I completed my internship at a community mental health center and accepted insurance for 14 years when I worked for Veridian Behavioral Health. As my practice evolved and insurance regulations/reimbursements changed, I realized accepting insurance no longer made sense for the work I do. Ultimately, my decision to conduct my practice differently came down acting with integrity and practicing what I preach to patients.
Lack of Privacy & Confidentiality
When insurance companies pay for your treatment, it also means that their employees (clinicians or not) will audit my treatment plans and read what we talked about in my session notes. These employees are paid to save the insurance company money by searching for fraud and determining whether you’re overusing your insurance coverage. In turn, the insurance company may decline authorization of additional sessions because you are not progressing fast enough; our work in psychotherapy does not qualify as “a medical necessity”; or because my treatment approach isn’t recognized by the insurance company as an “evidence-based treatment” (i.e., rigid manualized treatment conducted in 6-12 sessions).
That is the definition of a controlling, unhealthy relationship in my book.
I believe that you have a right to confidentiality of your medical records. You also have the liberty to progress through treatment at a pace that’s best for you – one that allows you sufficient time to take everything that you’re experiencing. That unfolds differently for each person.
Assumption of Illness
Insurance companies operate on a medical model, which means they require a diagnosis to establish that you have “a medical necessity” to seek services in order to pay providers. The vast majority of insurance companies don’t consider relationship issues, existential issues, life-transitions, personal development, or self-improvement as “a medical necessity.” So, I’d be forced to assign you a diagnosis to be reimbursed for our work together. Sadly, even then there are some diagnoses that insurance companies don’t consider debilitating enough to pay for. To get treatment reimbursed I’d have to label you with a more severe diagnosis that they will pay for, but one that may not really reflect your situation. You’re probably wondering, “What’s the harm in that? A little truth-bending never hurt anyone.” Well, that’s just it – it can. It can come back to bite us both.
Potential Negative Consequences for You
Once a diagnosis is given, it will become a part of your medical record. While that might not be such a big deal right now, it may become one later on if you want to: get life insurance, work in the financial sector managing other’s assets, regularly handle firearms, or seek employment in any sector in which your decision-making might be called into question due to your emotional state. People should get the help they need without fear, stigma, reprisal, or future financial consequences for making their mental health and personal growth a priority.
Potential Negative Consequences for Psychologists/Therapists
If I engaged in the aforementioned truth-bending, I’d essentially be committing insurance fraud. There are providers out there are willing to walk this fine line and take this risk. In my opinion, the penalties and professional consequences of insurance fraud are huge, and frankly, not worth it. I’d rather enjoy the peace of mind that comes with integrity, than a few extra bucks in my bank account.
In order to be “in-network” with an insurance company, I would have to agree to accept a lower fee in exchange for the insurance company listing my practice in their directory of providers and sending me referrals. In the spirit of transparency, a family meal at a nice restaurant is more than what some insurance companies pay per session. And each year, insurance companies continue to cut the rates they pay therapists for their work. (As you know, the cost of everything else in life generally goes up each year!)
Here are two examples with real numbers:
My fee is $175 per session. But, to join XYZ Insurance Co., I had to agree to their reimbursement rate of $60 per session. My client would also be responsible for a co-pay of $25 per session, bringing the total to $85 per session. That means I’m getting $85 less for every session I see clients from XYZ Insurance Co.
Insurance companies are driving psychologists away from doing assessments. Last year I conducted an evaluation that took 5 hours to complete and another 2 hours to score, interpret and write up the results. After several weeks, I got a check from the insurance company for $70. Of course, I assumed it was a mistake. However, the insurance company stated that they were paying out psychological assessments as a single visit, regardless of how much time was spent. So, after the expenses of the test materials are calculated, I made about minimum wage.
For many insurance-based practices, taking on more clients than is clinically prudent is the only way to make up the difference and keep their doors open. This leads to another problem…
Burnout & Exhaustion
Here’s the reality, many providers that accept insurance overbook their schedules in order to turn a modest profit after rent, utilities, malpractice, and other expenses.
Delayed (or Non) Payments
Despite the insurance companies agreeing to a set reimbursement rate, these companies require therapists to jump through a bunch of hoops to get paid. It is common practice for most insurance companies to reject submitted paperwork to delay payments. When they’re not seeing clients, therapists on insurance panels are drowning in insurance paperwork and resubmitting billing claims in order to get paid, or spending hours on the phone contesting unpaid claims. On average, it takes an additional 1.5 hours of UNPAID work outside of the session to get paid for sessions. And remember, the therapist is already making less by agreeing to take insurance. (In my previous example, it would cost $262.50 of my time (175 × 1.5) to get paid my $60 reimbursement rate from XYZ Insurance Co.) The alternative is to pay a medical billing company 5-10% to do the aforementioned, but that increases expenses and cuts into that modest profit. As you can imagine, there’s no paid sick or vacation time to be had either.
Retroactive Claim Denials (aka Claw Backs)
Imagine if your former employer sent you a bill requesting that you repay the income you’d earned 3 years ago. Would that seem fair to you? I didn’t think so. Unfortunately, it’s a common practice among insurance companies. They’ll audit your claims and paperwork for several years back. If they find any mistakes or inconsistencies in the therapist’s paperwork (including grammar, punctuation, margins, etc.) they missed when they originally approved the therapist’s claim, the insurance company will request/demand that the therapist return the fee s/he was paid. Claw backs can amount to thousands of dollars that can bankrupt a small business like a private practice. Many insurance-based clinicians live in fear of such retroactive audits. Talk about stressful!
That’s a recipe for a tired, overworked, and stressed out the therapist.
This may have been the problem if you’ve ever been to therapy you felt didn’t “work” with a provider from your insurance company. I should know. I started to experience the symptoms of burnout after many years of insurance-based practice. And guess what happened?! I started feeling like many of my clients which made me a less effective therapist. And that’s when I realized, “Uh oh! I’m doing the things I tell my patients not to do!” Talk about incongruence!
So, I changed my practice for the sake of my well-being, but also to preserve the quality of care I want to provide every patient. It breaks my heart to reduce access to care to people in need, but I realized that I couldn’t help anyone if I’m stressed-out or out of business.
What are the benefits of privately paying for mental health care?
No Labeling – You don’t have to carry an unnecessary (and perhaps inaccurate) diagnosis on your medical record.
Confidentiality & Privacy – You and your psychotherapist are the only people that will know you’re in therapy. You get to choose who you disclose this information to. Session notes are private records so there won’t be available prying eyes reading about your intimate details.
Self-Determination – You get to work with a psychotherapist that is free to use the best therapeutic approach to help you meet your goals. You and your psychotherapist are the only people involved in the decision about the length of your care. You won’t have to seek additional authorization to continue your work or return to psychotherapy if you have new goals you’d like to explore.
Quality Care & Attention – You’ll get a psychotherapist that’s not professionally overextended. Someone that’s alert and engaged during your session, remembering the details of previous conversations without you having to restate them every week. Most of all, you’ll have the help of a professional that’s invested in your process of growth because they’ve taken the time to do the same for themselves. S/he will be able to use the healing methods that are most appropriate for you.
If you tried psychotherapy and were disappointed with the results or the treatment didn’t seem to “fit” after working with a provider from your insurance company, I hope you have a better understanding of what might have been happening behind the scenes. We urge you to reconsider getting some support now that you do. There are great providers in the healing professions on both sides of the insurance panel.
Jeremy D. Morris, PhD