A Clarification for Therapy Consumers

Some problems that come up for people paying for therapy with health insurance

 Surprisingly sometimes clients in therapy are confused about who the insurance company is and who their therapist is...  Somehow the fact that they are 2 different entities escapes the understanding of the client.  When you pay for therapy with insurance (usually it is the bulk of the fee paid by the insurance and the patient pays a small co-payment), the insurance comes with you, not the therapist.  You are a subscriber to that insurance; your employer has made an agreement with them to pay a certain amount per employee every year to them and, in exchange, they will pay for a certain amount of therapy for any employee who chooses to use it.

 It has nothing to do with the therapist:  The therapist doesn't make their rules nor determine how they do business.  The therapist is independent.  They have created and built their practice; it belongs to them; it is an entity on it's own with nothing to do with your particular insurance company.  (In fact, sometimes some of us feel like the insurance companies have taken advantage of us by inserting themselves in between us and our patients)

Most insurance that therapy clients present with are called HMO's. This means that the company will only pay "providers" (this is what they call therapists) who are on their list.  To be on that list, a therapist agrees to their conditions, primarily to be paid at usually about half their normal rate.  For a new therapist, just building their practice, this is helpful to them as it brings patients to their practice.  For a seasoned, established therapist, they are doing you a favor to agree to deal with your insurance.  That's because for the therapist, it is extra paperwork, tracking, and phone calls-so, they do more work for less money.

The reason I am bringing this up is the occasional odd and unpleasant interactions I have had with some patients over insurance issues.  Somehow, they think I am responsible for what their insurance company does!  And the insurance companies, for their part, do seem to set it up that way, i.e. to make it look that way.  (They leave it to us to do their dirty work as you will see in the following 2 examples).
 
For example, recently one of the companies a few of my patients use, decided to raise the co-payment on some of their subscribers.  They didn't inform anyone---not me, not the patients.  It wasn't until I sent in my claims that I  saw this discrepancy.  Since I usually bill for a number of sessions at a time, usually about 6, there were some debts accumulated.  In this case, they had more than doubled the co-payment.  So, I had the unhappy task of telling my patients that they owed me money.  Some of them reacted angrily to me as if it were my doing.  One patient said:  "It sounds like the old 'bait and switch' to me."
Another time, the company decided that the patient had used enough of their benefit and, basically, didn't want to pay for anymore therapy for that patient.   When I told the patient, word for word, what the insurance representative had told me (basically that a limited number of sessions could be used going forward and that they had an end date), he thought that I was throwing him out of therapy.  I was able to straighten that out with him but, then, when I suggested that he could continue, paying himself for his sessions, he immediately and unequivocally refused.

Maybe you can see that these kinds of incidences can be hard on the therapist.  From our point of view, it is unfair.  Sometimes we feel devalued.  These examples I gave are but 2 of many things like this that happen.  So, I just thought that, for the sake of all of us---patients who want to use insurance to pay for the bulk of their therapy, and all therapists who agree to accept insurance---that I would try to clarify how this works.
Insurance is just an alternative method of payment but therapists are independent entities and are not the insurance company and have zero power over them.  (Most health insurers are for-profit businesses and so, naturally they have their eye on the bottom line; they are not helping professionals; they are in business to make a profit, not to help people.)
The therapists are just as subject to the whims of the insurance companies as the clients are.

Was this explanation useful to you?

Another Voice on the Privacy Issue

The unnoticed exposure

"Well, except for the diagnosis issue, are there any other reasons to avoid filing insurance claims through the office?
Perhaps the most important issue to many clients is the lack of privacy they sense when their therapy records are open to their insurance company. While the old-fashioned stigma of visiting a mental health professional has largely disappeared, most people do not want others having access to their therapy files. Therapy is, typically, a private, personal process and confidentiality is a concern of all professionals. However, to maintain tighter control on mental health expenditures, third-party payers may insist on having full access to client records."
Andrews and Associates

Here is a link to the post that introduced this topic:  http://therapiststhoughts.blogspot.com/2011/11/pay-as-you-go-choice.html 
Another related discussion: http://therapiststhoughts.blogspot.com/2012/09/a-clarification-for-therapy-consumers.html

The Therapy Relationship-Is It For Real?

