If you, a friend, or a family member need access to mental health services in California, there is a good chance you will wind up on a waiting list. There is likely a 2-week minimum to 6-month wait to get an appointment with a mental health provider. According to the National Union of Healthcare Workers, and my experience as a licensed marriage family therapist (LMFT) operating a solo private practice in California, 87% of therapists report that weekly individual psychotherapy appointments are unavailable for patients who need it. This trend will likely worsen because of closet, shady insurance practices that force therapists to quit insurance networks.
The disparity between consumer demand for mental health services and provider availability had been brewing before the pandemic struck. A 2018 research report from the Healthforce Center at the University of California San Francisco predicted a shortage of behavioral health providers. The report cited that there would be 11% fewer psychologists, clinical social workers, marriage and family therapists, and licensed professional counselors than needed to meet service demand.
This shortage of healthcare workers handicaps mental health consumers because psychological conditions can be as urgent as a physical health crisis. For people suffering from disorders such as anxiety and depression (or other mental health diseases), their condition may acutely worsen when they learn they cannot get an appointment for months. The longer they wait for an appointment, the greater the chance their condition will worsen.
Psychological disorders can be caused or exacerbated by various factors, such as genetics, environmental stress, and socioeconomic conditions. When our body is wounded and diseased, visible physical symptoms occur. But what if the "wound" is in the brain? Something you can’t see. How does a person suffering from a mental health condition manage their symptoms when treatment is months away? What happens to them?
Currently, demand for mental health services exceeds supply, as evidenced by the countless patients referred to me and my colleagues by hospitals, insurance companies, or community mental health agencies, which lack resources to manage the backlog. Many of my referrals are from insurance plans that do not have sufficient providers in their network.
The shortage of behavioral health providers has occurred due to various factors, such as an increase in mental health illness during the COVID-19 pandemic, high turnover rates by mental health professionals at community agencies, and the de-stigmatization of mental health (thanks, in part, to Governor Newsom's PR efforts to raise awareness of mental health). However, it is the underbelly practices of insurance companies that have forced therapists/providers to terminate their contracts with insurance plans, leaving consumers scrambling to find new therapists or psychiatrists who will take their insurance.
Like many of my colleagues, I have been part of this emerging exodus of mental health providers who have chosen to leave specific insurance networks because of unethical business practices, such as using impenetrable bureaucratic systems, passing the buck, abdicating responsibility, and nickel-chasing.
Providers render mental health services and subsequently file claims to insurance companies for payment. Errors in claims caused by providers or insurance system failures can delay reimbursement.
Even when a provider files an error-free claim, it can typically take 1-4 hours on the phone with an insurance representative to resolve an issue. But when a claim falls through the cracks, it can take months, not minutes, to correct.
Claim problems take a long time to fix because it is virtually impossible to speak with someone at insurance companies who has the power to resolve grievances. Barbara Griswold, LMFT, and author of Navigating the Insurance Maze: The Therapist's Complete Guide to Working with Insurance, said in a recent workshop to therapists, "Good luck in trying to get a hold of someone who can help you."
Insurance companies often have siloed data systems, requiring providers to be transferred to several departments because client health data is not shared uniformly within the company. These bureaucratic systems prohibit providers from getting a straight answer from customer service representatives who can only read a canned script. Escalating a call to an insurance company manager takes an Act of Congress because call center representatives are incentivized to manage provider inquiries, yet they have minimal authority to resolve complex issues.
The institutionalized deferment tactics frustrate providers to the extent that they abandon their efforts to recover unpaid claims. I have walked away from significant revenue because the process was too painful to endure. The irony is that the bureaucratic system works perfectly - but not for the providers. Ching Ching.
Chris Fussell, president of McChrystal Group, best explained the functionality of red tape when he said: "In any bureaucracy, there is a natural tendency to let the system become an excuse for inaction."
