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This blog was originally posted on our website in January 2017. Due to the high demand for this information, as well as the number of times this article has been cited in the mental health profession by others, we are reposting the article to make it more accessible to our readers.
INSURANCE IS GREAT FOR YOUR BODY, BUT NOT FOR YOUR MIND.
It happens multiple times every week. We get phone calls from potential patients asking if we take their insurance. The very simple answer to this question is “no,” and if we have an opportunity to educate the caller about why, we do our very best to educate them in the short window of time that we have them on the phone.
When willing to have a brief discussion about the pros and cons of using insurance for mental health treatment, most individuals tend to recognize the benefits of not using their insurance and proceed with scheduling an appointment. However, those who are only looking to use their insurance often decline and report they will call other clinicians to try to use their insurance.
These same individuals often call back, reporting they spent hours and hours calling multiple offices to only learn that most don’t take insurance (this is a common reality in mental health due to insurance companies limiting and restricting access to treatment, as well as not supporting clinicians and patients). They also typically report that even if they found providers who take insurance, these offices are booked out for months – more on this below.
This can be very frustrating for individuals who have finally made the important decision to seek professional help as there is usually a notable amount of immediacy to get in for an appointment (our understanding of this has also led Tampa Therapy to make it a priority to keep new client appointment slots in our weekly schedule).
{SOME PATIENTS ARE SURPRISED TO LEARN THAT THEIR INSURANCE DOESN’T COVER THERAPY AT ALL, OR ONLY COVERS A FEW SESSIONS WITH A MENTAL ILLNESS DIAGNOSIS, OR REQUIRES A HIGH CO-PAY OR DEDUCTIBLE.}
Before using your benefits, we encourage you to investigate all options and arrive at an informed decision regarding your health care. You can always decide to use your benefits, but you can’t reverse many of the negative consequences after using them. Considering the frequency that Tampa residents contact us about this, we want to share some insight on why you should strongly consider not using your medical insurance for mental health treatment.
REQUIRED DIAGNOSIS OF A MENTAL ILLNESS
The rule is that insurance companies only pay for services that are considered “medically necessary” (more on this below). This means that in order to utilize your medical insurance for mental health treatment, you must be diagnosed with a mental illness disorder. Additionally, the clinician must prove that your mental health condition is affecting your health and overall functioning on a daily basis.
The problem is that many of life’s difficulties, and the reasons why people seek mental health treatment, are not mental illness disorders and are not diagnosable.
When this is the case, your medical insurance is not going to cover the treatment. Insurance will not cover “I am having a hard time” or “I am grieving a loss” or “I just want to talk through some things.” Many of the patients that we see do not have a diagnosable disorder, so any intentions they had of ever using their medical insurance (in-network or not) to cover treatment becomes irrelevant.
You may be thinking, “so just diagnose me,” but equally important is that any ethical therapist will not diagnose you for the sake of using your insurance for treatment. At Tampa Therapy, we pride ourselves on practicing at the highest level of ethical practice, which means we will never do this even for the purpose of providing a superbill. While you may initially disregard the importance of this, this is a very positive thing that speaks volumes about the clinical practice you are seeking treatment from and can be protecting you from problems down the road.
(Note: Any therapist who will falsely diagnose you for the sake of using insurance is committing fraud, is largely unethical, and you should turn around and walk out the door. These are indications the clinician is not concerned about the integrity of their practice and the quality of care provided, which will likely become clearer in your interactions and the effectiveness of treatment if you were to continue seeing them.)
Couples Therapy
Couples therapy is an excellent example of where insurance often becomes an issue. We get lots of calls from couples looking to use insurance to cover treatment, and regardless of whether they come to our practice, we always educate them about the likelihood of insurance rejecting the claim even if they go to a provider who is in their insurance network.
Some insurance companies claim to provide coverage for couples therapy, however there is much, much more that goes into this. Insurance is billed using two pieces of information: the type and length of the session (e.g., individual therapy 30/45/60 minutes) and the mental illness diagnosis (the basis of medical necessity). The problem is that there is no procedural code explicitly for couples or marital therapy. In fact, the only related code is listed as “Family Psychotherapy with patient present.” This means the identified patient is the person whose insurance is being billed, this person has a diagnosed mental illness, and the understanding is that your partner is present as a support to you in treatment.
There is a V-code, listed as “Counseling for Marital and Partner Problems,” however, this is a code that is typically rejected by insurance companies for not being medically necessary. The equivalent would be trying to get your medical insurance to cover a face-lift or botox for anti-aging. It’s just not going to happen! As far as insurance companies are concerned, couples therapy may be great, but just like a face lift, it is elective and not medically necessary.
