For many in the U.S., it can be difficult to find a mental health provider that’s covered by insurance. But many mental health clinicians say insurance companies can make it difficult to be a part of their network. They say companies have “clawed back” payments from therapists or questioned a patient’s need for services.
Health care reporter Annie Waldman, along with a team of other ProPublica journalists, reported on why therapists leave insurance networks. The story was also co-published with NPR.
Melissa Todd, a licensed psychologist practicing in Eugene, said she left an insurance network after feeling pressured to limit a patient’s care.
We hear more from Waldman and Todd on what providers have experienced and what mental health care looks like in Oregon.
This transcript was created by a computer and edited by a volunteer.
Dave Miller: From the Gert Boyle Studio at OPB this is Think Out Loud. I’m Dave Miller. According to the federal government, more than half of Americans live in places defined as mental health professional shortage areas. But that’s not the full extent of the crisis in mental health care. Plenty of Americans cannot access that care not because of a shortage of providers per se, but because they can’t find a provider who will accept their insurance. So healthcare reporter Annie Waldman, along with a team of other ProPublica journalists reported on the experiences of more than 500 psychologists, psychiatrists, and therapists who chose to leave insurance networks. These providers cited low reimbursement rates, onerous and ever-changing red tape, and coverage restrictions that can lead to delays or denials of service.
Annie Waldman joins us now, along with one of the therapists who was interviewed for the story: Melissa Todd is a licensed psychologist in Eugene with a PhD in counseling psychology. Annie Waldman and Melissa Todd, welcome to Think Out Loud.
Annie Waldman: Thanks for having us on.
Melissa Todd: Thank you, Dave.
Miller: Annie Waldman, first – why did you set out to do this reporting?
Waldman: So in the most simple terms, my colleagues and I really wanted to understand why is it that when you have insurance, it can be so hard to access mental health care? And when people can’t access care, we all know that the consequences can be devastating, which is why we heard such a high level of frustration from so many people we spoke to, patients and families. But what many people don’t realize is that insurance companies play such a big role in this.
So as you mentioned, we interviewed hundreds of therapists who told us about how unsustainable and challenging it is to work with insurance companies. And what these conversations really revealed to us was how the nation’s insurance companies have really taken on a huge role in mental health care. What we heard is that it’s often the insurers, and not the therapists, that determine who can get treatment, what kind of treatment they can get, and for how long. Many therapists are deeply committed to their patients and to access like you talked about. But so many told us that the practices of insurance companies are pushing them out.
Miller: Do you have a sense for the percentage of Americans who have insurance but don’t have access to mental health care?
Waldman: Statistics show that almost all Americans are now insured with the ACA, or the Affordable Care Act, or through expansions of Medicaid programs. But about half of people with mental illness are still unable to access treatment. And my colleague Agnel Philip analyzed federal survey data for our project. And he even found that people are more than twice as likely to pay their full bill out of pocket for visits to mental health providers, compared to visits to primary care physicians. So when you look at this data, it really shows that there’s an urgent crisis going on when it comes to mental health care.
Miller: Melissa Todd, I wonder if you could tell us the story of what this meant for you in the care of one of your patients in particular – a patient whose name is not in the article and we needn’t worry about – whose story you told for this reporting, somebody who was diagnosed with bipolar disorder.
Todd: It was around 2016, 2017 that I was working with this client. And as I think a lot of people are aware, bipolar disorder is a mental illness that tends to be chronic and lifelong. And the hope in treating it is that over time, through a combination of therapy and medication, that we see a general improvement, and we see that person’s care needs decrease over time.
However, this person had UnitedHealthcare insurance. And very soon after we started working together, within six months or so, I received an inquiry from the insurance company saying that they wanted to review the case. And since I had been working with this insurance company for about a year, I was familiar with their pattern, that they conducted reviews probably about six months into any longer-term therapy where you met with a client more than 20 times in that six month period, which actually amounts to less than one time per week.
I went through, through this review, and was passed. But then shortly after, maybe two months later, I received a second notice that I was being reviewed again. And I was a bit confused, because I thought this was only going to happen about once every six months. And then the second review ended up being quite adversarial. I tried to push back when I was pressured to give an end date for when this person would no longer need treatment. I explained that this was a chronic mental illness, and that it was hard to say, but that the general trend would be for this person to need less and less care over time.
