11 ms·

Finding a therapist who takes your insurance can be nearly impossible

183 points by rntn 2y ago

firesteelrain 2y ago
This is very true. My Wife has seen a therapist for dealing with her dad’s death and her mom’s new boyfriend situation as well as mom’s irrational behavior. Luckily I have been saving in an HSA for nearly ten years. Paying for it is no big deal. My company also had free sessions as part of our company provided employee assistance program.
impendia 2y ago
Both of the therapists I've seen made it clear up front that they refuse to deal with insurance companies, and expect payment up front. The health insurance industry would make Franz Kafka proud. That said, I was surprised when I mailed a bunch of bills to my insurer, and requested reimbursement. I figured I was probably wasting my time, but why not see what happens. Anyway, they mailed me a check. The bills were higher than what my insurance would cover, but my insurance decided to cover a substantial portion.
- 23B1 2y ago
  Yep. A lot of people are unwilling to fight their insurance and the insurance providers are depending on this. Same with billing departments in the various healthcare systems, etc.
  - pedrosorio 2y ago
    > I mailed a bunch of bills to my insurer, and requested reimbursement (…) Anyway, they mailed me a check This is not what I’d describe as “fighting your insurance”.
    - impendia 2y ago
      I've had frustrating experiences with my insurance before, but indeed in this case I just mailed in a form.
- nradov 2y ago
  There's no reason to be surprised. This coverage benefit was probably clearly stated on your summary plan description. These are short, simple documents that most health insurance plans are legally required to distribute to members. https://www.dol.gov/general/topic/health-plans/planinformation https://www.dol.gov/general/topic/health-plans/planinformati...
  - impendia 2y ago
    Perhaps someone else would not have been surprised in my shoes. But, rightly or wrongly, reading my health insurance documentation feels to me like staring into the abyss. Indeed, I admit that the expression "clearly stated" provokes exactly the sort of dread I'm describing; it feels like the sort of thing a hospital or insurance company would say while sticking me with a massive unexpected bill. Whether my reaction is reasonable or not, I can't say, but I do feel deep empathy for the therapists out there who balk at dealing with insurance companies.
  - senkora 2y ago
    Thank you for inspiring me to read my health insurance plan’s SPD. I learned some stuff.
- wwweston 2y ago
  > The health insurance industry would make Franz Kafka proud. The incentives are Kafka-esque. If you're a provider, your incentive is to maximize billable treatment, and you often have prospective patients who have an extremely limited capacity to evaluate your relative expertise/value bs other options, and they often don't have the time luxury of being able to shop around even if they did (and might be justifiably wary of selecting medical treatment based on discounts anyway). If you're an insurer, you're selling a product with inherently cross-aligned incentives -- the people with the greatest need for it will not be able to pay enough in premiums to meet your risk pool, the people with the least need for it will have limited incentives to buy in. Good actuarial work can partially balance this out but at some level your incentives have to do with attracting/keeping those with the least need for your product and trying to avoid or ditch people with the greatest. On the other hand, other than patient bankruptcy, insurers are probably the single greatest (if limited) force for cost control in the US system, a fact which doesn't frequently win them any love, and thanks to a certain mix of legally compelled and inherent responsibility found in the industry they do at times come through for people, as your experience may indicate. Given the incentives, the wonder isn't that there are problems for people and providers who don't want to work with insurance. The wonder is that it works at all, and that there is anyone who continues to focus on market solutions. Hayek was about as big a laissez-faire advocate as you can find in the history of economic thought and even he thought that public insurance had things to recommend it over solely private institutions.
23B1 2y ago
Also hard to just find a therapist, let alone one you like. The simple fact is that there's plenty of demand and zero supply. This is why you see so many 'personal' and 'life' coaches now btw. It's an absolute cluster.
falcolas 2y ago
In every other respect, I have excellent insurance. But the shit they put my therapist through seriously makes me wonder why she even bothers. Every story in that article echoes her own experience with insurance.
AndrewKemendo 2y ago
The key legal and economic goal of a privately owned health insurance company, is to become entrenched as a legally required intermediary between patients and the “medical cartel.” So functionally the optimal approach for an insurance org is to ensure that they are only required to reimburse for expenses that are mandated by law. Then the trick is to reduce the number of mandatory payments through regulatory capture and obfuscation. See: Medical Biller role at each hospital and lack of consistency transparency etc… Therapists are not considered part of the medical cartel because they are not required to go to medical school or pass the licensing process for “Doctors.” They can’t increase the service costs unilaterally into longer term revenue. This is why it’s trivial to find a covered psychiatrist - because they legally prescribe medicine which is the best possible outcome for an insurance carrier - their equivalent to SaaS margins. So therapists aren’t legally “Doctors” and as a result they do not have the legal avenues to create an invoice that a health insurance company would accept as mandatory to pay by law. So there’s only downside to an insurance provider for this.
- nradov 2y ago
  That's not really accurate from a legal or health plan perspective. Therapists aren't physicians but they do have somewhat similar (though lower) legally mandated licensing requirements. https://www.bbs.ca.gov/applicants/ https://www.bbs.ca.gov/applicants/ Therapists are considered healthcare practitioners. They have NPI numbers. They can submit claims for professional services to payers using NUCC 1500 forms or X12 837P transactions, just like physicians. Therapists can choose to join health plan provider networks, just like physicians. On most health plans even out-of-network therapy is covered, but the patient financial responsibility may be higher. Mental health parity with medical benefits is legally required (although some payers aren't fully compliant). https://www.cms.gov/marketplace/private-health-insurance/mental-health-parity-addiction-equity https://www.cms.gov/marketplace/private-health-insurance/men... There is a legitimate shortage of licensed therapists in many areas because education is expensive and reimbursement rates are low. Most therapists still work in small, independent practices rather than as part of large health systems so dealing with insurance billing is a huge hassle and overhead. Thus many therapists don't join health plan networks and require patients to pay directly.
jaybrendansmith 2y ago
