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Health Insurance and the Managed Care System

Whether you have a PPO or HMO, private health insurance is generally more restrictive in coverage of mental illness than in coverage for somatic illness. Historically, this was motivated by several concerns. Of course, insurers feared that coverage of mental health services would result in high costs associated with long-term and intensive psychotherapy as well as extended hospital stays. They also were afraid that too much compliance on their part would result in payments for long-term hospital stays. These factors encouraged private insurers to limit coverage for mental health services to what they often call "medical neccesity," a term that many of us have learned to wince at.

Ultimately, some private insurers have now refused to cover any mental illness treatment, while others simply limit payment to acute care services. Those who do offer coverage psychiatric disorders often chose to impose various financial restrictions, such as separate and lower annual and lifetime limits on care (per person and per episode of care), as well as separate (and higher) deductibles and copayments. As a result, individuals end up paying out-of-pocket for a higher proportion of mental health services than general health services.

In 2011, the California Association of Marriage and Family Therapists (CAMFT) conducted a survey of Licensed Marriage Family Therapists in California. One of the questions that was asked determined how many therapists in California accept and bill insurance for their clients. The answer: only around 31%. There are a number of reaons for this, the primary ones being the following:

Insurance companies require that a therapist give a mental disorder diagnosis and many people only need new skills or strategies, they do not necessarily have a diagnosis. Additionally, once a mental disorder diagnosis is "assigned" to your social security number through your health insurance it goes into a national database.
Therapists who accept insurance have a contract with the insurance company that states that if the therapist sees a client who has insuracne with that company, the therapist must use their insurance. The amount that the insurance company pays is often half of what the therapist normally charges and the therapist cannot ask the client to pay the difference.
It often takes 3 monthes for the therapist to get paid by the insurance company.

I decided not to work directly with insurance companies for several reasons. The first is that they require me to give you a mental disorder diagnosis; many people that I work with would just like new skills or some different strategies to try at home or work, they do not necessarily have a diagnosis. Secondly, many insurance companies put profound restrictions on what types of services they will cover. For example, many insurance companies do not cover marriage counseling or family counseling. The third reason is that I want you to be actively involved in determining what type of care you are receiving, with insurance, many of your choices and my treatment options are limited. The fourth and most important reason for my not taking insurance is that it severly jeopardizes your confidentiality. If I submit a bill to the insurance companies on your behalf, your confidential information is processed by the insurance company and then stored in a database. Anyone who is involved in the processing or handling of your claim may have access to your records and anyone who has a legitimate reason to access the medical database, such as insurance companies and future employers, can view your confidential records. For all of these reasons, I've decided that I would rather provide care to you at rates that are reduced and comparable to your insurance company's negotiated prices instead of accepting insurance directly.

I do not take insurance. However, many PPOs and HMOs will cover all or a portion of my fee. If you would like to use your insurance, please contact your insurance company and ask what coverage you have to see an "out-of-network provider." They will tell you what your coverage is; if possible, ask them to fax you or email you a copy of your coverage so that you can use this when you submit any documents to them in the future. I will then start to provide care to you, you will pay for the sessions as we go, and once a month I will prepare a superbill for you that you can submit to your insurance company for reimbursement.

Healing & Wholeness: Complementary and Alternative Therapies for Mental Health
A Proven Guide to Evidenced-Based Approaches

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Randi Fredricks is a Psychotherapist and Licensed as a Marriage Family Therapist MFC 47803 and not licensed with the California Bureau of
Naturopathic Medicine. © 2012 Randi Fredricks, Marriage and Family Therapist, Inc. All rights reserved. Serving San Jose, Sunnyvale,
Santa Cruz, Palo Alto, Monte Sereno, Los Gatos, Cupertino, Mountain View, Scotts Valley, Campbell, Willow Glen, and Milpitas CA.