I was elevated to a peer review, which felt intimidating, and even punitive. And luckily for me, I encountered a psychologist who was quite sympathetic to my situation with this client, and supported our continued treatment, but informed me that I would expect further reviews on this case, and any other case that I was working with that was chronic and more severe.
And so I had to make a very difficult decision. I have a really strong value to work with insurance companies to increase access to care. I want to partner with insurance companies, I want to be in-network. So to find myself in this really difficult situation where I had an insurance company interfering with the care that I was providing, it was a real values conflict. And I made a very difficult decision to leave the network and move toward my value of being able to provide appropriate care to my clients.
Miller: Can you give us a sense for either the explicit or the implicit messages that you were getting when you would do those reviews? I’m wondering [about] the messages you were getting from the insurance company, when they were questioning the need for coverage for this client.
Todd: And again, this happened not just with this client. The message that I was getting was that I was walking a very, very fine line. They wanted to hear from me that the treatment I was providing was working, which is understandable. They wanted to hear that the person was making progress, that I had a treatment plan and there were markers of progress. However, when they hear that a person is making progress, then the conversation switches to “OK, when will they be finished? When will you be able to see them less frequently?”
Then, in order to walk that fine line, they also want you to demonstrate that the person has ongoing needs for care, their symptoms are sufficient to warrant the care that they’re receiving. And so you have this narrow line where yes, we’re making progress, and also this person’s current symptoms warrant continued care. This is also dependent on the diagnosis, treatment and the course of treatment. And prognosis may look different for somebody who has generalized anxiety disorder versus somebody who has bipolar disorder. And I didn’t feel like that was taken into consideration.
I felt pressured to give end dates every time I went through these reviews. And I knew that if we didn’t make the end date, that I would be up for another review, and I would have to explain at that point why we were not done with treatment at this particular end date. One of the challenges when treating mental health is that it’s different than physical health. The mind and the body are all part of being a human being, but we don’t have the ability to look into the mind in quite the same way as we do the body. And so while I also strongly believe that we need to treat mental illness the same as physical illness in terms of coverage, there are nuances, differences in how we approach that treatment.
I would draw a similar parallel to a chronic illness such as diabetes or somebody who has heart disease or a congenital condition physically. The expectation is that that person is going to need lifelong treatment, but that lifelong treatment is to look different depending on how that person is doing. And the same parallel can be drawn to mental health, in my opinion.
Miller: Annie Waldman, you and your team wrote that more than a dozen therapists said insurers urged them to reduce care when their patients were on the brink of harm, including suicide. What options do therapists have if they’re getting that message from insurers?
Waldman: As you mentioned, the consequences of this can be absolutely impossible for so many people to overcome. And as we just heard from Melissa, therapists are put in this position often where they have to choose between their internal values and working with the insurance company. And that is an unfortunate balancing act that we put upon so many mental health providers in our society who are signing up to be caretakers of us. We heard similar stories to what Melissa told us. 44 people actually told us that they had similar experiences where they left insurance networks after insurers questioned the necessity of their care.
And this is something that insurance companies frequently fixate on. There’s this term, “medical necessity.” And insurance companies use it a lot to deny claims. Many people assume that if your mental health provider believes that you need a certain type of treatment or length of treatment, they are the expert and should have the final say. But we actually found that’s not entirely true. In fact, insurance companies face few limitations on how they define what’s medically necessary. They also even create their own internal standards instead of relying on ones developed by nonprofit professional medical societies or experts. And these standards can be used to challenge diagnoses or treatment plans, which can lead to denials of care.
There is, again, this question that we have in our society, which are we going to support those mental health providers who are out there in the trenches providing the care that so many Americans need? And how are we going to balance that with the needs of our insurance system?
Miller: So we’ve been focusing first on restrictions on coverage, but that’s just one of the areas that you heard about from health care providers who have left various insurance company networks. What did you hear from them about both the challenges of getting reimbursed, and then just reimbursement rates themselves, assuming that they can get that money?