This is absolutely true, all of it. The insurance companies do not have the incentive to do what is best for the patient. I've been shocked at how little they were willing to cover, with very little justification, even when extreme depression and suicide was a possibility. Just think, they are willing to spent north of $1 million on a patient for complex cancer surgery, but are unwilling to spend 20k to pay for therapy that is proven to prevent a suicide.
- warkdarrior 2y ago
  Cancer when left untreated costs the insurance a lot of money, even if only for palliative care. Suicide on the other hand is a one-time event with minimal, if any, insurance cost. It's a trivial business decision.
  - feoren 2y ago
    Someone who has killed themselves is no longer paying you a monthly premium.
    - Kamq 2y ago
      In the US, the insurance is probably through (and mostly paid for by) the employer. As long as the employer hires a replacement, they're back to where they were. As depressing as it is, I bet there's a table out there that covers this (and the risk that the replacement is poached from some other company that pays the same insurance company).
donatj 2y ago
Our current and our previous major insurance companies both have covered therapists listed along side other types of doctors on their website. Made it super easy for us to find one. My wife saw one literally in walking distance from our house.
Spunkie 2y ago
My insurance just flat out says therapists are excluded from coverage.
- theGnuMe 2y ago
  You must have a grandfathered plan because the ACA mandated access and equal reimbursement for mental health vs medical.
PretzelJudge 2y ago
A PhD in psychology takes 6 years to complete plus another year for licensing. A PsyD is a little bit less, but typically you pay high tuition during that time, whereas most PhD programs are free (with a small stipend). So, you make little to no money (or pay money) for a long period of time and then you are presented with a choice to take or not take insurance. If you choose the former, you: - Get paid half as much - Have to deal with filing claims, which ultimately becomes an additional expense, since chances are you have to pay someone to do this for you. - Get your money later instead of now. - Have to keep meticulous notes in case you ever get audited by the insurance companies, who can refuse to issue payments if your notes don't meet their standards. - Have to lose patients when their coverage runs out Meanwhile, there's overwhelming demand for therapists in many cities and plenty of people who will pay cash. I truly believe that many therapists are not in it for the money... but if they are going to make less money, let's at least figure out a way to handle the bureaucracy so that their jobs are more enjoyable.
- BeetleB 2y ago
  You don't need a PhD to get a license...
  - nothercastle 2y ago
    But very few non phd therapists practice evidence based medicine
    - r00fus 2y ago
      Most therapists I’ve spoken to aren’t PhDs and the one we do work with isn’t noticeably better for outcomes.
    - hiddencost 2y ago
      lol you have that backwards. The LCSWs tend to be evidence based, the PhDs are busy working on their book promulgating their theories.
      - 2y ago
Arubis 2y ago
Finding an insurer that pays therapists a rate in line with their level of education and specialization can be nearly impossible, and time spent filling out the billing paperwork (often only to be rejected for payment or even "clawed back" after the fact) isn't billable. Many folks I know that have private clinical practices address the tension between this and ensuring that there's access for people that can't afford the full rate out of pocket by charging a really high rate for most patients and then doing sliding scale/pro bono work.
- nothercastle 2y ago
  Keep in mind that most therapists only get to keep 50-60% of the paid rate. So if insurance covers 200$ an hour, they take home 100-120. Which seems decent until you realize they only have 5-6 or so billable hours a day and the rest is paperwork and insurance bs. Also a typical Ph.D had an additional 10 or so years of post secondary education income/opportunity loss.
pipeline_peak 2y ago
>“The way to look at mental health care from an insurance perspective is: I don’t want to attract those people. I am never going to make money on them,” Exactly why healthcare should be a human right and not a business. As someone who’s grown more conservative over the years, this is where I draw the line. Unfortunately since people will always see mental health as secondary to physical, this will always be overlooked.
- feoren 2y ago
  > As someone who’s grown more conservative over the years, this is where I draw the line At the thing that personally affects you. Just like all conservatives: all problems are fake problems until they're real for you. Disgusting.
  - pipeline_peak 2y ago
    Never claimed it personally affected me. You can think it does because that’s convenient and fits your narrative but we both know you don’t know. Comments like these are lazy, destructive and downright judgmental. They only further explain why we can’t get along, take care friend.
jeffheard 2y ago
So let’s set aside for just a moment the notion of single payer healthcare as an answer to this. Why hasn’t a point of competitiveness between insurance companies ever been that they keep your workforce healthier, more productive, and easier to retain than the competition? The biggest cost to an employer is always their roster. The fewer sick days people need, the less burnout causes them to churn, and the healthier and happier people are overall, the lower the training, recruiting, and redundant staffing cost. It feels natural to me that in an employer paid healthcare system like the one we have in the us, the employer should demand the highest quality coverage possible by that metric as long as it reduces staffing overheads.
- galdosdi 2y ago
  My guess is that despite the strong long term overall link, it's too difficult to draw a meaingful link between any particular executive decision on this and any particular outcome, causing a tragedy of the commons. I think it's a good guess because it's a powerful explanation for many other such questions about "Why don't they just ____?"
- coryrc 2y ago
  My employer offers therapy solutions like Lyra, so somebody agrees with you. No reason for BCBS to be involved.
- Mountain_Skies 2y ago
  By far the number one thing any employer I've worked for has done to reduce my number of sick days and visits to the doctor/pharmacy was remote work. Offices and gathering large numbers of people from over a wide area into a confined space by its nature is a vector for spreading infections. This is before even getting into issues like what a stressful commute does to the body and how it limits one's time that could, though not necessarily will, be used for healthier activities. But just the elimination of picking up colds, flus, and other infections from the office has had a significant impact on the number of sick days I've used. There also have been times when I was sick but not too sick to be productive. In the past I would have had to consider if using up a sick day and having no productivity was a good trade-off for not going into the office and possibly infecting others.
robswc 2y ago
