Why I Left The Network
August 26, 2024 1:16 PM Subscribe
Finding a therapist who takes your insurance can be nearly impossible. NPR reports on a ProPublica investigation into why therapists, psychologists, and psychiatrists are leaving insurance networks and only accepting cash for treatment.
You may not be surprised to learn that the primary cause is that insurance companies are actively trying to avoid paying for mental health treatment. As insurance networks add more ghost therapists and refuse to raise reimbursement rates, many independent mental health providers have stopped taking insurance entirely. I definitely noticed this in my recent search for a mental health provider, none of the psychiatrists I looked into would accept insurance for initial payment (but some were in network and would help file for reimbursement).
You may not be surprised to learn that the primary cause is that insurance companies are actively trying to avoid paying for mental health treatment. As insurance networks add more ghost therapists and refuse to raise reimbursement rates, many independent mental health providers have stopped taking insurance entirely. I definitely noticed this in my recent search for a mental health provider, none of the psychiatrists I looked into would accept insurance for initial payment (but some were in network and would help file for reimbursement).
Back in like 2003 I was going to a therapist who I was paying out of pocket and when I finally got a job w/ insurance I asked him at one session if he would take my insurance, and he was all "let's talk about this next time" and I said "no, let's talk about it now" and after some back and forth he said that no, he would not take my insurance. At that point I fired him because clearly he was angling for one more session's worth of my money. And he had the temerity to call me multiple times trying to get me to come back by throwing crackerjack psychoanalytical terms at me! He was awful and made me distrust male therapists for a long time. He was also weirdly judgmental about me smoking weed at the time. Just a bad therapist overall.
I now have a great therapist, and I still pay out of pocket but that's mostly because I don't want any mental health stuff on my record.
posted by grumpybear69 at 1:41 PM on August 26 [16 favorites]
I now have a great therapist, and I still pay out of pocket but that's mostly because I don't want any mental health stuff on my record.
posted by grumpybear69 at 1:41 PM on August 26 [16 favorites]
I am frankly amazed that anyone chooses to practice medicine in the US anymore. Dealing with the sheer evil of the insurance industry on a daily basis has got to take a toll.
posted by sriracha at 2:04 PM on August 26 [42 favorites]
posted by sriracha at 2:04 PM on August 26 [42 favorites]
i am saddened to discover that “ghost therapists” does not in fact refer to therapists who are ghosts, because i would absolutely want to become a ghost therapist’s patient.
okay so lazy joke aside i have finally after a long arduous journey found a truly excellent therapist, like, next-level incredible, who i am unfortunately paying a staggering amount of money to per-session since as noted there are basically no therapists who take insurance and have openings.
can i rave about my therapist a little? cause i’m gonna. so i had never thought to look for a therapist who is themselves neurodivergent, but by chance stumbled on a link to a therapist who literally has the phrase “autistic therapist” in their practice name. working with them has been a goddamned revelation. literally life-changing
posted by bombastic lowercase pronouncements at 2:13 PM on August 26 [29 favorites]
okay so lazy joke aside i have finally after a long arduous journey found a truly excellent therapist, like, next-level incredible, who i am unfortunately paying a staggering amount of money to per-session since as noted there are basically no therapists who take insurance and have openings.
can i rave about my therapist a little? cause i’m gonna. so i had never thought to look for a therapist who is themselves neurodivergent, but by chance stumbled on a link to a therapist who literally has the phrase “autistic therapist” in their practice name. working with them has been a goddamned revelation. literally life-changing
posted by bombastic lowercase pronouncements at 2:13 PM on August 26 [29 favorites]
My dentist just bailed on insurance as well, but unfortch there's no way I can pay the new fee out of pocket. I believe that it's just awful to navigate but I sure hope someone around here decides to keep fighting the shitty fight, else it's RIP my teeth
posted by We put our faith in Blast Hardcheese at 2:14 PM on August 26 [3 favorites]
posted by We put our faith in Blast Hardcheese at 2:14 PM on August 26 [3 favorites]
My therapist of 10+ years retired several months ago. I’ve been trying to find a new therapist since then who’s in my network. I do now have an appointment with someone for October, but it took months of looking. The cost difference: in-network is around $50 per session. Out-of-network is around $300.
posted by josephtate at 2:22 PM on August 26
posted by josephtate at 2:22 PM on August 26
Dentist: dentists are now bailing on Delta Dental because Delta is screwing them over, but that's the "best" option available to at least get some money back out of the situation. It doesn't seem like any dentist are actually taking any insurance, really. With the new job I get access to new dental insurance that I'm told is terrible for two years and Delta isn't an option. However, there's the one loophole Iris Gambol found for me that meant I should be able to keep the Delta Dental and I was told it'd take a month or two (this was in June) to go through. I found out today it has not, at all! So, back to the "starting all over again" drawing board with that one.
