Navigating the Intersection of Work and Mental Health

Working Better and Stressing Less

Ideas on work and mental health

The hidden costs of insurance paying for mental health therapy

I made a difficult decision this month to resign from two additional insurance panels. I found myself wondering when I’d last gone through this process and discovered it was almost a year ago. In that post, I outlined many of the practical challenges for private practitioners accepting insurance but as I was contemplating what to do last week, other factors I hadn’t previously considered came to mind.

Here’s the short attention-span version

Humans suffer and not all suffering can be coded in a way that meets health insurance companies’ ideas of “medical necessity.” I found that treating and documenting appropriately to ensure that any health insurance administrator could understand my notes became a larger and larger part of my practice, to the point where it was compromising the quality of my work. Also, I do a lot of career counseling which is only billable to insurance companies if it’s being used to treat a mental health diagnosis. This is similar to couples counseling. Technically, insurance DOESN’T cover it unless it’s used to treat one partner’s mental health diagnosis. Walking that line everyday is exhausting and sometimes clients were upset when I said we were starting to do work that wouldn’t be covered by insurance. So, I resigned.

The unabridged version for the health policy nerds

YES, counseling is medical care. I am trained to diagnose a wide range of mental health disorders and treat them using evidence-based therapy approaches. I’m also trained to help clients cope with medical disorders that other members of their healthcare team are addressing. I do believe that medical insurance should pay for this type of treatment. Yet, counseling extends beyond discrete diagnoses and treatments and the fuzziness of that line is a large part of why it’s so challenging to take insurance, both in general and in my practice, specifically.

DSM diagnoses and ICD coding aren’t clear or specific enough for mental health reimbursement

Yes, psychological suffering is very real and just as debilitating as any medical condition. But the way we define suffering into discrete illnesses isn’t very natural or effective. Yes we have the Diagnostic and Statistical Manual of Mental Disorders (DSM) that defines symptoms of mental illnesses. If a client meets the description in the DSM for Obsessive Compulsive Disorder, I assign them ICD-10 code F42.2 and their insurance company knows I am treating their OCD. Many of my colleagues and I would agree on a diagnosis based on the DSM. The problem is that the DSM doesn’t then suggest what treatment I should use. This is rather UNLIKE medical coding. Check out the code set for anemia (click on it… SO many types of anemia). If I have access to a system called Up To Date, I can look up the most effective evidence-based treatments for each type of anemia and then (if I was a doctor) treat it because the diagnosis of a particular type of anemia points to CAUSE.

DSM diagnoses and ICD-10 code F42.2 does not get specific enough to tell me what any given client’s OCD is caused by. Without the cause, I don’t know what treatment to provide. Patient A may need 45 minute psychotherapy (treatment code 90834) every two weeks to cope with their OCD presentation. Patient B may need 60 minute psychotherapy (treatment code 90837) TWICE a week for their presentation. So it’s no wonder that when insurance companies see two clients with F42.2, they start wondering why I’m providing 45 minute sessions every two weeks to one person and 60 minute sessions twice a week to another.

Insurance company’s answer to the fuzziness in diagnosis, coding, and treatment of mental health disorders is to create “care guidelines” that say they’ll only pay for once-weekly 45 minute sessions without prior authorization OR by auditing records that fall outside their guidelines of what appropriate OCD treatment is. Unfortunately, most insurance companies don’t pay therapists enough to compensate us for the time to get prior authorizations or for the time to print and deliver records to prove the case as to why there is such variation in treatment from one client to another.

I don’t like thinking about how I can best serve the insurance company

I feel lucky that I’ve always passed the “care reviews” insurance companies have asked me to participate in. I feel good about my ability to diagnose, treat, and document sufficiently to pass those audits. I know that I meet their expectations. That said, what I started noticing in the last year or so is that I was always thinking about the insurance company when I wrote notes, planned sessions for my clients, and made treatment plans. I don’t think I harmed any clients in doing this but I’m not sure that I always provided the more holistic support I would if I didn’t have an insurer looking over my shoulder. I know I did move from 60 minute visits to 45 because some insurers refuse to pay for longer visits these days. I don’t know that the move benefited anyone other than insurers.

