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Insurance or Private Pay?

Posted on 13 September, 2016 at 20:00 Comments comments (5352)

Insurance or Private Pay?

Things that I would want to know if I were you…. and are planning to use insurance-approved therapists… why I chose not to participate on insurance panels and what you need to know.

I encourage you to investigate all options and arrive at an informed decision regarding your mental health care BEFORE using your benefits. This may mean using your insurance, and it may mean making another choice. You can always decide to use your benefits, but you cannot “undo” many of the negative consequences of using them.

Managed Care Explained

1. Your therapist has to diagnose you to get you reimbursed.

Most clients seek therapy to improve relationships or transition through "rough patches," but to an insurance company review board, these are not acceptable reasons. To be approved for therapy sessions, the therapist must make a case that therapy is "medically necessary" which includes accentuating the problems the client is experiencing and labeling the client with a mental illness. This is often required after the first visit, and then becomes part of your permanent health record.

2. Your mental health records won't be used against you.

 Did you know that your health records may limit your ability to qualify for health or life insurance or require that you pay substantially higher premiums in the future? The personal details of therapy are often entered into a database called the Medical Information Bureau (MIB) by your insurance company. Other providers, insurance companies and even non-medical services like personnel departments may have access to this information for the purposes of evaluating you. This might never matter to you. If you are one of the fortunate individuals who has medical, life and disability benefits through your employer... you might never worry about this. But if you're someone who might ever become unemployed, self-employed, or need to purchase your own benefits- a mental health diagnosis can make the difference between preferred coverage, and none at all.

 3. Your confidentiality will not be compromised.

 My commitment to care for my clients includes a desire to maintain their confidentiality. To be reimbursed by an insurance company, I would have to label you with a diagnosis and submit frequent updates on symptoms and what is happening in therapy. These may be scrutinized by the insurance company so in order to ensure continuation of treatment, I have to stress all the things that are not going well rather than focus on your strengths.

 Your insurer can audit your records at any time they wish. This means any details that your therapist might not have included in the paperwork (perhaps for good reason) is technically open to the eyes of any "claims specialist" the company hires. Again, this might not matter to you. But if you hold high clearance for a job, or have other reasons you want your information to be held confidential- this is important to know.

 4.  You (not a managed care panel) are making decisions about your treatment.

 Many insurance companies provide payment only for certain approaches of therapy (short-term and problem-focused) and many others won't pay for family therapy, even when the client is a child and the parents are vital to the therapeutic process. Obviously, it is in the best interest of the insurance company to pay as little as possible for services, work only with the same group of providers rather than a broad range of specialists and to end therapy as quickly as possible. None of their motives address the best interest of the client. Most insurance companies require some sort of treatment plan to be submitted by in-network providers. This means that (rather than giving you the care that best fits your needs) the therapist is responsible to the (non-mental health professional) claims representative for how you are spending your time. To put it simply, an in-network therapist works for the insurance company, not you. It doesn't matter what you and your therapist decide is in your best interest, it needs to fit their matrix of decisions. It also has to fit within the allotted sessions which are determined ahead of time, not based on need.

 5. You may save money in the long run.

 Your insurance plan most likely includes a co-pay and then covers only a percentage of the therapist's fee which means you would be paying cash for a portion of the therapy anyway. You might be surprised to find that the difference between private pay and insurance co-pays are not that much more. Therapy will ultimately save you money in the long run: less money spent on stress-related illness, fewer problems at home or with your child's school behavior which may result in less time off from work.

 6. You can set your priorities for what is most important.

 We find the money to pay for what's important. We pay cash for important services like car repairs, club memberships and salon visits, all of which are valuable services but meet only short-term needs. If it seems you can't afford weekly or bi-weekly therapy sessions for a period of time (therapy does not have to be a long-term commitment), there might be ways of re-prioritizing expenses to address this important service. A few adjustments to your family budget may ensure that you can receive the professional counseling that is needed to help make life-long changes.

7. If you absolutely must bill insurance and see an in-network therapist, do your homework ahead of time.

 If they are in-network with your insurer, they should have an idea of what level of transparency your insurer expects. They likely know if their notes will be requested, if their treatment plans will be required, and what diagnoses they will need to give you for coverage. Asking ahead of time can help you decide how you want to proceed. Therapy has the potential to create lasting change and to avert more serious problems later on.


The choice is up to you….


In summary, here are good reasons to pay privately for therapy:


- You choose the therapist best suited to your needs rather than the insurance company telling you who to see.

- You have flexibility in the type of therapy, who to include in the therapy session and the length of services.

- You will have complete confidentiality. Your records will not be shared with anyone without your permission. In fact, no one else will know you are even in therapy unless you tell them!

- You won't have to worry that your health records will be included in the MIB and possibly create problems for you or your family in the future.

- You will be able to stay with your therapist even if your insurance plan coverage changes.