According to their November newsletter emailed to providers, Blue Cross Blue Shield of Michigan announced that as of November they will deny claims from behavioral health providers for adjustment disorder services beyond six months from the initial diagnosis (we’ll talk later about whether this applies to other states).

The Michigan health plan stated in their opinion, “Adjustment disorders [diagnosis codes F43.20 – F43.25] are stress-related, time-limited conditions. The Diagnostic and Statistical Manual, or DSM, states … symptoms are usually resolved within six months after the stressful event ended.” The announcement states that they are hoping to motivate us to reevaluate diagnoses after six months.

However, it’s not hard to guess that this is an easy way for them to save money. If they automatically deny claims, they don’t have the trouble and expense of doing record requests or clinical reviews to look at each case individually to determine each client’s situation. Plus they know that some clinicians won’t resubmit claims or appeal, so they’ve already saved money.

The sneakiest thing they did? Sending out the email notifying providers of the new policy on October 31st – one day before it was to become effective.

BUT: This policy does not accurately represent what the DSM says. As I said in a previous article, many therapists (and now Blue Cross) often think we can only use adjustment disorders for 6 months from the initial diagnosis. But read the diagnostic criteria closely. The DSM-5 criteria for adjustment disorders states that “once the stressor or its consequences have terminated, the symptoms do not persist for more than an additional 6 months.” That means you start counting 6 months after the stressor or consequences have ended, not from the initial diagnosis.

Going even further, the DSM actually says that “stressors may be recurrent … or continuous,” giving the examples of a persistent painful illness with increasing disability, or living in a crime-ridden neighborhood. It goes on to say “if the stressor or its consequences persist [past the 6-month window], the adjustment disorder may also continue to be present and become the persistent form.”

In fact, the DSM-5-TR gives the option of a “Persistent (chronic) specifier” for adjustment disorders. “This specifier can be used to indicate persistence of symptoms for 6 months or longer … and applies when the duration of the disturbance is longer than 6 months in response to a chronic stressor or to a stressor that has enduring consequences.”

Both the Cleveland Clinic and the Mayo Clinic back this up. The Mayo Clinic website says “persistent or chronic adjustment disorders can continue for more than 6 months, especially if the stressor is ongoing, such as unemployment.” Another example of a chronic adjustment disorder might be caring for a disabled or special needs child.

What about clients who have repeated stressors? Let’s say you see a client who started treatment after one stressor and then months later is faced with a new stressor. For example, a client who lost a job and then months later lost their home and months later had to move back in with their parents. Normally, each of these sequential losses would restart the 6-month clock each time. But with this new policy from BCBS, your claim would be denied 6 months after the initial diagnosis.

So, what does BCBS say you should you do if the member continues exhibiting symptoms beyond six months? BCBS states “there can be instances when the member experiences multiple stressors and precipitates another initiating event that prolongs the diagnosis beyond six months.” In this case, BC providers are advised to reevaluate clients to see if they meet the criteria for another disorder, and if so, to submit claims using the [updated] diagnosis code.”

What should you do if a claim is denied? BCBS states, “if the member requires treatment under a new diagnosis, the provider should resubmit the claim using the correct diagnosis code.” On the other hand, if the member requires ongoing treatment under the same diagnosis, the provider can request a “clinical editing reconsideration” (for details about making the request, see the denial letter, and this link).

But, who wants to go through that hassle? To avoid triggering a review, many therapists will just change the diagnosis – in some cases, perhaps, to a diagnosis that may not fit as well.

Is this happening in health plans other than BCBS, and in places other than Michigan? I have previously heard of plans looking closely at (and sending letters to) clinicians who use Adjustment Disorder diagnoses beyond 6 months – see my previous article here. But this is the first time I’ve heard of claims being automatically denied at 6 months. Just in case it is the start of a new trend – within Blue Cross/Blue Shield plans, and in other plans – it’s a good idea to get proactive.

So, what can you do?

• If you are a Blue Cross of Michigan provider, I urge you to protest, even if you didn’t get a denial. Write an email or letter to the CEO of BCBSM Tricia Keith (tkeith@bcbsm.com, 600 E Lafayette Blvd, Detroit, MI, 48226) protesting this new policy. (Note: as of this publication, she had not responded to a request for comment). Use some of the arguments and citations from this article, and state the policy is not based on DSM criteria or medical necessity criteria. Send a copy to the State Department of Insurance. Perhaps flooding their inbox can make a difference to get this policy repealed – and send a message to any other BC plans that are considering it.
• For all of us, here are some good reminders:

• Revisit diagnoses every 3-6 months to see if they need updating, changing, or additions. But be sure you can back up any diagnosis.
• If you make diagnosis changes, update the treatment plan, and in the session note document the change and any support you have for it.
• If you find you are just doing personal growth work with no diagnosis, explain to the client that you can no longer bill insurance.
• As always, in each session note, document the client’s impairments and the symptoms of your diagnosis as well as the medical necessity for treatment, in case you ever need to defend it.

Read BCBS’s full post here