Therapy: I paid out of pocket for over a decade on sliding scale because you couldn't get therapy through my HMO. Therapist said billing was a giant pain in the ass, she never got around to filling it out, reimbursement was a pain, etc. I found out that my old job would let me use Optum (separately) for therapy since Kaiser would not do it, got a new therapist, only had to pay $20/hour. Then I had to change jobs and had to completely change my insurance (WHICH HAS BEEN SUCH A PAIN IN THE ASS, Y'ALL) and doctors so I could switch to an insurance that used Optum and I didn't have to start all over again with the therapist search, or use the Kaiser therapist search, which now exists but sounds like a mess. Therapy has been great with the switch (also $5 less), but everything else has been a big ol' pain, with rules like "I can switch PCP's but I literally can't start seeing the new one for over a month" and "no, you can't just move your prescriptions over either like we told you," and I have had to outsource some things in the meantime, and ARGH.
posted by jenfullmoon at 2:39 PM on August 26 [5 favorites]
Therapy: I paid out of pocket for over a decade on sliding scale because you couldn't get therapy through my HMO. Therapist said billing was a giant pain in the ass, she never got around to filling it out, reimbursement was a pain, etc. I found out that my old job would let me use Optum (separately) for therapy since Kaiser would not do it, got a new therapist, only had to pay $20/hour. Then I had to change jobs and had to completely change my insurance (WHICH HAS BEEN SUCH A PAIN IN THE ASS, Y'ALL) and doctors so I could switch to an insurance that used Optum and I didn't have to start all over again with the therapist search, or use the Kaiser therapist search, which now exists but sounds like a mess. Therapy has been great with the switch (also $5 less), but everything else has been a big ol' pain, with rules like "I can switch PCP's but I literally can't start seeing the new one for over a month" and "no, you can't just move your prescriptions over either like we told you," and I have had to outsource some things in the meantime, and ARGH.
posted by jenfullmoon at 2:39 PM on August 26 [5 favorites]
Earlier this year, I decided to go back to therapy. The wrench in the works was now I’m on Medicare. As hard as it is finding a therapist that takes insurance, it’s about quadruple that hard to find one that takes Medicare. I found one, thankfully, and they seem to be okay.
posted by Thorzdad at 2:48 PM on August 26 [13 favorites]
posted by Thorzdad at 2:48 PM on August 26 [13 favorites]
One thing they didn't hit on is that if you take insurance, you can't do sliding scale. Because insurance says that whatever your lowest point in the scale is, that's what they'll pay you for all insurance-based patients. Oh, and they also take a percentage off the top for the "privilege" of sending patients to you. So if your sliding scale fee is $50 - $150, then every session that goes through insurance is only paid out, say, $40.
A caseload that would be considered healthy work-life balance is about 20-25, given the intensity of therapy work and the fact that you need time for billing, scheduling, writing notes, consulting with new patients, managing your online presence, etc. A lot of people push to 35 and burn themselves out. Even that isn't enough to pay the bills at $40 an hour (last time I did the math, a rough estimate of $30k minimum to run your own private practice, probably even higher now), and that's assuming you actually get paid.
I've gone back and forth on taking insurance once I'm licensed and basically I've determined that the best way to actually provide help to the people who need it most and keep my conscience and wellbeing intact is to be a cash-only clinic for some amount of hours, and then dedicate a number of hours per week to entirely pro-bono assessments and/or therapy at a local clinic serving marginalized groups. Don't know if that'll pan out or not, we'll see.
posted by brook horse at 3:04 PM on August 26 [39 favorites]
A caseload that would be considered healthy work-life balance is about 20-25, given the intensity of therapy work and the fact that you need time for billing, scheduling, writing notes, consulting with new patients, managing your online presence, etc. A lot of people push to 35 and burn themselves out. Even that isn't enough to pay the bills at $40 an hour (last time I did the math, a rough estimate of $30k minimum to run your own private practice, probably even higher now), and that's assuming you actually get paid.
