“Cost Effective Treatment?”
I am working toward becoming a complete fee-for-service provider. This means that I will eventually NOT accept insurance for my services. This may sound a little strange to you if you have never obtained health care by paying out of pocket for it, but there is a good reason why I encourage my clients to not use their insurance.
Managed care providers (insurance companies) are not in the healthcare business. Their business is to manage those who attend to your healthcare. This means that their objective is to create profit from the process of management, not in making sure you get the best care. As a result, they continue to demand more out of providers, imposing more rules which make providing effective mental health services more and more difficult. Managed care companies often require therapists to limit their services to what they define as “cost effective” or “outcome based” approaches. This sounds reasonable right? It is absolutely reasonable, and I truly aspire to provide both “cost effective and outcome based measures” to each and every client. The difference is in who defines these terms.
In my experience people come to therapy not looking for a “fix” or an immediate repair, but rather to learn how to grow and maintain their mental/relationship health. People go to therapy because they are suffering on some level and want the type of care that will address their specific pain, rather than a pre-determined insurance protocol. This level of care often requires more time and more in-depth psychological services than is allowed under most health insurances. It is typical for insurance companies allow for the following: 15-20 sessions per year, weekly at most, and re-authorization may have to after 8-10 with specific details about the problem, diagnostic label, and detailed treatment plan indicating expected outcomes with dates and techniques employed. Some companies even limit the length of the session to 40 minutes.
In this case, most people start therapy, use their allotted number of sessions and then decide if they want to continue to see their therapist by paying out of pocket. This is very common, however, what if you cannot afford to pay the new higher rate? Your therapist may not be able to afford to do this for you. You end up being referred to another therapist or your therapist has to take a big pay cut to continue to see you, and most of us cannot afford to do this. Unlike doctors and other medical providers, there is a limited number of clients that I can see and remain effective. Thus the $85.00 fee to see your doctor for 15 minutes or less is something he can afford, especially when they schedule appointments back to back, thus accounting for no-shows with volume. Ever wonder why your appt. doesn’t start until well after the agreed time? Losing appointment reimbursement fee for therapists is too much of a financial loss. When you pay for therapy, you pay for your time. A therapy hour is a therapy hour. Thus, I prefer to set my fee with a client from the start so that we both know what to expect from the beginning. I won’t suffer a major financial loss and you won’t get hit with the payment shock.
In addition, avoiding insurance companies allows me to use my clinical judgment to determine the type of therapy I provide and the length of time needed to help someone. Some clients may only need a few sessions, while others truly need several months and sometimes years. Paying a fee-for-service fee gives me the freedom to offer you a wider range of services and remain true to the quality of service I can offer. It gives both of us options.
It is my belief that the restrictions placed upon providers by insurance companies have so interfered in the practice of therapy that clients are poorly served overall, despite our best efforts. Patient’s well-being is not prioritized by insurance companies. There are large numbers of therapists who are taking a stand against severely restricted insurance companies and their practices by offering fee-for-service therapy. In order to do this, therapists have had to use sliding scale fees to ensure that patients can afford their treatment.
Insurance companies set the rates for care under their umbrella and require certain levels of copay and deductibles that are non-negotiable. I offer a negotiable fee so that money doesn’t have to be an obstacle to obtaining therapy from me. Please note that I do have a limit as to the lowest payment I may offer clients. I also have to survive and pay my bills so that I can continue offering high quality therapy services to my clients. You and I will negotiate a fee during the first session. If we cannot agree upon a fee that is reasonable for both of us, I will refer you to a therapist who will be able to help you.
Possibly the most compelling reason that I encourage fee-for-service over use of insurance is privacy concerns. The more an insurance company wants justification for therapy services, the more they want to know about your mental health. This requires that I give you a diagnosis that meets their standards of “medical necessity,” that I provide them with a report of your progress and they may expect a treatment plan. In addition, therapist files are subject to audit by insurance companies, to ensure that the patients are being treated the way therapists report and to be sure that the records are in-keeping with their standards. Your mental health records become a part of your overall medical records, and the information contained becomes a permanent part of your records.
