1. Clawbacks or Retroactive Claim Denials:

Insurance companies have become notorious for this even several years after a session/therapeutic services were completed.
In fact, I am presently dealing with this with sessions as far back as January 2018!

What this means is that they re-audit insurance based claims and unilaterally decide to take back payment from the therapy provider.
Should they think you had additional coverage with another insurance provider at that time, determine that your therapy was not clinically or medically necessary or preauthorized (even when they told you it wasn’t required) they can retroactively take money out of my future payments or send me a bill for massive amounts of money that must be paid back within 30 days or interest based penalization sets in.

Over the past few years, this has happened to me several times totaling thousands of dollars having to be paid back and many hours of my free time trying to fight this process.
This means that what you thought was covered would now be owed to me out of pocket by you.
Of course, the first response you would have is to be pissed off at me ( or whatever therapist you are seeing) because you were told that your services were covered.
However, contractually by your insurance company, you would be legally liable to pay me should this happen.

Please think about it from our perspective as your therapist who has rendered hours of therapeutic services for you, under the assumption that your insurance would cover and was told there was no issue with billing or payment, for years.

Now imagine getting paid by your job and then 6 years later, they come after you to get your salary back and then tax you if you don’t pay it back within 30 days.
The accounting and tax implications alone are a pain in the butt.

Insane huh?

2. Misinformation Given To You About What Is and Isn’t Covered:

Did you know that if you ever used your medical insurance for individual, family, couples, or relationship counseling  someone was given a clinical diagnosis on their record? 

I am finding that many of the people who call me have no clue and that this can be both an ethical and legal issue.

We all pay a great deal for health insurance, and we all want our insurance providers to cover the maximum amount of services that we are entitled to. The services we as therapists provide you should not only be accurately stated, but it should reflect what services the therapist is actually providing.

Most insurance companies provide coverage for certain diagnoses and exclude other conditions.
Therapists may not submit false diagnoses or exaggerate their clients’ problems in order to gain coverage or ensure continuation of coverage. 

In other words, they can’t make stuff up to get paid by your insurance company. You could have called your insurance company and been told something along the following “A quote of benefits or authorization does not guarantee payment or verify eligibility. Payment of benefits are subject to all terms, conditions, limitations, and exclusions of the member’s contract at time of service.”

I was on the phone once with an insurance company with the client in my office who said ” couples counseling is covered on your plan but it’s up to your practitioner to provide a diagnosis that qualifies for treatment”.

I have received multiple subpoenas over the years that I had to quash with my attorney due to a client being sued and opposing counsel was trying to use their private medical history against them. One subpoena had a list of over 35 different medical professionals. This means your private insurance information, diagnosis and case notes can potentially be used against you if the attorneys find a way.

By “claiming” you are anxious, depressed, or have an “adjustment disorder” in order to provide help for your relationship or even your individual sessions to qualify for ” the discounted fee one pays under mental health insurance” may have serious implications to your life later down the road. 

Accepting a diagnosis of a clinical mental disorder should be taken seriously. And you should know when you are given one if you do qualify from the professional you are working with.
However, that takes a comprehensive conversation that takes into consideration present and past history and meeting certain criteria over a period of time.

Many times I bill under an “Adjustment Disorder” or what I like to call the most generic diagnosis that doesn’t seem to have the most implications.
I jokingly called it the diagnosis equivalent of getting a pair of Khaki pants from The Gap, it kinda goes with everything.
Also, many times people just need some simple guidance, direction or a sounding board and aren’t coming for significant emotional distress.
These consultations or coaching sessions are not ever covered by insurance. 

However, the diagnosis “Adjustment Disorder” cannot be used for longer than 6 months after the initial incident that you are seeking therapy for and then must meet criteria for another major clinical mental health diagnosis to continue services. Many insurance companies do not hold to that and allow it to be billed for many months or even years. This leaves the provider/therapist again in a very tricky ethical and legal place. Remember, if they find that your diagnosis didn’t progress into one of a more clinical concern, they can ask the provider to terminate sessions or attempt to recoup payment for already rendered services. 

Your health insurance benefits are limited to treatment that is considered a “medical necessity” or that is considered meeting full criteria for a psychological/psychiatric diagnosis as met by standards of the Diagnostic Statistical Manual.  All insurance based sessions require a CPT (Session Identifier Code) and a Diagnosis Code ( which a client needs to meet clinical criteria for). 