I've gone back and forth on taking insurance once I'm licensed and basically I've determined that the best way to actually provide help to the people who need it most and keep my conscience and wellbeing intact is to be a cash-only clinic for some amount of hours, and then dedicate a number of hours per week to entirely pro-bono assessments and/or therapy at a local clinic serving marginalized groups. Don't know if that'll pan out or not, we'll see.
posted by brook horse at 3:04 PM on August 26 [39 favorites]
Insurers pay only for time in session, not the documenting of notes or chasing down of payments.
I wonder if there's an avenue of regulation here -- something about requiring insurers to reimburse for the costs of dealing with them. I am sure they would still find some way to make it the fault of the doctor and not pay it...
posted by jacquilynne at 3:29 PM on August 26 [2 favorites]
I wonder if there's an avenue of regulation here -- something about requiring insurers to reimburse for the costs of dealing with them. I am sure they would still find some way to make it the fault of the doctor and not pay it...
posted by jacquilynne at 3:29 PM on August 26 [2 favorites]
Over the past few years I've come to suspect it's not just about the money, but that the insurance corporation machine's default setting, when presented with anything that looks like talk therapy -- even if it's not more costly -- is, "If Ambiguity, then Deny, Deny, Deny". Sure, partly it's about operations cost management ; employees who can effectively manage ambiguity are far more expensive than those who'll simply implement policy as quickly (cheaply) as possible.
There have been times I've seen my psychiatrist slash medication-proscriber-only for multiple instances in a short period of time (ah the joys of bipolar medication management), at rates which dwarf what I'd/they'd be paying a therapist for CBT or similar. My insurance has not once batted an eyelash at claims sent to them by the psychiatrist for med management, nor for the multiple rounds of Transcranial Magnetic Stimulation which in aggregate are def more costly than regular weekly therapy.
BUT, any claims for talk therapy I send in for myself or my child... it's like I've sent them a soiled diaper and they're holding their noses for as long as they can before reimbursing for a fraction of the claimed cost.
Their faith is highest in medication and machines because of a fetish for determinism, and those well-industrialized tools aren't beyond the limited capacity of the corporate mind. But when faced with the mere notion of humans providing nuanced, bespoke, empathetic care to other humans, accompanied as it must be by an uncertainty that's vital to the progress of all life? The machine simply cannot compute.
posted by jerome powell buys his sweatbands in bulk only at 3:45 PM on August 26 [27 favorites]
There have been times I've seen my psychiatrist slash medication-proscriber-only for multiple instances in a short period of time (ah the joys of bipolar medication management), at rates which dwarf what I'd/they'd be paying a therapist for CBT or similar. My insurance has not once batted an eyelash at claims sent to them by the psychiatrist for med management, nor for the multiple rounds of Transcranial Magnetic Stimulation which in aggregate are def more costly than regular weekly therapy.
BUT, any claims for talk therapy I send in for myself or my child... it's like I've sent them a soiled diaper and they're holding their noses for as long as they can before reimbursing for a fraction of the claimed cost.
Their faith is highest in medication and machines because of a fetish for determinism, and those well-industrialized tools aren't beyond the limited capacity of the corporate mind. But when faced with the mere notion of humans providing nuanced, bespoke, empathetic care to other humans, accompanied as it must be by an uncertainty that's vital to the progress of all life? The machine simply cannot compute.
posted by jerome powell buys his sweatbands in bulk only at 3:45 PM on August 26 [27 favorites]
Four therapists over the last four years. A total of eighteen over the last twenty-six:
“My position within our practice is transitioning into a managerial role and…”
“due to a romantic relationship with a patient I have decided to terminate my practice and return to psychiatric research and…”
“I am leaving my current practice to start my own and… (and bringing some of my patients with me (not you))”
“As I begin to prepare for retirement…”
[when I left Texas] “Unfortunately I’m not licensed to practice in Mass but I’ll submit the paperwork right away and…”
(Cut to five months later, after three calls and two emails to his office to ask if there were any updates went unanswered) “…hey so just FYI I’ve submitted the paperwork now and…” (eleven months of dead silence later) “so I’m sure you’ve found another therapist by now but I thought you should know that I am now licensed to…”
Christ it was like getting drunk-dialed by an ex. I did not reply with “Bruh, why are you even bothering?”
