Why don’t you work with insurance?
We live in a culture where insurance companies have become embedded into virtually every aspect of our healthcare system. They came with a promise of easing the financial burden of medical expenses. And yet, many of us instead experience increased stress, anxiety, frustration, and even hopelessness as a direct result of trying to navigate their systems which seem designed to confuse us while we pay increasing premiums for ever decreasing coverage. After much reflection and years engaging within this system, I made the decision to not use insurance as a therapist in private practice. Clients periodically ask why I’ve made that choice, and this post shares some of my thoughts.
Insurance is not designed to provide client-focused therapy services
For most of their existence, insurance policies only covered medical diagnoses (for example appendicitis) and services where a “treatment” involved a one-time event (e.g. a surgery) or a predictable, fixed duration of care (e.g. six sessions of physical therapy). While insurance companies have existed in the US since 1754, they only began wide-spread coverage of mental health therapy after the Mental Health Parity Act was signed into law in 1996.
Insurance as it exists currently is not designed to support mental health and addiction therapy. In contrast to an appendectomy surgery, therapy treating trauma symptoms or shifting a decades-old pattern of anxiety or depression involves moving with the organic pace of a specific client. In a medical context, the surgeon’s skill is the greatest predictor of a patient’s success. In the therapeutic setting, studies have repeatedly demonstrated that the client’s sense of connection or “rapport” with their therapist is more predictive of a client’s growth than any specific therapeutic modality. I’ll explore why therapeutic rapport is essential to a client’s healing process in a later article. For the purpose of this post, consider that therapy requires more care in regards to creating a healing container, and progresses at the speed of the client.
In my experience, insurance policies do not acknowledge the difference between mental health services and those of a medical professional. For example, insurance companies often preauthorize payment for a limited number of therapy sessions. The number of sessions is based on a policy rather than the therapist’s clinical judgment. Alternately, that number will be determined by an employee who rarely has any mental health training to guide their decision. This system leaves therapists in ongoing advocacy for insurance to pay for the number of sessions required to establish meaningful long-term changes. As a provider, it has been frustrating to witness insurance companies regularly deny payment because of a “lack of progress in treatment” which is to say healing that is not following a statistically determined pace. Many clients lose momentum in their healing process as a result of these design flaws.
Some issues with mental health diagnosis
In an attempt to mirror the medical field, therapists created a textbook in 1952 delineating every mental health “disorder”. This book is updated periodically to recognize new mental health diagnoses and remove others (for example, homosexuality was considered a mental health disorder until 1973). This textbook was designed to create greater reliability about who meets criteria for a specific diagnosis which is certainly important for a diagnosis to have any meaning. At the same time, my clients have described behaviors which appear highly disruptive to their mental health and relationships, but are not currently recognized within this system (for example, there currently is no diagnosis for a person who engages in addictively with video games). Insurance only considers paying for therapy services if a client receives a currently recognized mental health diagnosis. As a result, I have been in the position of telling clients that they weren’t impacted enough by their mental health symptoms to qualify for a diagnosis and, by extension, insurance coverage for therapy. These moments directly conflict with my code of ethics as a social worker to prioritize my client’s right to self-determination.
Stigma of diagnosis
Our society has matured significantly over the past decades in terms of recognizing the pervasiveness of mental health and addiction issues (statistically, in any given year, one in five people meets criteria for a mental health condition). Likewise, our culture is slowly normalizing the potential benefits of therapy and recovery services. That said, there continue to be social risks of engaging with therapy. At the interpersonal level, the general public feel anxious to learn that someone has a diagnosis such as schizophrenia even though their symptoms may be managed with effective supports such as therapy and mental health medication.
Professionally, numerous fields of employment such as law enforcement and healthcare treat a mental health diagnosis as a black mark on a person’s record which may negatively impact future opportunities for promotion. Some professions such as the military even require individuals to disclose any prior mental health diagnoses. These individuals are then deemed ineligible for positions based exclusively on this diagnosis which they may no longer meet criteria for as a result of effective therapeutic interventions.
Despite these and other risks of diagnosing, insurance companies only consider paying for services deemed “medically necessary” which means meeting the minimum criteria for a mental health “disorder”.
Thriving is not currently supported
The mental health field historically focused on relieving significant mental health symptoms (such as hallucinations, delusions, or self-harm). Certainly, helping someone feel “normal” after an extended experience of psychosis or depression cannot be overstated. At the same time, this focus ignores the capacity for therapy as a method for exploring our potential for flourishing. Only since the late 1990s have therapists incorporated this through “positive psychology”. As mentioned above, insurance companies currently limit their coverage to “disorders”. As a result, a therapist working within the insurance system is unable to justify additional sessions once a client’s disorder has been resolved. As a person who examines human potential, I want to support people both in resolving any mental health problems and investigate the range of meaning and life satisfaction. .
Ambiguous Rates
Perhaps someday we’ll discover a world beyond capitalism. But, for now, it’s necessary to acknowledge our reality where we need money to pay for our goods and services. Becoming a therapist involves a minimum of completing a multi-year masters-level education program, accumulating thousands of hours of supervised client sessions, and passing a national licensing board exam. The entire process usually takes five years or more and costs tens of thousands of dollars to build the combination of knowledge and skills. A licensed therapist has to apply to each insurance company in order to be considered “in network”, and each company tells a provider what they will receive as payment for therapy services. Each insurance company offers the same therapist a different payment for the same hour of highly skilled service. And, once a therapist accepts this offer, they are legally prohibited from sharing their wage information with any other therapists, keeping the payment structure a black box with no way of evaluating what a “fair” price is for their time and skills.
Delayed payments
Everyone appreciates getting paid in a timely manner for our work. In mental health, a therapist (or a medical biller) submits a “claim” to the insurance company for each therapy session in order to get paid. This is additional unpaid labor on the part of the therapist. When this system is effective, the claim is received, processed, and a payment is issued in two to four weeks time. However, insurance companies frequently deny claims for any number of reasons in which case the therapist needs to determine the reason for denial and resubmit each claim which involves more unpaid time and further delays in payment for services from months prior. Insurance companies may, in the end, flatly refuse to pay for services in which case the therapist has no recourse except withdrawing from the insurance system.
Focusing on providing high quality services
There is, of course, no perfect method for being in business. There are pros and cons of engaging with the insurance model. And, there are pros and cons of existing outside that system. But, rather than give my limited mental resources to navigating a complicated bureaucracy with all the issues of diagnosis, limits to approved services, shadowy wages, delayed payments, and potential denials, I’ve followed other therapists to instead receive payment directly at the time of service. This method ensures that I’m paid for services provided, and allows me to focus on providing the highest quality care to each client. It means the client and I decide the frequency and duration of services based on the their need rather than an insurance company’s policy. And, it allows me to work with clients who want to explore the upper threshold of life and relationship satisfaction.
Final Thoughts
I’ve tried to make space for those who are still engaging in the world of insurance. Clients can seek reimbursement from their insurance company by submitting a “superbill” which documents the date, length, and fee for each session. This method does require a client receiving a mental health diagnosis. Alternately, I have a limited number of slots available where clients pay a sliding scale.