The juxtaposition of the personal and the practical in the therapy relationship

Sometimes the practical aspects of therapy come up smack dab in conflict with the personal relationship between the therapist and the patient.  When this happens, it can be very hard on both.

Because this has occurred in my practice-sadly, a number of times-I try every way I can think of to derail it in advance.  So, for example, when a new patient begins I am quite careful to make clear the cancellation policy, the fee for extra paperwork, how the appointment time frame works and anything else I can think of that might trip us up!

Unfortunately, sometimes people agree at the outset and then either forget what the policy is or decide, when it actually comes up, that they have objections to it.  Several times this has happened with long-term patients, who occasionally 'no-show' an appointment and pay the fee, then suddenly decide on the next time that it happens, that they want to argue about it.  It surprises me when it occurs that way.

Then, they don't want to hear the explanation for the policy!   And, in fact, most private practice therapists have similar policies for the running of their practice and they really are reasonable.  But, if you don't know the why of it, they can seem unreasonable.  Indeed.

Having been on the other side of the fence (which as said before, all therapists should do from time-to-time), I know what it's like to suddenly be reminded that I had to pay for a session I didn't get!  In my case, I woke up with a cold, called as soon as I knew I wouldn't be able to make it, but, as my therapist said when I went in the next time:  "It wasn't 24 hours notice."  Yikes!  Well, of, course, I paid it without complaint since that was her policy and I had agreed to it.  This is many years later and here I am writing about it so it is obvious that this is a hard pill to swallow.

In this case, though, therapists are not like doctors who have people lined up in the waiting room to fill in if an appointment doesn't show up.  Even so, docs charge a standard fee for not cancelling the appointment.  We, however, dedicate a full hour for each person (not the usual 15 minutes that doctors allot), usually about 45-50 minutes for the session and a few minutes in between for notes, catching our breath and preparing for the next appointment.  Also, we prepared for the appointment that didn't come.  We paid the rent for that hour, the phone bill---well, anyway, you get the idea.  Basically, as a therapy patient in a private practice, you are the therapist's employer for each hour that you reserve.
(There is no invisible entity who pays your private practice therapist a salary.)

  

Another thing that can happen, in the case where a patient is using insurance to pay a portion of the therapy fee, is that the insurance changes.  Maybe the employer changed plans and the new insurance doesn't list the patient's therapist.  Collision! 

Most people, who have been used to paying a small co-payment for therapy are shocked when they are faced with paying the actual fee.  The collision is between the personal value both the therapist and the patient may have on the therapy relationship and having to pay out of pocket for that value.  

It's tough.  I've been on both sides of that dilemma.  Once I saw a Dad and son who had left the son's therapist for this very reason and were shopping for a new therapist.  The boy was very unhappy at the prospect of losing his therapist; I tried to encourage the Dad to return to her.  But, the Dad was adamant, refusing to even consider paying for the sessions.  (In this case, it's always worthwhile to attempt to negotiate with the therapist.  You may be able to agree to a reduced fee.  It would still be more than you are used to paying but may be worth it to maintain an established therapy relationship.) 

In another instance, it happened in my own practice where the insured had a job change which came with a different plan on which I was not listed.  It is such a conflict when this occurs because everyone wants to continue the way it was; yet, changes have to be made and sometimes, unfortunately, the therapy relationship ends up getting lost.

I don't have a sliding fee scale but some private practice therapists do-especially in the beginning of building their reputation.  What if two neighbors in the same community have different fees?  They compare notes.  Next comes an objection to why their fee isn't as low as their neighbor's.

These are of 3 examples of many.  So, you can see that thorny issues can come up about money and therapy.

The feelings that sometimes emerge in these situations can be quite profound.  This is why I do my best to get all the business aspects to therapy out on the table at the beginning before any personal feelings between the patient and therapist have developed.  On the patient's part, it usually has to do with feeling uncared for.  In the example with the neighbor, the patient might think, Doesn't my therapist care as much about me as about that other client...  Or, if the patient doesn't really think it through, when they have to pay for a missed appointment, they may feel that the therapist is being unfair to them and must not really care.  