I often wonder if therapy is "over prescribed" these days. I've struggled with various problems and therapy has seemingly always made it worse. We would "explore" things which caused me to dwell and dedicate so much brain power to "untangling" ideas. Eventually, I would always be "cured" after some relentless distractions and not the therapy. I truly believe the therapists wanted to help, and our progress felt real... but looking back, it was probably worse than doing noting. I bring this up because I believe some people need therapy, but many people are encouraged to seek it out for problems that could be overcome with other methods, causing a "therapist shortage." This has downstream effects, like the one posted here.
- DevX101 2y ago
  Agreed. There's a lot of therapy that used to be addressed via talking an issue out w/ friends/partners/family/church, or other built in cultural institutions. There's a lot of therapy that our in person social networks should be doing (and we should be giving). As we become more lonely and our social institutions fall, it opens the door for the therapization of our modern culture, which seems like a bandaid on a deeper problem. This isn't to admonish therapy, but ideally it should probably be for more severe issues.
- borroka 2y ago
  I will go even further than that. Talk therapy is the scam of the 2000s. The trickle that brought what we call therapeutic language into everyday life, the constant references to the narcissism of a partner who, if we are honest, had the great fault of just not wanting us anymore, the masochistic lingering over traumas that are nothing more than everyday life, the safe spaces, the escape from responsibilities that should be ours but we have been taught to assign to society, has had disastrous effects on human relations and also on political discourse. On top of that, I have rarely, if ever, found people participating in talk therapy getting better. If it were a pill, no honest doctor would prescribe it.
  - sneak 2y ago
    Cognitive behavioral therapy, the most common type of “talk therapy” these days, shows effectiveness on par with medications in a broad range of studies with good methodology. It is important to remember that anecdotes are not data.
Insanity 2y ago
Healthcare (in the US) is insanely expensive for physical health, often with insurance being “difficult”. Hence not sure why anyone would be surprised that mental health is similar.
logifail 2y ago
(Genuine Q) why do so many Americans [appear need to] have a therapist compared with - sorry, not sure how to put this - the rest of the planet?
- Nifty3929 2y ago
  It's not a question of need, it's a question of want, and available resources to support those wants. The US is sufficiently productive that it can allocate people to relatively less important tasks. If a country barely produces enough to eat, then there's no room for therapists. No knock on therapists - this is basically true of everything. The more productive we are, the more "extra stuff" we can afford to have/do.
- Red_Leaves_Flyy 2y ago
  >It is no measure of health to be well adjusted to a profoundly sick society. J. Krishnamurti
- harimau777 2y ago
  I suspect there's a number of factors: If you are comparing to the population of the world as a whole, then I suspect that's because many people in poorer regions simply don't have access to therapy. If you are comparing to wealthy industrialized nations (e.g. Western Europe and Scandinavia) then I suspect that America's lack of work life balance, lack of social safety net, repressive moral culture, high gun violence, etc. play a role. I suspect that in some cultures people like pastors and family members play some of the role of therapists to a greater degree than in America.
  - logifail 2y ago
    > I suspect that America's lack of work life balance, lack of social safety net, repressive moral culture, high gun violence Are Americans in therapy directly affected by those issues, or - how can I put this - merely worried about those issues in general terms? The Economist wrote recently about how political views appear to affect mental health in the USA. The title feels unnecessarily inflammatory, for which I apologise, the article's content feels much more balanced. https://www.economist.com/united-states/2024/04/04/are-american-progressives-making-themselves-sad https://www.economist.com/united-states/2024/04/04/are-ameri... ( https://archive.is/iWAaP https://archive.is/iWAaP )
neilv 2y ago
> Several insurers told ProPublica that they are committed to ensuring access to mental health providers, emphasizing that their plans are in compliance with state and federal laws. Insurers also said they have practices in place to make sure reimbursement rates reflect market value and to support and retain providers, for which they continually recruit. Journalists could use an LLM to fetch the obligatory predictable responses from corporate spokespeople, to insulate the journalists' souls from that.
- skybrian 2y ago
  The point is to give them a chance to respond. Then they can't come back later and say "why didn't you talk to us?" It's often not that helpful, but it's standard journalistic practice to give them a chance.
  - mindslight 2y ago
    Well then, lets go the other way. It would be nice if standard journalistic practice evolved to evaluating what business drones said rather than just repeating it verbatim. "When asked for comment, <company> responded but said nothing useful"
bradleyjg 2y ago
Your house is probably not going to burn down, but if it does the financial impact would ruinous. So we pay a little bit each month to insure against this rare outcome. Some of health insurance looks like this, but many parts of it don’t.
screye 2y ago
Cherry on the cake is - People start looking for therapists when they're struggling the most. Navigating the Kafka-esque mess is hard enough when you're well. But if you're clinically depressed and struggling to get out of bed, booking an appointment can feel like an unsurmountable wall.
- nradov 2y ago
  Yes, that is difficult. But someone who might be suffering from a severe mental health condition probably shouldn't start with looking for a therapist. Instead it would usually be better to make an appointment with their primary care provider and see if a referral to a psychiatrist is medically necessary. For lesser issues, many employers now offer Employee Assistance Programs (EAP) as part of their benefits package. This can be a relatively quicker path to get a few sessions with a therapist or counselor.
- halfcat 2y ago
  Not only that, but even if there were zero barriers with insurance, finding a therapist is still hard. Because finding good people that you click with is hard, whether that’s hiring employees, finding a romantic partner, or finding a therapist. The online therapy companies that provide an “instant match” haven’t really solved this, any more than a temp agency has solved hiring top talent.
kristianbrigman 2y ago
there is rula: https://www.rula.com https://www.rula.com you put in your insurance and location, and they find you a provider. also, some therapists don't take insurance (or recommend you don't use it) because supposedly if you do, then part of that agreement is that they tell the insurance company your treatment plan, which includes the diagnosis, that may be available to your employer. doctor/patient confidentiality seems like there are some exceptions here.
- monktastic1 2y ago
