The use of health insurance for mental health care is often surrounded by complexities that are not always widely known.
The actual coverage that you have can be quite confusing. This can lead to hours on the phone with insurance companies trying to figure out what is actually owed, frustrating the policyholder and taking away from time that providers could be actually providing care.
Insurance requires a diagnosis to receive mental health services, something many folks don’t realize. Employees at the insurance company, who may have no training in mental health, can make decisions to end payment for your therapy services. Individuals and companies who claim to assist providers in navigating the insurance maze can charge thousands of dollars and leave the provider with little to no assistance.
The issues related to insurance and mental health coverage have become so far-reaching that ProPublica recently did a multi-story series on the topic, which you can read here. ProPublica is an independent, nonprofit newsroom focused on investigative journalism to expose abuses of power and spur reform.
Recent shifts in how health, research, and science are viewed and understood in the public square of the US are leading to more conversations amongst providers about how to ethically work within the system while serving and protecting our clients. In the remainder of this post, I’m going to share a few of my own experiences as a licensed mental health counselor who spent 5 years working in insurance-based care prior to moving to my current private pay model of practice.
Confines of Community Mental Health
I spent 2 years working in community mental health agency settings, one in an urban area and one in a rural area. These agencies provide services to folks who have Medicaid-type insurance, as well as to those who may have no insurance or who have limited income. In my experience, some of the folks with the most acute needs and/or with multiple needs seek services in these settings. The clinical staff in these settings is often made up of individuals who are new to the profession as clinical counselors or social workers and who are practicing under supervision by an independently licensed provider. I, like many of my colleagues, recognized the confines that working with insurance and accepting government funding placed upon our provision of services.
One of the major ways this happened was that practically all clients were referred to therapy groups. Insurance contracts and payments were the driving force behind what was recommended and allowed for clients. I can recall many times where I completed an initial appointment with someone, gathering information about their concerns and needs, and was then left offering them services that weren’t necessarily the best fit for meeting those needs. Sometimes this was because the person would really benefit from individual therapy, but that wasn’t an available option based on their insurance plan. Other times it was due to the time limits around when we could offer services – it’s hard to attend therapy in the middle of the day when you are also trying to work full-time and support yourself / your family.
This speaks to one of the reasons I choose not to work with insurance in my private practice. The decision about what makes the most sense as far as type and frequency of therapy is between me and the individual client, with a focus on their needs. No outside entity is dictating what I’m allowed to offer, as long as my services are within my scope of practice and provided in an ethical manner.
Working With an Insurance Specialist
A lot of work, patience, and persistence goes into actually getting a contract with an insurance company. Many mental health providers hire specialists to help them navigate the process, in hopes of not waiting months and months to receive a contract. As with every role, some of the folks who provide these services are quite good at their role, while others may be unhelpful or even hinder the process, all while taking your money.
I was offered the assistance of an insurance specialist as part of my contract with a group practice. My experience was more frustrating than helpful. There was little direction regarding what insurance companies were most prevalent in the area, and therefore likely to provide coverage for most of the individuals I would be working with. When I asked how to locate the applications to apply for a contract, I was directed to do an internet search. There was one insurance company that required an additional form for various licenses (i.e. counselors needed to submit a form that social workers did not), but the insurance specialist was unaware of this and it held up my contract with that insurance company for 9 months. I likely would have sought that information out sooner had I not been led to believe this specialist knew all the ins-and-outs of insurance.
Most therapists go through the ordeal of getting contracts with insurance companies because we believe that mental healthcare should be accessible to all. When someone charges you a fee with the promise of helping you to navigate the process, it’s frustrating to be left feeling that you may have been better off investigating the process yourself. This all amounts to loss of income and loss of time serving clients.
Ghost Networks
ProPublica’s investigation included an article focused on ghost networks. “Ghost network” is the term used to refer to the phenomenon of insurance companies offering consumers a list of providers who supposedly take that insurance, yet are not actually available to take on new clients. Basically, the insurance company doesn’t bother to update their directories when providers let them know they are full or when providers leave the network, or even retire from the field of therapy.
I experienced this firsthand during the years that I provided insurance-based services. An individual came to the group practice where I was working to find a therapist. I had availability on my schedule and was competent in working with the concerns they were bringing to therapy. However, their specific insurance plan was a branch (often known as a “carve out”) of a larger plan. For example, BCBS is a huge insurance company, yet they have many plans that branch off for specific geographic locations or even specific employers. Just because a provider is in-network with BCBS doesn’t mean they are in-network for your specific plan.
This individual had been seeking a provider for months! They couldn’t find anyone who was accessible and in-network with their specific branched off insurance plan. I spent hours and hours on the phone with the larger insurance company attempting to explain that there were no local providers available. Yet, the insurance company had an old directory that listed 30 providers within a 5 mile radius who accepted that person’s insurance. The practice that was listed in that directory had never had a full-time presence in that geographic location (1-2 therapists came to the area once a week many years prior) and the practice had been completely closed for more than 5 years. Yet, the insurance directory listed all those providers as available and accepting this person’s insurance!
These ghost networks effectively leave folks frustrated and feeling hopeless. This is another reason I have chosen not to work with insurance. If I have availability and a person’s concerns are within my scope of competence, then the person and I can discuss cost and scheduling without jumping through hoops in an attempt to get access to care.
Clawbacks and Unexpected Bills
Clawback is a word that strikes fear in the heart of many therapists. Let’s say that a therapist provides 10 sessions of therapy to a client. The therapist has a contract with the client’s insurance company and has verified what, if anything, the client will owe for each session. The therapist charged the client the owed amount, if applicable, and then filed the service with insurance and was paid based on the therapist’s contract with that insurance company.
A clawback is when that insurance company, sometimes years later, decides that the charge for the service shouldn’t have actually been covered and contacts the therapist demanding that money back. The therapist is then left with the choice of being unpaid for those hours of work or passing that charge along to the client who thought their insurance was covering the service. Neither is a good situation.
I have personal experience with this in a couple ways. One instance involved a large insurance company offering to cover policyholders’ copays for a period of time during the Covid-19 pandemic. This offer was communicated as a way to take away the financial burden and encourage the policyholders to seek out mental health support. This was a time-limited benefit and did result in several folks seeking out therapy when the financial burden was removed. However, about 10 months after the no-cost benefit ended, the insurance company sent me a letter that they decided those co-pays weren’t actually covered and demanded that I return multiple thousands of dollars. This left me with a drastic and unexpected loss of income, and also left those policyholders with large, unexpected bills.
I was notified of another clawback attempt, by a different insurer, just last year. They sent a letter – to my previous group practice, not to the updated address I provided them when I terminated my contract with them – notifying me that they decided they shouldn’t have paid for services provided in the summer of 2020. These were therapy appointments held in the midst of a global pandemic – more than 4 years prior – for military service members and their families!
This is another reason I have chosen to offer my services private pay. My pricing is clear and discussed up front. Clients know what they will be charged. The charge occurs the date of the service. I am able to focus on their needs and not be concerned with an insurance company’s impact on my finances. And my clients know they will not receive unexpected bills at any point in the future.
Unethical Directives from Insurance Companies
All licensed mental health providers have a code of ethics that we have committed to follow. For counselors, like myself, that code can be found here. Ethics extend to all areas of our professional practice, including documenting the services provided accurately.
The documentation for a therapy session includes the time of the session, the length, who was present, what was discussed, and how the session relates to the client’s overall goals for therapy. Insurance companies require specific codes for the length of sessions, and also require that a diagnosis be recorded in the client’s medical record. Many insurance companies pay less for sessions under 52 minutes, and strongly encourage therapists to limit sessions to fall within that time frame.
In fall 2021, I received a call from an insurance company – a different one from the 2 previously mentioned – questioning my reasoning for having 60 minute sessions with a particular client. This person had been deeply impacted by the Covid-19 pandemic in multiple ways and was regularly dealing with thoughts of suicide. We met for 60 minute sessions because that is what was needed to ensure this person was safe and their needs were met.
I explained this to the person from the insurance company, who then responded, “Well, you need to limit your sessions to 52 minutes moving forward.” I defended my clinical judgment of the client’s needs and stated that the longer sessions were “medically necessary” (the phrase that insurance requires) based on my actual knowledge of the client. Yet, I was still told to decrease the length of my sessions because the insurance company could not continue to pay for the longer sessions. Basically, I was to ignore my training and knowledge as the professional in the room with the client in order to save the insurance company a few dollars (single digits) per session.
This is another reason that I choose not to work with insurance. I believe the decision about what is most beneficial for a client should be made within the therapy space between the client and the provider. An outside entity who is driven by money should not be making decisions about a client’s need or safety.
A Broken System
Even though we may have differing ideas about how to address things, I think most of us in the US can agree that our current medical system is broken. Insurance companies, driven by financial gain, determine healthcare decisions. Folks pay monthly for ongoing coverage, and can then be left broke following one unexpected medical need. People avoid seeking the care they need, both physical and mental, because they can’t afford the costs. Our current insurance system is not working in a way that helps the majority of the people.
I also recognize that for many people the option to pay out of pocket for things like therapy is not actually an option. I work to bridge the gap between corrupt insurance companies and individual needs by providing therapy services at a price point that allows me to truly show up for each client, meet my own financial needs, and is clearly communicated on my website. It is important to me that both prospective and current clients know the financial investment that is part of therapy, and can be assured they will not receive unexpected bills related to our work together.
If you’re interested in working together (and are located in NC), please check out my website, including the fees page, and feel free to contact me to schedule a free, virtual consultation.
Stay tuned for more about insurance and mental healthcare.
Michelle F. Moseley is a Licensed Clinical Mental Health Counselor in NC. She believes ALL people deserve respect, compassion, and access to mental and physical healthcare. Michelle specializes in working with survivors of religious trauma, and with those who have body image concerns, finding there is frequent overlap in these areas. She also frequently supports late-identified neurodivergent individuals as they navigate the grief and relief of a new understanding of self. You can learn more about Michelle by visiting her website at MichelleFMoseley.com or following her on Instagram – @therapy_with_michelle
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