My practice specifically

Then there’s the fact that approximately half of my practice is career counseling and work-related coaching. Often, I do use career counseling to address underlying anxiety disorders that have a large work-related component. But there have been times when a client whose insurance I was paneled with, wanted me to do career counseling separate from any diagnosis, and bill it to their insurance. Some folks have been unhappy when I tell them that only medically necessary counseling is billable to health insurance. There are other times when a client wants to talk about something that’s bothering them that is totally unrelated to a diagnosis. It’s really difficult to say, “Oh hey today we talked about you getting into a fight with your husband about the type of music you each like and I really don’t see how that’s related directly to your phobia… so I guess you owe me for this session.” Sometimes, it’s ok to let your client go off on a one-session tangent about something that’s bothering them that’s not related to your treatment plan but with clients on insurance, it’s technically NOT ok. I find that sad. Sometimes that unrelated fight results in a powerful psychotherapy session that creates positive change, even if it’s not targeting the diagnosis at hand.

So, did I free myself up or did I just tank my practice?

After thinking about all of this stuff, I resigned from two more panels, leaving me paneled with one insurer and one EAP, both of which I feel are most supportive of quality mental health care both in spirit and in structure. I feel a sense of relief in that I can have a bit more autonomy, answering mostly to my clients directly rather than their insurance companies. I also have a sense of anxiety and some worries about whether in a world where people expect their health insurance to pay for mental health treatment, people will be willing to pay out of pocket for truly unbiased advice. I hope they do and I hope I provide enough value where they feel it was worth every penny.

Katie PlayfairComment
Insomnia and digestive issues - Yep we can treat those!

And my colleague, Scott, is especially good at it. I’ve written before about how mental health practitioners can treat various medical concerns including insomnia. But no blog can replace the kind of advice he is providing in two online courses:

  1. Do you suffer from digestive complaints but either “medical” causes have been ruled out or you’ve been told that stress is a contributor to symptoms? His new Rest and Digest course might be a great resource!

  2. Was my blog on insomnia helpful but you want to learn more? Consider Scott’s CBT for Insomnia class!

I’m guessing we’ll see more great courses from Scott in the years to come so stay tuned.

Katie PlayfairComment
Our new team member needs a bit of support

I will be mostly out of the office through January, 2019, caring for new baby, Surin!

I will be available to clients, former clients, and community members via email to help connect folks with resources in Portland, but may be slower to respond than usual.

Katie PlayfairComment
'Afflicted' on Netflix and misconceptions about therapists' roles in treating mystery chronic illnesses

My husband and I just finished watching Afflicted on Netflix, a documentary series on mystery chronic illnesses. He's a physician and I'm a counselor and we both finished watching with feelings of deep sadness, outrage, helplessness, and discomfort. I hope to explain all of my feelings in what I write below but may struggle to do so in the limited format of a blog. The largest sources of my discomfort and what I'll focus on here was how the subjects, their friends/family, and practitioners seemed to hyper-focus on making a false distinction between whether symptoms were "in their head" or "real," and how licensed healthcare practitioners capitalized on the subjects' need to feel validated that symptoms were "real." Nearly every person featured had been financially ruined by the pursuit of treatment for their symptoms and none, as far as could be seen from the documentary, had an integrated team of professionals collaborating on conceptualization and treatment.

The stories featured in Afflicted reminded me so much of clients I have worked with and of some close friends and family members who have struggled for years with similar conditions. I wanted to reach into the screen and help the people featured - not necessarily as a professional, but just as a human with some lived experience. I also wanted to say "Please let the mental health team help too! It doesn't mean you're crazy or that you're not sick. I just want you to have good support as you go through this and our friends and family members always have their own agendas with our health, no matter how well-intentioned." 

