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.