Beyond managed care: Out-of-network psychotherapy in NYC

For the purpose of this conversation, psychotherapists in NYC (the market is quite different elsewhere) can be roughly divided into two camps: those who accept insurance as an in-network provider and those who do not.

When we talk about psychotherapists, by the way, we're including a whole lot of folks: psychologists, psychiatrists, clinical social workers, marriage and family therapists, even psychiatric nurses. For some help on sorting out just who all these characters are, you can check out an article I wrote about finding a psychotherapist in NYC.

What's the difference?

Going in-network refers to the decision that some therapists and other health care providers make to align themselves with health insurance companies by joining one or more health insurance panels. This means that they agree to accept any insurance plan member as a patient, and to charge the health insurance company a pre-determined rate, which is paid directly by the insurance company, on the insurance company's terms, plus, of course, a co-pay from the patient.

If you have health insurance, it's probably the case that all (or nearly all) of the doctors you've seen in New York are in-network with your insurance company. In other words, they "take your insurance."

Why would a therapist not join a panel and go in-network?

To start with, let's lay out the advantages of going in-network:

In-network therapists have a steady flow of patients who find them on their insurance company's website or in their member handbook.

In-network therapists only charge a co-pay from patients and never have to negotiate a fee (the co-pay and fee are both set by the insurance company, and are non-negotiable as per the insurance company's regulations).

Patients are accustomed to a particular system from years of working that way with doctors: paying a simple co-pay, giving the receptionist their insurance information, and having everything else just taken care of by the doctor's office.

The managed-care swap meet is a veritable bonanza--if you don't take insurance plan X, but you do take insurance plan Y, you can simply hook up with a fellow provider who takes insurance plan X but not Y and swap referrals.

For most health care providers, particularly physicians, aligning their practice with all the popular health plans in the area is an obvious choice.

Not so for psychotherapists:

Psychotherapists are paid poorly by insurance companies. That's because while there are not a lot of great therapists, there are plenty of mediocre therapists willing to accept these low fees and the hassle that goes with it. Your insurance company figures a therapist is a therapist, and as long as someone is willing to do the work at a given rate, then you, the consumer, should see whomever is available. To them, all therapists are the same. But the quality of psychotherapists varies wildly, much more than with doctors. The training to become a physician is highly-competitive (there are a mere 134 medical schools in the United States, compared with thousands of options for training in degrees that lead to a license to practice psychotherapy).

Therapists' small, generally solo-practices, would be swamped with paperwork or need to hire full-time insurance specialists to deal with all of the paperwork from insurance companies (most doctors offices have several insurance specialists, but their larger, commonly group-practices, can absorb this cost).

They don't call it "managed care" for nothing. Insurance companies demand regular updates on progress, dictate treatment plans, dramatically limit the number of covered sessions (often to just a few), and never include the patient in decisions about what sort of care is called for. Your therapist will be forced to spend time on the phone with insurance company bureaucrats, and that's time that's not devoted to providing the best care.

Insurance companies insist that, provided a therapist has availability, he or she must see any appropriate patient who inquires; he or she cannot turn patients away, for any reason. A responsible therapist, however, needs to help patients make good decisions about who is a good fit for them, and be able to refer patients to a more appropriate therapist. With managed care, this isn't really an option.
 

Insurance companies have a right to demand details about the therapy. When you sign up for therapy with an in-network provider who will accept payment from an insurance company, you are consenting for that therapist to share any details the insurance company asks for.

Paperwork, paperwork, paperwork: Not only do therapist have to submit forms and take calls to justify ongoing treatment, they must submit regular paperwork and bills to insurance companies and wait to get paid. For a psychotherapist in solo practice, this paperwork adds up to volumes, which means they're going to be less available to you.

As health care premiums are increasing, employers are asking their employees to shoulder an increasing portion of their health care costs. This means purchasing plans for employees that have higher co-pays, and less coverage. As a result, staying in network might not save you much money at all.

This therapist sees the choice as a no-brainer. Yes, there's more work to do in getting your point of view in front of prospective patients. Yes, there's less of a guarantee of income. But for me, it comes at far too great a cost to my patients.

What if I've got an HMO, or I just don't have out-of-network coverage?

You might be really surprised. Plenty of therapists in NYC are interested in working with all sorts of people, not just those who have tons of money to spend on therapy. You might be shocked at the number of therapist who'd be willing to offer a sliding-scale fee. This isn't just for the unemployed, or people with a very low income.

Different therapists work differently. In New York, I've heard of therapists who have a set fee that's lower than their full fee, and offer a certain number of therapy slots at that rate until those slots are full. Others base all of their fees on an ability to pay. If you've got a moderate income, you'll be offered a moderate fee. More than anything, if you're in NYC and you're struggling to afford therapy and don't want to stay stuck inside your in-network options, don't be afraid to ask. Find a therapist you like and find out if he or she is willing to slide their fee; you could be pleasantly surprised.

So does this mean my insurance is worthless for psychotherapy?

Not necessarily. In fact, especially in highly-competitive industries in NYC, where a number of companies still provide excellent health insurance for their employees, and where going out of network is necessary for finding a good therapist, many plans have great out-of-network coverage.

This sounds like a lot of work...

Really, not at all. I'll walk you through it:

Step one: Find a great out-of-network therapist

Rather than logging onto your health plan's website and typing in your zip code to find the closest therapist to your NYC neighborhood, start by talking to your family, friends and colleagues--anyone with whom you feel comfortable talking about your need for a therapist. Word of mouth referrals are a great way to find a good match. Yes, you might have to travel a bit further, but it's worth it.

If that's not an option, head to the internet. More and more therapists in New York have substantial websites that can give you a real flavor of how they practice therapy, how they see the world, and even how they help with some of the specific issues you're looking for help with.

Make several appointments

There's no shame in shopping around, and a good therapist won't mind meeting with you with the understanding that you'll be talking to a few therapists before making a final decision. In fact, if he or she isn't, cross him or her off the list.

Know before you go

Put a call into your health insurance company's member hotline. Commonly there's a separate number for mental health (or "behavioral health") that can be found on the back of your insurance card. You'll want to ask a few questions:

Do I have out-of-network mental health coverage?

Do I need to meet an out-of-network deductible?

At what rate will I be reimbursed?

Is there an annual limit on the number of sessions or the total amount that's reimbursable?

What's the process for getting reimbursed?

Don't be discouraged

Perhaps you have a plan that doesn't have any out of network coverage. Does that mean you're stuck?

Not at all. While it might seem like bad economic sense to have health insurance with in-network coverage (such as an HMO), it might make better mental health sense to skip using your insurance altogether and pay out of pocket. Chances are you'll get much better care. And, if you ask, plenty of out-of-network therapists will offer you a sliding scale fee.

Even if it doesn't seem like you've got great coverage, bring this information to the first session with the therapist you want to work with. Because out-of-network therapists are free to set their own fees, we're generally very open to working on a sliding scale that factors in your particular insurance benefit as well as other factors that inform your ability to pay, including your health savings account, if you've got one.

Once you've set a fee, you'll need to pay your therapist directly as you go, save your bills, and then submit them to your insurance company for reimbursement. Typically this involves filling out an online form and mailing or faxing a copy of your bill to your insurance company. It can be a bit of a hassle at first, but once you've got a system down, it should only take a few minutes, and you can file a few months' worth of claims at once. Depending on your coverage, your insurance company will send you a check within a few weeks.

It's a bit more work, but the odds are huge that the result will be better care and better help. After all, getting help in therapy is going to involve a lot more work than a few phone calls to your insurance company anyway.