So when an insurance company says they cover couples therapy, what they really mean is that, you, the identified patient who has a diagnosed mental illness disorder, is permitted to have your partner present in the room while you receive treatment for a diagnosed mental illness. And the therapy is supposed to be addressing the disorder. The problem again lies in that many couples seeking therapy do not meet criteria for a diagnosable mental illness and are not in therapy to treat a mental illness; they are in therapy to work on their relationship. Again, this is not medically necessary.
{All that being said, most of the time couples therapy ends up not being covered by medical insurance.}
“MEDICAL NECESSITY”
This is the term used by medical insurance to describe procedures or treatments they believe must occur, or if not, the person may suffer insurmountable consequences. A large goal of the insurance company is to contain costs, and one big way of doing this is by only providing coverage for services that fit into their matrix and which they deem “necessary.” Medical necessity is extremely important to insurance companies as they will only pay for services they agree must occur, and they will stop paying as soon as possible.
As described above, the first component of medical necessity is having a diagnosable mental illness. Without a reimbursable diagnosis, insurance companies already view the therapy as unnecessary, and will not provide coverage. This rules out a large sector of insured patients who are looking to work on coping, managing stressors, relationship problems, grieving, or life coaching. Second, the illness must be causing significant functional impairment. Without these factors present, it is likely the insurance company will deny your claim.
YOUR TREATMENT WILL BECOME A PRE-EXISTING CONDITION ON YOUR RECORD
Any documented mental health treatment that is filed through your insurance will go on your permanent medical record. This can have a significant impact on your future ability to secure any health insurance coverage at all; if you are able to obtain insurance with this on your record, your insurance premium, deductible, and co-pays are likely to be much higher. If pre-existing conditions become a barrier in obtaining insurance, the mental illness diagnosis will be considered a pre-existing condition that could prevent you from even getting insurance at all. Given the ongoing state of affairs in the United States with regard to health insurance coverage, this concern is applicable to every person who possesses health insurance and is thinking of using their health insurance for mental health treatment.
Is it worth it to you to potentially lose the ability to obtain quality and affordable health insurance, or any health insurance at all, because you want to file your therapy sessions through your insurance?
LOSS OF CONFIDENTIALITY
One of the biggest concerns about using medical insurance for mental health treatment is the possibility of losing confidentiality. When your insurance is billed, not only do they require a diagnosis, but they gather information about the type of treatment you are receiving and whether you have improved or not (this is important to them because their goal is stop paying as quickly as possible). The insurer can also audit your records at any time they wish, which means they have full access to any details your therapist has, including information the therapist intentionally did not include in the claim submitted to the insurance company. Any and all information, including progress notes, which can include details about what occurred during the therapy session, is open to the claims specialist.
Similarly, the average insurance claim passes through 14 people while it is being processed. These people are able to view information about your treatment including your diagnosis, treatment plans, progress notes, as well as any other information pertinent to them approving (or denying) your claim. These details should be private, but are open to anyone with access when you use your health insurance. Confidentiality is also often lost when your information is being faxed to anyone in the health care industry who ever requires access to it, which often occurs while claims are being processed.
While you may not care about this, if you a hold a high security clearance for a job, are seeking a military or federal job, a political position, an aviation position or any other job that requires health-care checks (many institutions are now screening out employees who may be unstable or cost too much money in mental health treatment and lost work days) or have other reasons you want your information to remain confidential, this is important to know.
Additionally, children often have an even more difficult time when given a diagnosis, as their diagnosis follows them for much longer and can impact school, college, and be a barrier to pursuing certain careers. If your child’s condition warrants a diagnosis, you may want to have some say over how that diagnosis functions in their life – you may want to keep all treatment private.
{Loss of confidentiality means loss of control of your information, who gets it, and how they use it.}
LONG WAIT TIMES FOR APPOINTMENTS
If you are a new patient using a in-network provider through your insurance, it is very likely you will have to wait a significant period of time before getting in for your first session. Patients, as well as peers and other professionals in the mental health industry, frequently share they were quoted anywhere from two to four months before being able to get in for a first appointment. This is truly unacceptable.
If you have ever sought therapy before, or are currently seeking it now, you know what a big decision this can be, and how immediate the need is to get in for an appointment. Typically, you have already tried to manage the problem in some way on your own – be it an external situation or an internal psychological issue. Perhaps you have read some self-help articles, sought advice from friends and family, tried to ride it out and allow “time to heal,” but finally realized you needed something more. To then hear that you must wait another two to four months before you can attend an intake session is both disappointing and potentially harmful.
