Wednesday, November 14, 2007

Why Shrinks Don't Take Your Insurance

Many psychiatrists in private practice don't take insurance, or don't 'accept assignment.' They require the to patient pay them and then the patient can submit to his health insurance company and reimbursement is made directly to the patient. This often means that the patient, having gone Out-Of-Network, has a higher co-pay &/or a higher deductible, and the hassle of paperwork. Generally, if a patient sees an In-Network psychiatrist, they make a copay and the hassle of getting the rest of the money falls on the doctor.

This means that access to psychiatric care is limited to those who have the money to pay up front, the wherewithal to stick their statements into an envelope and send them to the insurance company-- after they've called a separate managed care company, gotten
pre-authorization, had Dr. Shrink submit a treatment plan, yada yada yada, as Mr. Seinfeld would say-- and the willingness to take on the financial risk that the insurance company might find some reason not to reimburse. By not accepting assignment, the doctor has greater control about little things like getting paid, but the patient supply becomes limited in a way that restricts access to care. Patients who want the financial and logistical benefit of remaining in their network are often surprised to find that it's difficult to find an in-network psychiatrist (even though the insurance company has this large list of providers) or that those psychiatrists aren't taking patients, or that they see patients for brief med checks but not for psychotherapy, or that it's hard to find a psychiatrist who feels warm and fuzzy enough. From the patient's point of view, it's not fair. There's a reason for this: it's not fair.

So why don't all shrinks accept assignment, why aren't they lining up to be members of insurance networks who would funnel lots of patients their way?

Let me tell the story from the psychiatrist's point of view. If a psychiatrist doesn't accept assignment, s/he sets his own fee-- generally what the market will bear-- perhaps decides when and if and for whom to slide or even forgo his fee, and he gets paid by the patient. This one is easy.

If the psychiatrist accepts assignment, he agrees to practice according to the terms of the insurance company. He sees the patient and collects the copay. Maybe it's a flat $30 co-pay. Maybe it's 80% for the first 5 visits and 70% for the next 5 visits and 60% for all the visits after that oh but the patient is only covered for 25 visits a year and the psychiatrist has agreed not to balance-bill as part of the deal. I don't know what happens if the patient needs a 26th appointment, I believe the doc eats the fee or simply doesn't offer the extra sessions. At any rate, the doctor now needs to figure out how much the patient has to pay and it's his responsibility to collect this. Oh, but it's not 80%/70%/60% of HIS fee that the insurance company will pay, it's 80% of what the insurance company has decided is Usual & Customary. And if they decide that Usual & Customary Rate (UCR) is $10/session or $25/session or $50/session less than anyone in town charges, then that's what they pay on. And while it might be a piece of cake to calculate if the the UCR was say $100/session and the patient paid $20 and the insurance company paid $80, well it's a pain in the neck if the UCR is $97.84/ session and you have to keep count of the sessions and figure out the percentages. Should I mention that different insurance policies by the same company can have different payment rates so someone has to call for each patient, verify the insurance, find out the terms,
co-pays, deductibles, and this involves sitting on hold and dealing with assorted prompting menus. And if the insurance company finds a reason Not to pay, the doc is stuck--he can't bill the patient, he's just out the money. For a psychiatrist who does psychotherapy and sees maybe 8 patients/day at an insurance company discounted fee, well, it can be a big deal to have the insurance issues. And if the patient has two insurance policies and they each have different terms and they each decide not to pay because the other is the primary insurer-- oy! So not only is the psychiatrist taking his chances on getting paid, but he now has to have a secretary, an overhead expense his I-don't-accept-assignment compatriot may or may not want or need. And he now has to have an office big enough to accommodate secretarial space. I'll also tell you that while the secretary is paid an hourly fee, his ability to get paid is only as good as her motivation to follow through on dealing with the insurance companies, refiling denied claims, clarifying primary versus secondary insurance and getting the amount of the co-pays correct.

So how and why does any psychiatrist accept insurance? Basically, the insurance companies pay okay for short appointments with a psychiatrist. While there are time standards for coding psychotherapy appointments (25 minutes, 45-50 minutes), nearly everyone charges more per hour for a 25 minute appointment than for a 50 minute appointment, even many of the out-of-network docs. So a psychiatrist who sees two patients in an hour makes more than a psychiatrist who sees one patient in an hour, and often the insurance companies-- perhaps eager to encourage their policy holders to seek psychotherapy with a cheaper provider-- will pay a reasonable amount for a shorter session-- perhaps they make this worth doing. And "Med Management" 90862 for those of you who like
CPT codes-- has no time restrictions on it. If a psychiatrist can squeeze four or five patients into an hour, he can do okay by the insurance companies.

Okay, I googled it and this is what I found: for Medicare, based on 2004 rates, irrespective of geography (so I guess a national average as each state has a different fee), the allowable fee for a 45-50 min psychotherapy session with medication management is $103.80. Half an hour is allowed at $71.31, and a 90862 med management with no time stipulation goes for $51.15 (here
is my source)-- if you can see a patient in 10 minutes, you're doing as well as some lawyers. I'm not sure I'd call it psychiatry, and I'm not sure how long I'd survive or how much better the patients would get, but hey.