Of course, the therapist can have similar feelings come up.  Doesn't this person have any value on our relationship?  Don't they realize I am a person too?  Do they think so little of what they are receiving in therapy?  Therapists may have thoughts like that when patients start wrangling with them about money.

When a long-standing patient quits over a money disagreement, it is very hard for the therapist:  They are involved, invested in the issues they are working on together with the patient; they have a personal connection to the individual, they've been putting out their best effort-isn't the patient aware of that...? These might be some feelings that will emerge for the therapist in this situation. 

It's tricky territory and has lots of potential for misunderstandings and hurt feelings.  As a patient, what you can do, instead of refusing to listen to your therapist when they offer to explain the rationale behind a practice policy, is listen and try to understand it.  (There is a lot of work and activity that goes on in a therapy practice that is invisible to the patient)  
If you do have to part ways  due to financial constraints, be clear with your therapist about whatever your feelings are-maybe that you feel a great loss in leaving but that it is financially impossible to continue, or whatever your feelings are.  
When you cut a therapist off abruptly (without that kind of discussion) due to dissatisfaction with financial matters, it leaves a therapist stunned and sad.  They have been sincerely devoted to trying to help you sort out whatever you were bringing to therapy and suddenly they seem to be treated as if they can be easily replaced.  Disposable.  Some therapists burn out and quit the field.  It's often thought that this is due to an overload of dealing with heavy problems.  I think it may more likely be-at least for private practice therapists, who don't usually have support staff-dealing with the sense of being unappreciated when these money struggles come up.
One of my colleagues who is also a long-term friend was expressing something like this to me the other day.  She was talking about "...what has happened to our field"  and saying she could imagine closing her practice because of being so disillusioned.  That would be a great loss as she is a seasoned, conscientious, bright therapist.
 

On the patient's side, you may wonder, when money matters come up, "...does my therapist really care about me?"  I say, the therapy relationship-as different as it is from all other relationships in life-is for real.  I do care about my patients and I think most therapists do.  Maybe a way to think about it, as the patient, is that you are paying for their training and experience--------and think of that part as separate from the genuine caring relationship that usually develops.

Comments?  Any ideas about traversing these treacherous waters?  Have you had experiences with this dilemma?

The Pay As You Go Choice

Paying Out of Your Own Pocket For Your Therapy

Those who have no health insurance or, more commonly, have a health insurance plan that does not include mental health benefits, pay for their therapy themselves.  Occasionally, someone who does have an applicable insurance benefit will choose not to use it.  Why would they do that?

Here are some of the advantages to self-pay therapy:  First and foremost, it is entirely private. The information that you offer in your therapy sessions is between you and your therapist, period.  When a third party is in the picture, the confidentiality is compromised; it's as simple as that.

  Various insurance companies have different reporting requirements.  Some demand clinical treatment reports that the therapist must write on the patient and which can be quite extensive.  They may include a five axis diagnosis, a number designating your level of functioning, some physical information such as weight and height, a delineation of the stressors in your life and more.  The purpose is to prove "medical necessity".  If you have budgeted for a small co-payment, you are in the midst of your therapy process, and the insurance company decides your treatment is not a medical necessity, you may no longer receive the benefit of your sessions being partly subsidized. Some insurance companies require repeated requests for authorizations and may decline a request so, then, unless you can negotiate a fee with your therapist, your treatment will halt.  But then, what happens to all the information the insurance company has collected on you?  I don't know.  But, as long as you remain a subscriber, it seems that there is the chance that you will try again to use their coverage, so it probably makes sense that they would keep your information.  Some say the information is kept in databases accessible to certain entities at the insurance company's choice.
Prior to some sort of report being asked for, because you are a subscriber, the company will already have your basic information, such as, name address, phone number, social security number, and birth date. In addition, a one axis diagnosis will be required for the therapist to be able to bill them for your sessions.

Complete confidentiality is such a cornerstone of therapy, (a therapist is trained to not even reveal that you are their patient, i.e., if someone called your therapist to talk about you, not only would they not enter into a discussion of your personal business, they would not even acknowledge that you were their patient); the code of confidentiality allows a person to come into the therapy office and feel comfortable enough to reveal all; this is why it is so important.