More specifically, here is what I wish everyone with chronic, mystery illnesses understood, particularly about how mental health professionals can help:

  1. Yes, every symptom you experience is "real" because you are experiencing it. You are suffering and those of us in mental health see that. Our support is not contingent on whether the ultimate cause(s) of your symptoms is infectious, autoimmune, environmental, psychological, neurological, or other.
  2. Accepting help, medication or therapy, from mental health professionals does not make your illness any less real or any less physical in nature. Refusing help from an entire discipline of healthcare because you think accepting it means you're "crazy" may be slowing your recovery and/or increasing your suffering. 
  3. You do NOT have to stop pursuing medical diagnosis and treatment of your condition in order to accept support from people in mental health disciplines. 
  4. You can indeed have BOTH Illness Anxiety Disorder (described below) AND 100% valid, diagnosable medical conditions that need treatment. Those of of who specialize in treating people with chronic illnesses do not subscribe to a false dichotomy of "it's either in your head or in your body." 
  5. There is probably no magic pill for what ails you. Anyone who promises one should be looked at with great skepticism. Mystery illnesses are mysteries for a reason and it is probably going to take a team-approach from multiple disciplines working together, to find a cohesive conceptualization of your case and an organized treatment plan. 
  6. Your practitioner(s) needs to be watching your wallet (and not in a vulture-like way). One of our ethical principles is non-maleficence and that means not doing things to harm your financial future in the pursuit of a cure. Yes, some treatments will be expensive, but ethical practitioners will work with you to minimize your out-of-pocket costs and try to convince your insurance company to cover non-standard treatments. 

What to expect from your mental health team

Diagnosis: Illness Anxiety Disorder vs. Adjustment Disorder

Most clients who present to a mental health practitioner wanting support for a chronic mystery illness will be diagnosed initially with Adjustment Disorder (often with depressive or anxious symptoms) Adjustment Disorder means you're having an intense psychological reaction to an identifiable stressor (like having a chronic illness that isn't getting resolved). Yes, that means that most of us will start with the assumption that you're stressed out because you're sick. If you have a previous mental health diagnosis, (for example, Generalized Anxiety Disorder (GAD)), it may be more appropriate to call your current distress an exacerbation of GAD previously in remission (exacerbated by being sick). Very few of us will make an Illness Anxiety Disorder diagnosis for the first several sessions, unless you have a history of it. 

We then get to a critical point in assessment and treatment where we risk making you, our client, feel very invalidated if we don't explain what I'm about to explain, very carefully. Here's my less careful written explanation: There is a chance that I could meet with you, take a thorough history, observe your relationship with your chronic mystery illness over several sessions, read through your medical records, consult your other medical team members, and realize that you are experiencing a very particular psychological relationship with your illness that qualifies you for an Illness Anxiety Disorder (IAD) diagnosis. This is where some folks with chronic mystery illnesses feel invalidated and get angry because IAD used to be called hypochondriasis and no one wants to be called a hypochondriac. 

At its core, having IAD means that you are generally worried about your health and that you tend to spend a significant amount of time, energy, and resources attending to diagnosis and treatment of symptoms, so much so that you're not really living the life you want to live. Having IAD does not mean that you are not physically ill! You can be very ill or completely well and have IAD. 

In addition to being worried about health and missing out on valued parts of life to attend to health concerns, folks with IAD often report the following experiences:

  • First, they're sensitive to bodily sensations - tingling, digestive activity, their own heartbeat, etc. They actually seem to be able to feel things and pay attention to them better than most of the population. "Well" folks with IAD tend to perceive normal sensations as alarming and "sick" folks with IAD experience more disruption from the sensations associated with their illness. 
  • Sensations often provoke catastrophic thoughts about possible causes of those sensations and intense feelings of fear. 
  • In response to those thoughts and feelings, sufferers of IAD seek reassurance from others about their symptoms. This could be online research, and discussions with friends and family, and doctors. Often reassurance results in temporary relief of symptoms, only to have them return. Often when they return, the person with IAD feels defeated, disappointed, and depressed, being "back to square one." 
  • This sensation - fear - thoughts - reassurance cycle usually starts small and gradually takes up more time, energy, and resources as it goes, eventually taking over the sufferer's life and squeezing out all other valued activities they once engaged in. Being sick becomes a 24/7/365 job. 
  • Feeling stuck "being sick" 24/7/365 is the real problem. Sufferers of IAD have stopped living life and this is ultimately the clinical problem we want to address. 

Again, I want to emphasize that having IAD does not mean you're not sick. It just means that being sick has become too large a part of your life. Treatment is about taking back as much time, energy, and resources for the things that matter to you, as your health will allow. 

Treatment: Taking back your life 

My goal when supporting anyone through a health crisis, chronic or acute, is to keep them engaged to the maximum extent possible, in valued activities. This is the same goal I have for clients with cancer, Crohn's, fibromyalgia, chronic fatigue, or chemical sensitivity. That means we need to gradually increase your engagement in the things you actually want to spend your life doing and decrease the amount of time, effort, and money you spend on your sickness. 

