Guest Post by Lauren Muhlheim, Psy.D., CEDS, and Alli Spotts-De Lazzer, LMFT, LPCC, CEDS
In our previous article, "Consumer Beware: What You Should Know About In-Network Insurance Provider Lists," we described how parent advocate, James Cameron, had difficulty finding qualified eating disorder trained providers among the list of "eating disorder therapists" provided by his insurer. Upon investigating, we discovered that a number of insurance companies seem to rely exclusively on a clinician's self-report when choosing their eating disorder providers. We later read, "Frustrated You Can't Find A Therapist? They're Frustrated, Too." In this National Public Radio (NPR) piece, April Demborsky explored the various insurance factors keeping patients and therapists apart. She wrote:
"Insurance companies, for their part, say there's a shortage of therapists ... But it's not that simple. Especially in urban areas, there are lots of therapists. They just don't want to work with the insurance companies."
We decided to explore how the current insurance system impacts patients with eating disorders and specialized outpatient providers who treat eating disorders. We reached out to therapist colleagues (both masters and doctoral level clinicians) in private practice (both in our local community and elsewhere in the United States) and asked them some questions about their insurance practices. Though our email survey was too informal to assume it as a representative sample or yielding a statistic, the following offers context. Of the 13 who responded, 5 were on insurance panels, and 8 were not. Of the 5 who were in-network providers, one was working towards terminating the insurance contract; of the 8 not in-network, 2 had been contracted previously.
Based on our informal survey, in this article, we explore the reasons why some eating disorder therapists do not accept insurance. We discuss the perceived benefits of specialist eating disorder therapists being insurance providers. Lastly, we examine the importance of specialist treatment availability, problems with the current insurance system, and a proposed solution.
Why Some Eating Disorder Therapists Do Not Accept Insurance
The main reason cited amongst therapists we surveyed for not taking insurance was the same reason highlighted in the NPR article: low reimbursement rates. The reimbursement rates offered by insurance companies were reported as about 50% of the market rate for the same services; some therapists said rates have not been raised in 9 or as many as 18 years. Therapists, both contracted with insurance and not, cited that they had (or would have) to work more hours and see more patients to make the same income when seeing patients via panels.
For those not on panels, perceived negatives of contracting with insurance included concerns about:
- Insurance dictating the terms of treatment, "such as what type of therapy I should be providing," length of sessions, and frequency of sessions
- Insurance curtailing the length of treatment via a limit on number of sessions
- Additional non-reimbursable administrative tasks and administrative burden, including time-consuming insurance billing
- Delays in payment by insurers (reported as commonly 2 to 4 weeks after services are delivered, and potentially longer if processing errors)
- Additional expenses associated with being Health Insurance Portability and Accountability Act (HIPAA) compliant (e.g. encrypted email)
The actual experience of those therapists who took insurance supported some of the above concerns. However, the fear many non-insurance therapists had that insurance would curtail the length of treatment did not prove true for every provider. Because of the lower cost involved for patients, "People can afford to see me for longer. By contrast, when I see patients who I am not contracted with I notice that they often want to attend less frequently or drop out sooner due to cost."
Yet for some paneled clinicians, "mistakes in getting reimbursed," "having to chase down payments," and "lots of paperwork," supported time-consuming billing issues as a realistic problem to manage. One clinician summarized her experience as:
"The drawbacks of being paneled can be extra paperwork and phone calls, necessary pre-authorizations, continuing authorizations and case reviews. It is very difficult when the insurance company dictates the type of service provided (for example reimbursing for a 90834 procedure code [45 minute session] instead of allowing a 90837 procedure code [60 minute session], allowing only 12 sessions a year, etc.) rather than allowing a professional treatment recommendation inform the length of sessions, frequency of sessions and amount of sessions."
Benefits of Being on Insurance Panels
Both on- and off-panel therapists cited two primary advantages of being on insurance company panels. The first was treatment affordability, a benefit for clients. The second involved referrals, a benefit to a clinician's business (e.g., "I get more referrals," "steady referral stream," and "those hours that are empty can be filled."). Of therapists surveyed who did accept insurance, several stated that a main reason for initially joining a panel was to increase referrals. By contrast, some therapists not on panels reported difficulty in keeping practices full, "Being off insurance panels requires more work in building and maintaining a caseload."
