F.A.Q.'s

Insurance companies are forced by law to provide mental health counseling services, but not what they pay therapists/counselors for those services.  The industry as a whole does not value mental health counseling and their payment rates to therapists/counselors demonstrates that.  They pay about 50-60% of what therapists/counselors in a market charge for individual sessions, and only about 40% for couples sessions (if they will even cover couples sessions for the reasons a couple comes to counseling), even though couples counseling generally is much more complex than individual counseling.

When a mental health provider directly bills your insurance for counseling or psychotherapy services, your insurance requires a lot of personal information about you to ensure that you have a “medical necessity” which requires the need for mental health and counseling services.  “Medical necessity” means that you have a mental health diagnosis that is severe enough to be impacting your daily functioning, meaning your ability to get your day to day things done (e.g. work, school, social interactions, activities of daily living such as bathing, eating, etc.). This means that a therapist directly billing your insurance needs to make a strong justification for what your diagnosis is and how it impairs you from being a functional individual.

Insurance doesn’t reimburse for “marriage therapy” or “I’m having a hard time” or even “grief”. It is a medical model, and so this means that payment can only be for a diagnosis. This means that (even in family therapy) one person must receive a label. And these labels will be part of your official record, permanently. This might never matter to you. If you are one of the fortunate ones who has medical, life and disability benefits through your employer… you might never worry about this. But if you’re someone who might ever be unemployed, self-employed, or need to purchase your own benefits- a mental health diagnosis can make the difference between preferred coverage or none at all.

Most insurance requires some sort of treatment plan to be submitted by in-network providers. This means that (rather than giving you the care that best fits your needs) the therapist is responsible to the claims representative (usually a non-mental health professional) for how you spend your time. To put it simply, an in-network therapist works for the insurance company, not you. It doesn’t matter what you and your therapist decide is in your best interest, it needs to fit their matrix of decisions. It also must fit within the allotted sessions which are determined ahead of time, not based on need.  Also, this treatment plan becomes a part of your permanent record with the insurance company.

Your insurer can audit your records at any time they wish. This means any details that your therapist might not have included in the paperwork (perhaps for good reason) is technically open to the eyes of any “claims specialist” the company hires. Again, this might not matter to you. But if you hold high clearance for a job or have other reasons you want your information to be held confidential, this is important to know.

“It is often the insurers, not the therapists, that determine who can get treatment, what kind they can get and for how long. More than a dozen therapists said insurers urged them to reduce care when their patients were on the brink of harm, including suicide.”

Learn more here: https://projects.propublica.org/why-i-left-the-network/