Budgeting resources for chronic disease management

Setting a reasonable resources budget for mystery illnesses is challenging. Better-understood illnesses are more predictable in terms of defining a reasonable amount of time, effort, and money for a patient to spend on diagnosis, consultation, and treatment. Most chronic mystery illnesses involve so much uncertainty that a definite time/money/effort budget is hard to prescribe. There is always the illusion that "if only I did MORE to care for this illness, I'd get better and everything would go back to normal." Unfortuantely this is rarely the case so budgeting for a long road and allowing time for engagement in other valued activities is important for optimal treatment. 

Physician approval of "budget" 

If you come to my office for support around your chronic mystery illness, I first want to make sure that at minimum, you're under the care of a primary care physician with whom you've discussed these symptoms and completed appropriate high-level workups (at least ruling out the really obvious stuff that can kill you). A primary care physician, usually an M.D. or D.O., board-certified in internal medicine or family medicine, is a key part of our support team in ensuring a coordinated effort at addressing your suffering. They are also the person I will turn to when I have a question about whether a time/effort/financial budget we want to set is safe for you. 

Gathering a baseline and setting goals for reengagement 

We then figure out how much time, effort, and money you're currently spending on diagnosis and treatment of the chronic mystery illness and talk about what you are missing out in terms of valued activities. Once we understand where you're at, we outline a vision of where you want to be in terms of greater engagement in life. What have you been missing out on to take care of yourself? 

Once we've established your baseline engagement in chronic disease management activities, a vision/goal of eventual engagement in more valued activities, and received your primary care doctor's buy-in on safety and pace of the plan, we can start taking tiny pieces of your life back, one at a time. Example medium-term goals could be stated like the following:

  1. Reduce spending on supplements from $1,500 per month to $100 per month so that I can save $1,400 per month towards a downpayment on a house. 
  2. Taper time spent engaging on chronic disease boards from three hours per day to thirty minutes so that I can have one hour for sewing and 90 minutes for exercising with a friend. 
  3. Trim my practitioner team from 10 health professionals to three so that I am managing less conflicting advice and fewer care activities each week and can return to work part time. 

Notice that each goal includes both something to do and a reason WHY you might be willing to do it. You aren't trimming your supplement budget just to do it. You're doing it so you can make a downpayment on a house. It can feel dangerous to scale back on activities and expenditures that help us feel safe, but so long as we have good medical approval for scaling back certain parts of treatment, we can reinvest those resources into something that may improve your wellbeing in a different way. 

Predatory practitioners

Why do I count on traditional primary care physicians to be the "safety monitors" of my treatment plans to help clients get their lives back? Some practitioners who serve people with chronic mystery illnesses are financial predators practicing junk medicine in exchange for huge sums of money. I count on PCPs to be my scientific reality checkers to help me and my patient understand which therapies are probably helpful/potentially helpful/likely unhelpful/harmful.

I want to be clear that I am completely pro-alternative medicine. I personally have found acupuncture and traditional Chinese medical nutrition to be the key to reducing the frequency and intensity of my migraine headaches. I refer clients to specialists, acupuncturists, naturopathic doctors, and other health practitioners all the time. But I count on M.D.s and D.O.s to check the basic science of the diagnostics and treatments at hand for all of us. I also make sure those physicians have good reputations with their colleagues locally.  I try to be very careful to exclude predatory practitioners from care teams, first to protect my clients' financial wellbeing but also because they often use scare tactics with patients to get them to invest more time and money into their practices. Predatory practitioners are dangerous both financially and to the psychological wellbeing of clients with chronic mystery illnesses. 

