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?
- 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.
- 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.
- 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.
- 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.
- 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...