Waldman: To start with reimbursement rates, we spoke with over 130 providers who said that they left insurance networks because of low reimbursement rates. We heard from them that reimbursement rates have been stagnant and notoriously low, and have barely shifted in years. And I think that we frequently forget that even if the dollar amount per hour seems like a lot for us as patients, that’s actually covering the overhead of running an entire higher practice, including your therapist’s own malpractice and health insurance, their billing and their administrative services, their office front, their utilities. Insurers are only paying for that time in session, but what we’re not seeing when we pay that hourly rate is the documenting of notes or the chasing down of payments.
And that’s another thing that we heard as you mentioned, that therapists are having to chase down the payments from the insurance companies. Sometimes it can take hours and hours of waiting on hold or making dozens and dozens of calls, waiting months until you get payments. And that can often mean that therapist is spending that time chasing down the insurance company to get paid instead of helping people in the therapy chair.
With the combination of the low reimbursement rates and the red tape, it is just squeezing providers out of these insurance networks.
Miller: Melissa Todd, can you give us a sense for what that red tape was like, what you had to navigate? I suppose you still do have to navigate, because even though you’ve left UnitedHealthcare, you still are a part of other insurance networks.
Todd: It’s interesting because it’s a moving target that has changed over the years. When I was trying to verify when I actually left UnitedHealthcare, I dug up a letter that I sent them when I decided to terminate, and it was actually four pages long. I was actually surprised that I had written this four-page-long letter, and who knows how many hours I spent doing that. And I outlined all of the difficulties that I had with them since I started working with them.
Without getting too much into the weeds, there are so many things. And what we find is that certain insurers are the worst offenders, there are multiple problems with certain insurers. And then there are some insurers that are better to work with and easier to work with, and we don’t quite see these issues.
But chasing down payments is something … One of the trends that we’re seeing nationally is a thing called repayment reviews, where certain insurers, UnitedHealthcare being one of the main ones, are asking therapists to send records every time they submit a claim. And then they are allowed to withhold payment while they are allegedly reviewing these records. So they’re reviewing the records to see whether they’re going to pay you. And they apparently can hold on to your payments as long as they want to.
And while they’re reviewing your records, they might decide to claw back payments that they already made to you. And clawbacks is another thing that we’re seeing an increase in nationally, we’re starting to see it here in Oregon as well. A clawback is when an insurance company says we’re going to take back money that we paid you for past services because we didn’t like something in your records. And it isn’t what you think it would be, it isn’t that they didn’t think it was medically necessary. It’s things like clerical errors. “Oh, you didn’t properly document the start and stop time of your session.” “There’s a coding inconsistency.” And so then you’re having to file an appeal and write letters, make phone calls, send emails. For some of these insurance companies, the burden is so great.
And one of the other things that I want to point out that’s unique about mental health providers is that a lot of us are still independent. We are solo practitioners. I’m a one woman show. I do everything for my practice. And so there’s just a lot of pressure being put on providers. And really what it is is a way to limit treatment. It’s a way to limit mental health treatment by squeezing providers. Because due to the laws and due to all of the wonderful attention that is on mental health, they can’t really squeeze patients directly anymore. So squeezing the providers is a way to limit mental health treatment, and to essentially discriminate against people who have mental health issues.
Miller: Annie Waldman on this note, I thought that the 2008 version of a federal mental health parity law – and behavioral health as well – was supposed to address these issues or many of these issues. So does your reporting suggest that the law is not being followed? Or that there are big loopholes in it?
Waldman: Yeah, that’s a great question. You’re right, the Mental Health Parity and Addiction Equity Act passed in 2008. And that means insurance companies are supposed to be providing the same access to mental and physical health care. But what we found is that this idea of the law, and it was just actually recently updated last week by the Biden administration, it doesn’t really match up with the experiences that we heard from therapists or analyses by policy experts and mental health advocates, who have found that there are huge gaps in parity. There have also been several lawsuits against insurance companies for failing to provide adequate coverage, and state regulators in the Department of Labor, they’re starting to do more in recent years in terms of holding insurance companies accountable. But our reporting found that these issues continue.
Miller: Annie Waldman and Melissa Todd, thank you very much for joining us.
Waldman: Thanks so much.
Todd: Thank you.
Miller: Annie Waldman is part of the reporting team that wrote about the reasons that mental health care providers are choosing to leave insurance networks. The team wrote about this most recently for ProPublica and NPR. Melissa Todd is one of the people that they interviewed. She is a licensed psychologist practicing in Eugene.
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