What Your Therapist Hasn't Told You About Using Insurance

(I have updated this post to reflect the changes to managed care in my area since 2010)

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Once upon a time, I started out as an idealistic new therapist. My work with a non-profit as well as my heart told me that mental health care shouldn't be a privilege for only the wealthy. 

And so I decided to accept insurance, hoping it would help ease the burden of cost for those seeking therapy. And I tried. I really did. Even when I was spending hours on hold (to get payment I had already been promised). Even when I had to write off payment I was owed because it was costing me too much time to pursue it. Even when I was full of private pay clients.

It was a bitter pill to swallow, but I had to admit it: I could no longer afford to be in-network for insurance But I learned a lot of things along the way. Things consumers don't know. Things that I would want to know if I were you. And so I'm here to tell you the

Things I wish all clients knew before/when they are using insurance-approved therapists.

1. Your therapist has to diagnose you to get you reimbursed.

Insurance doesn't reimburse for "marriage therapy" or "I'm having a hard time" or even "grief". It is a medical model, and so this means that payment can only be for a diagnosis. This means that (even in family therapy) a person has to receive a label. And these labels will be part of your official record permanently. This might never matter to you. If you are one of the fortunate ones who has medical, life and disability benefits through your employer... you might never worry about this. But if you're someone who might ever be unemployed, self-employed, or need to purchase your own benefits- a mental health diagnosis can make the difference between preferred coverage or none at all.

2. Your records are not protected.

Your insurer can audit your records at any time they wish. This means any details that your therapist might not have included in the paperwork (perhaps for good reason) is technically open to the eyes of any "claims specialist" the company hires. Again, this might not matter to you. But if you hold high clearance for a job, or have other reasons you want your information to be held confidential- this is important to know.

3. Your care is dictated by the insurer

Most insurance requires some sort of treatment plan to be submitted by in-network providers. This means that (rather than giving you the care that best fits your needs) the therapist is responsible to the (non-mental health professional) claims representative for how you spend your time. To put it simply, an in-network therapist works for the insurance company, not you. It doesn't matter what you and your therapist decide is in your best interest, it needs to fit their matrix of decisions. It also has to fit within the allotted sessions which are determined ahead of time, not based on need.

4. Insurance almost never pays the full fee

This means you are either going to be responsible for the remainder (which you need to clarify ahead of time) or it means your therapist is working for less than a fair market wage. Which leads me to my final, and most unpopoular point.

5. Insurance limits your options

I have said it before, to an angry response. I cringe even as I type. But the truth is: I know very few licensed and experienced therapist on insurance panels.  I have been in this profession over a decade and supervised over 25 interns on their path to licensure.

That is a dirty secret. I'm not supposed to say that. Therapists don't like that, because it is a sad commentary on the availability of quality mental healthcare. Consumers don't like that because it is obviously unfair. But it is accurate in my area. And so you need to know, that choosing to utilize an insurance-approved therapist means your options will be severely limited.

So what can you do about it? There are options!

1. If possible, pay cash for sessions. 

This ensures that your records and diagnoses are entirely confidential documents. The content of your session stays entirely between you and your therapist. And your care is dictated by what you think you need, not your insurer. Many people have a Health Savings Account (HSA) that will help them pay for sessions and operates just like cash- but they don't realize it.

2. If you cannot afford to do that, consider a non-profit (like the one I co-direct)

Many areas have nonprofits that offer low fee counseling based on income or other eligibility. That takes a little digging, but often you can find it on google by looking for "low fee" or "affordable" or "nonprofit" counseling. You will likely see less experienced clinicians, but you will maintain control and confidentiality.

3. If you need to bill insurance, but have a PPO, attempt to pay for therapy up front and submit for reimbursement.

 This will cost you up front, and your diagnosis will be recorded, but it gives you the freedom to choose any licensed clinician and their records are more protected than if you go with an in-network therapist. Here's an article I wrote about how to do that.

4. If you absolutely must bill insurance and see an in-network therapist, do your due-diligence ahead of time. 

If they are in-network with your insurer, they should have an idea of what level of transparency your insurer expects. They likely know if their notes will be requested, if their treatment plans will be required, and what diagnoses they will need to give you for coverage. Asking ahead of time can help you decide how you want to proceed.

This news does not feel good to report. I don't like the way it is. I hope for a world where quality mental health care is available to everyone that wants it. But if I were you, I would want to know. And I believe in the golden rule. I think consumers deserve to know the nitty gritty details. In fact, I think educated consumers are our best shot at system change. And so... there it is.

Hoping for a change,