I've been giving a lot of thought about whether or not to apply for and become an in-network provider for insurance companies ever since I've graduated from psychology school. After I obtained my license, which made me eligible to be on insurance panels, both clients and other mental health professionals have been asking if I'm "going to get on panel" with insurance agencies. I've finally decided the answer is a resounding NO. Here is why, and here is what you need to know as a consumer of mental health benefits.
Ridiculous rules
I do not want to play by insurance companies rules, and I do not think anyone else should, either. Let's start with their rules about treatment. Insurance companies determine what type of therapy the therapist should use and for how long (about 10 sessions). Excuse me, did you go to school for 10 years to learn how to do psychotherapy?! This also leaves you, the client, powerless as to what type of therapy you get to do and for how long. Additionally, 10 sessions is simply not long enough for most people, especially for people who have experienced significant trauma(s). Sometimes it takes 10 sessions for someone to begin to feel safe in therapy. After 10 sessions, therapists have the option to "petition" the company and request more sessions (boo paperwork, more on that), but this petition can be declined. It seems re-traumatizing to me to begin treatment with someone and then have to stop treatment because a request for additional sessions might get denied. As an out-of-network provider, I love being able to collaborate with my clients regarding what type of therapy we do and for how long. I don't believe people should be in therapy forever, but when research repeatedly shows us that the quality of the relationship between the therapist and client is the best predictor of how well the client improves, then that relationship is worth spending the time to build.
Then there are ridiculous rules about being a provider for the insurance company. These rules include being subject to file reviews, contacting the company before referring the client to another provider, and being available for emergency situations. Seriously?! Why does the insurance company need to inspect your files? As a perfectionist, trust me, your files are upheld to federal and state standards, and no one else needs to skim through your file to verify that. And how is it a good idea to require providers to be accessible to clients for emergencies? A mental health emergency means someone is suicidal (planning to kill his/herself) or homicidal (planning to kill someone else) or detoxing from a substance; if this is occurring, the standard of care is to have the person go to an emergency room where the person can be provided 24/7 supervision. How the hell am I supposed to provide that? I can't.
Ridiculous reimbursement rates
Insurance companies only reimburse professionals 40-60% of their stated fee. Let's do the math. My fee is $125/hr, and let's say I get reimbursed at $60/hr and I see 25 clients a week (therapists don't see 40 clients a week for 40 hours because we need time for paperwork. We also don't get a paid lunch). And this assumes everybody shows up that week, which is unlikely, but we're trying to make this simple. This is only $1,500/week, $6,000/month, $72k a year. I know some of you are thinking, "Not bad, why is she complaining" BUT! Therapists then have to pay for self-employment taxes, their own vacation and sick days, business expenses, student loans, and professional fees (continuing education credits, organizational membership fees, license fees, business fees), which does not leave much of that $72k.
This also assumes insurance companies pay on a regular basis, which they do not. Providers sometimes have to wait MONTHS to get reimbursed. The insurance company can also change its rate at anytime without notice. How would you feel if you got paid irregularly by your employer? How would you like taking a random $10/hr pay-cut without reason? These hard truths of reimbursement leave many of my fellow colleagues bitter and resentful. Also, because the reimbursement rates are so low, providers have to take more clients to fill in the gap. It is easy to see how seeing increased clients can = decreased ability to provide adequate services = inefficient therapists = you, the client, not getting the help you need. By not taking insurance, I'm decreasing my risk for burnout, which means I can provide you with better services.
I do not want to play by insurance companies rules, and I do not think anyone else should, either. Let's start with their rules about treatment. Insurance companies determine what type of therapy the therapist should use and for how long (about 10 sessions). Excuse me, did you go to school for 10 years to learn how to do psychotherapy?! This also leaves you, the client, powerless as to what type of therapy you get to do and for how long. Additionally, 10 sessions is simply not long enough for most people, especially for people who have experienced significant trauma(s). Sometimes it takes 10 sessions for someone to begin to feel safe in therapy. After 10 sessions, therapists have the option to "petition" the company and request more sessions (boo paperwork, more on that), but this petition can be declined. It seems re-traumatizing to me to begin treatment with someone and then have to stop treatment because a request for additional sessions might get denied. As an out-of-network provider, I love being able to collaborate with my clients regarding what type of therapy we do and for how long. I don't believe people should be in therapy forever, but when research repeatedly shows us that the quality of the relationship between the therapist and client is the best predictor of how well the client improves, then that relationship is worth spending the time to build.
Then there are ridiculous rules about being a provider for the insurance company. These rules include being subject to file reviews, contacting the company before referring the client to another provider, and being available for emergency situations. Seriously?! Why does the insurance company need to inspect your files? As a perfectionist, trust me, your files are upheld to federal and state standards, and no one else needs to skim through your file to verify that. And how is it a good idea to require providers to be accessible to clients for emergencies? A mental health emergency means someone is suicidal (planning to kill his/herself) or homicidal (planning to kill someone else) or detoxing from a substance; if this is occurring, the standard of care is to have the person go to an emergency room where the person can be provided 24/7 supervision. How the hell am I supposed to provide that? I can't.