A topic that got a lot of attention when I was in graduate school but which I haven't heard much mention of recently is, labeling.  The concern is that once a person is given a mental health diagnosis, in any context, it may remain associated with their name.   The idea was that they could be labeled and that there might be implications to having a label follow you in life.

In a private pay situation, there is no need for a formal diagnosis.  The therapist may or may not think about this, depending on the case.  But, if it were a part of the therapist's treatment planning, it would be held in confidence.

Even more to the practical perspective, in the U.S., therapy with a credentialed, licensed therapist is an expense you can deduct from your taxes.  You can also claim it as an expense on a medical reimbursement account.  In that case, it is helpful for your finances to pay for your therapy yourself (if you decide to take advantage of these options, of course, you do reveal to the government and the resource who processes your medical account that you are seeing a therapist.  But that it is extent of it).  

So, you control completely who knows what about your therapy.

The fee for therapy may seem high at first blush because most Americans are used to paying a small co-payment for their doctor visits.  ~On the other hand, many do pay out of pocket for the dentist, the chiropractor, the optometrist or the acupuncturist.~  But, if you think just a bit about these services and what the fees are, it will begin to make sense.  If you have any questions about how a fee is set by a therapist, you can ask me in a comment here; also, there is some information on that topic in the post, The Imperfect Therapist.  http://therapiststhoughts.blogspot.com/2011/05/imperfect-therapist.html

On the subject of having control, when a patient uses health insurance (referring to HMO type here) to pay part of the fee for therapy, the insurer decides how frequent the visits will be and how many there will be.  If a subscriber calls and inquires about their benefits, as one of my patients did the other day, they may be told, as she was, that the number of visits is "unlimited".  Technically this may be true; possibly this is what it says in the insurer's contract with her employer-the purveyor of this benefit.  However, that statement,  is actually misleading since the number of visits may be fewer than the patient would like if, again, "medical necessity" is not possible to be proven.   There are some subtle ways  the insurer may use to discourage visits from occurring more frequently than they would like to pay for.  

For example, should a provider be able to make a case for medical necessity in a patient report, the insurer may ask for these reports more often and award fewer visits for the report each time.  When this happens, to be able to continue in a process they find beneficial, some patients will opt to schedule sessions less frequently to make overall therapy last longer.  Of course, they miss out on an optimal experience, in making that adaptation.

Back to the subject of confidentiality:  Every company is different.  Some are more hands off than others.  Some are quite pesky.  One of the things that can happen is something called an audit.  It has nothing to do with money, at least on the face of it.  It is a supposedly random check on the quality of a listed provider's (therapist's) record keeping.  The insurer will randomly select a case and the therapist is required to hand over all clinical notes on the requested cases.  Any and all records found to be not to their liking, the therapist will have to correct or supply required information.  This can be a current case or one from the past.  While this is a very occasional occurrence,  it does happen.  This compromises confidentiality completely.

Another infrequent event is if the insurance has denied any more coverage of future visits, the therapist, on the patient's behalf, may produce an appeal.  Sometimes this leads to the therapist being required to discuss the case with a "clinical case manager" or "care manager".  These are people licensed to be therapists, who are employees of the insurer, and can decide whether or not a case can continue to be covered.  (Yet another person privy to your personal business)

Here is a link to an article on this subject which I found after I wrote mine.  It says  most of the same things but more concisely:
 http://www.americanmentalhealth.com/whyself-pay.trust

Another one I liked, that is an easy read:
http://vswoodpsyd.com/faqs/willmyinsurancepay.html

For description of the Medical Information Bureau, see this site:
 http://www.drsomov.com/paying-for-therapy/

Also see the second half of my post titled, Answering Questions

The Imperfect Therapist

                                      What can you expect of a therapist?
Good therapists, bad therapists, outright quacks, inspired brilliant therapists, terrible therapists, therapists who have a seemingly endless reservoir of compassion, and, the truly gifted therapist---they're all out there.  I get some of the fall-out in my office from the not-so-good counselors and it is sometimes astonishing to me, the things I hear clients tell me that happened to them with another therapist.  Some of the outrageous things I have heard include, the therapist falling asleep in the session, the therapist reprimanding a patient for nervously wringing her hands in a first session, the therapist asking a question and then getting angry at the patient for their (honest) answer.  And the list goes on and on.  The resilience and determination of these people who got unlucky on their first try but still persisted until they found someone who could actually help, is laudable.
Therapy is a valuable and wonderful resource for us all.  In the post titled, Cute Client Comment, I have a link to a concise article about the benefits of psychotherapy.  But to be effective, it has to be the right match.  No therapist is going to be the best choice for everyone.  But, there are some, who are almost in a calling to the profession,  and those, will be best for most people.

You would think, with all the training* that we are required to get, that we would all be excellent helpers, but, just like doctors---some are better than others.  Part of the effectiveness of the therapist is in the match or, that elusive thing we sometimes call, "chemistry":   How do you feel in that person's presence?  How's the interaction between the two of you?  Do you feel accepted?  Does the therapist seem comfortable in their job, comfortable with you, and in considering the problems you present?  Does the therapist seem to have less anxiety than you do?!
 
As time goes on, you should begin to feel that you are in a real relationship.  A professional helping relationship is, of course, different from your friendships---you want it to be; that's why you're there.  It is mostly one-sided, you will not learn much about the therapist's personal life.  They may share a little, here and there-especially the more relaxed, experienced ones or they may share for a purpose:  There may be something you are struggling with and the therapist herself has a good example from her personal life to illuminate the topic.  Or, sometimes a therapist may share with you that something difficult is going on with them in their own life so that the patient doesn't sense something is wrong and misinterpret it to be about them.  I have done both of these.  But, generally, a therapist is trained to be not too revealing and there is solid scientific reason for that.


If you are currently in therapy, there are a few things you should not hold against your therapist.  The therapist may not always remember every detail of your life.  This is especially true if you don't attend regular weekly sessions.  There's something about that consistent contact that seems to keep the file on you in the forward position in the therapist's mind.  But, think for a minute how much a therapist has to remember...They have to keep the names, relationships, events, and facts of a person's entire life---whatever has been shared in the therapy office---in their immediate memory.  And the therapist has to do this for a number of people.  It isn't easy to remember all about a person you've never met but we must do that as, often, patients want counseling about their relationships with other people in their lives.  Thus the therapist has to remember and retain an impression of, and even facts about, that other person-so important to the patient but, only heard about-by the therapist.  Sometimes my patients will bring me a picture, a snapshot of their family or, a particular person they have issues with.  That helps me to fill out the image in my mind.

A reason that I may miss a detail (and so I imagine other therapists may do this too-I hope they do!), is that facts are not where my focus is.  I am looking for the deeper meaning for the patient or I am working on delineating a pattern in the person's functioning or I may be noticing an incongruency that seems important.  This kind of listening is what is different from what one can expect from a friend.  It is what you come to a therapist for.  So, try not to be impatient if a therapist forgets one little fact.  Try not to say to your therapist:  "I told you that!!"

Also, while it appears that therapists make big money, we don't.  The public sees us getting anywhere from $40. to $200 or more, per session, and multiplies that by 40 hours per week.  Well, with all the paperwork, phone calls, treatment planning, and, yes, sometimes worrying about people, we do clock in 40 hours, and then some.  However, a full-time practice is but 20 sessions per week.  Some practitioners can't tolerate even that much and only see a few patients---6 or 12.   (The last survey by my professional association reported an average fee of $70. per session and this does not subtract rent, phone, insurance, licensing fees, association dues etc., in other words, overhead). This  is why private practice therapists usually don't have secretaries or receptionists.  Sometimes in a building that rents to  therapists only, a receptionist salary can be shared.  But, by and large, therapists do all of your letter writing, filing, insurance claims, report writing, copying , etc. for you, themselves.  The nice part for you is that it all is, really private.  No one else sees anything to do with you but the therapist himself.  If you pay for your own treatment (don't use insurance), it is really exclusive because, in that case, even  insurance company personnel will not see your paperwork.
  So, just don't be annoyed if the therapist asks you to do some part of this yourself or maybe complains a bit about your insurance company (most are difficult and time-consuming to deal with), or isn't as quick as you would like with whatever---writing a letter for you, having your account at the ready, etc.  Each patient has a different payment method, and this the therapist also has to keep track of.  It can be complicated.  Most of us don't like this part as we are clinicians and were not trained to do clerical work (and aren't good at it!).  We want to do the interpersonal work.  So, if you have a therapist you respect and are fond of, help him or her out by keeping it (the business aspect) simple.
Most of us are used to the doctor's office where all paperwork is handled by support staff.  When you have a therapist who agrees to do this for you, they are actually doing you a favor.

