Ten Reasons Why Your Mental Health Provider Stopped (or Never Started) Taking Your Health Insurance
by Dr. K. Hixson
12/10/21
Many people have sought out therapy for the first time as COVID and the associated psychological fallout from it continues. However, it can be difficult to connect with a mental health provider as the demand for care is far outstripping the supply of providers and available appointments. It’s not easy to lift the veil on this whole system as it can make us feel hopeless and without options. But if we become more knowledgeable about how things actually function behind the scenes, we can demand better. We can find the pathways to advocate for change in these systems that often pit clients and providers against each other. There are some suggestions at the end of the list if you are struggling to find an available in-network mental healthcare provider.
- If you are wondering why you never get a call back from the dozen therapists you’ve called—especially since COVID—it’s because most of us are bombarded by inquiries when we’re already full. Most insurance companies won’t accept enough people in the network for adequate coverage of their members. People looking for a provider end up scrolling through a list that is predominantly a “ghost network.” Sometimes, we can’t even apply to be in the network as much of the time they are not even accepting new providers on their in-network panel because they “already have enough providers in that service area.” Solution: Insurance companies should accept all mental health providers in good standing who want to be in the network to increase the availability of providers with openings.
- Each health insurance company decides to pay mental health providers whatever they individually deem acceptable. There can be up to a $100 (or more) difference in payment between two different insurance companies. Some Employee Assistance Programs pay $30/session which is less than minimum wage when factoring in taxes and the cost of doing business. There is no standard payment for mental health care. Insurance companies just subtract the amount providers ask for from their standard contracted rate. Your provider gets paid less 90% of the time to be in-network. Providers still try to accept insurance so that you have access. Then, the discount you obtain for going in-network impacts us. Insurance companies can also take weeks or months to pay us. They change billing codes without communication which forces us to re-bill and wait longer for payment, and they generally make it extremely difficult to tolerate this whole process of taking your insurance. Solution: Pay all mental health providers the same rate for the same work and give us yearly COLA’s.
- Health insurance companies can and do “clawback” money from us if there has been a mistake, even if it was on their part. Let’s say the company said you were covered on February 14, 2021, by their plan (confirmed by you and your provider), you obtained services, and your provider was paid. If during their audit they figure out you weren’t actually covered, insurance companies can ask for their money back from practitioners who have already provided the services. Insurance companies have clawed back thousands of dollars at a time from small businesses, often solo practitioners, causing immense stress and financial problems. Many other mistakes can cause clawbacks so providers think, why take the risk? Solution: Pass legislation in each state that limits clawbacks from insurance companies to 12 months from the date of service.
- The insurance companies pressure us through audit letters to see you for 45 minutes of psychotherapy (or even 30 minutes) instead of 60 minutes to save a few bucks. One well known company recently sent a letter to some providers explaining they hired a third party to audit us during the pandemic, and they want us to bill for 45-minute sessions more often or risk future audits. At times they also request phone reviews for providers to justify why we’re still seeing you for counseling and then may also request all your clinical notes. They can do this even if we’re working with them out of network—aka, aren’t in network and don’t have a contract with them. Providers have deep concerns about insurance companies dictating the type of care they provide while invading your privacy. Solution: Trust providers to provide the care they are trained to provide. Trust clients to judge the effectiveness of the care and ask them directly whether the care they are receiving is effective.
- Each company has separate departments for credentialing (background checks, licensure verification, etc.) and contracting (setting up a legal contract that allows you to be in-network). It can take several months to get through this process, and communication is notoriously poor. This is a highly inefficient process, and many practitioners don’t want to jump through these hoops. Solution: We need state-wide centralized credentialing and contracting that is efficient and transparent.
- While the Affordable Care Act forced insurance companies to provide mental health health coverage equitably with medical coverage (this is called parity), we are forced to diagnose you with a mental health disorder to be reimbursed. Ever try to get long-term disability insurance or life insurance with a documented serious mental health disorder on your health record? While many clients do have a diagnosable condition, not all do, and some don’t want a disorder listed on their medical records due to privacy. Solution: Let us bill for the problems of living in this difficult world without the need to pathologize and justify it with a diagnosis.
- All insurance companies are focused on getting us to reduce your symptoms to get you out the door as quickly as possible. Everything is about rationing care to increase profits. EVERYTHING. Psychotherapy is a drain on their profits, because we need one hour each week to do good work and we need a confidential space to do it. Providers can also only see so many people per week. There is pressure to get symptoms down, to reduce frequency of visits, and to discharge you as fast as possible. As providers, we know your problems aren’t clear cut and that reducing symptoms doesn’t change the underlying condition. Solution: Trust clients and providers to do long-term work if it is deemed the best path forward for the client.
- We are blocked from organizing together to negotiate our business practices or achieve better contracted rates due to antitrust laws. This is laughable. There has been one union that included private practitioners in the entire country. Please explain to me how thousands of independent solo practitioners could “stifle competition” if they were able to band together? More likely the insurance companies have benefited from the scare tactics of not allowing us to even share what our contracted rates are with each other. There are ways to create group practices to negotiate, but many of us want to remain independent. Mental health providers have very low union representation rates compared with other professions in healthcare. Solution: Allow all mental health providers to engage in collective bargaining.
- Many insurance companies are sued for the way they manage mental healthcare within their plans. They just keep on paying the fines with minimal changes to their business practices. United, Aetna, and Kaiser lawsuits are great examples. Solution: Hold companies accountable for making the changes necessary to provide better mental healthcare options to their members and providers.
- Each health insurance company has lobbyists or lobbying firms that are paid thousands of dollars to influence or block legislative efforts designed to improve healthcare for members and providers. For example, Blue Cross Blue Shield Association paid $12,018,300 for lobbying in the first six months of 2021. According to them, they provide health insurance to 1 in 3 Americans. Solution: Limit the influence of healthcare lobbying and make their goals and agenda transparent to the public. Honestly, single payer now.
As the Client Looking for Care, What Can I Do?
If you need mental healthcare and are struggling to find an in-network mental health provider with an opening, don’t give up! If you’ve already reached out to providers and aren’t getting anywhere, reach out to your insurance company directly (using the number on the back of your card) to ask for help finding an in-network mental health provider who has current openings. If you continue to hit roadblocks because of the issues listed above, get in contact with your state insurance commissioner to report inadequate network coverage. Let them know how many folks you’ve contacted and what other efforts you have taken to find care. Find the insurance commissioner for your state here. You can also consider paying out-of-network to have access to more providers if your plan has that benefit. Of course, it’s complicated, so call your insurance company and discuss this option with the prospective provider. In the mean time, let’s all work together to interrogate and change this rotten system.
If you or anyone you know is in crisis, please reach out National Suicide Prevention Lifeline 800–273–8255 or the Trans Lifeline at (877) 565–8860.