The fees we charge for psychotherapy, as discussed in the last two posts, also link to some ethical considerations that arise when psychotherapists accept health insurance for payment. I’d like to discuss my experience in this area and invite my colleagues to share theirs. I’d also like to hear how other readers who’ve been in treatment feel about these issues.
It’s been quite a while since I’ve accepted insurance, so this first issue may now be moot. Earlier in my career, when insurance carriers offered more generous mental health benefits, it wasn’t unusual for a policy to pay 80% of the provider’s fee up to a fairly high limit. Thus if my fee were $100 per session, it would pay $80 and the client would pay $20 out-of-pocket. The maximum coverage used to be higher than what I actually charged. On several occasions, I had clients ask if I would provide them with a bill that over-stated my charges so that the insurance company would reimburse me for the full amount of my actual fee; the client would pay nothing out-of-pocket.
I never agreed to do so because the practice constitutes insurance fraud. In 1996 when Congress passed the Health Insurance Portability and Accountability Act (HIPPA), it made health insurance fraud a criminal offense that carries financial penalties and may involve time in prison. I do understand that even the co-pay may be difficult for some clients; I also know that many people — psychotherapists and clients alike — believe defrauding the insurance company represents some higher type of social justice, and I’ve heard many justifications for doing so. “If we lived in a truly just society …” or “the insurance companies are making money hand-over-fist; they can afford it.” My own opinion is that when people defraud insurance companies, we all suffer in the form of higher premiums, but I don’t expect everyone to agree with me. The fact remains that over-stating your actual fee to an insurance carrier is a criminal offense.
Early in my career, before my own ideas on the subject were settled, a client asked me to give her an inflated bill and I told her I would think about it. During our next session, she told me the following dream: she came for her usual appointment but my office was in a different place, a disreputable part of town. I was late for her session and when she went to look for me, she found me in the alley with a group of seedy characters, smoking a cigar. Her associations linked the men to the mafia and organized crime. To me, the dream expressed her anxiety that I might be “corrupt” and actually give her a fraudulent bill. While consciously she wanted me to help her defraud the insurance company, on another level, she’d question my integrity if I were to do so. The fact that I said I’d even consider her request made me suspect. This dream — along with the guidance of my own therapist (I was still in treatment myself at the time) — helped me settle my views on the
As managed care came increasingly to influence insurance carriers, another problem arose for me. In the good old days, a psychotherapist only needed to supply a minor diagnosis such as Generalized Anxiety Disorder and the carrier would pay his or her bill. As outlined in this earlier post, I see little value in psychological diagnosis but I’d made peace with the fact that I had to provide one for my clients to receive reimbursement. When carriers began to require treatment plans and psychotherapy goals, however, I really struggled. While therapists who practice cognitive-behavioral therapy would have no such problem, I found that I had to falsify myself entirely to complete the insurance forms.
If you practice psychodynamic therapy the way I do, the actual goal of therapy is to listen to the client’s material in a state of patient waiting, without struggling to understand it, until the unconscious material becomes clear enough for you to make an interpretation. Can you imagine writing that on an insurance form?! As I have to write something for the client to benefit from coverage, however, I found myself lying. I’d invent a treatment plan that had nothing to do with our work together and establish goals I didn’t believe in. I had to lie about the nature of progress in treatment. After all, I couldn’t write: “Client has begun to regress in the context of the transference, with early dependency issues and infantile omnipotence coming to the fore.”
Some of you may think I’m being overly fastidious, though I really did feel uncomfortable when completing those forms. Even so, I probably would have gone on misrepresenting myself and my work, but it eventually came too feel too burdensome. I understand that insurance carriers need to control costs and ensure quality, but I’m irked by the idea of some medical claims evaluator with no experience in psychotherapy reviewing my work to determine if a claim should be paid. I’m sure opinions on the subject will vary widely, but for me, the answer was to reduce my fee to a more affordable range and decline to accept insurance. I find that the reduction in income is off-balanced by the benefit of escaping those time demands and ethical conflicts involved (for me) in completing insurance forms.
Feel free to chime in.