Though in some particular situations (such as relationship break-ups) it is true that time is one of the biggest components for healing, in many others (particularly with traumatic events) time only leads to more severe symptoms and internal psychological distress. As with anything else, the best results and less difficult path to healing comes when problems are caught and treated early.
{THE EARLIER YOU CAN TREAT A PROBLEM, THE BETTER}
YOU ARE NOT SEEING A SPECIALIST
When a clinician accepts insurance, they by nature of their contract with the insurance company cannot really specialize. The clinician can note the areas where they prefer to practice, and likewise advertise this to insured consumers, but they cannot turn away a potential client simply based on the person not being their “ideal” client so long as they have an opening and take that individual’s insurance.
For example, Tampa Therapy specializes in treating trauma, PTSD, grief, depression, anxiety, couples, and conducting psychological testing. If we were contracted with insurance companies to provide services, we would be able to advertise that we have a focus on these areas, but that is the extent of our being able to specialize.
We would be required to see any and all patients who contacted us, so long as we accepted their insurance and had an open appointment. Due to the terms of the contract, we could not turn down patients on the basis of them seeking treatment in an area outside our “specialities.” If that were the case, then by nature of our association with insurance, we would not be able to specialize as we would be required to see every type of problem just by virtue of our insurance agreement.
The problem with this is comparable to going to a family practitioner when you really need to see a neurologist. Sure, the family practitioner has medical training and can probably identify from a more general standpoint what may be going on, and they may be able to provide general treatments, but they do not have advanced training or experience in treating your precise problem. This is akin to seeing specialists for mental health treatment. This is also precisely the saying “jack of all trades, but master of none.” Just like you would seek a specialist to get the best care and outcomes for a physical medical concern, it is equally as important to seek a specialist for psychological concerns.
What About Scope of Practice?
So, you might be thinking and ask, what about scope of practice? This is an ethical concept!, and has nothing to do with the contract signed between the therapist and the insurance company. Insurance companies are not concerned with specialities or scope of practice, and that is because their stance is a licensed mental health professional is qualified to see mental health concerns (which, in fact, they are, but this does not mean the clinician is specialized or knowledgable in a particular area). To the insurance company, if a provider is a licensed mental health professional, they should be able to manage common mental health concerns just as a family medical practitioner should be able to manage common physical health concerns (but, as we know, sometimes you need more than managing; you need a specialist for advanced techniques and treatments and that is the key difference here).
As such, insurance companies are focused on the legalities contained within the signed agreement between the clinician and the insurance company, which typically state they cannot turn a client away so long as there is an opening. No one forces a clinician to sign a contract with an insurance company, so when a clinician makes the decision to do so, they (legally) must comply with the requirements of the contract, which again, means they must take clients if there is an opening, which means they cannot truly specialize.
{Specialists have advanced training and experience in working with your presenting problem. If you use your medical insurance for mental health treatment, chances are you aren’t seeing a specialist.}
YOU MAY NOT BE SEEING A THERAPIST WITH LOTS OF EXPERIENCE
This goes against what we tend to think of, as most medical providers are seen through your medical insurance. However, simply put, mental health treatment is very different. In the mental health field, most experienced and seasoned therapists simply do not take insurance. This is because they don’t have to and don’t want to for clinical effectiveness and efficiency purposes.
Logically speaking, experienced and seasoned therapists are specialized and have enough of a following and community reputation that they do not need to acquire patients from insurance mills. New patients are referred to these experienced clinicians by other patients, other medical providers, attorneys, etc. Even when therapists start out on insurance panels, as they gain experience and become more established, in most cases they realize the number of limitations present and eventually move away completely from being paneled with insurance. This is not to say that all providers who take insurance are unexperienced, but this is often the case.
LOSS OF CONTROL OF TREATMENT
When you see an in-network provider through your insurance, neither you nor the clinician get to decide how you spend your time in treatment. Insurance companies require that a treatment plan be submitted in order to approve the number of sessions and ultimately, they use this to determine how your time in therapy is spent. The number of sessions is determined ahead of time by the claims specialist (a non-mental health professional who you have never met and does not know your plight) and is not based on need, but based on containing costs.
Attempting to extend the number of covered sessions often proves futile, as the insurance company has a matrix for determining what they believe are the number of sessions needed to correct the problem. The huge difficulty with this is that therapy is not at all predictable, so treatment may very well take longer. Further, their version of correcting the problem often means getting you out of crisis or back to a very minimal level of functioning. Truly effective and thorough therapy requires time, and insurance companies NEVER cover this type of treatment.
Rather than giving you the care that best meets your needs (which in therapy sometimes means deviating from the treatment plan and discussing the terrible interaction you had with your boss yesterday), the therapist is responsible to the insurance company for “completing” your treatment within the pre-determined number of sessions.
