Wednesday, November 14, 2007

Why Shrinks Don't Take Your Insurance

Many psychiatrists in private practice don't take insurance, or don't 'accept assignment.' They require the to patient pay them and then the patient can submit to his health insurance company and reimbursement is made directly to the patient. This often means that the patient, having gone Out-Of-Network, has a higher co-pay &/or a higher deductible, and the hassle of paperwork. Generally, if a patient sees an In-Network psychiatrist, they make a copay and the hassle of getting the rest of the money falls on the doctor.

This means that access to psychiatric care is limited to those who have the money to pay up front, the wherewithal to stick their statements into an envelope and send them to the insurance company-- after they've called a separate managed care company, gotten
pre-authorization, had Dr. Shrink submit a treatment plan, yada yada yada, as Mr. Seinfeld would say-- and the willingness to take on the financial risk that the insurance company might find some reason not to reimburse. By not accepting assignment, the doctor has greater control about little things like getting paid, but the patient supply becomes limited in a way that restricts access to care. Patients who want the financial and logistical benefit of remaining in their network are often surprised to find that it's difficult to find an in-network psychiatrist (even though the insurance company has this large list of providers) or that those psychiatrists aren't taking patients, or that they see patients for brief med checks but not for psychotherapy, or that it's hard to find a psychiatrist who feels warm and fuzzy enough. From the patient's point of view, it's not fair. There's a reason for this: it's not fair.

So why don't all shrinks accept assignment, why aren't they lining up to be members of insurance networks who would funnel lots of patients their way?

Let me tell the story from the psychiatrist's point of view. If a psychiatrist doesn't accept assignment, s/he sets his own fee-- generally what the market will bear-- perhaps decides when and if and for whom to slide or even forgo his fee, and he gets paid by the patient. This one is easy.

If the psychiatrist accepts assignment, he agrees to practice according to the terms of the insurance company. He sees the patient and collects the copay. Maybe it's a flat $30 co-pay. Maybe it's 80% for the first 5 visits and 70% for the next 5 visits and 60% for all the visits after that oh but the patient is only covered for 25 visits a year and the psychiatrist has agreed not to balance-bill as part of the deal. I don't know what happens if the patient needs a 26th appointment, I believe the doc eats the fee or simply doesn't offer the extra sessions. At any rate, the doctor now needs to figure out how much the patient has to pay and it's his responsibility to collect this. Oh, but it's not 80%/70%/60% of HIS fee that the insurance company will pay, it's 80% of what the insurance company has decided is Usual & Customary. And if they decide that Usual & Customary Rate (UCR) is $10/session or $25/session or $50/session less than anyone in town charges, then that's what they pay on. And while it might be a piece of cake to calculate if the the UCR was say $100/session and the patient paid $20 and the insurance company paid $80, well it's a pain in the neck if the UCR is $97.84/ session and you have to keep count of the sessions and figure out the percentages. Should I mention that different insurance policies by the same company can have different payment rates so someone has to call for each patient, verify the insurance, find out the terms,
co-pays, deductibles, and this involves sitting on hold and dealing with assorted prompting menus. And if the insurance company finds a reason Not to pay, the doc is stuck--he can't bill the patient, he's just out the money. For a psychiatrist who does psychotherapy and sees maybe 8 patients/day at an insurance company discounted fee, well, it can be a big deal to have the insurance issues. And if the patient has two insurance policies and they each have different terms and they each decide not to pay because the other is the primary insurer-- oy! So not only is the psychiatrist taking his chances on getting paid, but he now has to have a secretary, an overhead expense his I-don't-accept-assignment compatriot may or may not want or need. And he now has to have an office big enough to accommodate secretarial space. I'll also tell you that while the secretary is paid an hourly fee, his ability to get paid is only as good as her motivation to follow through on dealing with the insurance companies, refiling denied claims, clarifying primary versus secondary insurance and getting the amount of the co-pays correct.

