The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Eating Disorders, 3rd Edition, outlines each level of care, along with the criteria a patient must meet in order to require that level of treatment. Lisa Kantor, partner at Kantor & Kantor, LLP, LLP has created a tremendous documentation tool- which uses the APA Guidelines to help treatment providers determine the most appropriate and effective level of treatment. Additionally, this tool can be used to enhance documentation during ongoing treatment. The Inner Door Center® uses this documentation tool (referred to as the "APA Grid") in our clinic when determining patient placement either in our Partial Hospitalization, Intensive Outpatient or Outpatient Therapy Program for Eating Disorders or in a higher level of care outside of our facility.
The "APA Grid" is part of our electronic medical record system. It is utilized once a patient has initial assessments completed for program admission, including: Psychological Assessment, Psychiatric Assessment, Nursing Assessment, Nutrition Assessment and Occupational Therapy Assessment. Clinical information is taken from the assessments and incorporated into the "APA Grid" by our Clinical Program Coordinator, then reviewed by our nursing staff and our Certified Eating Disorder Specialist.
As a Michigan Licensed Partial Hospitalization Program, every two weeks we are required to update treatment plans (every 30 days if in Intensive Outpatient Program). We adhere to this standard, and also update the "APA Grid" simultaneously. We use the "APA Grid" to determine the current and appropriate level of treatment needed, and speak from the "APA Grid" when obtaining pre- certification or requesting continued stay through the insurance company. Although most insurance companies do not want this type of documentation on file, we continue to fax this information to them in order to assure it becomes a part of the patient's claim file. We find this to be a valuable method in effective communication (in writing!) between The Inner Door Center and our patient's insurance company.
When dealing with self-funded policies, your patient's HR (Human Resources) representative can actually change the insurance company's decision. In this case, the HR representative will need to work with the insurance company to coordinate the exception (or single- case agreement) and guide the insurance claim through the system. When pursuing a single-case agreement, you will need to provide clinical information to the insurance company. This is where the "APA Grid" comes in handy, allowing you to show clear and unmistakable documentation of why your patient will need a specific level of treatment.
In terms of diagnosis, along with thorough documentation, we have found that the best practice is defined by the American Psychiatric Association (APA), peer reviewed literature, and collaboration with eating disorder professionals in our community. The Kantor & Kantor, LLP "APA Grid" provides further support when accurately diagnosing our patients.
Within the consortium of eating disorder professionals across the country, it is important that we are all on the same page when it comes to proper diagnosis and thorough documentation of eating disorders. The "APA Grid" is as great way to pull it all together in order to support your patient in the most appropriate level of treatment.
Most eating disorder professionals understand that an improvement in clinical symptoms does not necessarily merit a change in treatment. Without consistent and appropriate treatment, it can be easy to fall back into active disease (i.e. weight restoration in Anorexia Nervosa-AN, cessation of vomiting or laxative abuse in Bulimia Nervosa-BN). Thus, experts have become cautious when diagnosing treated AN or BN as Eating Disorder Not Otherwise Specified (EDNOS) once clinical symptoms have improved. Experts are also careful when using the diagnosis of EDNOS to capture a patient that falls short on symptoms.
It is interesting to note that statistics on mortality rates of EDNOS are higher than both AN and BN. Could it be that there are so many individuals being misdiagnosed as EDNOS? As you can see, the line between the cessation or absence of clinical symptoms - and the need for a different level of care - can be unclear. Unfortunately, insurance companies do not always see things the way we do and use this ambiguity to deny treatment. It becomes the responsibility of the eating disorder community to consistently utilize a uniform documentation tool, in order to convince insurance companies of the most appropriate and effective level of treatment.
If you have questions on how to make use of the "APA Grid", contact Beverly Price or Kantor & Kantor, LLP. Beverly Price is a Certified Eating Disorder Specialist and owner/founder of the Inner Door Center® Partial Hospitalization, Intensive Outpatient and Outpatient Therapy Clinic in Royal Oak, Michigan. She can be reached for further information on how to utilize the "APA Grid" at www.innerdoorcenter.com. You can find the "APA Grid" here.