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Insurance upheaval? American Psychiatric Association changes diagnoses in the DSM
If you have a family member with a psychiatric diagnosis like Asperger's Syndrome, autism or anorexia, you probably have heard of the Diagnostic and Statistical Manual-Fourth Edition (DSM-IV). It's published by the American Psychiatric Association and is the primary manual for clinicians to help identify a formal psychiatric diagnosis. To the bane of some psychiatrists in the field who'd rather it just be a simple guideline, it's often referred to as the bible of psychiatry.
The DSM outlines the specific criteria that must be met to receive each diagnosis, as well as the corresponding label and numerical code used by insurance companies. In the spring of 2013, DSM-5 will be published and usher in several changes.
Some disorders were rolled into umbrella terms that encompass many variations of the disorder, whereas other illnesses were pulled out as stand-alone diagnoses. Just what do these changes mean for patients and their insurance benefits?
Let's take a look
Asperger's Syndrome = Autism Spectrum Disorder
Under the current DSM-IV, children who meet the criteria for having autism are diagnosed with autistic disorder (classic autism), Asperger's Syndrome or Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS).
In the new DSM-5, these diagnoses will roll under one umbrella term called Autism Spectrum Disorder. The intention is to consistently diagnose children, though families of those with a current diagnosis of Asperger's may balk at their condition being essentially wiped away.
"The major differentiation between Asperger's Syndrome and autism is speech delay in the cognitive milestones," says William Shryer, LCSW, clinical director at Diablo Behavioral Healthcare in Danville, Calif. Asperger kids don't have speech delay; autistic kids all have speech delay.
"So trying to tease out when they are 5 or 6 if they are high-functioning Asperger's Syndrome or high-functioning autistic became like shooting feathers in the dark; it was just impossible. And so this new term, Autistic Spectrum Disorder puts away the unnecessary attempt to differentiate them. They are autistic kids," says Shryer.
Answers about whether insurance benefits and services may be affected are still up in the air. Shryer says he doesn't think the change will affect benefits. Everyone with a former Asperger's diagnosis should seamlessly morph into the new Autism Spectrum Disorder and should be fully covered, he says.
But critics contend that some children may not qualify under the new autism term and be excluded from services.
"I think there are many children who would normally get an Asperger's diagnosis that will somehow not qualify for Autism Spectrum Disorder. They will say this child is 'too normal,' and those children won't get services covered," says Fran Walfish, a Beverly Hills psychotherapist.
The shift of individuals off the autism spectrum into other diagnoses, such as the new Social Communication Disorder, or to no diagnosis at all, will likely diminish access to some mandated services as well as SSI and SSDI programs and their associated public health insurance and Medicaid-based services, says the Autistic Self Advocacy Network in their June 2012 policy brief.
"These concerns are serious and would have practical consequences to children and adults on the autism spectrum, their families and the professionals who serve them," say lead authors Ari Ne'eman and Steven Kapp.
Hoarding was not considered an illness in its own right in the DSM-IV. Compulsive hoarding was treated as a symptom of Obsessive Compulsive Disorder (OCD). But the DSM-5 cites hoarding as its own diagnosis rather than a symptom.
Seems research has raised doubts about the OCD connection, finding that some hoarding behaviors do respond to OCD treatment but many do not.
"This may be my own prejudice, but my fantasy of the psychiatrists who rewrote the DSM-5 are probably older folks and I think they may view some of these things like hoarding as pathology, when I believe everyone has a little bit of something," says Walfish. "We all live on a learning curve and a spectrum and when the anxiety levels -- meaning the stressors in life -- go over the limit, all of us could fall into some diagnosis. I like to normalize people rather than pathologize them."
Giving a diagnosis to numerous traits and characteristics we previously thought of as quirks has both positive and negative implications. People may be able to get financial help for treatment of some of these problems through health insurance, yet insurers may be overwhelmed or balk at adding scores of new diagnoses to their coverage roster, and perhaps be slow in initiating coverage for many of these "new" health disorders.
Apart from anorexia, bulimia and anorexia/bulimia combined, binge eating was also added as a stand-alone disorder in the new DSM. Eating-disorder treatment benefits are already a tough sell insurance-wise, with benefits typically considered under-funded.
As far as insurance benefits for binge eating, Walfish says she thinks they will be flimsy. Whereas previously someone with this disorder may have been diagnosed with anxiety issues or an adjustment reaction to a life stressor, and probably received insurance benefits for therapy and medication, it may be tough to garner benefits now for binge eating. Walfish suspects many insurers will not rush to add this diagnosis to their roster of coverage.
In fact, psychiatrists may be likely to use the terms anorexia and bulimia to get someone benefits for binge eating whose coverage doesn't allow for it.
"So what they do with these code changes are force practitioners into lying and using a different category to get insurance coverage," explains Shryer.
Bipolar children = Disruptive Mood Dysregulation Disorder (DMDD)
Another controversial new diagnosis is Disruptive Mood Dysregulation Disorder (DMDD). Many children are diagnosed with bipolar disorder, which is typically treated using antipsychotic medications that come with a slew of side effects. Shryer thinks this has been a huge disservice to kids and that this new diagnosis will prevent over-diagnosis of bipolar disorder.
Some critics contend the new DMDD could lead to the pathologizing of normal behavior, including temper tantrums caused by poor parenting and other factors. Shryer says he hopes DMDD protects kids by not immediately putting them on anti-psychotic medications.
If it helps one kid not be put on antipsychotic drugs, it's worth it, explains Shryer. It then forces the professional to figure if a child is being bullied at school or angry at mom and dad and having tantrums. Spending time working with children and families can help suss these issues out rather than labeling the child bipolar and putting him on medication.
Of course, confusion is likely to arise when billing for some of these new diagnoses, says Katherine Woodfield, a New Jersey-based insurance broker and author of Don't Buy That Health Insurance: Become an Educated Health Care Consumer. "If a disorder is coded 526.3 and changes to 573.8, then the "standard of care" must also be re-coded to coincide with the new name. This alone will confuse billers [not everyone is consistently trained], office people [may forget to update the code] and then insurance will kick the claim back because the care does not match the diagnosis," she says.
Depending on the office staff, they may just balance bill the patient because they don't understand the reason for the kick-back. So, it stands to reason that coding changes will cause confusion, which will look like failure to pay, but will most likely be a the result of billing errors.
Getting the bill paid
But just because some conditions will now stand alone in the new DSM, while others are absorbed under umbrella terms, patients aren't likely to notice much difference. As far as insurers are concerned, the disorders which have simply been subsumed into an umbrella diagnosis will likely continue coverage as usual, albeit with the potential for some problems with billing and coverage says Ne'eman and Kapp.
For new diagnoses, patients should check with their insurance companies to see if and when the coverage for those conditions will come into effect. Insurers are free to update and cover new diagnoses at their discretion, which could mean that some will be slower than others to get put on their to-pay lists. And if you have a family member with one of these diagnoses, talk with your mental health practitioner as well as your insurance company to ask about changes in coverage and to make certain everyone is using the appropriate code numbers for claims.
More from Jennifer Nelson here