Clues that a practitioner might be predatory

  • Treatments aren't covered by insurance and can't be coded for reimbursement. This is a warning sign to pay attention to but it doesn't automatically mean the practitioner is predatory! Some emerging treatments do not yet have enough evidence to warrant widespread use or to make it on an insurance company's "covered services" list but they end up being totally legitimate. For example, there is growing evidence that sub-anesthetic doses of ketamine may be helpful for treatment resistant unipolar and bipolar depression. Yet, while many insurance companies don't cover it yet, you can find evidence that insurers are considering the evidence at hand and may cover it in the future. A non-predatory practitioner will explain this ahead of your first appointment and give you the opportunity and resources to help you advocate with your insurance company for coverage. They'll also often have programs for people with financial need to prevent the treatment from ruining you financially. 
  • There are no peer-reviewed studies demonstrating the treatment's effectiveness. If a practitioner is relying on "in my experience," as opposed to studies that have been published in peer-reviewed journals to substantiate their treatments, they may be predators. A non-predatory practitioner will be very upfront about a novel combination of treatments being completely experimental and will discuss the benefits and risks of trying the new treatment, openly. If they don't present risks, that's another red flag.  
  • They aren't treating the cost of the treatment as a potential risk to your wellbeing. A high quality practitioner whose services will not be covered by your insurance should discuss with you an estimated total cost of treatment, what that expense means to your budget, and how to reduce its impact. They should also be open to discussing alternative treatment plans that may be less expensive. 
  • The treatment is characterized as a magical unicorn without a reasonable failure rate. Even strong evidence-based treatments for known afflictions can fail. Non-predatory practitioners will set reasonable expectations for the treatment and most treatments shouldn't be promised to be anywhere near 100% effective, especially for chronic mystery illnesses. A realistic "high" cure rate could be 60-80% for complicated cases of anything. Even prolonged exposure therapy for acute PTSD (gold standard treatment for wartime trauma) is somewhere around 90% effective. If a practitioner is making unrealistic promises in exchange for payment, that's a strong sign of predatory practices. 
  • Their approach is non-systematic. Any practitioner who suggests changing multiple variables at once when addressing a chronic mystery illness should viewed skeptically. This isn't to say that if several well understood issues emerge in an initial examination, that they can't be treated simultaneously (I think a Dr. might be able to begin treating high blood pressure, thyroid problems, high cholesterol, and diabetes all at once if they were all diagnosed on the same day. I don't know for sure, but this wouldn't raise my personal alarm.). I become concerned when a patient walks out of a practitioner's office with 20 different supplements, all purchased from the practitioner's office (profit to the practitioner), with no particular plan of how to monitor how each intervention influences the patient's overall condition. Most of the alternative practitioners I collaborate with will change only a few variables each visit, using the scientific method (observe/examine, identify a question, form a hypothesis, conduct an experiment, collect and analyze data, draw a conclusion, and repeat) and peer-reviewed evidence to identify next steps. 

Again, avoiding predatory practitioners isn't just about protecting you from financial demise and ineffective treatments but also the scare tactics they use to raise your anxiety in the pursuit of getting you to open your wallet. Please consider carefully who you allow on your care team if you have a chronic mystery illness!

Please don't shut us out... please don't close the door

"You don't have to keep your distance anymore....." (A little parent humor)

"You don't have to keep your distance anymore....." (A little parent humor)

Whew... Apparently I had a lot to say on these two little topics Afflicted brought up for me. All this to say, please don't count us out as members of your support team, if you have a chronic mystery illness. Non-prescribing mental health providers can be wonderful support people who can help you take back some of your valued life, even as you pursue treatment! We can also be your advocates for high quality healthcare and help prevent you from being taken advantage of by predators who want to capitalize on your hopelessness. Finally, we can help you manage the anxiety associated with stopping some "illness management" activities (as approved by your medical team) in order to live your life in a more flexible way. 

Also, please don't count out my prescribing colleagues. Psychiatrists and Prescribing Mental Health Nurse Practitioners (PMHNPs) may be able to help alleviate your suffering and increase your quality of life, even if they don't "cure" the illness in your body. For example, I take low dose venlafaxine (an SNRI class antidepressant) to help manage my migraine headaches along with acupuncture and some changes to my diet. Do I think that having experienced some relief with this medication means I was just crazy and not afflicted with migraines? No! But I do notice that when I started taking it, based on some relatively loose scientific data about its effectiveness with migraines, that it also took the edge off the hopelessness I was feeling when I was getting daily headaches. Was that because it reduced my headache frequency or because of its antidepressant qualities? I don't know but I'll take the improvement. 

You are not crazy and seeing us does not affirm or validate your "craziness." We are here to support you in your journey to healing and hope we can offer a different kind of relief, regardless of where you're at in your medical journey. 

