? sessions, but it seemed that whenever he called, he was connected to a different case manager who identified him- or herself only by first name. The case managers began the telephone conferences by keying in Martin.s client's Social Security number to gain access to the client's computerized file. Before he began to work with HealthCo, Martin had been required to give diagnosis when completing paperwork for third-payers, and he was comfortable with giving that information. But these case managers insisted that if they were going to manage, they needed much more information. They inquired about client's childhood traumas, marital problems, addictions, and other matters. Martin realized that this questioning was legal because the client had signed Health Co disclosure form. But he wondered, was it ethical? He became concerned about just what happened to the information he disclosed over the telephone.
Soon after these concerns began to emerge, one of Martin's clients ran out of insurance benefits. The case manager suggested that Martin space out the last 3 of the 20 allocated visit over a period of several months or arrange a referral to a community mental health center. Martin did not feel that these options were acceptable. The client needed weekly sessions, and considerably more than the 3 that remained. He also believed that she needed continuity of care, and that a transfer t a new counselor was not in her best interest. Martin attempted to explain his concerns to the case manager but was unsuccessful in convincing her to alter her decision. Because he could not consider abandoning a client and would not make a referral, he decided, with some resentment toward HealthCo, to continue to see the client pro bono. This interaction caused Martin to wonder what professional credentials HealthCo's case managers possessed. Were they qualified to make decisions about psychotherapy?
Soon thereafter, an 11-year-old boy named Joshua was referred to Martin under the boy' father's company insurance plan administered by HealthCo. Joshua was getting in fights at school. It quickly became clear to Martin that Joshua's parents were in conflict, so Martin recommended marital counseling. However, this particular HealthCo plan didn't cover marital counseling. Martin, beginning to feel frustrated with managed care, saw the parents in counseling and billed the sessions under Joshua's name. He justified his decision to himself by reasoning that; after all, gains in the marital relationship should surely yield benefits for Joshua.

Give a brief description of two ethical violations from this case study . Evaluate the consequences (e.g., sanctions) of engaging in each violation. Finally, analyze and explain what a counselor would do to safeguard against such situations in a counseling practice

Solution Preview

Two ethical violations merge in Martin's case. One is based on standards set forth under the Health Insurance Portability and Accountability (HIPPA, 1976) Transaction rule. Although, the client has originally signed an agreement with the managed care company, under the HIPPA rule states that when information is transmitted communications such computer, fax, telephone or internet, a second consent inform must be signed in addition to the initial consent form (Beresoff, 2003). Psychologists are required to obtain a patients consent before personal health information (PHI) can be transmitted. The APA addresses this rule under Standards 4.05, Privacy and Confidentiality" in which psychologists are to protect confidential information transmitted by electronic media.

The other ethical violation committed in Martin's case is fraudulent billing. Under Standard 6.01c, "psychologists do not misrepresent fees. This standard is further enforced concerning bill payments to third parties (e.g., insurance companies) under Standard 6.06 in which psychologists must maintain accuracy in reports to funding sources in a way that reflects value and honesty.

(2) Evaluate the consequences in each ...

Solution Summary

This solution discusses ethical violations in managed health care for a specific case study.