The ethics of insurance companies influencing access and care
Should insurance companies dictate the duration of appointments your counselor offers? I'm not sure but right or wrong, many are now doing that. Two of the major insurers I contract with have largely stopped paying for hour-long therapy visits (Code 90837) in favor of 45 minute visits (90834) except in cases of medical necessity.
I structured my entire practice around offering full hour-long visits and I scheduled myself 30-minute breaks between appointments so I could allow appointments to run over time when needed. I often found myself needing more like 75 minutes for some clients and I really didn't mind that insurers would only pay for 60 minutes. However when some companies started limiting visits to 45 minutes for most clients, allowing 90 minutes of time for 45 minutes of compensation became unsustainable for my practice.
I don't like making business decisions based on financial factors. I just want to deliver what I think is the best care but ultimately, counseling is my source of income and I have to be responsible to my family by running it well. At first, I was angry to be making the decision to offer two days a week of 45 minute visits (followed by 15 minute breaks). But structuring my schedule this way solved another problem I'd had in my practice: Limited access.
Access is as much an ethical issue as appointment duration. By adding two days of 45-minute visits, I was able to see more people - people that the week prior to making this change, I was referring out, sometimes with no clinicians to accept them within their insurance panel. I was able to say yes to taking on more clients.
This is the conundrum of having more access to care via the Affordable Care Act (ACA) - more people have insurance but there aren't always enough providers to care for them. Agencies are having to take on so many clients that they sometimes clients only get seen once every six weeks. Private practitioners like me are having to turn more people away.
At first I was angry at being told by insurance companies that I could only provide 45 minutes of care per visit but now I'm not sure how I feel. I'm able to care for more people. Most are getting adequate care at 45 minutes. I put some people in my 60/90 minute spots who really need it when their insurance refuses to pay and I absorb the cost. I still have more flexibility than agency counselors who are way overloaded, but I'm also doing my part to see more clients.
I keep asking myself, which is the lesser of two evils; limiting visit duration for some clients but being able to take on more clients who need help or having full hour visits for everyone while turning away more clients in need? I don't know so I guess I'm splitting the difference by offering both durations in my practice.