Katie Playfair Comment
Using LinkedIn for networking - A four-step guide for most people

LinkedIn has been a gold-standard for networking in the tech industry for some time. Many of you know that I did management consulting, client relationship management, and even some sales in tech and I sometimes forget that LinkedIn isn't something everyone knows how to use. I find myself writing the guide below, many times per month, for clients of mine and thought to myself, "I just need to post this publicly so it's available to everyone and so I can point clients to a blog post rather than rewriting it." 

If you think you might want to use LinkedIn to search for jobs, meet professional contacts, post your resume online, or manage your professional network, here's my quick and dirty guide to the basics. 

First, check your privacy settings

Before you begin, or the second you sign up, go to your privacy settings page. Think about who you want to receive notifications when you update your profile. If you don't want an announcement saying "Look who just updated their profile!" going out to all of your connections, adjust accordingly. Read their FAQs and privacy guides so that your settings are configured correctly. 

Author/update your own profile

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Before you start using LinkedIn for networking, you need to make sure your profile is up to date! It doesn't have to be perfect (mine's not!) but it does need to be recent. 

  1. Update your title/description. Mine says "Counselor and Workplace Behaviorist." This does not have to be your technical job title, but rather a description of who you are as a professional. 
  2. Next, post each job from your resume along with a job description and a list of accomplishments that might be relevant to your job search. Include descriptions of things you liked doing or things you'd be willing to do at your next job. Leave out things you hated doing or are unwilling to do. If you have gaps in employment and took classes or did volunteer work during those gaps, feel free to include those to fill out the timeline. The rules of LinkedIn are less stringent than those for resumes so do what you need to do to help readers understand your professional story. 
  3. Update your photo to a 3/4 headshot (a friend or family member can take it) that goes from about armpit-level up to an inch or two above your head. It does not have to be done by a professional photographer... Look on Pinterest for some inspiration! 
  4. Write your "summary," that says a bit about who you are as a professional. Look at other folks' pages for inspiration and ideas. If you get stuck, ask a friend to help you write something useful. 

Search for others to connect to

  1. Start with your own "real life" network and search for friends, family members, former colleagues, current colleagues, old classmates, and friends-of-friends. At first, it might not matter if they are relevant to your current job search, especially if you have very few connections overall. Connecting with people you know in real life will help you expand the network of people you're connected to by second or third degrees. 
  2. Use the search function at the top of each LinkedIn page to search for individuals in organizations of interest to you. If you type in "Intel" you'll get both corporate pages and pages of people who work there. You can narrow your search to "people." 
  3. Invite people of interest to connect. Send a personal invitation message that's friendly, a bit specific, but not asking for anything. "Hello! I'm a counselor in Portland looking to expand my network in Vancouver for referrals. Could we connect?" 
  4. Remember, many folks don't check LinkedIn regularly (I just accepted 5 invitations that were weeks old). So be patient in waiting for responses. 
  5. Don't invite everyone to connect. Make your network meaningful. 

Start dialogue with the connections you've made

  1. Once someone accepts your invitation, use LinkedIn messaging to thank them for connecting with you and to let them know what you're looking in terms of advice, help, or follow-up with. For example, I might write to another counselor who accepts my invitation, "Thanks for accepting my invitation. I'm receiving a lot of inquiries for Vancouver, presumably because I'm licensed in Washington, but I don't currently have an office there. Are you by chance taking new clients? I'm also wondering if I should consider opening an office in Vancouver given the number of referrals I see! How has your experience been working there?"
  2. Notice that I'm offering something along with asking for advice. It's also ok to just ask for advice as many people actually do want to help a stranger on their career path!

Some people will ignore you, others won't help you, but some WILL help you. In my personal experience, I find that 80% of folks I send invitations to tend to accept my initial invitation and perhaps 75% of those will respond to a message. 

So don't be afraid of using LinkedIn! Put yourself up there and start conversations with other professionals in four easy steps. 