  Piggybacking on this to share my BIL's company https://www.meetnirvana.com/ https://www.meetnirvana.com/. It helps therapists look up patients' insurance details quickly and easily. Not just a shameless plug, either: I really believe in their mission, and did a short stint with them.
djoldman 2y ago
Lawyers: where's the class action lawsuit on behalf of therapists alleging a pattern of denial of payment?
- halfcat 2y ago
  Don’t think it would help people get therapy. The big companies already have a pile of cash they’ve allocated for when they get sued, as the cost of doing business. So maybe a class action suit happens, and insurance companies have to pay $1 billion in damages. Lawyers get their cut, a bunch of therapists get a $1k check, and zero patients get more therapy.
  - kmoser 2y ago
    There must be a pain point beyond which insurance companies are willing to actually provide the services they promise. Perhaps jail time for execs might move the needle?
theogravity 2y ago
I wanted to get short term therapy for a mental health related thing this year, and made the mistake of switching from my PPO to Kaiser thinking that Kaiser would cover therapy sessions since they appeared to have thousands of therapists under their network. It turns out that Kaiser will only cover you if you have a diagnosed mental condition (eg bi-polar / ADHD). If you don't, then you're completely out of luck. Instead, they refer you to use an app where you can get counseling via text message, and it's only for 90 days. https://organizations.headspace.com/kp/faq https://organizations.headspace.com/kp/faq
- lukevp 2y ago
  Do you have access to an employee assistance program through work? We have made use of the therapy multiple times and it’s been great. Totally free, 8 sessions per person per incident. You can kick off another set of sessions if there’s another incident you need to discuss. It’s not a long term solution but it’s good to fill in the gaps and get you seen soon.
  - theogravity 2y ago
    I haven't thought about it at all. I'll definitely check it out, thanks!
  - theogravity 2y ago
    Update: Trinet does provide this service. Thanks so much for letting me know about it.
- theoreticalmal 2y ago
  It sounds like there’s a financial incentive for therapists to diagnose patients with conditions they may or may not have…big yikes
  - KptMarchewa 2y ago
    Therapists don't diagnose, psychiatists do.
999900000999 2y ago
The entire American Medical Industrial Complex is designed to extract as much money from customers as possible. Fun fact, therapy is usually not covered by Medicare at all( and when it is you can literally have a year wait). So you have a system in which working class person just have to get through it, and anyone with means will be told they have dozens of things wrong with them. Better Help sells user information. The venture capitalist tech bros have a new market. When I was at my lowest, broke , without any health insurance at all, I had a friend who listened to me complain about my latest eviction for hours at a time. That did more for me that any therapist ( who almost always watch the clock to cut you off ). I plan to pay for her children to go to college. I make a tech bro salary and it's not a lot of money to me. The Quest For Community and Tribe are great books on what's wrong with modern society. In my grandma's time the average person attended church ( I'm am atheist, but I value the community aspects), at least one social club, and she was a member of a union. How many community connections does the average person have today ?
ldehaan 2y ago
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dottjt 2y ago
This is not to be taken as mental health advice (merely an anecdote), but yesterday I was thinking about needing therapy to deal with my issues and I had the thought to use ChatGPT. Wow, it was absolutely incredible in providing me with what I needed. I think therapy with a professional would be really useful if you have no idea what your problem is, but I think if you're able to put your problem into words then LLMs can be useful.
- hirvi74 2y ago
  I might have to give this a try one day. In my experience, therapy as a tool to improve one's life is overrated and not worth the money. But hey, that has been my experience over a long period of time with many different providers. Everyone is different.
tonymet 2y ago
What does the business side of therapy look like ? How do they measure success ? I’ve seen patient surveys , but stated conditions are biased. Therapy doesn’t seem like healthcare . People enter the system and receive care without recovery It just seems like legitimized drug dealing. Just make the psychotropics over the counter and save the world hundreds of billions
- nradov 2y ago
  Therapists generally can't prescribe drugs. Usually only physicians (or PAs/NPs supervised by physicians) can prescribe psychoactive medications, especially the scheduled ones. A few states do grant limited prescribing authority to licensed psychologists (not therapists).
  - tonymet 2y ago
    In practice they refer a clinician who writes a prescription based on their report and a 15 minute screening. It’s theatre
smeej 2y ago
I got new insurance this year through my state's insurance marketplace. They said my existing therapist was in-network. This was news to her. I called and spoke to them. They insisted. She called and spoke to them. They insisted. So they've been paying her $150 a week for me instead this year. She doesn't know how she ended up being considered in their network as she practices solo, but here we are. The system is vastly more convoluted than I think anybody on any side actually realizes it is.
- xyst 2y ago
  > The system is vastly more convoluted than I think anybody on any side actually realizes it is. This is intentional. It's a game of attrition, and the insurance companies hold all of the cards.
  - smeej 2y ago
    I'll be honest, I've been really pleasantly surprised with mine. They cover mental health visits without a limit. They cover consultation with a dietitian without limit. They cover physical therapy at 60 sessions, no other questions asked. They even have a number you can call when your doctor is recommending you have a procedure to find out where you can have it done at the lowest cost. It's staffed by "nurse navigators" whose job is to dig through their data and find what the average cost has been with in-network providers for other people with your plan and find out which one saves you (and the company) the most money. If you decide to go with one of their recommendations of your doctor's original one, they'll call both providers and arrange to have the relevant documents and approvals moved for you, and then they'll send you a gift card because you saved them money too! It hasn't been flawless by any means, but it has really seemed like they're on my side and helping me through all this confusing stuff. And I'm on a marketplace plan with cost-sharing reduction because I'm making sure my income ends up being just high enough not to be on Medicaid, but to get full subsidy plus CSR, so I'm paying <$50 a month for it with $0 deductible and <$2k OOP max. I've decided they're what I wish all health insurance companies were like.
o999 2y ago
Psychotherapy is easy to acquire overseas with online meeting software with a fraction of the cost.
Ellardo654 2y ago
[flagged]

