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Derailed by the insurance system

September 18, 2012
by Thomas A. Peltz, MEd, LMHC, LADC-1, CAS
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 Have the therapeutic voices of private practitioners become quieted in the process of signing up for contractual agreements to join insurance panels?

We are supposed to be communicators, able to listen deeply and speak clearly amid the storm of disorders in our patients’ lives. Perhaps like a guide, we are able and willing to walk with our patients along their journey and to help them arrive at a sober and safer spot. An increasingly complicated problem in our work, however, involves the rift caused by the insurance business tide intersecting with our clinical approach. Here are some examples.

Look for a moment at the different requirements various insurance companies ask of us as we activate a case. Some want treatment goals to be determined at the first session, and reviewed periodically after that. Some want a patient assessment completed by the patient at the first and fourth sessions. Some want a letter sent from the therapist to the primary care physician and other providers. Each of these tasks certainly has value, yet each causes paperwork to cut into the therapist’s clinical time with the patient.

Look at how an insurance company will not accept the clinical license of, for example, a licensed mental health counselor to work independently with Medicare patients. Or, how the independent licensed addiction provider is not eligible for reimbursement by some insurance companies.

Some companies want an online review 24/7, while some want a live verbal review—only during business hours. Some want a single Axis I diagnosis, and some accept several. None seem to really care about capturing the complicated, chronic nature of this illness, and details of the patient’s treatment history are often left out of the review altogether. This therefore erroneously becomes, just by the collection of the data, an acute illness. If the disease is treated as though it is an acute illness, then working under only a short-term detox model makes sense. But long-term studies show over and over again that acute care does not suffice for a chronic illness.

In my experience, insurance companies will have information about the treatment history of a patient, but cannot or will not offer that information to the provider (confidentiality laws play into this). This leads to difficulties in knowing how to provide care at the most effective level, which can result in needless duplication of services and increased costs. In turn, some patients can continue denial and manipulation for a long period of time, revolving through the doors of multiple care levels or locations.

Payment exposure

A related issue involves how some patients move from therapist to therapist without proper closure or completion. For example, a patient drops out of therapy after a few sessions without any notice. This may result in a number of no-show appointments. A bill is generated for those services, yet often it cannot be collected if the patient refuses to pay. Insurance won’t pay for no-shows, small claims court may not do much other than anger the patient enough to counter-sue, and there is no tax break for the services as they are considered services not offered. The therapist is left with little control. The patient who does this with one therapist will likely do this with others, and there currently is no way to know about the pattern.

The area of payment offers another example of how the business of insurance and the business of therapy have not resolved their differences. Fast-food restaurants have a simple system for their drive-through windows. You pay at the first window and collect your food at the second window. When it comes to learning about patients’ coverage, however, we come to realize that what is agreed upon in the beginning is not necessarily what the insurance company will cover later on.

One example of this occurred with an insurance company that agreed to pay for services for patient A. Therapy occurred for months, and payments came in. Then I received a letter stating that the same insurance company had found a mistake, and patient A was in fact not covered. Because by then patient A had ended treatment, the insurance company elected not to cover my services for patient B. The second patient was not connected in any way to the first, but the insurance company wanted to recoup its loss and decided that this would be fair. As a therapist, there is no way to refuse, other than to drop the contract with the insurance company.

Even the playing field