Katie PlayfairComment
Deciding whether to "take insurance" - A therapist's dilemma

After another insurance headache this week, I find myself again torn on whether to continue accepting insurance in my practice. Folks who don't work on the business side of healthcare might find this confusing. Why on Earth would someone licensed to provide a valid health service NOT choose to contract with insurers, except perhaps from a desire to make more money? I feel like I need to explain so that if I do make a decision to not accept it in the future, my clients, my community, and the general public hopefully see that I'm not just greedy. (PS if you're a client reading this, all plans require a MINIMUM of 90 days of notice for changes.)

So, why is whether to take insurance a huge dilemma for me and many of my therapist colleagues? Let me tell you a bit about the process so I can explain why it's hard to sustain it. 

Getting started with insurance (super-abbreviated version)

How does one go from being an "unpaneled" but licensed provider to being a "preferred provider" with various insurers?

  1. First, you fill out an extensive centralized application that includes a ton of information on you, your education, your licensure, your identification, financial and tax information, and other information that I can't quite recall. It involves a lot of copying and scanning and takes a few hours to complete. You also must update this application quarterly to ensure all of your information is current. This is the database many insurance companies use to get application information from. 
  2. The next part you can do yourself, or pay a credentialing agency a few hundred dollars to do for you. You must express interest to each insurance company you HOPE to become credentialed with. If you're lucky, they can pull your information from the central database, but many companies require you to complete all steps in #1 in their proprietary credentialing system. 
  3. After a few weeks or months, some companies respond to your letter of interest/credentialing application and provide you with a contract and a paneling date. If you are ok with the terms of the contract, you sign it and begin seeing their clients and billing the insurance company for services. If you're lucky, you can afford a lawyer to look over the contracts but most of us just limp through and do our best to look for unfavorable terms. 
  4. In order to bill most insurance companies, you need an Electronic Health Record (EHR) system with the ability to electronically transmit claims to each insurer. (Yes you can do it on paper but it's SO cumbersome.) In my opinion, everyone should have an EHR, but the extra feature of transmitting claims can cost anywhere from $20-$100 a month. You also need logins and passwords for EACH insurance site and you need to learn a different provider portal system for every insurer you work with. Some portals are good and others are not. 
  5. When an insured client presents to your practice, you make sure you have their insurance information correct in your system, see them, document each visit, finalize a bill, and then fill out an insurance claim form that gets transmitted to the appropriate insurer. If your claim is "clean" (no errors) most insurers pay you within 30 days of the day you submit the claim or tell you something is wrong with the claim and you begin the process again. Once you receive a check or electronic transfer, you must reconcile each client's account with insurance payments, copay/coinsurance payments, write-offs, etc. If the claim has a problem or is denied, you have to research each one, call the insurer, and figure out what happened and how to fix it. Sometimes, you get paid and sometimes you don't. Researching and disputing a claim can take hours. 

There are a lot of other details but these are the basics. Your doctor's office probably has a person or department of people to handle these things as their full time job(s) but as a single practitioner, I have me.

I estimate getting started with insurance takes a practitioner 10-40 hours of effort and approximately $2,000 of fees, depending on how much help they get from other professionals doing it. Over time, insurance adds an extra 5-15 minutes per visit of documentation and billing time and results in paymets that are 60-80% of an average practitioner's "regular fee." 

Why contract in the first place?

Therapists have different reasons for contracting with insurers. A few common ones include:

  • Access. My primary reason to contract with many insurers after I got licensed was to facilitate affordable access to care for as many people as possible. Many folks cannot afford therapy without insurance coverage and I wanted to be able to serve all people in my practice, not just those who could afford to pay in full. 
  • Referrals. Folks look for therapists on their insurers' panels who will be covered at in-network rates and so it's likely that a paneled therapist will receive more inquiries than one who does not take insurance. Paneled therapists have more clients. 
  • Diverse clients. Pairing closely with access, most of my colleagues really enjoy working with clients of diverse backgrounds and socioeconomic status. Insurance lowers the barriers to therapy for people whose finances, cultures, and communities may have prevented them from getting treatment before and we ENJOY working with diverse populations. Insurance brings us a wider variety of clients which is cool.
  • Legitimacy. We train for two initial years in school and then for three to five additional supervised years after school, to be able to provide a healthcare service. We believe mental health conditions are health conditions like any others and should be reimbursed as such. Since most doctors take most insurance, shouldn't we too?

Why would you stop taking insurance?

If there are so many good reasons to participate in insurance panels as a preferred provider, why would a private practitioner like me feel like continued participation is unsustainable? 

