A number of blog posts have appeared on the Internet encouraging consumers to not use their health insurance to pay for mental health care and to avoid psychotherapists who accept it. There appears to be an undercurrent of disdain in the profession for insurance plans and carriers and I believe these opinions are fueled by ignorance and scare-tactics. Further I believe there is an effort on the part of clinicians to convince consumers to make a decision that is more beneficial to the cash-only clinician than to the consumer seeking care.
Here are my rebuttals to the arguments made in favor of the cash-only private practice:
Mental health care paid for by insurance reduces costs for the client.
Employer-sponsored health plans have part of the premium paid by the employer. Exchange-based health plans can have the premium subsidized with federal contributions. When the client comes to a session, they pay only their copay (if any), which is much less than what would be charged by the cash-only practice. The balance of the contracted rate is picked up by the health plan. Cash-only therapists want to focus their attention on helping people, not cranking out forms so they can get paid. It’s pretty self-centered!. Health insurance therapists consider the financial well-being of the client as well as their practice.
Mental health clinicians who accept health insurance are at least as good as their cash-collecting colleagues.
An argument oft read is that mental health clinicians (psychotherapists) who accept health insurance are of questionable or poor quality. This argument contends that a psychotherapist falls into one of three categories:
- New to the profession (just got their license and starting out),
- New to private practice (experienced, yet trying to establish their reputation in the community), or
- A poor quality clinician (needing the help of a health plan to fill their calendar because word-of-mouth is not working favorably for them).
In short, better quality therapists don’t take health insurance because they don’t need to (they’re just that good!). Consider this:
- If a clinician applies to join a health insurance panel, the application process requires them to be credentialed. This means their entire educational and professional history is substantiated and verified. In a cash-only practice, all you know about that clinician is what they tell you.
- Clinical specialties do exist on health insurance panels and health plans will verify the credentials of anyone claiming a specialty. For example, if someone claims to be a certified SUD (substance use disorder) professional, they must provide a copy of the certification, which is then validated.
Mental health clinicians who accept health insurance will likely keep better records.
- If a clinician receives a clinical review of records from the health plan (a process by which the plan authenticates the clinician’s work with the client), they must be expected to answer these 4 basic questions:
- What is the client’s diagnosis?
- How did the clinician arrive at that diagnosis?
- What is the treatment plan for that diagnosis?
- How much time is needed to fulfill the treatment plan?
Clinicians who do not keep good client records will find it arduous to answer these questions, so to avoid maintaining accurate records, cash-only clinicians will avoid health insurance panels. Ask your cash-only therapist to provide you a copy of your history in treatment. Your hope is that they have something on file to offer!
- Clinicians who accept health insurance will maintain accurate financial records. They must collect copays from the client, bill fees to health plans, receive payment advice, and ensure payments are deposited in their bank account. All this must be accurately tracked! A cash-only clinician will maintain just enough information to note that they’ve been paid for the last session, but if they make a mistake, who is to be believed that the payment was properly recorded, especially if it was in cash? Did you get a receipt?
Mental health clinicians who accept insurance maintain client confidentiality just as effectively as, or better than, their cash-only counterparts.
- Practices based on health insurance feel accountable to the health plan, therefore they have heightened awareness of HIPAA rules pertaining to securing client documentation and sharing protected health information with others. A clinician can’t simply attach client information to a Gmail message and send it out into the wild! That information must be encrypted! How do health plan clinicians know this? Because anything they receive from the health plan will come in an encrypted format! Health plan clinicians simply respond in kind.
- One fear that cash-only therapists perpetuate is that your mental health diagnosis and treatment will become a permanent pre-existing condition on your health record, which could limit your ability to get something you want in the future. What a shameful scare-tactic! The Affordable Care Act (ACA) pretty much made the use of pre-existing conditions a thing of the past. Besides, health plans have all sorts of procedures and protocols in place to secure a client’s protected health information, so there needs to be a legal release of information to access it.
- Some clients prefer the cash-only practice to ensure there is no record of their mental illness or ever having seen a therapist (and that’s not shady because…?). Fine. But what if there is a need to prove you’ve been to therapy, like to a judge? If there are no records, when did you start therapy? How many sessions have you attended? Was your attendance consistent? What progress have you made? Yup, nothing to subpoena there.
- Cash-only therapists often argue that once a health plan has the claim form, all control over the medical record is lost. The reality is that when a claim is submitted, the only information that the health plan receives is a diagnosis code and a treatment code. This information is strictly maintained in a system fraught with accountability that is secured and protected. Interestingly, consumers are less worried that the plan receives claim information from their MD for a sexually transmitted disease as long as the treatment is paid.
Mental health clinicians who accept insurance cannot have long wait times between sessions.
Cash-only clinicians want consumers to believe that health insurance clinicians are so overbooked that they take forever to schedule appointments. It’s a myth. Every year, I receive a survey from each health plan asking how long my wait times are for emergent, urgent, and regular appointments. An emergent appointment request must be scheduled within 24 hours. An urgent appointment must be scheduled within 72 hours and a regular appointment must be scheduled within 10 days. If I can’t meet that, I must inform the health plan accordingly. Where did this myth come from? A few years ago, Kaiser-Permanente in California was taking more than 30 days to schedule subsequent therapy appointments for their members and was lying about it to the California Dept of Managed Healthcare! They paid a huge fine and with pressure from the National Union of Healthcare Workers, Kaiser finally started outsourcing psychotherapy to other health plans. Yes, there was a time when Kaiser had long wait times between psychotherapy appointments, but those days are largely in the past.
So the consumer can see that the cash-only private practitioner is propagating ancient history and myths in an effort to misinform and coerce prospective clients to choose their businesses. Further, they avoid recordkeeping and any form of accountability in their practice all in favor of collecting a higher fee (ask a cash-only therapist what happens if you cancel your appointment within 24 hours of the scheduled date–health plan therapists can’t do it). As a consumer, you have already paid a health insurance premium and your plan is required by the ACA to include mental health care as one of your benefits. Use your health insurance to pay for your psychotherapy. You’ll save money in the long run and the care you receive will be of high quality and effective.