Using insurance, part 2

Not the catchiest title, I know. I want to talk a little more about using insurance for mental health care. Joy gave some excellent insight into what you need to know about the process of using your benefits. I want to give you some cautions. With all the recent media coverage of mental health, not to mention the events of the last couple of years, most of us are more aware of our mental health than ever before. The stigma around mental health issues is changing. Insurers are responding, and now most commercial insurance companies offer improved coverage for mental health care. “That’s great!” we say. That will help multitudes of people get the care they need. But, and this might be a big “but,” there are a few things most people don’t realize about using insurance for therapy. I will not throw the commercial insurers under the bus here. My goal is to help you make thoughtful choices about paying for your care (and some of this may apply to other covered care as well.)

Insurances are businesses.

They are organized and run to have revenue (income) from the services (insurance plans) they provide. No business stays in business without making more income than what it spends. So they charge a fee (your premiums) for services and want to keep those competitive, while working to keep expenses (payments) as low as possible. What does that mean? It is in their long term interests to keep costs as low as possible. That means not paying for some services, or negotiating lower rates with providers, and using managed care. They provide a valuable service for many, many people. But their focus is on keeping cost down.

Insurance pays for medically necessary treatment.

What does that mean? That means your therapist must give you a mental health diagnosis based (in the US) on the DSM-5-TR. That may not be an issue for some – many mental health concerns, starting with anxiety and depression, are recognized as needing professional treatment. What about marriage therapy to save your relationship? Or processing grief after the loss of a loved one? Or improving your quality of life by working on how you handle stress? These are very good things to work on in therapy, and it may feel absolutely necessary to your overall health and well-being, but they generally are not considered medically necessary. (And your therapist cannot just give you a diagnosis so that insurance covers treatment – that is insurance fraud.) As for preventative services so you don’t end up with a diagnosis, well… Ahem. Let’s hope for some improvement.

It goes on your medical record.

You should also know that diagnoses remain on your medical record. They follow you to new insurance companies and can affect premiums or coverage as a “preexisting condition.” This can affect future job prospects, especially those that require higher security levels (or they become media fodder if you run for political office…). Side note: HIPAA is not quite what most think it is. Follow the link to find out more about the requirements and loopholes.  

You and your therapist aren’t in charge.

When you bill insurance, insurance companies (their protocols and standards) become the determining factor in therapy, not what your therapist or you decide is most helpful. They may periodically review your records to determine if treatment is “appropriate” (not whether you feel it has been helpful). They may also cap the number of sessions or how often they happen. This review process can even happen years later, and now you’re stuck paying for something you thought was covered.

In the end…

Using your mental health insurance benefits might make the difference between getting the help you need and not getting it. We get that. We also want you to be informed. Using your insurance isn’t your only option, even if funds are tight. Many therapists offer some kind of financial help. Don’t be afraid to have that financial conversation with your therapist. (Money can be a therapy issue too!) We’ll do our best to give you good options and help you make the best decision for you.