Question

Samuel has a private practice and he receives most of his income from clients covered by managed care companies. He is completing the paperwork to get both reimbursement and approval of the number of sessions for two new clients. Samuel is aware that the diagnosis he gives will affect the responses of the managed care reviewer. The first client, Charlie, has experienced a recent interpersonal loss and has some behaviors that meet the criteria for major depression. The second client, Amanda, has also experienced a recent interpersonal loss and has some behaviors that meet the criteria for a personality disorder. For Charlie, Samuel knows that if he gives a diagnosis of bereavement he will likely be told that the client does not need treatment and he will not be reimbursed, but if the client has Major Depressive Disorder, then the client may be given six or eight sessions. Similarly, if Samuel gives Amanda a diagnosis of Major Depressive Disorder, she will likely be approved for several sessions. However, if he assigns a diagnosis of a personality disorder, then she will not be approved for counseling. Samuel truly believes that both individuals could benefit from counseling with him.

Regarding the case study above, what diagnosis should Samuel give Charlie and Amanda? Why? Do you think it is unethical or illegal for Samuel to give Charlie or Amanda one diagnosis or another? Is it unethical that an insurance company, who has not yet met the client can determine whether they will have services paid for, or how many sessions they can have? Why/why not?

Answer 1

Regarding the case study above, what diagnosis should Samuel give Charlie and Amanda? Why?

Samuel must give Charlie and Amanda the real diagnosis of their illnesses. In case of Charlies as he is showing signs of major depression he will benefit from counselling. As for Amanda, Samuel will need to give the proper and genuine diagnosis which is a personality disorder. The reason being, irrespective of what Samuel ‘believes’ in (‘Samuel truly believes that both individuals could benefit from counseling with him.’), he has an ethical and legal duty to call out the real diagnosis of his clients so the right treatment can be availed by them and also it will refrain him for charging the insurance companies in a fraudulent way.

Do you think it is unethical or illegal for Samuel to give Charlie or Amanda one diagnosis or another?

It is both unethical and mainly illegal for Samuel to give the wrong/incorrect diagnosis to his clients.

Is it unethical that an insurance company, who has not yet met the client can determine whether they will have services paid for, or how many sessions they can have? Why/why not?

In my opinion I don’t think its unethical for the insurance company to determine on the services paid for and the number of sessions they can have. The reason is, the insurance companies decide on such things only after doing much research on the diagnosis and required treatment plans that will largely benefit both the clientele and the company.