I also did not reply that I had not, in fact, found another therapist. Would not. Will not. What I had done was decide that the meme about men doing anything to avoid therapy was itself toxic bullshit dragging me down and it can fuck off into the sun. That whether because of the system or just a profession that starts with messed up kids trying to figure themselves out, the only thing I was accomplishing here was adding an entirely needless (and expensive) cycle of abuse to my life.
That I am tired - so very tired - of slowly pouring my entire soul out to strangers only to have them just walk away from me. Again and again and again. At least with dating you usually get laid a few times before they decide you’re too damaged to put up with (which is entirely fair).
I’m done. I am not at all okay and am in fact keenly aware that I still need serious, serious help but I am so fucking done. At this point it would require the therapy equivalent to that one scene from Team America “I Promise I will never die,” and that, my friends, is textbook delusional thinking. And possibly an abandonment complex created entirely by botched mental healthcare and an orphan-grinder insurance apparatus run amok.
posted by Ryvar at 3:59 PM on August 26 [18 favorites]
“My position within our practice is transitioning into a managerial role and…”
“due to a romantic relationship with a patient I have decided to terminate my practice and return to psychiatric research and…”
“I am leaving my current practice to start my own and… (and bringing some of my patients with me (not you))”
“As I begin to prepare for retirement…”
[when I left Texas] “Unfortunately I’m not licensed to practice in Mass but I’ll submit the paperwork right away and…”
(Cut to five months later, after three calls and two emails to his office to ask if there were any updates went unanswered) “…hey so just FYI I’ve submitted the paperwork now and…” (eleven months of dead silence later) “so I’m sure you’ve found another therapist by now but I thought you should know that I am now licensed to…”
Christ it was like getting drunk-dialed by an ex. I did not reply with “Bruh, why are you even bothering?”
I also did not reply that I had not, in fact, found another therapist. Would not. Will not. What I had done was decide that the meme about men doing anything to avoid therapy was itself toxic bullshit dragging me down and it can fuck off into the sun. That whether because of the system or just a profession that starts with messed up kids trying to figure themselves out, the only thing I was accomplishing here was adding an entirely needless (and expensive) cycle of abuse to my life.
That I am tired - so very tired - of slowly pouring my entire soul out to strangers only to have them just walk away from me. Again and again and again. At least with dating you usually get laid a few times before they decide you’re too damaged to put up with (which is entirely fair).
I’m done. I am not at all okay and am in fact keenly aware that I still need serious, serious help but I am so fucking done. At this point it would require the therapy equivalent to that one scene from Team America “I Promise I will never die,” and that, my friends, is textbook delusional thinking. And possibly an abandonment complex created entirely by botched mental healthcare and an orphan-grinder insurance apparatus run amok.
posted by Ryvar at 3:59 PM on August 26 [18 favorites]
Health Insurance is definitely near the top of the list of American Industries That Need Burned to the Fucking Ground.
posted by gottabefunky at 4:04 PM on August 26 [21 favorites]
posted by gottabefunky at 4:04 PM on August 26 [21 favorites]
*sigh*. We have therapists/psychologists for both our kids on the spectrum who have various therapy needs.
Good luck trying to find adolescent therapists/psychologists. An in-network one? *LOL* - not a chance. Oh and then throw in the fact the kids are at school so you are fighting for that elusive after 4pm slot with every other parent….or you have to basically take them out of school once a week for 90 minutes…..and then the school team is asking why you can’t schedule medical appointments out of school time…..and trying to make you feel like a shitty parent for doing it.
And no Aetna, picking a kid up at 3:30 from school and then driving them 90 minutes each way to a therapy appointment is not a “local provider”. It’s a failure of the provider network. Especially when all the truly local providers no longer take your insurance because you are screwing them on rates.
We just pay out of pocket now and Mrs Inflatablekiwi has managed to get single case agreement with one of the kids therapists. But honestly that must have taken her months of paperwork and effort.
