Are more psychologists serving only self-pay patients? Difficulties with insurance companies highlighted

Mark Spellman Ph.D, 2020 CPA treasurer and member of the legislative committee

The complaints documented in a 2019 survey released by the Connecticut Psychological Association (CPA) illustrate the on-going difficulties that psychologists have with insurance companies.

From understanding administrative requirements, to filing claims, following up on reimbursements, submitting further documentation, waiting on telephone hold, and accepting low reimbursement rates, the range of complaints covers just about every step of the process.

It would be no wonder if, as recent news and opinion articles posit, fewer and fewer psychologists are agreeing to join insurance panels, leaving patients with nowhere to turn.

While it is difficult to ascertain just how many psychologists currently accept insurance since insurance companies are loath to release their numbers, calling it proprietary, the outlook may not be as dire as some would claim.

The CPA survey, for instance, found that 86 percent of the responding psychologists accepted some form of insurance. However, the study also shows that 70 percent have resigned or plan to resign from specific panels.

“Most of our membership takes at least some insurance,” said Mark Spellman Ph.D, 2020 CPA treasurer and member of the legislative committee. “But then if you look at the numbers more closely, you see that people who are resigning from insurance are definitely resigning much more from one particular panel. It is not people saying that they are done with taking insurance altogether.”

Nationally, the American Psychological Association has shown that only about 21 percent of psychologists surveyed said that they saw mostly self-pay clients.

“It is hard to track that information other than what psychologists self-report,” said Jared Skillings, Ph.D, APA’s chief of professional practice, “Data bases are all kept individually by the insurance companies and they keep it close to the chest.”

Most complaints that the APA has heard are about reimbursement rates, an overload of paperwork, and mental health parity.

In Massachusetts, the numbers, and the issues, appear to be about the same.

“I would guess that the vast majority of psychologists here accept some type of insurance,” said Jennifer Warkentin, Ph.D, director of professional affairs for the Massachusetts Psychological Association. “But, what I hear is that the low payment rates, the administrative burden, and unfair business practices are the major issues.”

Unfair practices include the lack of transparency with mental health coverage and a trend of not keeping network lists up to date. In Connecticut, the CPA study was useful in helping the organization advocate for a mental health bill that will require insurance companies to share their plans for achieving mental health parity with the state’s insurance commissioner.

“There is a Milliman report that suggests mental health parity is worse compared to physical health than it has been in past,” said Skillings. “Our attorneys at APA are a part of a coalition led by former Representative Joe Kennedy to advocate for state laws like one in Connecticut to require insurers to be accountable.”

“It’s about price transparency,” he added. “If you decide to remodel a kitchen, you get an estimate of the cost before you start. But if you are in the ER, they may never have a conversation with you about costs or whether you are in or out of network. And with modern technology, we should be able to do that. The health care system has chosen not to prioritize transparency in their practice. ”

In Vermont, a state that prides itself on being somewhat ahead of the curve, mental health parity has been in place for some time. They are now working on ensuring clarity with the way insurance companies list their in-network resources and negotiating higher rates for Medicaid.

“Pay rates were higher in 2006 than they were in 2019,” said Milton J. Marasch, Ph.D, insurance chair for the Vermont Psychological Association. “They are finally just beginning to come back up to 2006 rates.”

An accusation often thrown out at therapists trying to negotiate or legislate better rates is that they are only in it for the money. It’s not a fair claim, however, said Spellman.

“The important insight to realize in the CPA survey,” he said, “is that psychologists are taking in-network payments out of a sense of social justice and a desire to provide access to people who cannot make payments on their own.”

But when they are not paid a fair rate, he added, it creates an unbalanced situation for therapists. One comment on the survey mentions receiving a check for $9 for a therapy session.

“When you sign up for a panel out of a sense of social justice commitment, and a lot of our membership does feel it is the right thing to do,” he said, “but then feel like you are being exploited on those social justice values, it makes you want to resign from the panel.”

The main takeaway is not that psychologists are dropping insurance but that especially with some insurance companies, the system is not working to support a relationship.

“Some groups have painted therapists as being greedy,” said Warkentin, “but a lot of our members want to see patients who use insurance and they are willing to do the basic things necessary to work with them. But they want to see clients and get paid living wage and it is not happening now and it won’t until health plans make some changes.”