This is an unfortunate situation (the insurance conundrum, not the diagnosis itself). I'd like to set aside for a moment the issue of whether or not the diagnosis carries any/much stigma. It's a good question, and a practical one, but it's not the main issue in situations like this. This rather long post is not intended to affect Ira's work with her therapist (something we avoid here), but to address the broad and important issue she has brought up. First, let's assume the poster (Ira) is correct and that her therapist doesn't really believe he has a mental disorder (or has "upcoded" it from a DSM non-disorder "problem"), with Ira's knowledge. I fully understand clinicians' wishes to help patients who cannot pay for therapy, and their wish to get paid for the work they do, but what is described here is both unethical and illegal. (Please, no flames about people in need, unfair insurance companies, or the venerable "if I steal bread to feed my starving family, have I really commited a crime." I already said I fully understand, and I do.) The practice of knowingly documenting a fake diagnosis is, as I said, unethical and illegal. One can think of many examples to shock well-meaning clinicians into realizing that they are placing themselves in the same class as, for example, (a) workers compensation mills that cheat employers and insurance plans out of millions every year; (b) dishonest personal injury lawyers who hover around minor accidents and shill "victims" to dishonest doctors and chiropractors; (c) doctors and chiropractors who, even without referral lawyers, prey on people's fears and greed and treat them for nonexistent (or markedly exaggerated) maladies and subluxations; (d) unscrupulous therapists who "churn" patients who are required to seek evaluation or counseling because of legal or child custody problems, knowing they have to pay or face loss of freedom, professional license, or visitation rights; (e) doctors and other clinicians who, without the semblance of altruism implied in Ira's matter, simply "upcode" diagnoses, therapies, and procedures out of greed. The consequences of even altruistic-sounding upcoding are sometimes intended and sometimes not, but they are significant. (1) Doing something unethical (and illegal) wears on the soul, so to speak, of good clinicians. It erodes their overall ethic and self concept. Never mind those clinicians who are chronically dishonest. (2) No professional organization I know of approves the practice, and most will take action against members who knowingly upcode. (3) If discovered, the insurance company may well take action against the clinician, the patient, or both (which could include cancelling the coverage, demanding the money back, or reporting the clinician to law enforcement -- just ask anyone who has been accused of Medicaid or Medicare fraud for things like this, it's potentially a felony). There are at least two other (negative) patient consequences: (4) The mental disorder diagnosis will never disappear once it is in the insurance company records and is accessible to a wide variety of other people and insurance companies. (I agree that the stigma is minimal in this particular case, and I am not suggesting inappropriate "downcoding" to deal with stigma -- that's another rant.) (5) The patient is being told, rather clearly, that the therapist is dishonest, and that the therapist believes it's O.K. to be dishonest for money. What kind of message is that from a clinician who is no doubt _encouraging_ honesty and frankness from the patient in sessions and is, in many therapeutic settings, a kind of model for the patient? In fact, the patient and therapist appear to be colluding to defraud the insurance company. That means the patient is essentially stealing (sorry to be so blunt, but that's the way it looks) thousands of dollars from the company, in the form of payments for psychotherapy because she "wanted to see" the therapist. I want a Mercedes, and it would be good for my mental health, but I'm not allowed to get it under false pretenses. (6) Finally, there is an important public health and research consequence. Governments, insurance companies, and countless graduate students, study incidence and prevalence trends in diagnosis, and the accompanying treatment data. The data from millions of insurance records are used to study illness patterns and shape policy for the public health, medical and behavioral health funding (both public and private), training program needs, and the like. The presence of wholesale upcoding and changing diagnoses in order to be paid has become such a problem that public and private health care decision makers now are often unable to rely on epidemiologic data. Incidence and prevalence data for major depressive disorder and PTSD, for example (for separate reasons), have been virtually useless since the early 1990s, largely because of clinicians who have used them to justify insurance payment, hospital admission, etc.
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