Ridiculous reimbursement rates
Insurance companies only reimburse professionals 40-60% of their stated fee. Let's do the math. My fee is $125/hr, and let's say I get reimbursed at $60/hr and I see 25 clients a week (therapists don't see 40 clients a week for 40 hours because we need time for paperwork. We also don't get a paid lunch). And this assumes everybody shows up that week, which is unlikely, but we're trying to make this simple. This is only $1,500/week, $6,000/month, $72k a year. I know some of you are thinking, "Not bad, why is she complaining" BUT! Therapists then have to pay for self-employment taxes, their own vacation and sick days, business expenses, student loans, and professional fees (continuing education credits, organizational membership fees, license fees, business fees), which does not leave much of that $72k.
This also assumes insurance companies pay on a regular basis, which they do not. Providers sometimes have to wait MONTHS to get reimbursed. The insurance company can also change its rate at anytime without notice. How would you feel if you got paid irregularly by your employer? How would you like taking a random $10/hr pay-cut without reason? These hard truths of reimbursement leave many of my fellow colleagues bitter and resentful. Also, because the reimbursement rates are so low, providers have to take more clients to fill in the gap. It is easy to see how seeing increased clients can = decreased ability to provide adequate services = inefficient therapists = you, the client, not getting the help you need. By not taking insurance, I'm decreasing my risk for burnout, which means I can provide you with better services.
I HATE paperwork
Insurance companies
require therapists to
provide them with
treatment summaries of
what they do in session with the client and any other
paperwork they desire. I
feel this paperwork is
unnecessary and really
none of their business. I
have to complete session notes and other related documentation to maintain your record, and that is enough to keep up with as is!
More time doing paperwork = decreased time with clients = unhappy therapist = unhappy clients. I love being able to spend more of my time in therapy with clients, which is what I am
passionate about.
Insurance companies
require therapists to
provide them with
treatment summaries of
what they do in session with the client and any other
paperwork they desire. I
feel this paperwork is
unnecessary and really
none of their business. I
have to complete session notes and other related documentation to maintain your record, and that is enough to keep up with as is!
More time doing paperwork = decreased time with clients = unhappy therapist = unhappy clients. I love being able to spend more of my time in therapy with clients, which is what I am
passionate about.
Due to some unethical insurance rules, therapists are often forced to be unethical in order to provide services
Insurance companies will not cover therapy if a person does not have a mental health diagnosis, but they also will not cover therapy for certain diagnoses (absurd, I know). This forces therapists to make inaccurate diagnoses in two ways, which is unethical and feels yucky. The first is to record diagnoses for clients whose concerns do not warrant a diagnosis so clients can receive coverage for their treatment, which then becomes part of their health record. Think about the implications that could have for your life insurance policy or career. Or, someone may have a diagnosis that the company will not cover therapy for, so the provider leaves that diagnosis out of the clients' record, which would not be helpful to future providers should the person need a referral. In my practice, my clients can rest assured knowing their protected health information is accurate and that only people with access to their information is me and them.
I have been strongly advised not to take insurance
My residency supervisor has a very successful private practice. However, she told me that, given the chance to do it all over again, she would choose not to take insurance and she would have a fee-for-service private practice only. I have also received similar advice from other professionals who are very successful and do not take insurance. That's really inspiring to me.
I'm excited to see what the future holds for my practice and my clients. I'm not sure I could say that if I were working for insurance companies who were irregularly paying me and I was burning out from seeing 35+ clients a week and doing 20+ hours worth of paperwork. Are you a mental health consumer who sees a therapist who does not take insurance? Are you a provider who maintains a fee-for-service practice? If so, I would love to hear from you!
Insurance companies will not cover therapy if a person does not have a mental health diagnosis, but they also will not cover therapy for certain diagnoses (absurd, I know). This forces therapists to make inaccurate diagnoses in two ways, which is unethical and feels yucky. The first is to record diagnoses for clients whose concerns do not warrant a diagnosis so clients can receive coverage for their treatment, which then becomes part of their health record. Think about the implications that could have for your life insurance policy or career. Or, someone may have a diagnosis that the company will not cover therapy for, so the provider leaves that diagnosis out of the clients' record, which would not be helpful to future providers should the person need a referral. In my practice, my clients can rest assured knowing their protected health information is accurate and that only people with access to their information is me and them.
I have been strongly advised not to take insurance
My residency supervisor has a very successful private practice. However, she told me that, given the chance to do it all over again, she would choose not to take insurance and she would have a fee-for-service private practice only. I have also received similar advice from other professionals who are very successful and do not take insurance. That's really inspiring to me.
I'm excited to see what the future holds for my practice and my clients. I'm not sure I could say that if I were working for insurance companies who were irregularly paying me and I was burning out from seeing 35+ clients a week and doing 20+ hours worth of paperwork. Are you a mental health consumer who sees a therapist who does not take insurance? Are you a provider who maintains a fee-for-service practice? If so, I would love to hear from you!