183 points by rntn 2y ago

This is very true. My Wife has seen a therapist for dealing with her dad’s death and her mom’s new boyfriend situation as well as mom’s irrational behavior. Luckily I have been saving in an HSA for nearly ten years. Paying for it is no big deal. My company also had free sessions as part of our company provided employee assistance program.

impendia 2y ago

Both of the therapists I've seen made it clear up front that they refuse to deal with insurance companies, and expect payment up front. The health insurance industry would make Franz Kafka proud. That said, I was surprised when I mailed a bunch of bills to my insurer, and requested reimbursement. I figured I was probably wasting my time, but why not see what happens. Anyway, they mailed me a check. The bills were higher than what my insurance would cover, but my insurance decided to cover a substantial portion.

23B1 2y ago
Yep. A lot of people are unwilling to fight their insurance and the insurance providers are depending on this. Same with billing departments in the various healthcare systems, etc.
- pedrosorio 2y ago
  > I mailed a bunch of bills to my insurer, and requested reimbursement (…) Anyway, they mailed me a check This is not what I’d describe as “fighting your insurance”.
  - impendia 2y ago
    I've had frustrating experiences with my insurance before, but indeed in this case I just mailed in a form.
nradov 2y ago
There's no reason to be surprised. This coverage benefit was probably clearly stated on your summary plan description. These are short, simple documents that most health insurance plans are legally required to distribute to members. https://www.dol.gov/general/topic/health-plans/planinformation https://www.dol.gov/general/topic/health-plans/planinformati...
- impendia 2y ago
  Perhaps someone else would not have been surprised in my shoes. But, rightly or wrongly, reading my health insurance documentation feels to me like staring into the abyss. Indeed, I admit that the expression "clearly stated" provokes exactly the sort of dread I'm describing; it feels like the sort of thing a hospital or insurance company would say while sticking me with a massive unexpected bill. Whether my reaction is reasonable or not, I can't say, but I do feel deep empathy for the therapists out there who balk at dealing with insurance companies.
- senkora 2y ago
  Thank you for inspiring me to read my health insurance plan’s SPD. I learned some stuff.
wwweston 2y ago
> The health insurance industry would make Franz Kafka proud. The incentives are Kafka-esque. If you're a provider, your incentive is to maximize billable treatment, and you often have prospective patients who have an extremely limited capacity to evaluate your relative expertise/value bs other options, and they often don't have the time luxury of being able to shop around even if they did (and might be justifiably wary of selecting medical treatment based on discounts anyway). If you're an insurer, you're selling a product with inherently cross-aligned incentives -- the people with the greatest need for it will not be able to pay enough in premiums to meet your risk pool, the people with the least need for it will have limited incentives to buy in. Good actuarial work can partially balance this out but at some level your incentives have to do with attracting/keeping those with the least need for your product and trying to avoid or ditch people with the greatest. On the other hand, other than patient bankruptcy, insurers are probably the single greatest (if limited) force for cost control in the US system, a fact which doesn't frequently win them any love, and thanks to a certain mix of legally compelled and inherent responsibility found in the industry they do at times come through for people, as your experience may indicate. Given the incentives, the wonder isn't that there are problems for people and providers who don't want to work with insurance. The wonder is that it works at all, and that there is anyone who continues to focus on market solutions. Hayek was about as big a laissez-faire advocate as you can find in the history of economic thought and even he thought that public insurance had things to recommend it over solely private institutions.

23B1 2y ago

Also hard to just find a therapist, let alone one you like. The simple fact is that there's plenty of demand and zero supply. This is why you see so many 'personal' and 'life' coaches now btw. It's an absolute cluster.

falcolas 2y ago

In every other respect, I have excellent insurance. But the shit they put my therapist through seriously makes me wonder why she even bothers. Every story in that article echoes her own experience with insurance.

AndrewKemendo 2y ago

The key legal and economic goal of a privately owned health insurance company, is to become entrenched as a legally required intermediary between patients and the “medical cartel.” So functionally the optimal approach for an insurance org is to ensure that they are only required to reimburse for expenses that are mandated by law. Then the trick is to reduce the number of mandatory payments through regulatory capture and obfuscation. See: Medical Biller role at each hospital and lack of consistency transparency etc… Therapists are not considered part of the medical cartel because they are not required to go to medical school or pass the licensing process for “Doctors.” They can’t increase the service costs unilaterally into longer term revenue. This is why it’s trivial to find a covered psychiatrist - because they legally prescribe medicine which is the best possible outcome for an insurance carrier - their equivalent to SaaS margins. So therapists aren’t legally “Doctors” and as a result they do not have the legal avenues to create an invoice that a health insurance company would accept as mandatory to pay by law. So there’s only downside to an insurance provider for this.

nradov 2y ago
That's not really accurate from a legal or health plan perspective. Therapists aren't physicians but they do have somewhat similar (though lower) legally mandated licensing requirements. https://www.bbs.ca.gov/applicants/ https://www.bbs.ca.gov/applicants/ Therapists are considered healthcare practitioners. They have NPI numbers. They can submit claims for professional services to payers using NUCC 1500 forms or X12 837P transactions, just like physicians. Therapists can choose to join health plan provider networks, just like physicians. On most health plans even out-of-network therapy is covered, but the patient financial responsibility may be higher. Mental health parity with medical benefits is legally required (although some payers aren't fully compliant). https://www.cms.gov/marketplace/private-health-insurance/mental-health-parity-addiction-equity https://www.cms.gov/marketplace/private-health-insurance/men... There is a legitimate shortage of licensed therapists in many areas because education is expensive and reimbursement rates are low. Most therapists still work in small, independent practices rather than as part of large health systems so dealing with insurance billing is a huge hassle and overhead. Thus many therapists don't join health plan networks and require patients to pay directly.