Surprise - it sucks to be a parent.
posted by inflatablekiwi at 4:18 PM on August 26 [12 favorites]
Good luck trying to find adolescent therapists/psychologists. An in-network one? *LOL* - not a chance. Oh and then throw in the fact the kids are at school so you are fighting for that elusive after 4pm slot with every other parent….or you have to basically take them out of school once a week for 90 minutes…..and then the school team is asking why you can’t schedule medical appointments out of school time…..and trying to make you feel like a shitty parent for doing it.
And no Aetna, picking a kid up at 3:30 from school and then driving them 90 minutes each way to a therapy appointment is not a “local provider”. It’s a failure of the provider network. Especially when all the truly local providers no longer take your insurance because you are screwing them on rates.
We just pay out of pocket now and Mrs Inflatablekiwi has managed to get single case agreement with one of the kids therapists. But honestly that must have taken her months of paperwork and effort.
Surprise - it sucks to be a parent.
posted by inflatablekiwi at 4:18 PM on August 26 [12 favorites]
I remember this when I was on Tricare and almost no therapist would take it because its reimbursements were so low.
Part of the problem I also see is that the frequency and length of talk therapy necessary is really not desired to be reimbursed by insurance. Some people really need once a week for months or even a year or so.
posted by corb at 5:43 PM on August 26 [2 favorites]
Part of the problem I also see is that the frequency and length of talk therapy necessary is really not desired to be reimbursed by insurance. Some people really need once a week for months or even a year or so.
posted by corb at 5:43 PM on August 26 [2 favorites]
I've been looking into therapists for a few months. I have insurance - a high deductible plan since even that stretches my budget - and I've been able to build my HSA to a modest amount. Yet one thing I get hung up on is the whole insurance thing. There are therapists listed that take my insurance and that are accepting new patients. But I'll have to pay up to my deductible, something I've accepted. I can afford to pay out of pocket for a while due to the HSA. That, however, if it doesn't go through insurance, doesn't apply to my deductible and holy shit y'all, I'm already squeezed by my premiums and HSA contributions. If I'm not getting things applied to my deductible then I'm paying five figures a year in premiums for... what, again? At the same time, I cannot in good conscience insist on a professional working for me for peanuts. I don't want people doing that to me and I recognize the value of other people's work. I guess I'll figure this all out eventually. It would all be much simpler if it was worth it for therapists to take insurance and get reimbursed at a fair rate.
posted by azpenguin at 7:17 PM on August 26 [1 favorite]
posted by azpenguin at 7:17 PM on August 26 [1 favorite]
Is this better in Massachusetts? Or am I a unicorn? My family has plenty of the problems of finding folks for talk therapy, but dentists seem okay and never get problems getting therapy covered once we have a therapist. Town I love it subscribed to a service that found one of my family members last therapists and they are in network and great.
In any case let’s move to single payer or just nationalize all of it.
posted by creiszhanson at 7:21 PM on August 26 [3 favorites]
In any case let’s move to single payer or just nationalize all of it.
posted by creiszhanson at 7:21 PM on August 26 [3 favorites]
None of my son's therapists (he has three different ones) take health insurance. I spend a good chunk of time with health insurance claims. I totally understand why they don't take health insurance - the companies are a pain in the neck. If health insurance companies do not become more customer/client friendly, I can easily see more providers not taking health insurance and more people paying for healthcare out of pocket. I think Asian companies working in the USA just have their employees book medical appointments and they pay for everything out of pocket.
posted by ichimunki at 8:09 PM on August 26 [2 favorites]
posted by ichimunki at 8:09 PM on August 26 [2 favorites]
People often complain about why healthcare is so expensive in the US - having an insurance middleman who needs to make a profit is one reason - but the 5 people behind the reception desk in a medical practice who's sole job is to harass insurance companies into paying is another ....
posted by mbo at 9:23 PM on August 26 [9 favorites]
posted by mbo at 9:23 PM on August 26 [9 favorites]
If I'm not getting things applied to my deductible then I'm paying five figures a year in premiums for... what, again?
There's two scenarios for high deductible plans, either you normally hit your deductible or you only hit it in case of some big medical emergency. In the first case, then it's probably worth it to try to go through insurance. If you don't think you'll hit the deductible (which is my case), then it's probably not worth trying to get insurance to cover it for all the reasons in the article. That's what I decided to do, and I am paying for my psychiatrist out of my HSA. The value of my high deductible plan is that if there is a big problem I won't go bankrupt.
