Can’t therapists AT LEAST take insurance? And who we can complain to!
I was deeply annoyed to find that the therapists I was most drawn to were the ones not taking insurance. Don’t they understand how much everything is already? Shouldn’t they be compassionate about how hard it is?
Here’s the thing: yes, and sometimes overly yes.
Simply put, therapists are impacted by the mental health industrial complex*, just as clients are. Most of us would love to take insurance, and feel immense guilt when we don’t (read: can’t). I am one of these therapists. We feel like shit about it. Here is my take on what makes it so difficult for those who do take insurance, and why I don’t.
Remember: The ultimate goal of insurance companies is to make money, and thus make attempts at getting money owed by them intentionally confusing, frustrating, and time-consuming.
More than anything, insurance companies can and do disrupt treatment. Insurance companies can decide when you’ve had enough therapy (completely arbitrary) and can just stop paying therapists for sessions. They can often determine how many sessions they think you need upfront.
Insurance companies always require “medical necessity,” which means you must meet criteria for a DSM-recognized (I’ll get to that eventually) disorder to “justify” ongoing therapy. Stress from living in a capitalistic, racist, sexist society? Doesn’t cut it for insurance. Justified anger from being overworked and underpaid? No dice. The insurance companies need you to be the cause of your pain.
What this also means is therapists who work with insurance have to diagnose you at your first session. They are expected to have a complete assessment of your suffering and its cause after one fifty-minute meeting. This is unrealistic and feels unethical.
Even if everything works out, it takes months for insurance companies to pay therapists for completed sessions. And even then, the pay is notoriously low (typically $80-90 a session in CA). Remember, we’re still paying taxes on that.
When there is a dispute, therapists must interact with insurance company employees who have ZERO training in mental health conditions. The companies will make decisions about your treatment having no knowledge about what is best for you, only what is best for the company. These disputes are notoriously extremely time-consuming and frustrating.
Insurance companies can audit therapist notes. That means they can look through the therapist’s progress notes about your time together. That can feel really quite invasive (though we often try to keep our notes vague for this reason) and they can make treatment decisions based on what they find.
Finally, and this one really grinds my fucking gears. If insurance companies make mistakes (pay for sessions they later deem unnecessary, overpay by mistake, etc.), they will come after the therapists and demand what are called “clawbacks.” They will take back years of money that they paid, even if it was their mistake, and even though we have no way of knowing it was a mistake. (Sometimes the rates actually do increase; we are somehow expected to know if it was actually their error, alert them, and reimburse them.) This could easily put a private practice out of business.
So, when we talk about who is able to go to therapy and who can’t, and how unfair this is, we should all be pointing to the insurance companies. They have the power to change this system. They have the funding. They control it all. If all therapists could be paid a living wage within a decent timeframe, were granted some authority as the experts on mental health, and could practice without the fear of clawbacks and auditing, you would see significantly more private therapists accepting insurance. This is what limits access to care.
*The mental health industrial complex refers to the for-profit, focus-on-money-over-patient/therapist-wellbeing system that we exist in now. Insurance companies, whose stakeholders have NO training or knowledge about mental health, run the show.
*For more information about clawbacks being experienced by therapists, please visit this article by Barbara Griswold, LMFT, who is our local Knows-All-Things Therapist: