“ There are several reasons why many therapists are not on insurance panels. Here are some of them. ”
Why some therapists are not on insurance panels
As a subscriber, you might expect to be able to use your insurance to offset, if not cover, your health care, including mental health care. When a therapist you want to see is not on your insurance company panel, it may be puzzling. There are several reasons why many therapists are not on insurance panels. Here are some of them:
Thanks to the 1996 passage of the federal Mental Health Parity Act, most insurance companies now include some coverage for mental health care, and are prohibited from requiring separate deductibles or different standards of care for mental health services. This was a positive step, which allows people to use their benefits without onerous limitations. With the implementation of the 2010 Affordable Care Act (ACA), we are entering another new era in health care and insurance. Some necessary changes are coming. During the transition, however, many mental health care providers feel the burden of cost-savings is coming more out of providers' income than out of hospital and insurance industry revenues.
What you can do
We can help shape this unfolding health care discussion by writing to our legislators, voicing our concerns to our insurers and employers' HR departments, supporting the efforts of the Coalition of Mental Health Professionals and Consumers, and generally bringing out these issues for discussion.
Here are some useful resources for keeping up to date on the discussion:
Affordable Care Act: http://www.healthcare.gov/law
The Washington State Coalition of Mental Health Professionals and Consumers: http://www.wacoalition.org
Intrusion into the therapy
In order for an insurance company to pay for your treatment it must establish that treatment is medically necessary. Necessity is established based on your symptoms, general functioning, and a diagnosis determined by your therapist. Sometimes a treatment plan is also required. Increasingly insurance companies are weighing in on what they believe should be an adequate number of sessions for particular symptoms and circumstances. Sessions in excess of their determination may be denied, and an appeal is necessary to challenge this. Further, one large local insurer is tagging therapists who deviate from their standard as "high utilizers." The long-term consequence of this new practice is not yet clear.
For such reasons, therapists feel pressure from insurers to be specific and treatment-goal focused. This can contribute to some difficult circumstances, including having conflicting interests as a result of this pressure. A therapist might overly direct the conversation to stay "on task," foreclosing or limiting the space to let as yet undefined issues come into the conversation, or she or he might consider whether to nudge a client out of therapy because of concern about his or her reputation with the insurer, rather than allowing the client's needs to guide the therapy and termination process.
Your diagnosis becomes part of your medical record. Although insurance companies must protect your information both because of ethical practice and the Federal HIPAA law, there are circumstances under which various entities have access to your record. For example, when you apply for life or disability insurance, you are required to give a blanket release for all medical records. You may then be considered ineligible for such insurance because of the diagnosis that was used to describe your need for therapy. Many forms we sign in a variety of situations included blanket releases we may not question or even remember.
For some therapists this is one of several reasons to avoid insurance panels.
Insurance reimbursement to many providers, including psychotherapists, has been going down steadily in recent years.
If a therapist is on an insurance company panel, this means she has agreed to accept a significantly reduced "allowable" fee for the subscribers of that insurance. The savings to the patient is achieved by lowering payment to the provider.
This reimbursement issue impacts therapists' capacity to lower fees for low income or uninsured patients, as therapist income is already reduced dramatically. Ironically patients who have the resource of insurance ARE our low fee clients, even though some of our insurance clients may actually be relatively or very wealthy.
One advantage of seeing an 'out of network' therapist is that you're not limited to a relatively small pool of providers. You're able to choose a therapist from a much larger pool, based on a good clinical fit, location, and other considerations. In these situations, the therapist is allowed to charge her full fee, so your out-of-pocket expense will be greater than if you saw an in-network provider, but still less than if you had no insurance.