jaybrendansmith 2y ago

This is absolutely true, all of it. The insurance companies do not have the incentive to do what is best for the patient. I've been shocked at how little they were willing to cover, with very little justification, even when extreme depression and suicide was a possibility. Just think, they are willing to spent north of $1 million on a patient for complex cancer surgery, but are unwilling to spend 20k to pay for therapy that is proven to prevent a suicide.

warkdarrior 2y ago
Cancer when left untreated costs the insurance a lot of money, even if only for palliative care. Suicide on the other hand is a one-time event with minimal, if any, insurance cost. It's a trivial business decision.
- feoren 2y ago
  Someone who has killed themselves is no longer paying you a monthly premium.
  - Kamq 2y ago
    In the US, the insurance is probably through (and mostly paid for by) the employer. As long as the employer hires a replacement, they're back to where they were. As depressing as it is, I bet there's a table out there that covers this (and the risk that the replacement is poached from some other company that pays the same insurance company).

donatj 2y ago

Our current and our previous major insurance companies both have covered therapists listed along side other types of doctors on their website. Made it super easy for us to find one. My wife saw one literally in walking distance from our house.

Spunkie 2y ago

My insurance just flat out says therapists are excluded from coverage.

theGnuMe 2y ago
You must have a grandfathered plan because the ACA mandated access and equal reimbursement for mental health vs medical.

PretzelJudge 2y ago

A PhD in psychology takes 6 years to complete plus another year for licensing. A PsyD is a little bit less, but typically you pay high tuition during that time, whereas most PhD programs are free (with a small stipend). So, you make little to no money (or pay money) for a long period of time and then you are presented with a choice to take or not take insurance. If you choose the former, you: - Get paid half as much - Have to deal with filing claims, which ultimately becomes an additional expense, since chances are you have to pay someone to do this for you. - Get your money later instead of now. - Have to keep meticulous notes in case you ever get audited by the insurance companies, who can refuse to issue payments if your notes don't meet their standards. - Have to lose patients when their coverage runs out Meanwhile, there's overwhelming demand for therapists in many cities and plenty of people who will pay cash. I truly believe that many therapists are not in it for the money... but if they are going to make less money, let's at least figure out a way to handle the bureaucracy so that their jobs are more enjoyable.

BeetleB 2y ago
You don't need a PhD to get a license...
- nothercastle 2y ago
  But very few non phd therapists practice evidence based medicine
  - r00fus 2y ago
    Most therapists I’ve spoken to aren’t PhDs and the one we do work with isn’t noticeably better for outcomes.
  - hiddencost 2y ago
    lol you have that backwards. The LCSWs tend to be evidence based, the PhDs are busy working on their book promulgating their theories.
    - 2y ago

Arubis 2y ago

Finding an insurer that pays therapists a rate in line with their level of education and specialization can be nearly impossible, and time spent filling out the billing paperwork (often only to be rejected for payment or even "clawed back" after the fact) isn't billable. Many folks I know that have private clinical practices address the tension between this and ensuring that there's access for people that can't afford the full rate out of pocket by charging a really high rate for most patients and then doing sliding scale/pro bono work.

nothercastle 2y ago
Keep in mind that most therapists only get to keep 50-60% of the paid rate. So if insurance covers 200$ an hour, they take home 100-120. Which seems decent until you realize they only have 5-6 or so billable hours a day and the rest is paperwork and insurance bs. Also a typical Ph.D had an additional 10 or so years of post secondary education income/opportunity loss.

pipeline_peak 2y ago

>“The way to look at mental health care from an insurance perspective is: I don’t want to attract those people. I am never going to make money on them,” Exactly why healthcare should be a human right and not a business. As someone who’s grown more conservative over the years, this is where I draw the line. Unfortunately since people will always see mental health as secondary to physical, this will always be overlooked.

feoren 2y ago
> As someone who’s grown more conservative over the years, this is where I draw the line At the thing that personally affects you. Just like all conservatives: all problems are fake problems until they're real for you. Disgusting.
- pipeline_peak 2y ago
  Never claimed it personally affected me. You can think it does because that’s convenient and fits your narrative but we both know you don’t know. Comments like these are lazy, destructive and downright judgmental. They only further explain why we can’t get along, take care friend.

jeffheard 2y ago

So let’s set aside for just a moment the notion of single payer healthcare as an answer to this. Why hasn’t a point of competitiveness between insurance companies ever been that they keep your workforce healthier, more productive, and easier to retain than the competition? The biggest cost to an employer is always their roster. The fewer sick days people need, the less burnout causes them to churn, and the healthier and happier people are overall, the lower the training, recruiting, and redundant staffing cost. It feels natural to me that in an employer paid healthcare system like the one we have in the us, the employer should demand the highest quality coverage possible by that metric as long as it reduces staffing overheads.

galdosdi 2y ago
My guess is that despite the strong long term overall link, it's too difficult to draw a meaingful link between any particular executive decision on this and any particular outcome, causing a tragedy of the commons. I think it's a good guess because it's a powerful explanation for many other such questions about "Why don't they just ____?"
coryrc 2y ago
My employer offers therapy solutions like Lyra, so somebody agrees with you. No reason for BCBS to be involved.
Mountain_Skies 2y ago
By far the number one thing any employer I've worked for has done to reduce my number of sick days and visits to the doctor/pharmacy was remote work. Offices and gathering large numbers of people from over a wide area into a confined space by its nature is a vector for spreading infections. This is before even getting into issues like what a stressful commute does to the body and how it limits one's time that could, though not necessarily will, be used for healthier activities. But just the elimination of picking up colds, flus, and other infections from the office has had a significant impact on the number of sick days I've used. There also have been times when I was sick but not too sick to be productive. In the past I would have had to consider if using up a sick day and having no productivity was a good trade-off for not going into the office and possibly infecting others.

robswc 2y ago

I often wonder if therapy is "over prescribed" these days. I've struggled with various problems and therapy has seemingly always made it worse. We would "explore" things which caused me to dwell and dedicate so much brain power to "untangling" ideas. Eventually, I would always be "cured" after some relentless distractions and not the therapy. I truly believe the therapists wanted to help, and our progress felt real... but looking back, it was probably worse than doing noting. I bring this up because I believe some people need therapy, but many people are encouraged to seek it out for problems that could be overcome with other methods, causing a "therapist shortage." This has downstream effects, like the one posted here.