Among those whose practices incorporate being on panels, many cited a sense of fairness to consumers/clients/patients as their justification:
- "I feel strongly that consumers should be able to use their insurance benefits for behavioral health. I also count on my medical providers to accept my insurance and so it seems fair to me to be willing to accept insurance."
- "I like being able to provide specialty services…. It doesn't seem fair to have treatment be a privilege only for those who can only afford to pay out-of-pocket."
- "I also feel like if people pay for insurance there should be decent providers for them to see."
- "I have selected to be in-network because behavioral health treatment (especially for eating disorder patients who are often working with a multidisciplinary team and thus multiple providers) is expensive. There are many, many barriers preventing patients from accessing comprehensive quality care. I believe participating on insurance panels can reduce the burden for insured families and improve access to care for those families/patients who are insured."
Importance of Treatment Availability and Problems with the Current System
As Demborsky highlighted in her NPR piece, the current system fails both therapists and consumers. Likely nowhere is this more problematic than in the case of eating disorders. Because eating disorders can be both chronic and life-threatening, early intervention is important. If more patients had access to specialized treatment at the outpatient level before they were ill enough to require residential treatment, it is conceivable that outcomes would likely be better and money would be saved by insurance in the long-term.
The current system seems to provide insufficient options for eating disorder treatment because in many cases, it limits the availability of specialized services to those with financial privilege. Even though some non-insurance therapists mentioned offering sliding scale and lower fees to increase their treatment availability, it is safe to assume that those fees cannot rival a $10 or $20 copay. Furthermore, as one specialist we interviewed stated,"If they cannot afford my fee (although I do negotiate), I cannot help them." She added, "There are certain clients that would otherwise come to see me but can only afford to see someone under their insurance plan." And another said, "The unfortunate reality is that none of my colleagues take insurance, so quality treatment is offered to people who are financially capable of paying out of pocket. It is an unfair system, but at the same time, I am not willing to lower my fee and accept insurance."
On the other hand, even though taking insurance serves those with eating disorders, it can negatively affect the therapist's business, bottom line, and effective use of time. It is well documented that graduate and doctoral programs generally do not include much, if any, eating disorder training. So becoming an eating disorders specialist is often an expensive and time-consuming path (e.g., training, certification, continuing education, conferences, supervision, and consultation fees, many of which are costly.) For specialists who are not HIPAA-covered entities, contracting with insurance often immediately requires initial and then ongoing added fees to maintain compliance. Billing services for insurance may be needed to manage the increase in billing paperwork. Furthermore, the complexity of eating disorders usually requires additional time investment by a therapist striving to provide treatment at, or above, a standard of care. "None of this is typically compensated since, unlike other professionals (e.g., lawyers), therapists don't generally get paid for time spent outside of the usual 45- or 60-minute session." "The extra collaboration (with doctors, registered dietitians, families, schools, etc.) required to responsibly treat clients with eating disorders is significant. Therefore managing insurance paperwork on top of what is already necessary for great care is too cumbersome and time-consuming."
An easy solution for all involved—therapists, patients, families, and insurance companies—is unlikely. However, a potential starting point would be to lobby insurance companies to have specialty provider lists for eating disorders and offer a higher reimbursement rate for seeing an eating disorder specialist. This might encourage more qualified therapists to join panels, thus enabling more patients to be able to use their insurance benefits to get quality treatment.
To our esteemed colleagues who took the time to thoughtfully answer our questions, thank you!
If you are a consumer who has an experience with outpatient insurance panels and eating disorder treatment that you would like to share with us for a future post, please email us at:
Lauren Muhlheim, Psy.D., CEDS, is a Psychologist and Certified Eating Disorders Specialist practicing in Los Angeles. She specializes in providing evidence-based psychotherapy for adults and adolescents.
Allison Spotts-De Lazzer, M.A., LMFT, LPCC, CEDS, is a Licensed Marriage and Family Therapist, Licensed Professional Clinical Counselor, and Certified Eating Disorders Specialist practicing in the San Fernando Valley, Los Angeles area. She is also the creator of #ShakeIt for Self-Acceptance!®