The honest truth about “medical necessity” criteria – In order for a therapist to get paid, you have to be ill. You have to have a diagnosable psychiatric mental illness, according to the standard psychiatric diagnostic criteria found within the Diagnosis and Statistical Manual (DSM-5). In reality, most people who go see a therapist are not mentally ill, per say, but seek out therapy to help them cope with difficult, temporary life crises or relational problems. Even if a person who attends therapy does have a mental illness, the reason for seeking out therapy typically is NOT for treatment of the illness.
For example, lets say that you are breaking up with your spouse or life partner. The two of you have been together for 8+ years or longer, and the end of the relationship along with all the struggles of dividing up a married life is excruciating! You have a lot of moodiness, depression, trouble sleeping, anxiety, nightmares and sometimes you just don’t want to get out of bed in the morning. The diagnosis that is appropriate for you, if you do not have a history of mental illness, is a “Life Transition” or adjustment disorder. You are going through a hard time and seeing a therapist will help you through this difficult transition. An insurance company may not reimburse for adjustment disorders, or limit the type of services that a therapist can offer for you. You may not be able to have more than 10 sessions. In truth, most people take a good 6 months to 2 years to come back after a major break-up. Two and a half months of therapy, while helpful, is not nearly enough time for this type of issue. You really may benefit from having the extra support for the full 6 months to a year. But, if your insurance company doesn’t pay for adjustment disorders or severely limits the number of sessions, then a provider may have to diagnose you with a another disorder, like Major Depressive Disorder or Depressive Disorder NOS, or an anxiety disorder if appropriate. All the sudden, you have a psychiatric illness on your medical record. This is known as “upcoding.” The opposite also happens when client is being treated for a serious psychiatric disorder, but insurance won’t cover certain diagnoses, so the client’s diagnosis could be downgraded to what insurance will cover.
The required “medical necessity” criteria has left many therapist giving diagnoses that do not accurately describe their clients’ struggles. While this is not an ethical practice, it is done routinely to qualify clients for their insurance payments. These diagnoses become a permanent part of your medical records. The diagnosis is recorded in your insurance company records and will be utilized as they deem appropriate. As technology and integration of data continues drive healthcare and algorithms are increasingly involved in decision making, it is unknown the damaging consequences to patients that may occur. Avoiding the use of insurance eliminates the need to diagnose and no one has to be informed or aware that you ever went to therapy. It allows me to protect your interests as much as possible under the law.
Under current law, your mental health records are only disclosed under certain circumstances, however, there are many instances when we, as providers, or insurance companies are not required to obtain your permission to provide your records to third parties. Thus your records can be accessed without your knowledge, and not necessarily for your benefit.
Without insurance company records, the only records to worry about are my records. This severely limits who can access your records. There are no audits of my files. I am solely responsible for your records. No other healthcare provider, insurance company, or other entity can access your files without your written permission. This is the best safeguard of your privacy. It leaves you in control 100%.
There is only one exception to this, and it has to do with court proceedings. A judge can order me to produce your mental health records if they are absolutely necessary in a legal case. No one but the court can do this. Your attorney cannot obtain your records without your permission, an attorney of someone else cannot obtain your records, and no police or anyone else can have access to your files without a court order from a judge directly ordering me as a therapist to produce your records. Because of this, I am very careful in how I keep your records. What I do is focus on the services that I provide to you and the reasons why I provide them. Thus your confidentiality is protected in all ways.
Because I do not need to use a diagnosis for your health insurance doesn’t mean that I do not assess and document your condition in my therapy records; I do. The good news is that I will give a diagnosis that fits your situation and is practical for my use; it won’t necessarily be a psychiatric diagnosis, unless you already have one. My diagnoses fit the type of issue you bring to therapy. Practical diagnoses are used for the purpose of planning the most effective treatment for your needs. I am very careful about the type of diagnosis I give to my clients. You are always welcome to inquire about your diagnoses. This way you are never left guessing and wondering. You and I also will develop and discuss a “treatment plan” together so you always know what to expect and the type of service I am giving you.