DevX101 2y ago
Agreed. There's a lot of therapy that used to be addressed via talking an issue out w/ friends/partners/family/church, or other built in cultural institutions. There's a lot of therapy that our in person social networks should be doing (and we should be giving). As we become more lonely and our social institutions fall, it opens the door for the therapization of our modern culture, which seems like a bandaid on a deeper problem. This isn't to admonish therapy, but ideally it should probably be for more severe issues.
borroka 2y ago
I will go even further than that. Talk therapy is the scam of the 2000s. The trickle that brought what we call therapeutic language into everyday life, the constant references to the narcissism of a partner who, if we are honest, had the great fault of just not wanting us anymore, the masochistic lingering over traumas that are nothing more than everyday life, the safe spaces, the escape from responsibilities that should be ours but we have been taught to assign to society, has had disastrous effects on human relations and also on political discourse. On top of that, I have rarely, if ever, found people participating in talk therapy getting better. If it were a pill, no honest doctor would prescribe it.
- sneak 2y ago
  Cognitive behavioral therapy, the most common type of “talk therapy” these days, shows effectiveness on par with medications in a broad range of studies with good methodology. It is important to remember that anecdotes are not data.

Insanity 2y ago

Healthcare (in the US) is insanely expensive for physical health, often with insurance being “difficult”. Hence not sure why anyone would be surprised that mental health is similar.

logifail 2y ago

(Genuine Q) why do so many Americans [appear need to] have a therapist compared with - sorry, not sure how to put this - the rest of the planet?

Nifty3929 2y ago
It's not a question of need, it's a question of want, and available resources to support those wants. The US is sufficiently productive that it can allocate people to relatively less important tasks. If a country barely produces enough to eat, then there's no room for therapists. No knock on therapists - this is basically true of everything. The more productive we are, the more "extra stuff" we can afford to have/do.
Red_Leaves_Flyy 2y ago
>It is no measure of health to be well adjusted to a profoundly sick society. J. Krishnamurti
harimau777 2y ago
I suspect there's a number of factors: If you are comparing to the population of the world as a whole, then I suspect that's because many people in poorer regions simply don't have access to therapy. If you are comparing to wealthy industrialized nations (e.g. Western Europe and Scandinavia) then I suspect that America's lack of work life balance, lack of social safety net, repressive moral culture, high gun violence, etc. play a role. I suspect that in some cultures people like pastors and family members play some of the role of therapists to a greater degree than in America.
- logifail 2y ago
  > I suspect that America's lack of work life balance, lack of social safety net, repressive moral culture, high gun violence Are Americans in therapy directly affected by those issues, or - how can I put this - merely worried about those issues in general terms? The Economist wrote recently about how political views appear to affect mental health in the USA. The title feels unnecessarily inflammatory, for which I apologise, the article's content feels much more balanced. https://www.economist.com/united-states/2024/04/04/are-american-progressives-making-themselves-sad https://www.economist.com/united-states/2024/04/04/are-ameri... ( https://archive.is/iWAaP https://archive.is/iWAaP )

neilv 2y ago

> Several insurers told ProPublica that they are committed to ensuring access to mental health providers, emphasizing that their plans are in compliance with state and federal laws. Insurers also said they have practices in place to make sure reimbursement rates reflect market value and to support and retain providers, for which they continually recruit. Journalists could use an LLM to fetch the obligatory predictable responses from corporate spokespeople, to insulate the journalists' souls from that.

skybrian 2y ago
The point is to give them a chance to respond. Then they can't come back later and say "why didn't you talk to us?" It's often not that helpful, but it's standard journalistic practice to give them a chance.
- mindslight 2y ago
  Well then, lets go the other way. It would be nice if standard journalistic practice evolved to evaluating what business drones said rather than just repeating it verbatim. "When asked for comment, <company> responded but said nothing useful"

bradleyjg 2y ago

Your house is probably not going to burn down, but if it does the financial impact would ruinous. So we pay a little bit each month to insure against this rare outcome. Some of health insurance looks like this, but many parts of it don’t.

screye 2y ago

Cherry on the cake is - People start looking for therapists when they're struggling the most. Navigating the Kafka-esque mess is hard enough when you're well. But if you're clinically depressed and struggling to get out of bed, booking an appointment can feel like an unsurmountable wall.

nradov 2y ago
Yes, that is difficult. But someone who might be suffering from a severe mental health condition probably shouldn't start with looking for a therapist. Instead it would usually be better to make an appointment with their primary care provider and see if a referral to a psychiatrist is medically necessary. For lesser issues, many employers now offer Employee Assistance Programs (EAP) as part of their benefits package. This can be a relatively quicker path to get a few sessions with a therapist or counselor.
halfcat 2y ago
Not only that, but even if there were zero barriers with insurance, finding a therapist is still hard. Because finding good people that you click with is hard, whether that’s hiring employees, finding a romantic partner, or finding a therapist. The online therapy companies that provide an “instant match” haven’t really solved this, any more than a temp agency has solved hiring top talent.

kristianbrigman 2y ago

there is rula: https://www.rula.com https://www.rula.com you put in your insurance and location, and they find you a provider. also, some therapists don't take insurance (or recommend you don't use it) because supposedly if you do, then part of that agreement is that they tell the insurance company your treatment plan, which includes the diagnosis, that may be available to your employer. doctor/patient confidentiality seems like there are some exceptions here.

