August 18, 2017

Fees and Insurance

“There are many ways of going forward, but only one way of standing still.”

~ FDR


Three Reasons Why I Don’t Accept Managed Care Reimbursement for Mental Health Services
Reason #1: Lack of confidentiality.All managed care plans (MCP’s) involve direct clinical management by the plan’s case managers. If you access therapy through your MCP, it makes it necessary for your psychologist to disclose anything and everything related to your case to your MCP.This information is used by the MCP for determining benefits, which they allocate at their own discretion. This impacts your right of confidentiality, and it is possible that your information will be stored in a computer system which could be accessed by anyone.The FBI and law enforcement officials can access your insurance information at any time. This information could be used to your disadvantage should a legal problem arise.Furthermore, this lack of confidentiality could impact your minor children even more negatively. Should they ever desire to apply for certain jobs or educational programs, such as law enforcement or the military, the information in their insurance files could be used against them.


Reason #2: Difficulty getting treatment authorized.

Due to the direct care management by MCP’s and their desire to keep costs to a minimum, getting therapy sessions authorized often becomes cumbersome and time consuming. Every plan has different requirements and standards for authorizations. Usually they require many hours a week of paperwork and phone calls by the psychologist in order to get authorizations. Some will deny therapy in lieu of taking prescription medications.

MCP’s allow certain number of treatment sessions per year for each plan. Let’s assume your MCP allows up to 20 sessions per year of outpatient psychotherapy. This does not mean you can automatically access your benefits. Often you first have to be referred by a primary care physician member of the MCP. Then you may have to go through a phone interview with an MCP case manager. Then you may have to contact several plan providers to find one who is accepting new patients, who has a convenient location, or who has expertise in your issues. Once you have found a provider, there may be a long wait for an appointment due to pre-authorization requirements. Then you are often given only one to three sessions to start (50 minutes a week – though you may feel you need more), as an assessment. Then you may need to wait for more visits to be authorized – often weeks of phone calls and paperwork flow back and forth between your provider and the MCP. Then the MCP may only authorize three sessions at a time, with this continual waiting period in between. This causes your treatment to be inconsistent, broken up, and can cause you more anxiety not knowing if you will in fact get your benefits authorized at all. Some patients give up on their treatment due to these frustrations.

Furthermore, some MCP’s want to control the treatment plan. Some will even dictate the specific treatment plan, which is often very subjective and may even be anti-therapeutic. Some plans will determine when it is time to terminate treatment, even when the patient continues to be in distress, or their problem has not been sufficiently solved.


Reason #3: Misdiagnosing and/or over-diagnosing in order to get treatment authorized.

Some MCP’s will not cover treatment unless it is a “medical necessity.” This may mean the patient has to “pretend” they are “sick,” or worse off than they are in order to receive their benefits.

Most MCP’s do not cover therapy or psychological issues such as marriage or family counseling, adjustment reactions, or personal growth.

This situation puts both the psychologist and patient in a negative situation. Often the “assessment” sessions that are initially authorized are not sufficient to give an accurate diagnosis, yet the MCP will not authorize more visits without one. The therapist may be inclined to “make up” or “guess at” a diagnosis, which is not in the best interest of the patient.

Most importantly, you, the patient, should not be given a mental illness diagnosis that is not correct, or is more serious than what is true, simply to

get treatment paid by the MCP.

© GROW Publications
Reprinted with permission
of the author

In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. However, you (not your insurance company) are responsible for full payment of my fees.

Professional Fees

My fee is $150 per 50-minute session. In addition to regular appointments, I charge this amount for other professional services you may need, though I will break down the cost if I work for periods of less than 50 minutes and more than 10 minutes. Other services include extended telephone conversations with you, attendance at meetings with other professionals you have authorized, verbal/written interactions with third parties (i.e., insurance company), and the time spent performing any other service you may request of me.  Charges for these services will be agreed upon, at least verbally, either before or during provision of the services.

You are expected to pay for each session at the time it is held.  All fees will be your responsibility to pay.  In addition, you will be responsible for filing any claims with your insurance company.  You will be provided with a receipt for insurance purposes whenever you request one.

Insurance Reimbursement

For several reasons, I have decided to be an out-of-network provider for all insurance companies. I am not on the provider panels of any insurance companies.

It is very important that you find out exactly what mental health services your insurance policy covers for out-of-network providers.  You should carefully read the section in your insurance coverage booklet that describes mental health services.  If you have questions about the coverage, call your plan administrator.

Please note that, if you contact your insurance company with coverage questions, they may tell you that I am a covered provider under your plan. THIS IS INCORRECT. This confusion arises because I am an in-network provider for my work at the Norris Cotton Cancer Center through Dartmouth-Hitchcock Medical Center. Through my private practice, I am not on any provider panels, and as such, it is important that you ask about your out-of-network benefits, as that is what your insurance company will reimburse you for your therapy with me.

If you do decide to use your out-of-network mental health benefits, please consider carefully what this may involve. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While a lot can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end.

You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it.

Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end our sessions. It is important to remember that you have the right to pay for my services yourself to avoid the problems described above.