HMO’s and PPO’s are very clear that active symptoms must be present at some level of severity for treatment to be medically necessary. If you read the guidelines defining medical necessity, you will note, treatment is considered complete as folks report a level of ‘stabilization’, not ‘cure’. Stabilization is defined as approximate to the status quo prior to difficulty associated with a recent ‘triggering’ event.

HMO’s make no bones about it. The goal is ‘stabilization’ not cure.

The goal is not relapse prevention. The goal is not assisting folks with ‘resolution’ of long standing issues of concern. The goal is not to improve the quality of client’s lives. The goal is not to stand by and provide support as folks might elect to make major life changes.

Payment for services rendered is contingent upon determination of ongoing medical necessity by service providers. Service providers are contractually obligated to screen to ensure that only services rising to the standard of medical necessity are billed to the HMO or PPO.

This is the context within which HMO’s and PPO”s operate.