CPT codes include:
90791 Intake/Initial Session and can only be billed by a provider once annually.
90834- 45 Min individual session
90837- Up to 60 Min sessions
90846- Session without identified client/patient present aka support system session
90847- Cojoint therapy (what insurances can mistakenly call couples or family therapy sessions). See below.

Couples-If you go for “couples therapy,” your therapist must bill for relationship problems (V61.1/Z63.0) as a “diagnostic code.” However, most insurances won’t cover that code unless specifically stated.
When they say you have “Couples Counseling” or “Family Therapy” covered, what they are referring to is the 90847 CPT ( Session identifier code) which is technically a therapy session with additional people joining. This means the person who is being billed for the session has to still meet medically necessary criteria for diagnosis even if the clinical concern is about or for another person.

It is illegal and unethical to bill more than one party for the same session for couples or family therapy.

Couples therapy isn’t individual treatment with two people. It’s different. Couples therapy treats couples for relationship problems. It doesn’t label one of you as “the problem,” even though each of you may have problems of your own. It treats you as a dynamic “system” that needs to be worked on in order to work more effectively.

Individual-Insurance doesn’t cover life transitions, work issues, personal development or personal growth (coaching) related concerns as there is not a diagnosis that exists for them.
This is why insurance tries to have a diagnosis “rounded up” under a medical diagnosis so they can tell you that it is covered.

Stress and overwhelm doesn’t mean someone meets criteria for an Anxiety based diagnosis.
Sadness, short term grief, lack of motivation, etc doesn’t mean that one meets criteria for a Depression based diagnosis, etc.
You can look up the clinical criteria by searching for DSM Diagnosis criteria for depression, anxiety, post traumatic stress disorder, etc to see each of the qualifications. 

Problem/Issue Resolution- You may be wondering what happens when things get better for you after attending therapy for a while and you want to continue seeing your therapist for new or additional concerns?

Remember, your insurance only covers what they deem “medically necessary” which leaves your therapist and you in an ethically challenging area that can be seen potentially as insurance fraud. Once you no longer meet diagnosis criteria, you ethically cannot bill sessions for that. Even if you wanted to continue working with your therapist for additional goals, a new diagnosis would need to be given. As stated above, growth oriented, solution focused based treatment isn’t typically covered especially when one doesn’t meet criteria for “clinical necessity”.

3. Low Provider Reimbursement Rates:

Did you know that therapists can try to make an annual request for reimbursement increases but my payment rates have either stayed the same or decreased in all the years I have been credentialed on an insurance panel. This means many therapists who are in network have not only not had a rate increase but have had their  reimbursement rates lowered over the years. 
Yet every year your insurance costs have risen probably along with deductible/out-of-pocket costs you have to pay for your insurance.

If you have a copay or deductible, that fee goes towards that total number. I cannot bill a client the difference between my contracted rate and my actual fee for service rate. Any provider that does this is breaking the law and should be reported.

Taking into consideration costs and fees for licensure, required continued education, specialized training, liability insurance, credit card processing and insurance submission fees ( plus any other overhead such as office rent, etc), you can see how this can become an issue for highly trained and expert therapists to stay in business. 

Despite some companies waiving copays for many clients throughout the pandemic, they have not increased payment to therapists despite reports of the professional community asking for a pay increase from these companies for years and us having to see more clients than our typical schedule during this time frame.

After being in the field for more than 16 years and becoming an expert in mind-body healing modalities, insurance companies do not take any of that into consideration nor do they cover modalities such as Neuro Emotional Technique and other clinically researched and journal published integrative medicine/therapy modalities.
In fact, a few years ago, the billing code for Hypnosis based sessions started to get denied. 

When you look at the numbers, I need to work 3-4 insurance based sessions to every 1 session that is self-pay. That means I need to work 3-4x as much to make the same amount of money. 

I believe every person on this planet should have the self determination to make a living wage and even become profitable and successful without limitation. Insurance companies make it impossible to do that for mental health clinicians.

I chose this profession due to my passion and love for being with people and helping them reach their potential, personally and professionally.
I would be a hypocrite if I didn’t hold myself to the same standards. I plan to serve my clients for decades to come and want to avoid burnout so I can be the best for you and your loved ones.
Staying on insurance panels at this point in my career, would be against my personal self care and ethics.