Why private pay only?

Why private pay only?  An explanation of why I am moving to a private pay only model in my practice

In short, the big reason is privacy.  Yes, there are HIPAA compliance standards, so there is privacy to a degree.  But remember: once you use your insurance for your mental health coverage, you have to have a diagnosis on paper.  This is what is known as medical necessity.  If the insurance carrier receives a claim following your visit without a diagnosis, they will reject the claim and not pay the provider (i.e. Me.)  The problem with this is that a claim submission is essentially a legal document, and that diagnosis has the potential to follow you around for the rest of your life.

If you try to purchase a life insurance policy, there is an excellent chance you will be asked if you’ve ever been diagnoses with depression or another mental illness.  If you answer “yes”, the interview concludes and you either do not get to purchase the coverage or you can purchase it at a much higher rate.  If you answer, “no”, the life insurance company will do a medical background check and see that you have had mental health treatment and you will either be denied coverage or have to purchase it at a very high rate.  Each life insurance carrier is different, so they may potentially make exceptions for certain diagnoses.  But consider this scenario: you go to see a psychiatrist for a couple of visits.  The psychiatrist doesn’t know you well because they only see you every couple of months.  One month the write an incorrect diagnosis code on their note and give it to the billing people.  All of a sudden, a what could have been a more benign diagnosis become a serious & persistent mental illness.  Now, this serious & persistent mental illness (i.e. Schizophrenia, Bipolar Disorder) is next to your name on paper.   This this won’t happen? It will.  It is human error, and I know people this has happened to personally.

Now picture this scenario: a patient decides to take a medical leave of absence from their job after seeing treatment for depression at a local clinic.  The patient is assigned a case manager to help with the paperwork this entails and is tasked with faxing over the medical leave paper work to the patient’s HR department.  The case manager goes to the company website and gets the fax number, but this is not the HR fax number, just a general fax number.  The case manager has never worked on a leave of absence case before, and sends not only the HR paperwork but also psychotherapy progress notes, psychiatrist notes, and lab work.  After the fax with the paperwork is sent, which contains very personal information about the patient’s mental health, it is picked up by the patient’s direct supervisor who then leaves it on his desk to read the next morning.  Another employee picks up the fax, thinking it was something else, and reads all of it.  Think this can’t happen? Think again.  I am recounting a real scenario of a situation that I remember happening in a clinic that I interned in.

But private pay also the affords me the time to be able to see patients for a  full 60 minutes, whereas insurance will only pay for 45.  One may not think that a 15 minute difference is a big deal, but it actually makes a huge deal.  Insurance carriers may tell you that you get unlimited visits, but in reality, you only get unlimited visits if you have specific diagnoses.  Usually after 12 visits in a year in total—not just with one particular provider (so if you meet with multiple therapists before deciding on the person you want to work with consistently, you limit your visits)– you will have to certify with the insurance carrier.  Usually this is when the carrier will cut off your coverage.  The carrier may also request to see your psychotherapy notes—in other words, read about all of the personal things you’ve shared and then decide those items are not severe enough to need therapy.  They usually won’t grant an extension so that you can have a few session to terminate with your therapist either.

Insurance carriers (who certainly are not medical or mental health professionals, mind you) expect your therapy session to be conducted in a very particular way. So in addition to limiting the length of your sessions and the number of your sessions, they also limit the interventions that we can use.  Have you been feeling like your therapy has been blah? If you’re using insurance, it probably has been.  You’re going to be limited to Cognitive Behavioral Therapy.  If you’re looking for Psychoanalysis, the insurance won’t pay for it.  If you’re looking for creative arts therapy, the insurance won’t pay for it.  If you’re looking for EMDR therapy, the insurance won’t pay for it.  Would you enjoy having my therapy cats in session with you consistently? Looking to have therapy online or over the phone? Your insurance carrier likely will not pay for it.  Need to speak with your provider in between appointments? When you use insurance, there is not expectation of paying the provider for their time.  The provider is speaking to you during their personal time and are not getting paid for it.

Furthermore, a mental health diagnosis is a pre-existing condition.  As of the 2017 presidential inauguration, it was suggested that health coverage would be reverting back to what it had been prior to 2014.  So if you have a change of insurance coverage or insurance carrier, your care in the future might not be covered.

Additionally, all of these apply if you pay out of pocket and seek out of network reimbursement from your insurance carrier.

Insurance-only providers are often overwhelmed with patients.  Unless someone is new to their practice, it may be very difficult to get an appointment, especially with an experienced provider.  Another goal of using a private pay only model in my practice is to ensure that I can be able to provide a new patient an appointment within one to two weeks.

In many ways, the future of mental health care has made great strides in the United States.  But in many other ways, there is still a huge stigma surrounding it and care is not built in a way that is in our favor.  You are a person, you are not a diagnosis.  You deserve the attention, privacy, and personalized care that you simply cannot get when using insurance.