The systems used by insurance companies continue to affect small private practices. For instance, if a mental health provider is supposed to be reimbursed $80.00 for a 1-hour therapy session, but it costs the provider two hours on the phone with the insurance company to resolve a claim problem that is not their fault, the therapist has lost the entire profit for the session. Scratch that, it is more like working in the red.
Clients have less access to mental health services when providers are distracted with fighting insurance companies. I encountered such issues with Magellan Health and left the panel. However, Magellan is still informing clients that I am in their network after I terminated the contract in writing. I told my former client that she was misinformed. She had high hopes she would not have to start the process over with a new therapist.
The United States Senate Committee has investigated this practice of ghost networks. According to an article by Psychiatric News, the American Psychiatric Association reported that Robert Trestman, Ph.D., M.D., told the Senate Committee on Finance in May that “ghost networks are false promises by insurers to provide access to care that shift the expense to the patient.”
In a ghost network, insurance companies claim to have more credentialed in-network providers on their panel than they do. The alleged providers are listed in a directory published by the insurance companies.
Trestman further explained “how for patients who are largely healthy and well educated, encountering inaccurate directories on insurance websites can be frustrating. But for people experiencing significant mental illness or substance use disorders, the process, at best, is demoralizing. At worst, it is a setup for clinical deterioration and a preventable crisis. Many are already experiencing profound feelings of worthlessness, grief from loss or trauma, and/or the impact of substance use… Some give up looking for care.”
Read here about how such ghost panels are worsening the mental health crisis.
My impetus for writing this article is to illuminate a real-time claims problem with Halcyon Insurance. I filed a clean claim with Halcyon. It was verified error-free. Halcyon has a 45-day window to pay the claim per contractual obligations. It’s been over 70 days. I am experiencing financial hardship because they are passing the buck. I spoke to Halcyon Customer Advocate Supervisor Eva Guizar who said, “We met our obligation to pay it out in 45 days and sent it out for processing."
She said the claim was sent to third-party entities, Delta and Zelis for check processing. She indicated it was not Halcyon's responsibility anymore to ensure I was paid. She attempted to palm me off to these vendors. Guizar said she would give me the telephone numbers of these firms so I could track down my money.
I think there is a name for this tactic: cross-delegating. It is the crafty art of having an obligation (like making good on your debts) but then skirting that responsibility by asking others to do the work.
At that point, I had enough of the dodgy go-find-your-money shenanigans and was not about to search for my payments by navigating a labyrinth of third-party vendors.
I told Guizar, “My contract is with Halcyon, not your vendors, Delta and Zelis." So I asked Guizar to follow up and track down my check. Two weeks later, nothing. Today, the mailbox was still empty.
It appears that Halcyon needed my money more than I did. Silly me for having plans to pay the mortgage. I wondered how they would profit from holding onto my money. This conduct is an outright unethical, if not illegal, violation of our contract.
How do we hold insurance companies accountable, when the fortress is impenetrable?
If that was not bad enough, I also learned from Guizar that one of these payments was a credit card. There are fees associated with using credit cards. Now, Halcyon wanted to impose a fee on the money I earned, as withholding my check was not enough. Learning about the credit card fees was the last straw, and I almost became unhinged, realizing I would need therapy after the call.
I asked Guizar why I had not been informed of this policy to be paid by credit card. Guizar responded, "Oh, I think they just do that automatically. I don't like it. I think you have to opt-out," she said.
Well, I did not get the memo either!
It is mind-boggling how far insurance companies will bend to nickel-and-dime therapists to inflate their profits. That is a nice chunk of change insurance companies will "earn" off the backs of America's mental health workers. Slick, with a capital S!
My experience with Magellan and Halcyon is not representative of all insurance companies. I have had good working relationships with Cigna and Evernorth Behavioral, as well as other panels. The practices employed by these reputable insurance companies indicate that good models do exist.
When insurance companies operate in bad faith, take no responsibility for honoring their obligations, and have total disregard for the financial strain their operations impose on small businesses, then therapists will continue to flee insurance panels due to hardships and shrinking profits — making it even harder for people suffering with mental health illnesses to access care.