So how and why does any psychiatrist accept insurance? Basically, the insurance companies pay okay for short appointments with a psychiatrist. While there are time standards for coding psychotherapy appointments (25 minutes, 45-50 minutes), nearly everyone charges more per hour for a 25 minute appointment than for a 50 minute appointment, even many of the out-of-network docs. So a psychiatrist who sees two patients in an hour makes more than a psychiatrist who sees one patient in an hour, and often the insurance companies-- perhaps eager to encourage their policy holders to seek psychotherapy with a cheaper provider-- will pay a reasonable amount for a shorter session-- perhaps they make this worth doing. And "Med Management" 90862 for those of you who like
CPT codes-- has no time restrictions on it. If a psychiatrist can squeeze four or five patients into an hour, he can do okay by the insurance companies.

Okay, I googled it and this is what I found: for Medicare, based on 2004 rates, irrespective of geography (so I guess a national average as each state has a different fee), the allowable fee for a 45-50 min psychotherapy session with medication management is $103.80. Half an hour is allowed at $71.31, and a 90862 med management with no time stipulation goes for $51.15 (here
is my source)-- if you can see a patient in 10 minutes, you're doing as well as some lawyers. I'm not sure I'd call it psychiatry, and I'm not sure how long I'd survive or how much better the patients would get, but hey.


Gerbil said...

Alternate title for this post: "What Gerbil has to explain at least 25 times a week."

I have recurring dreams about explaining what exactly is the UCR. ("No, it's not your own provider's rate...") Oddly enough, most of these happen right before I get up for a middle-of-the-night pregnant potty run. Coincidence?

Roy said...

Hundred bucks an hour! That's about what I pay my electrician and a bit less than my plumber. And I know they don't have to deal with authorization forms and third party payers.

Dinah, you've done a great job of capturing the joys of private practice. This is one of the reasons I gave up my practice, as I accepted Medicare, BCBS, Aetna, MDIPA, Medicaid, and several others. I started out doing my own billing, filling out HCFA 1500 forms by hand, but then contracted with a woman (Dottie... she was great) to handle my billing after figuring out how much money I lost by not getting the billing right or not following thru with all the pesky details one must track to finally get that check 2-4 months later (sometimes 6-8 months). Because of this frustration with managed care, I have noted that increasing numbers of PCPs and other physicians are not taking insurance.

It isn't fair, I agree. Insurance companies need to make it as easy as swiping a credit card to submit a claim and get paid. Many docs would gladly accept lower amounts if it were easier to get paid. My PCP has 3 full-time employees whose jobs only involve doing things necessary to get paid (this does not include the billing company he uses which does most of the backroom work).

Dinah said...

I don't generally give patients the whole "why" explanation. May you have sweeter dreams.

No insurance, no Dottie. I used to be in a group, 3 billing secretaries, I was there for 7 years. I took Blue Cross, nothing else. The month I left, my income quadrupled. I never did figure out why Blue Cross would send checks for $12.44. What percent of what is that and why???

Anonymous said...

Yeah... it sucks. It sucks worse for us who are insured. Cause we are paying for the insurance (usually a % shared with the employer), the copay, and lots of $$$ for the meds.

In my part of the world, there are only three major insurance companies and each has two major plans. So a provider can take those, and out of network the rest. I was in the healthcare biz as a bean counter, so I know what crap billing can be.

However, lots and lots and lots of patients are no being served.

Gerbil said...

Dinah: and that is why they call me! ;)

FooFoo5 said...

I weigh the perceived benefits of working alone, and conclude it much more challenging, instructive, and fulfilling to 1) work as a member of a treatment team (the constant exchange of ideas, the oversight, and the atmosphere of challenge), and 2) to have an assured monthly direct-deposit for my time and contribution. Not that it's everyone's cup of tea, but the perks of "academic medicine" is really quite phenomenal. Several small examples: I could never afford to subscribe to the journals I read, but I have unlimited access, from home, to the best available; nor could I ever afford to attend lectures or conferences conducted by "cutting-edge" researchers and experts, but I have such access here; and I am able to work with the population with which I have the greatest affinity and skill. As Jimi Hendrix said at Monterey, "Everything's good; no buttons to push..."