  • Financial costs. I keep a credentialing company on retainer to ensure that my contracts stay up to date which costs a few hundred dollars a year. For each insurance client I treat, I receive, on average, 30-40% less than my regular rate (this I can totally live with but it's one more thing). I pay an extra $30/month or so to have features that allow me to do insurance billing. The worst financial cost, however, is the constant fear that at any moment, one of my files might be audited and treatment determined medically unnecessary, resulting in me having to pay an insurance company back hundreds or thousands of dollars for treatment I honestly felt 100% was medically warranted. 
  • Time costs. Each claim only takes a couple of minutes to file, true. Each payment, five at most to fully reconcile into each client's account. However, I notice that I spend much more time documenting things about my visits not that are useful to me or my client but that are instead necessary for the insurance company. I'd say taking insurance adds 10 minutes to each visit by the time I figure in documentation, billing, claims, payment, and reconciliation. Over a year, based on the number of clients I see each week, this amounts to 120-180 hours of extra work to continue accepting insurance. For a "full time" practitioner, insurance maintenance time could total 240 hours, or six extra weeks of full time work each year. This is why most full time practitioners hire a billing service to handle insurance billing, which costs more money and less time. 
  • Privacy costs. Generally, conversations between therapists and their clients are even more confidential than regular medical interactions with only a few safety-related exceptions (preventing child-abuse, self-harm, etc.). When practitioners contract with insurers, they agree to allow the insurance company to inspect patient records at any time. This makes sense, as insurers want to make sure practitioners aren't defrauding them by providing unnecessary services, padding claims with extra costs that aren't warranted by the case, etc. However, most clients don't show up to therapy thinking "what I say in today's session could end up being read by an insurance company employee." Therapists SHOULD be protecting against this privacy breach by making their notes process-based with clinical assessments, general language on topics discussed, etc. However, this way of documenting makes notes SIGNIFICANTLY less useful to practitioners and clients than they would be if they were entirely confidential. I am lucky to have a pretty darned good memory for clients' stories over years but I am not confident that I will remember the horrible fight you had with your cousin, Emily, in 2012 when you return for therapy in 2020 because what my note says is "Discussed family conflict and boundary issue around inheritance matter." My notes are written for the insurance company and to protect you from unnecessary disclosure of your personal information. I would write them differently if they were just for you and me. 
  • Autonomy costs. Some clients do better with 90 or 120 minute appointments. Insurance companies don't allow me to bill differently for a 60 minute appointment vs. a 90 or 120 minute one. If an insurance company is already paying 40% below my regular rate for 60 minutes and refuses to pay any 90 minute rate because 90837 is "60+ minutes of psychotherapy," I can't make a practice of long-duration appointments work. Clients with OCD, hoarding disorder, certain types of PTSD, and other disorders I treat sometimes need long-duration exposure sessions and I can't afford to provide them. In fact, many insurers have started calling 45-minute appointments standard and so in order to get authorized for even 60-minute appointments, it can take hours on the phone with the insurer. How have I responded? I made 45 minutes my standard appointment and I've largely stopped doing traditional exposure therapy in my practice except with clients who have DIRE need (and I absorb the costs). I feel ashamed to write this. Taking insurance may be preventing me from doing some creative and evidence-based interventions I really ought to be and would like to be doing in my practice but simply aren't considered "standard" by most insurers. 

Why not just resign today, then?

As I read my reasons for considering this change, I feel so convinced that becoming an insurance-free practice is a good way to go. It will save me three or four weeks of time each year, it would allow me to practice the way my clients and I agree is beneficial, without regard to a third party, and it would protect my clients' confidentiality more thoroughly. What stops me is that I have current clients who rely on their insurer to pay for sessions at an in-network rate and it pains me greatly to imagine telling them that they'll have to submit claims themselves for services I render and potentially incur "out of network" costs. Some don't have out of network coverage and others have such high deductibles that it's unlikely they can afford to see anyone out of network. I don't want to hurt my clients because I care about them so much. I have always been and continue to be willing to be paid less and do a bit more work to help get folks access to care. But I find myself wondering if perhaps I can take that willingness and do it differently, without being under the influence of insurers. 

Stay tuned as I figure out how to approach this...






Katie PlayfairComment