In either case, some good therapy is better than both no therapy and a lot of bad therapy. So, I personally would focus on who seems like the best fit for whatever you're looking for.
posted by JZig at 10:32 PM on August 26 [1 favorite]
There's two scenarios for high deductible plans, either you normally hit your deductible or you only hit it in case of some big medical emergency. In the first case, then it's probably worth it to try to go through insurance. If you don't think you'll hit the deductible (which is my case), then it's probably not worth trying to get insurance to cover it for all the reasons in the article. That's what I decided to do, and I am paying for my psychiatrist out of my HSA. The value of my high deductible plan is that if there is a big problem I won't go bankrupt.
In either case, some good therapy is better than both no therapy and a lot of bad therapy. So, I personally would focus on who seems like the best fit for whatever you're looking for.
posted by JZig at 10:32 PM on August 26 [1 favorite]
All the incentives for the insurance company are wrong. You may need to turn on auto-translated CC for this video https://www.youtube.com/watch?v=uqK-aZARkGM but it shows that it can be done right. This is about dutch health insurance companies funding free sun-screen devices near our beaches. Their incentive: prevent skin-cancer costs down the road for them.
Whenever you do get around to redesigning your health care system, remember this. Set it up so the incentive for the insurance companies is to prevent costs this way, and not prevent costs by simply denying.
posted by DreamerFi at 1:16 AM on August 27 [2 favorites]
Whenever you do get around to redesigning your health care system, remember this. Set it up so the incentive for the insurance companies is to prevent costs this way, and not prevent costs by simply denying.
posted by DreamerFi at 1:16 AM on August 27 [2 favorites]
I'm waiting for the Medical Insurance Industry to fund a Republican Presidential Candidate. For example Halliburton did pretty well at getting tax deductions for itself under George Bush.
With their public relations skills they'd be good at selecting a candidate who sounded working class.
posted by Narrative_Historian at 3:44 AM on August 27
With their public relations skills they'd be good at selecting a candidate who sounded working class.
posted by Narrative_Historian at 3:44 AM on August 27
I tried to find a therapist. Made many phone calls, easy 35+. About half did not respond at all; I left my phone # and email. A few wouldn't accept my insurance - Medicare. The rest said they had no openings.
Was waiting for a therapist opening at my doctor's office. Turns out they offer an initial screening, then 1/2 hour visits every several weeks. This is fine if you have a mild adjustment issue and need occasional check-ins, but is not a one size fits all approach. Except that's all they offer.
posted by theora55 at 8:45 AM on August 27 [2 favorites]
Was waiting for a therapist opening at my doctor's office. Turns out they offer an initial screening, then 1/2 hour visits every several weeks. This is fine if you have a mild adjustment issue and need occasional check-ins, but is not a one size fits all approach. Except that's all they offer.
posted by theora55 at 8:45 AM on August 27 [2 favorites]
There is a sort of gentrification of psychotherapy. Those rich enough can pay out of pocket to practitioners who don’t take insurance. Those with insurance can try to get someone who takes it, but good luck. And those without insurance? Maybe wait until you get arrested and jail psych services can take care of you.
posted by larrybob at 10:45 AM on August 27 [4 favorites]
posted by larrybob at 10:45 AM on August 27 [4 favorites]
Lots of doctors don't take insurance. And if they could afford to stay in business while doing it, no doctor you've ever seen in your life would take insurance either.
The reason that so many therapists don't take it is that normies can just afford to pay the full $200/hr, or maybe they have coverage that pays 70% for out-of-network coverage.
Most other doctors take insurance because the pool of potential customers who could afford the jillion dollars it actually takes for a full cardiology workup is too small to be sustainable.
posted by Back At It Again At Krispy Kreme at 1:48 PM on August 27 [1 favorite]
The reason that so many therapists don't take it is that normies can just afford to pay the full $200/hr, or maybe they have coverage that pays 70% for out-of-network coverage.
Most other doctors take insurance because the pool of potential customers who could afford the jillion dollars it actually takes for a full cardiology workup is too small to be sustainable.
posted by Back At It Again At Krispy Kreme at 1:48 PM on August 27 [1 favorite]
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