SteveBMD said...

I was a psychiatry resident for three years at a prestigious west coast psychiatry program (I resigned to deal with some personal issues, and may return soon). Upon graduation, most of my co-residents eschewed the group-practice, academic, VA, or HMO settings in order to go directly into private practice. The rationale? Greater income, of course.

Never mind that 50-60% of the prospective patients in this community can't afford the outrageous (yet market-appropriate) fees they're charging.

Or what really bothers me, is the fact that these newly-minted psychiatrists haven't even experienced the "assignment" issues Dinah describes here. Who's to say that these patients aren't incredibly rewarding and interesting, and insurance is actually not that bad?? (You won't be living on the street!) Otherwise, you run the risk of "cherry-picking" those patients who (a) you can tolerate, (b) who won't cause any trouble (like requiring hospitalization or constant phone calls), and (c) who can pay your fees. In my experience, the psychiatric patients who need the most help DON'T fit neatly into one (or any) of these categories.

I don't know, I just think many of my colleagues have a strong sense of entitlement (and greed) which trumps their commitment to helping the community and making a positive change in the lives of people who need them the most.

Rach said...

Just thinking about the canadian system, and the differences to what you posted, DInah...

We're a socialized system, right? So one would think that it makes it easier for the patient. It does. I just need to show up to the doc's office and show my Health Card (green, with a picture of me that looks like I'm being murdered from the chin down). My psychiatrist then electronically bills the province for seeing me however many times he's seen me, using some billing code.

Where it gets complicated is when you involve services not covered by the provincial insurance - copying files, writing letters, phone calls (in my case, the shrink is happy to call me for 2 minutes... he doesn't have a secretary to relay messages. So I guess he's SOL. If I need to talk to him longer, I probably want to see him face to face). Most private supplementary insurance companies (mine included) will not cover these types of services, which means patients must cover out of pocket. Grumble grumble.

I don't think I'd want Gerbil's job, but then again, I don't think I'd want Roy's lady's Dottie's job either.

Alison Cummins said...

fmvlfpc"Insurance companies need to make it as easy as swiping a credit card to submit a claim and get paid. Many docs would gladly accept lower amounts if it were easier to get paid."

Gosh. That's exactly what my insurance company - the Quebec government - does. Meaning that I was able to see a psychiatrist when I was earning $300 per month and could barely get out of bed.

Not only that, that insurance company pays for meds with a $25 monthly co-pay. For everyone, everyone the same.

Oh - paying for insurance - all employed people pay for it. It's 6% of your income. 2% comes off your salary, 4% is a payroll tax paid by your employer. (IIRC.) Self-employed people pay it directly. If you're salaried it comes off your paycheque before you even see it. Gross salary $20,000 per year? Insurance is (IIRC) $400 per year. I never hear people complain about unaffordable premiums. (Well, employers do, actually.)

Really, does our system suck that much?

DrivingMissMolly said...

Here's the bitter patient scenario.

Patient is depressed and has been chronically depressed for years. She now has anxiety and has been diagnosed with a personality disorder (the only reason she knows this is by accident). As a grad student she saw the Health Center Shrink (a second year resident) for $10 an apt., but since she can no longer attend school because of her illness, she no longer has this option. She gets a list from Resident of people he thinks are good psychiatrists.

Patient's insurance changes yet again. The university where she works changes medical insurance companies almost every year, so every year Patient must learn new RX co-pay system and who she can see in an emergency. There is also that moment when she holds her breath to see if the primary care physician that she has had for about 13 years and 10 different insurances is covered on the new plan.

