Why Is It So Hard To Find a Therapist In-Network (INN)?
My hope is that this information helps clarify the complex world of insurance via managed care organizations. This post is written specifically for a person who wants to use their insurance for therapy, and I believe the information may be useful to providers thinking about working with insurance as well!
A contact living in California recently asked me to help them find a therapist. This contact preferred to use insurance, but after doing their own research and coming up empty-handed, was open to self-paying for the right fit. After some brief googling, I discovered that a majority of therapists in California, especially in major metropolitan areas, are out-of-network (OON) with insurance.
Where I am located in the Hampton Roads, the majority of private and group practices accept most major insurances, so I found it curious that these therapists in California seem to be making an income just fine as OON.
First, some brief, watered-down, background information on insurance
Insurance is marketed as something that will save you, the customer, money. You see a doctor or behavioral health therapist who is in network (INN) and will see you at the insurance “discounted” rate. For example, a self-pay fee to see a therapist for an hour of therapy may cost $150, and your insurance has negotiated a “reasonable and allowable” amount for the therapist to instead accept $90 for that same hour of therapy. The terms in quotes merely emphasize the marketing language aimed toward you, the customer.
It is unclear how insurance determines what is a “reasonable and allowable” charge. To establish these “discounts,” insurances may consider inflation, standard of living costs, and the amount of providers located in a certain area. Some insurances will base their “discounted” rates on what state medicaid is paying providers.
Objectively it looks like the “discount” is saving you, the customer, so much money!
Another way of looking at these discounted rates is that INN providers get paid less for the work they do. To compensate, mental health agencies, private practices, and even hospitals will demand their employees to see more patients (more than is sustainable) to make a reasonable living and, of course, to turn a profit. I would even go so far to say these discounts may be one of the reasons therapists who accept insurance are more likely to get burned out.
The reality of the situation lacks transparency and accountability on the end of major private insurance companies. As a therapist working to be in network with a select few insurance companies, I am left overwhelmed and confused with what determines a “reasonable and allowable” charge.
What it means to be in network as a provider
Privatized insurances that are not medicare or medicaid are also known as managed care organizations (MCO). Managed care in general means that insurances check to see if you indeed hold a valid, unrestricted license to practice. Managed care also means that once you are in network, insurance companies have to make sure that you are providing “value-based care” and quality care to their insurance members.
What this really means is that they will periodically do chart reviews and audits to make sure providers are showing, via chart documentation, that they are doing what they are supposed to be doing. Chart reviews in theory are great to hold providers accountable. Chart reviews are also an opportunity for insurances to “claw back” money they originally paid a provider for some arbitrary reason. More on “claw backs” later.
In order for a provider to get paid for services rendered to insurance members, providers have to file a claim with insurance companies. The process to fill out these claims have become so complicated and convoluted, to the point that a provider may spend countless hours of unpaid administrative time filling out forms such as the CMS-1500 and still get a claim rejected for various reasons.
Insurance may deny to pay an INN provider for a therapy session for all sorts of reasons such as:
45 min sessions are authorized while 60 min are not
Only covering individual and group counseling, not couples counseling
Only covering select diagnoses in the Diagnostic and Statistical Manual (DSM), thereby determining that services are “medically necessary.”
These means if an insurance member does not meet full criteria for a diagnosis, insurance may not cover services at all even if the insurance member has autonomously sought out therapy services for a specific reason, like relationship issues, or adjusting to a major life change.
Only covering certain forms of therapy
for example, one insurance in the Hampton Roads area will not cover art therapy in an outpatient office setting, only in facilities that qualify as residential, inpatient, intensive outpatient, and other hospital settings.
Only covering one type of service per day
If an insurance member gets discharged from a hospital after being stabilized for suicidal ideation, they cannot continue mental health services at an outpatient office setting until the next day.
At this time insurance will not cover two hours of therapy in one day, regardless of the insurance member’s temperament, ability to be vulnerable with the therapist, and the time it takes to regulate behavior and emotions after experiencing psychological distress in session.
On top of claim denials, some insurances, especially the bigger company ones, will erroneously pay INN providers, such as:
losing the claims entirely
this puts the burden to get paid on the INN provider to resubmit the claim and follow up with the insurance company, which could take weeks to months to resolve
paying more than the negotiated contracted rate
paying less than the contracted rate
taking months to pay a claim (there are state insurance commissioners to help prevent this from happening)
Even more, insurance companies will “claw back” money from an INN provider who submitted a claim and got paid successfully. Claw backs:
are arbitrary and nefarious
lack accountability, transparency, and regulation of the insurance company
can be for claims submitted months to YEARS prior.
And those discounted rates (that have a chance get clawed back) AKA the “reasonable and allowable” charge that the provider agreed to accept to be INN with insurance rarely has the opportunity to be negotiated. Private insurances may or may not proactively increase the rates (to thereby pay the provider a more “reasonable and allowable” amount for services rendered) leading a lot of INN providers to feel taken advantage of and powerless. Many providers choose to leave insurance panels or avoid them altogether, understandably.
So now you mostly know what INN providers are dealing with on their end.
It is no surprise then, that a therapist chooses to be OON to avoid the hassle, lack of transparency, potential loss of income, and unpaid admin time managing the managed care organizations! OON providers can instead spend more time focusing on providing quality care to their patients because they do not have to worry about insurance.
The good news is you are still able to see a therapist who is OON, and your insurance will reimburse you directly for seeing them. More on this in a future blog post.
Insurance at Coastal Art Therapy Services
We are INN with a select few insurances in order to increase accessibility to art therapy and mental health services in the Hampton Roads community and Virginia at large, and also to be mindful of the demands and impact being INN has on our providers and employees. To see what insurances we are paneled with, check out our FAQs here when you schedule a new patient appointment, or on our home page.