Therapists  may sometimes behave in ways that seem really odd.  If you don't fully understand the powerful constraints of confidentiality, you may be taken aback when you accidentally bump into your therapist in a public place and the therapist doesn't run over to you to say "Hi!"  We must wait to see what you do---you may be with someone, you may have any number of circumstances at that time, you may for some reason  not want to reveal that you are acquainted with the therapist; so the therapist will follow your lead.  They try to gracefully await a sign from you as to whether or not you want to be acknowledged.  But, it is awkward sometimes.

The other part of that problem is, what if the therapist is out with someone?  If you were to speak to each other, the polite thing to do is to introduce people.  But, if the therapist introduces you to her companion, she cannot say, "I'd like you to meet Mary Smith, one of my patients."  This would betray confidentiality.  Probably, a friendly nod is really the best bet most of the time.

Therapists are not allowed to have what is referred to as "dual relationships".  It may seem so natural to you to invite your long-standing, beloved therapist to your daughter's wedding.  But, the therapist cannot attend.  The definition and protection of the therapy relationship requires it to be kept separate from the other parts of your life.  We can't go into business with you,we aren't even allowed to do bartering; we cannot exchange our services for yours, we can't ask you for hot stock tips, etc!!!  (You can, however, give us a raise...!)

You can and should expect to be treated with regard and respect by your therapist.  Your therapist should be genuine and straightforward but professional in conduct.  Your therapist should not be expected to be and should not pose as, a 'guru'.  Your therapist should be human and compassionate.
In this unique, not like any other, sort of odd relationship, can you expect your therapist to care for you personally?  Maybe, but, not necessarily:  I have heard some therapists say that they can treat anyone, whether they like the person, or not.  Not me.  I have rarely refused to treat anyone, but if I can't find something in them to feel for, I would.    I look for that loving part or that growth motivated part or some part that I can connect with in a positive way, personally.  But, usually I find it easy to like the people who come my way.  Many therapists will become quite fond of a patient if they see them regularly for a long time.  The close attention that a therapist pays to a patient, the effort to understand what is beneath the surface, the careful listening, the thinking about that person and their issues, all of this leads to feeling affection.  It's normal; therapists are human.  At the same time , the therapist must maintain a professional position in relation to the client so that the client can feel that they can depend on the therapist.  And the therapist always has to remain ready to hear that client decide to say good-bye.

 There's so much to say on the subject of what you can expect from a therapist but this is already a long post.  If it gets a lot of traffic, I'll write more on this topic.  Be sure to let me know if you have any questions about this.  In any case, I hope that, in your therapy experience,  you are happily surprised.  I hope what I've offered here  helps.
If you'd like to read another therapist's offering on this subject, here's a link to one I think is down-to-earth and thorough.  It's also a chance to see the difference in style between she and I.  As I've mentioned, each therapist is so different and thus, you have to find the one who is a match for you. http://www.therapist4me.com/what_makes_a_good_therapist.htm
Here is another one with yet a different tone:  http://www.
wheneverydaymatters.com/?p=96
 
*The training is slightly different for each license but for my license, this is required: 19 years of school (not counting nursery school!), 3000 hours of supervised (unpaid) internship hours, an oral and written exam from the state and 36 hours of continuing education every 2 years.

Please join the discussion and leave a comment.

Addendum:  I said I would write more on this topic if it got a lot of traffic.  Turns out this has become one of the All Time Most Popular Posts and continues to be.  So, I did write more on the topic, as promised.  Here is Part 2:  http://therapiststhoughts.blogspot.com/2012/03/look-before-you-leapthe-imperfect.htm  And, you can look forward to more; there is a Part 3, in draft.