Everybody wants their money, but the system has not caught up with the "consumer" way of doing things. I have been going to the lab my Shrink sends me to in order to get my lithium levels checked for about a year. I have no idea how much this costs as I have never received a bill, and although I have called the university twice to get this figured out and tried to talk to someone the last time I had blood drawn, no one can tell me how much I owe and who to give my insurance information to. The next time I see Shrink (I can't afford to see him now because I am spending almost $800 tomorrow (with insurance) to have all my wisdom teeth pulled) and he wants me to have lab work, I will say "NO" and will briefly tell him the situation as it appears that no one else can or will help me (I am assuming he can because docs are still gods). I asked the tech the last time if I could have a copy of my bloodwork results and he said, "You have to ask your doctor." I asked doc's sect'y and she said; "You have to ask the lab."


Last time I had an appointment with Shrink I did not show up or call. Bad, Bad, Lilly, but I spent about 5 days in bed, unbathed and depressed. I did not have the ability to get up and go, and knowing the cost was going to be $190 didn't exactly help motivate me.

I have a nice $100,000 life insurance policy that would help my family. The suicide restriction was 2 years and I have worked here about 11. It isn't worth it to try to live and give yourself an existence when everything is against you and you are at your most vulnerable. This is what I'm up against.

Honestly, every time I spend that $190 on the Shrink, I think, maybe I'd feel better if I just went to a spa. You're right, he is NOT "warm and fuzzy." With my DX and history and the fact that I have had multiple shrinks, I feel like I "have to take what I can get."

I picked up D magazines issues with "the best doctor's in Dallas." Yes, my Shrink was in there, so what gives? I want 50 minutes of non-stop intense SOMETHING for $190.

My greatest fear is ending up homeless and mentally ill with no money or family to help me. I got to thinking the other day, that maybe, if that was the case, I would get better care.


Anonymous said...

Dinah, Excellent write-up of private practice insurance hell! I'm in private practice with my husband (also a shrink) in upstate NY and I can tell you the hassles of taking insurance are enough to ALMOST, but not quite, make me want to stop practicing. For ten years, I ran the practice(my husband is brilliant but administratively challenged)in between taking care of patients, the house, the kid, the marriage and my personal life (about five minutes in the day excluding sleeping). We were working super hard, and always running in the red financially. We were robbed of scads of money by insurance companies because of the diabolical maze of paperwork that takes so much time to negotiate, and which we couldn't because of clinical demands and the occasional need for sleep and a potty break.(I'm convinced this is a deliberate strategy of the insurance industry.) It just got too much, and it was either close down or hire an office manager. We hired an office manager, about six months ago. We were very careful in our interview process, and lucked out and got a gem. We advertised the job as 20 hours a week. Within 3 months she was working 40, and couldn't get it all done. She then hired an assistant for herself. Her assistant works 20 hours a week. I work 20 clinical (billable) hours per week, my husband 40. It takes 60 (efficient) woman hours of support per week to run the practice reasonably well. No wonder we couldn't do it on our own. This is clearly unreasonable! Why should it take so many support hours to run a low-tech out-patient 1 and 1/2 doctor psych practice? It shouldn't. It's crazy (and that's my professional opinion)! We revisit the idea of becoming a cash only practice often. We could lower our fees ( for example, by charging for 10 minute increments of consultation time) and make more money, easily. Many patients already pay $40 to $50 copays for the session. We think most people would make the transition, except for the following sticking point. SOME INSURANCES WILL NOT PAY FOR YOUR PRESCRIPTION IF YOU ARE OUT OF NETWORK. How this can be legal eludes me. Still, that's the way it is. This reality would force patients to go to their family practice docs, who, for various reasons (the most obvious of which is that they are themselves totally overloaded),will provide sub-standard care, and as the final kicker, will be super pissed at us for what would justifiably feel like a dump. The community is too small, and we don't want to generate that kind of bad feeling. So, we're stuck in insurance hell. For now. I haven't stopped trying to figure out how to escape.