Bottom lime, an in-network therapist works for the insurance company, not for you.
This is because of the contract with the insurance company that the therapist is required to uphold. Another common issue is that it can take months for your therapist to get reimbursement, if at all. These delays can interrupt treatment until your therapist is paid by the insurance company (or you) for services rendered.
YOUR MEDICAL RECORD
While many patients come to therapy who do not have a diagnosable mental illness, just as many come to therapy because they do have a diagnosable mental health condition (e.g., major depression, generalized anxiety, bipolar disorder, etc.). For these patients, it comes as no surprise the therapist would notate their diagnosis in the record, primarily to know what they are treating and then provide effective treatments based on the presenting issues. There is a huge difference, however, between filing insurance claims with this information versus not using your insurance. Simply put, when you don’t use your insurance, this information remains private. When you use your insurance, your mental illness diagnosis, as well as your treatment, becomes part of your permanentmedical record. You don’t get to take this information out once treatment is over, or ever.
This can make applying for new health insurance, life insurance, or a new job incredibly difficult as they can require an authorization to release information to view your entire medical record. It is possible in the future that people may once again be denied coverage based on a preexisting condition which includes mental health diagnoses. If this happens and you do secure coverage, companies can charge significantly higher premiums because of having ever been treated for a mental illness diagnosis. If you are someone who might ever be unemployed, self-employed, or need to purchase your own benefits, a mental health diagnosis can make the difference between preferred coverage or none at all.
This is often one of the more significant reasons that resonates with patients, and why many who are insured often choose to not use their medical insurance for mental health treatment.
SURPRISE COSTS
Insurance companies will warn you, “A quote for benefits does not guarantee payment…” This means that despite being told verbally (over the phone) that something is covered and possibly even being given an authorization number, you can still be denied once they review the diagnosis. If you attend therapy sessions under the belief you are using health insurance to cover your visit, and the therapist receives a denial of the claim, you are then responsible for the full payment to your therapist. You can attempt to appeal the claim with your insurance company, but be prepared to go through several levels of appeals, which can take weeks to months – all while your treatment is likely interrupted.
Additionally, you may have a deductible that needs to be met or a particularly high copay. For example, depending on your deductible, you may have to pay $500 or even $5,000 out-of-pocket before your insurance company will begin making payments on claims.
{In all of these scenarios, you are still paying out of pocket, but since the claim was filed through your insurance, your personal healthcare information is now out there. This includes your diagnosis, and possibly your treatment plan and progress notes.}
ANOTHER PRACTICAL CONSIDERATION
In addition to the aforementioned reasons, which are focused on the client side, it is still important to recognize there are many, many well-intentioned therapists who would like to be able to provide in-network services to those who are insured (given that the client has taken the above factors into consideration). These same therapists often are unable to get paneled on insurance plans due to long waiting periods, multi-year waiting lists, and even after repeatedly going through the process of reapplying only to get declined due to full panels.
Getting paneled with insurance companies is NOT as simple as “just applying.” Most of the time the process involves repeated denials, multi-year waiting periods, and incredibly low reimbursement rates. The decision comes down to practicing without taking insurance and being able to help some, or not practicing at all and not being able to help anyone; as you can understand, not taking insurance becomes the only option for many therapists.
SOME SOLUTIONS
Unfortunately, medical insurance often becomes a hindrance to obtaining timely and effective mental health treatment. The biggest, and most sincere, suggestion we can offer is to pay out-of-pocket. This has many benefits as you are likely to get in for an appointment much quicker, you are putting the power back in your own hands in terms of finding the right therapist, choosing one who specializes in your particular problem area, and one who is likely very experienced. You are also in full control of the length of treatment and how often you attend therapy sessions. And, your record remains private.
Another solution is to use pre-tax dollars, such as by using your Health Savings or Flexible Spending Accounts to pay for therapy. These accounts typically come in the form of a credit card with major credit logos.
Also, unbeknownst to many, visits to your psychologist or psychiatrist can be tax deductible when paying out-of-pocket (however, this same rule does not apply to mental health counselor or social worker visits unless you are receiving psychoanalysis). This link to the IRS shows all available tax deductible medical expenses.
You can also work with an out-of-network provider, which is something we often do with our patients. This means you pay the therapist directly but submit a statement to your insurance for direct reimbursement. However, the statement you submit (called a superbill) still must contain a mental illness diagnosis and the type and length of session attended. This option does not resolve issues concerning confidentiality and your medical record, but allows you to maintain more control of your treatment than when using an in-network provider. You will want to call your insurance company ahead of time to confirm they will reimburse you. More information about the steps to do so can be found at https://tampatherapy.com/forms/