My Professional Rant
As a psychotherapist, I am often asked, “How can you listen to people’s problems all day?” In truth, it is a privilege and pleasure to meet with clients. What I find challenging is what occurs between sessions. Administrative tasks can be overwhelming. Dealing with insurance companies for the reimbursement of my services is the bane of my existence. This is a long column, but settle back and indulge me in a rant about the plight of those of us who are therapists and those seeking mental health treatment.
I have a doctorate in counseling and two additional years of specialized training in family therapy. I am licensed as a marriage and family therapist in two states and certified as an addiction counselor in the same states. I am required to complete 30 hours of continuing education every two years, where I learn new treatment approaches to maintain my professional license. I am an AAMFT-approved supervisor. But this is not sufficient for getting reimbursed for my services. As a private practice clinician, it has been a process of hit and miss to secure reimbursement from insurance.
During the tenure of my career, I have seen insurance coverage and practices change dramatically. Don’t get me wrong. I am fully in favor of insurance coverage for mental health services. I don’t believe that most middle- and lower-class individuals can afford the cost of treatment without insurance. As a helper, I want counseling to be available to everyone.
As background information, health insurance in the United States began with the Great Depression in the 1930s. Medicare was introduced in 1965. EAPs (Employee Assistance Programs) have their origins in the late 1930s and were formed out of programs that dealt with occupational alcoholism. In 1980, the Employee Assistance Society of North America (EASNA) was formed. The 1980s saw the development of managed care such as PPOs and HMOs. In the 2000s, healthcare costs rose, requiring individuals to pay more out-of-pocket due to high-deductible health plans. In 2010, the Patient Protection and Affordable Care Act (ACA) was enacted.
How has this affected my practice as a psychotherapist? I have ridden the wave from traditional insurance, through PPOs, HMOs, and EAPs, with increasing frustration over their high level of control and scrutiny.
I saw a Facebook post that provides an analogy of managed care coverage. This was taken from “RN for Pushing Left@progessive_RN”. It reads, “Gonna start a company where people pay me $400/month for access to pizza, and when they want pizza, they can call me for preauthorization and I’ll tell them where they can go, how much they can buy, and what kind they can get. My company will pay for 50% after the first $240 spent.”
I shared this post with another Facebook group of psychotherapists in private practice. One therapist (I am omitting his identity for confidentiality purposes) replied, “That is the Cadillac of Pizza plans! Mine makes me get a doctor’s permission to get the pizza and I can only get it from a really terrible pizza place. Oh! And I have to wait two weeks for the pizza. My friend’s pizza plan can get the pizza anywhere he wants but only after he pays for $3000 of pizza this year. Even then, the pizza still costs a lot, but the pizza places get paid more from the plan for the pizza, so all the pizza places favor the people with that plan, so wait times are shorter. I can’t even buy pizza from my favorite places unless I pretend I don’t have a plan and just pay for it myself.”
The 1980s through to the present day have been a roller coaster of changes for health insurance. When I began my career in the mid to late 80s, a conventional insurance plan typically allowed the policyholder to receive care from any licensed provider at the provider’s determined cost. I think of those as the good old days. They trusted me and reimbursed me at my full rate. Then PPOs (Preferred Provider Organizations), HMOs (Health Maintenance Organizations), and EAPs (Employee Assistance Plans) entered the scene. Many of my proud colleagues refused to join these networks because they didn’t want to accept lower pay. As I was beginning my career, I was happy to accept a financial discount on services in exchange for referrals. It seemed easier than marketing, and I figured I could make up the loss with volume. The problem is that I no longer set my fees. If I accept a contract with a PPO, HMO, or EAP, I am agreeing to accept whatever they determine to be a fair rate of reimbursement. These fees are typically half or less than my full rate.
At one time I was personally enrolled with over fifty managed care companies. I watched as these companies essentially gobbled each other up, leaving a smaller number of big players in place. Managed care required preauthorization for services and generally approved a small set of sessions (between 2-10 sessions) after gathering information from the clinician. They asked for specific information to determine if the treatment was appropriate and fell within their guidelines of approved care. Managed-care plans have used a variety of management techniques to try to control the utilization of services. These methods include preadmission certification and concurrent reviews. Rather than trusting primary care providers’ expertise regarding needed care, these insurance plans serve as “gatekeepers”. They no longer trust me.
HMO enrollment peaked in about 2000 and has declined since. High-deductible health plans emerged in the mid-2000s. This has served as a barrier to treatment. Many people cannot afford the upfront deductible costs before insurance kicks in to pay for a portion of the treatment.
The two bright spots during these decades have been the passage of the Mental Health Parity Act in 2008 and the ACA (Patient Protection and Affordable Care Act) of 2010.
Before 2008, insurance generally covered medical conditions and excluded mental health and substance abuse conditions. This again provided a barrier to the treatment of the people that I serve. The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) is a federal law that generally requires the same level of coverage for medical and behavioral health conditions. MHPAEA does not apply to employer self-funded plans of under 50 employees.
The ACA introduced the requirement that individuals purchase health insurance and expanded the Medicaid program to cover low-income adults. It was at this time that I directly saw a sizeable increase in the number of people seeking treatment for addictions and mental illnesses that were previously unable to access help.
We therapists live in fear of “clawbacks” – an insurance provision that requires we return money already paid if they do a chart review and find our services or our documentation lacking. Clawbacks are established in the event of fraud or misconduct or for poor therapist performance. This is a perfectly reasonable idea. Except when it’s not. For example, I once had $500 recouped because they wanted to know what time I saw my client. My records indicated that the client was seen between 5 pm to 6 pm on specific dates. That wasn’t sufficient. I needed to prove that I saw them from about 5:01 pm to 5:55 pm to justify reimbursement for code 90837 (53+ minutes). If I saw them for under 53, mins I would only be reimbursed for code 90834 (38-52 mins), or it would be determined to be a fraud. Again, this seems reasonable. But who teaches the clinician to document services to the minute? Long gone are the days of paper charts and trust in the therapist’s word. The level of documentation required causes therapists to lose sleep. I would be lost if I could not access workshops in documentation and professional consultations.
In case you are still reading this, I could go on. The decrease in psychiatric facilities, a decrease in the number of hospital beds, and a decrease in the number of psychiatrists and other social service providers creates a barrier for people to access treatment. Treatment has dramatically changed again with the Covid pandemic in both good and bad ways. But that’s another rant for another time.
What’s the answer to all this? It is my opinion that universal healthcare can help the plight of mental health professionals and open access to the general public.
Thank you for listening.