monktastic1 2y ago
Piggybacking on this to share my BIL's company https://www.meetnirvana.com/ https://www.meetnirvana.com/. It helps therapists look up patients' insurance details quickly and easily. Not just a shameless plug, either: I really believe in their mission, and did a short stint with them.

djoldman 2y ago

Lawyers: where's the class action lawsuit on behalf of therapists alleging a pattern of denial of payment?

halfcat 2y ago
Don’t think it would help people get therapy. The big companies already have a pile of cash they’ve allocated for when they get sued, as the cost of doing business. So maybe a class action suit happens, and insurance companies have to pay $1 billion in damages. Lawyers get their cut, a bunch of therapists get a $1k check, and zero patients get more therapy.
- kmoser 2y ago
  There must be a pain point beyond which insurance companies are willing to actually provide the services they promise. Perhaps jail time for execs might move the needle?

theogravity 2y ago

I wanted to get short term therapy for a mental health related thing this year, and made the mistake of switching from my PPO to Kaiser thinking that Kaiser would cover therapy sessions since they appeared to have thousands of therapists under their network. It turns out that Kaiser will only cover you if you have a diagnosed mental condition (eg bi-polar / ADHD). If you don't, then you're completely out of luck. Instead, they refer you to use an app where you can get counseling via text message, and it's only for 90 days. https://organizations.headspace.com/kp/faq https://organizations.headspace.com/kp/faq

lukevp 2y ago
Do you have access to an employee assistance program through work? We have made use of the therapy multiple times and it’s been great. Totally free, 8 sessions per person per incident. You can kick off another set of sessions if there’s another incident you need to discuss. It’s not a long term solution but it’s good to fill in the gaps and get you seen soon.
- theogravity 2y ago
  I haven't thought about it at all. I'll definitely check it out, thanks!
- theogravity 2y ago
  Update: Trinet does provide this service. Thanks so much for letting me know about it.
theoreticalmal 2y ago
It sounds like there’s a financial incentive for therapists to diagnose patients with conditions they may or may not have…big yikes
- KptMarchewa 2y ago
  Therapists don't diagnose, psychiatists do.

999900000999 2y ago

The entire American Medical Industrial Complex is designed to extract as much money from customers as possible. Fun fact, therapy is usually not covered by Medicare at all( and when it is you can literally have a year wait). So you have a system in which working class person just have to get through it, and anyone with means will be told they have dozens of things wrong with them. Better Help sells user information. The venture capitalist tech bros have a new market. When I was at my lowest, broke , without any health insurance at all, I had a friend who listened to me complain about my latest eviction for hours at a time. That did more for me that any therapist ( who almost always watch the clock to cut you off ). I plan to pay for her children to go to college. I make a tech bro salary and it's not a lot of money to me. The Quest For Community and Tribe are great books on what's wrong with modern society. In my grandma's time the average person attended church ( I'm am atheist, but I value the community aspects), at least one social club, and she was a member of a union. How many community connections does the average person have today ?

ldehaan 2y ago

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dottjt 2y ago

This is not to be taken as mental health advice (merely an anecdote), but yesterday I was thinking about needing therapy to deal with my issues and I had the thought to use ChatGPT. Wow, it was absolutely incredible in providing me with what I needed. I think therapy with a professional would be really useful if you have no idea what your problem is, but I think if you're able to put your problem into words then LLMs can be useful.

hirvi74 2y ago
I might have to give this a try one day. In my experience, therapy as a tool to improve one's life is overrated and not worth the money. But hey, that has been my experience over a long period of time with many different providers. Everyone is different.

tonymet 2y ago

What does the business side of therapy look like ? How do they measure success ? I’ve seen patient surveys , but stated conditions are biased. Therapy doesn’t seem like healthcare . People enter the system and receive care without recovery It just seems like legitimized drug dealing. Just make the psychotropics over the counter and save the world hundreds of billions

nradov 2y ago
Therapists generally can't prescribe drugs. Usually only physicians (or PAs/NPs supervised by physicians) can prescribe psychoactive medications, especially the scheduled ones. A few states do grant limited prescribing authority to licensed psychologists (not therapists).
- tonymet 2y ago
  In practice they refer a clinician who writes a prescription based on their report and a 15 minute screening. It’s theatre

smeej 2y ago

I got new insurance this year through my state's insurance marketplace. They said my existing therapist was in-network. This was news to her. I called and spoke to them. They insisted. She called and spoke to them. They insisted. So they've been paying her $150 a week for me instead this year. She doesn't know how she ended up being considered in their network as she practices solo, but here we are. The system is vastly more convoluted than I think anybody on any side actually realizes it is.

xyst 2y ago
> The system is vastly more convoluted than I think anybody on any side actually realizes it is. This is intentional. It's a game of attrition, and the insurance companies hold all of the cards.
- smeej 2y ago
  I'll be honest, I've been really pleasantly surprised with mine. They cover mental health visits without a limit. They cover consultation with a dietitian without limit. They cover physical therapy at 60 sessions, no other questions asked. They even have a number you can call when your doctor is recommending you have a procedure to find out where you can have it done at the lowest cost. It's staffed by "nurse navigators" whose job is to dig through their data and find what the average cost has been with in-network providers for other people with your plan and find out which one saves you (and the company) the most money. If you decide to go with one of their recommendations of your doctor's original one, they'll call both providers and arrange to have the relevant documents and approvals moved for you, and then they'll send you a gift card because you saved them money too! It hasn't been flawless by any means, but it has really seemed like they're on my side and helping me through all this confusing stuff. And I'm on a marketplace plan with cost-sharing reduction because I'm making sure my income ends up being just high enough not to be on Medicaid, but to get full subsidy plus CSR, so I'm paying <$50 a month for it with $0 deductible and <$2k OOP max. I've decided they're what I wish all health insurance companies were like.

o999 2y ago

Psychotherapy is easy to acquire overseas with online meeting software with a fraction of the cost.

Ellardo654 2y ago

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