11 The Referral: Magda “Maggie” Perez

Psychosocial/Diagnostic Evaluation Session: Magda Perez 

 You’ve just finished writing a progress note in your office at the private counseling center where you work. It’s late afternoon and you feel pleasantly tired as you look out the window toward the patch of scrub pines in the field behind the clinic.

You’ve had a full day, with three clients in the morning and three this afternoon. This year marked your 30th anniversary as a licensed clinical social worker, and you still find the career every bit as emotionally satisfying and intellectually challenging as you’d hoped it would be when you decided in college to become a counselor.

You reach to your computer to shut it down and then notice the EMR (electronic medical record) icon flashing on your screen. Tapping it open, you find a standard referral face sheet:

//Confidential//

• Client: Magda Amalia Perez DOB:         07/05/82
• Address: 1617 Fairhaven Road, Round Rock, FL 34931 Phone:   (797) 555-0985
• Insurance: Cengene Health PPO
• ID: JKXL4182
• Copay: $10 (1-10)
• Copay: $50 (11-20)
• Copay: $60 (21+)
• Preauth: Concurrent review 21st then q4 w Employer: New City Surgical Center Referral: Dr. S. Munson
• Complaint: Anxiety/family stress/job stress Priority: Urgent

 //Confidential//

That last line catches your eye. Most referrals come to you with a “routine” priority designation, which requires you to offer an appointment within ten days. Urgent referrals, which require you to offer an appointment within 24 hours of the request, are relatively rare. Even more unusual are the highest priority “emergent” referrals, which require a same-day appointment, usually because of a high-risk situation such as the threat of harm to self or others, psychosis, or domestic violence. You rarely see emergent patients, though, because your clinic has a crisis interventionist who generally receives those referrals.

You feel lucky to have been employed for the past eight years at this well-staffed counseling center, where every member of the clinical team has a distinct specialty. Your best friend, who has the office next to yours, is a psychodynamic traumatologist and DBT specialist; she provides long-term therapy, mostly to clients with personality and dissociative disorders. The counselor at the other end of the hall is a play/art therapist who only sees children under the age of eleven. She mostly works with the ADHD crowd; kids are ever bursting from her office like rowdy, good-natured hurricanes, yelling, “See you soon, Miss Jill,” and proudly bearing their smudgy paintings and lumpy clay creations to their parents in the waiting room. Rounding out the group are a crisis counselor, an addiction specialist, a marriage and family counselor, and a therapist specializing in group work. There’s also a part-time psychologist who does psychological and educational testing and a part-time psychiatrist who provides medication management. You complete the team with your specialty in short-term clinical interventions, specifically, cognitive behavioral therapy and solution-focused brief therapy for the treatment of anxiety and depressive disorders in adolescents and adults.

Increasingly, there is a growing need for your brand of counseling, and a glance at Magda Perez’s profile sheet explains why. Over the past decade, it has become common practice for insurance companies to approve an initial batch of psychotherapy sessions, typically eight to ten, without requiring advance permission or pre-authorization, and at a very affordable copay, which is the fee that the patient pays per session. Beyond those initial visits, however, the patient’s copay rises steeply, as is the case with Magda Perez’s coverage. Her first ten sessions will cost her only $10 each, and her insurance will cover $90 per visit, which will be the balance of her $100-per-session fee. The 11th through the 20th sessions will cost her $50 each, with the insurance paying the other $50. She’ll pay $60, and the insurance company will kick in $40 for any “medically necessary” sessions from the 21st visit onward. The intent of this financial incentivizing is clear: the insurance companies don’t want patients to linger in therapy any longer than absolutely necessary. This is your goal, too, of course. In the middle of the last century, when psychoanalytic therapy was all the rage, it was common practice for patients to see their therapists several times each week for a period of five to ten years, but those days are long gone. Now, even long-term therapy for the most disturbed patients typically lasts no more than a couple of years, and only those in acute crisis can expect to see their counselors more than once a week.

You note that Magda’s insurance company requires concurrent review after the 20th session and every four weeks thereafter. This means that if you are still seeing her beyond 20 sessions, you will need to have a monthly phone consultation with a case manager from her insurance company to obtain authorization for those additional sessions. Those concurrent reviews are often time-consuming and frustrating affairs, so you do your best to equip your clients with the necessary skills and get them on their way before the concurrent review is required. Fortunately, with your specialty in short-term therapy with patients who are not severely mentally ill, you rarely need to provide services beyond the 20th or even the 15th session. For this, you’re grateful.

Your best friend next door, who specializes in complex trauma cases, frequently battles with various insurance companies in order to advocate for her clients’ need for extended psychotherapy. She almost always prevails because of her well-documented treatment plans and her many advanced credentials, but still… you’re glad that you’re mostly able to get your clients, overwhelmingly women with anxiety and/or mild to moderate depression, on their way to recovery before confrontational engagement with their insurance companies is necessary.

Reaching for the phone, you study the face sheet again and note the referral source with a smile. Susan Munson is a primary care physician who has sent many patients to the agency over the years you’ve been there. The two of you confer about patients at least once a month, and you enjoy working with her. Thus prepared, you dial the patient’s number.

On the third ring, a small voice says, “hello?” The voice is young, female, slightly tremulous. You wonder if she’s been crying.

“Hello,” you say warmly. “This is Mary Williams. I’m trying to reach Magda Perez?”

“That’s me, I’m Maggie Perez.” You note again that her voice has a quavering, distressed quality.

“Hello Maggie. As I said, my name is Mary Williams. I’m calling from the Round Rock Counseling Center.”

“Oh wow, that was fast,” she says. “I just got off the phone from the receptionist about fifteen minutes ago. I’m glad you called back so quickly.” There is a small pause. Then, “I really need help.” On the last word, her voice breaks; she is crying.

“It’s good you reached out,” you say matter-of-factly. “Let’s set up a meeting.”