Aqua said...

It sounds like a bad deal for the psychiatrists trying to bill insurance companies, and it sound like an even worse deal for the patients trying to do the same.

I can't imagine how many people who are severely ill can get it together enough to bill their insurance company. I honestly don't think I could have managed to collect money from my insurance company for the first 5 years of this MDE. I don't even know if I could now.

I missed out on dentist, medication, physiotherapist and massage therapist claims during that time, all because I was to sick to to keep the receipts, or find them when I did keep them, or manage to do the paperwork if I got that far.

I am glad to say I am Canadian and we see psychiatrists for free. That doesn't mean it's perfect, or even fair though. It took me years to get in to see a psychiatrist. I was on one person's waiting list for 2 years. Luckily I gave up on that person and went for a consultation at my city's mood disorder clinic.

I was lucky enough to meet someone I was immediately comfortable seeing and he happened to practice therapy. From what others tell me it sounds like many psychiatrists here are for medication only.

I know people who need help and simply cannot find an available psychiatrist, or if they do they do not connect with the person and are left trying to find one when there are few to be found.

I wish someone would challenge the insurance companies and the burden they place on both psychiatrists and their patients. We do after all pay for our insurance and I did not ask to get sick anymore than someone with heart disease asked for their heart problems.

Midwife with a Knife said...

Sometimes I wonder how people who work at insurance companies, or at least those who establish the policies/rules can sleep at night.

NeoNurseChic said...

I do not consider myself to be a lucky person in any way, shape or form. (This January will be 7 years since I got my constant headache, and I'm trying to remember what kind of mirror I must have broken!) HOWEVER, that being said - I am VERY lucky to have found a psychiatrist who does therapy, that I click very well with, and who allows me to come for a very low price even now, when he is finished his training and is an attending psychiatrist. I only had to pay $5 more than when I started seeing him 3 years ago, which was a huge help since even though I have a good job, I still can't afford to see a psychiatrist as often as I see this doctor. The psychiatrist I saw before him was charging me a reduced fee of $125/appt, and I was going broke paying for it - which was why I started seeing this doc when he was a resident.

If I hadn't started working with someone like him, I would be dead by now - and I can guarantee that. It's not just some general lightly thrown around statement. I even said to my boyfriend the other day (who doesn't really understand this whole therapy thing and makes fun of it all the time) that my psychiatrist is the reason I'm still alive....but my bf still doesn't really believe it. I am 100% sure that this is true.

Guess this unlucky person found luck at least with one thing! I feel really badly for the people who just can't get access - even though I understand how horrible it is for a psychiatrist to take insurance. When I was on an HMO for 2 months, I had to sign over all these wavers for my parents to talk to them because I couldn't take it anymore. I was physically sick, and the insurance problems were making it so much worse. I actually did lose around $400 that I never re-claimed simply cuz I didn't have the energy to jump through their hoops - and that's when I started on the stand that the people who need insurance the most are the least-able to jump through all those hoops and fight through all that red-tape.

I'm on an insurance warpath today since they're refusing to cover liquid O2 for me....soooo an insurance rant is just what I needed after spending the afternoon in tears over this! They know how to find your breaking point and stand on it....IMHO

Unknown said...

Question: what is a reasonable fee to see a psychiatrist? I live in Washington, DC and after doing some research online and then following up with a call, I found a psychiatrist with exactly the specialties I'm looking for (psychosomatic disorders, speech disorders, depression, and anxiety), except he does 2-hour initial session and 45-minute follow up sessions and charges $800 for the initial session and $400 for the followup sessions. Is it just me or is that just plain outrageous and greedy? Of course, he doesn't take insurance, so I would have to file the claim myself, and my insurance will only pay about $125 of the session (if they even decide they will pay any of it). Actually, they won't pay anything because I'd have to satisfy a $250 deductible when it's out of network.