17.8 Case Studies

Jordan Myers operates a private practice and works with several major health insurance providers to make her services accessible to a broader range of clients. One of her clients, David, a 29-year-old software engineer, has been attending weekly therapy sessions for six months to address significant anxiety and depression stemming from workplace stress and perfectionism. Over this time, David has made meaningful progress, developing healthier coping mechanisms and improving his ability to manage stress. However, his treatment is ongoing, and both Jordan and David agree that continued therapy would be beneficial to sustain his progress.

Recently, Jordan received a notification from David’s insurance company stating that no additional sessions would be authorized unless she provided detailed documentation to establish “medical necessity.” The company requested treatment goals, progress updates, and specific symptom details. While Jordan recognizes that David still benefits from therapy, his symptoms no longer meet the insurance company’s rigid criteria for “severe functional impairment,” which appears to be required for continued coverage. Jordan faces an ethical dilemma: she is torn between accurately documenting David’s current progress and embellishing his symptoms to fit the insurer’s standards to ensure he can continue therapy.

Jordan is caught in a conflict between her ethical obligation to maintain honesty in documentation and her desire to advocate for her client’s access to care. The ACA (2014) Code of Ethics emphasizes the importance of truthfulness in all professional interactions, including those with third-party payers. However, Jordan is acutely aware that if she reports David’s progress truthfully, the insurance company may deny his claim, leaving him unable to afford therapy. This decision could negatively impact David’s mental health and undo the progress he has made. On the other hand, exaggerating David’s symptoms to meet the insurer’s criteria could jeopardize Jordan’s professional integrity and violate ethical guidelines.

The dilemma is compounded by the systemic challenges of working with managed care. The insurance company’s rigid definitions of “medical necessity” fail to account for the nuances of mental health recovery, where progress does not mean the absence of a need for continued support. Jordan also struggles with the administrative burden of navigating insurance requirements, which detracts from the time and energy she can devote to her clinical work.

Discussion Questions

1. How can counselors ethically balance the need to advocate for a client’s continued care with the obligation to provide truthful documentation to insurance companies?
2. What are the risks of embellishing client symptoms to meet medical necessity criteria, and how can these risks affect the counselor’s professional practice?
3. How can Jordan effectively communicate the limitations of insurance coverage to David without compromising the therapeutic relationship?
4. What systemic changes could improve how insurance companies evaluate mental health care and determine medical necessity?
5. What alternatives exist for Jordan and David if the insurance company denies continued coverage?

Samantha Rivera runs a solo private practice specializing in trauma counseling, having transitioned from an agency setting where she previously worked. Unlike her agency role, where she had access to immediate supervision and established protocols, Samantha now operates independently, handling clinical and administrative responsibilities. She recently began working with James, a 35-year-old client managing PTSD related to childhood abuse. During their fourth session, James disclosed ongoing thoughts of self-harm and a vague mention of a “plan,” though he denied any intent to act on it. Samantha is profoundly concerned but feels the weight of navigating this complex situation without the resources and support she had in her agency position. While she recognizes her ethical and legal responsibility to prioritize James’s safety, she is worried that breaching confidentiality to involve emergency services could damage their therapeutic relationship and discourage James from seeking future help.

Discussion Questions

1. In the absence of agency resources such as supervision or established crisis protocols, what steps can private practitioners like Samantha take to ensure they are prepared to handle crises?
2. How can counselors in private practice build a network of professional support to help them navigate complex or high-stakes ethical dilemmas?
3. How might the isolation of private practice influence Samantha’s ability to make sound clinical decisions, and what steps can she take to mitigate this impact?
4. What opportunities for professional development could Samantha pursue to strengthen her crisis management skills in a solo practice setting?