Insurance companies fill their networks with ‘ghost’ therapists
seattletimes.com
seattletimes.com
She takes cash now. It was an abusive system and I’m not surprised it’s falling apart.
For example, I had need for a medical device. My doctors office submitted the claim for that device with documentation of it's necessity 5 times over 6 months before it was finally approved. The prior 4 times it was "You didn't include all the required information" even though each submission was identical.
There's simply far too little oversight on insurance agencies. They are perversely incentivized to give the worst outcomes for everyone which being to command high premiums because of the relatively low amount of competition or threat of "switching" (After all, you are using your employer's insurance. You didn't get to pick it, HR did. And they picked it based on who's cheapest. How did they become the cheapest? A race to the bottom in terms of service).
All of this burdens the whole system with cost and delay.
I'm all for universal healthcare, but if we can't get that can we at least get stronger regulations and punitive measure against insurance companies for playing these games? It's crazy that everyone has stories, regardless of agency, of illegitimate claim denials.
And to be clear, they do this because it saves them money and costs them nothing. By denying by default, a certain percentage of the population and doctors offices will ultimately just go away because of the headache it takes to convince the agency to provide the product you pay for.
This means my care is ultimately in the hands of someone with zero medical training.
Astounding.
Sorry bud, random bureaucrat at Premera thinks not! But you’re welcome to spend hours of your time filing and following-up on an appeal with absolutely zero chance of a different outcome!
Heck, even have a list of 2-3 'preferred' plans that employees can choose from, if they don't want to do all the research. But seeing all that money go into their pay-stub, and then right back out for insurance is going to be very, very eye opening to people who currently just have their employer pay it, and they ever see it in their check.
My allowance is quite generous, and it pays for 100% of the cost of the most comprehensive insurance I could find for both me and my husband. The platform is called PeopleKeep.
It's really, really nice to pick my own policy. Now I never, ever have to deal with CVS Caremark ever again.
https://www.cms.gov/priorities/key-initiatives/burden-reduct...
I have had a profoundly deviated septum since childhood. A couple of years ago I went to an ENT to get it fixed. "Yup, 90% deviated on the right side." "Great, when do we schedule surgery?"
"Well, first, I prescribe you these two nasal sprays so that you can come back in four weeks and tell me they didn't fix your breathing, so I can tell the insurer that so they can approve surgery."
Someone comes in and has insurance “x”. “Am I in network?” I don’t know. Probably. I take those plans most of the time. I check Navinet, or provider express, or one of the many other insurance benefits verification websites because the various insurers can’t agree on one centralized platform for this.
It says you’re good and I’m in network, great! Or you checked the provider directory online and I’m listed. Most of the time we’re okay. Sometimes this is out of date though (the “computer issues” you mentioned). The only way to truly be sure is to call the insurance company and have them check their systems which I simply don’t have time to do, sorry, or submit billing. This is why I and basically every healthcare practitioner have the policy that you are ultimately responsible to verify your benefits.
So we meet and it’s fine and I collect your copay. Then I submit billing. Then we meet again weekly. Then the insurance takes four fucking months to process your intake session only to come back and say “hey wait, this actually isn’t covered because it’s technically out of network so neither are the 15 sessions that happened afterward”. Now you suddenly owe me 2-3 grand out of pocket and I either have to collect that, probably worsening your mental health by adding a signicant sudden expense, or write it off and basically say goodbye to any renumeration for the 16 hours of work I did. I will ask you to appeal of course.
This isn’t even a “rare exception” situation. It comes up like once a month and I run an independent solo outpatient practice. Low volume.
It’s a fucking nightmare. I get why your wife went to out of pocket. I don’t blame her. but then it’s the conflict of making services less accessible. My patients often have no clue how to submit for reimbursement and insurers seem to purposely make this a difficult process. It really just sucks. I tend to work with lower income populations that really rely on insurance coverage so it’s not an option to go cash only for me but I definitely understand those who do. the system we have is deeply flawed, maybe irreparably.
The only setting that alleviated this was larger settings. Major healthcare networks/hospitals, large agencies, etc. it still came up but less often and when it did there was an army of billing staff to appeal. But the downside is that imo care was inherently compromised in these settings due to demands placed on staff. There were benefits of having teams, training resources, increased supervision, etc. but all of these were outweighed by significant overhead costs and productivity demands. For perspective moving to private work allowed me to earn 35% more while working 20% less within the first year. I’m not struggling to make ends meet and I’m not constantly flirting with burnout anymore. So imo those institutions aren’t the solution unless they can make real systemic changes
Not a clinician but did (previously) work in software developing claims benefit management software.
One of the parts of the recent Surprise Billing reforms was that if a patient "could reasonably believe" that they were in network (and in particular, the prominent example of note being the insurer's website or a provider they use lists the provider as being in-network, because they ostensibly have control or input thereinto), then the insurer was obligated to remunerate the claim as being in-network.
i.e. if insurance's directory says "sure, provider X is in-network", they don't get to turn around after you use their service and say "You know what, they're not, so this is uncovered/out-of-network".
That’s a whole different issue though; I’ve had to change subcontractors twice in my career because after auditing I found they were dropping the ball on stuff like this and just billing clients when there was a path to insurance reimbursement that could be pursued. To insurance companies credit this is an issue at least a part of the time; billing departments and subcontractors that flake on their own work. Far less common but a non zero part of the issue.
Thankfully as things transfer to software solutions this becomes less of an issue; I’ve moved a portion of my billing to a software based billing solution rather than a human one and while it still has issues it has less. Sucks for job creation but better for my patients I guess
Now I might do another deep billing audit
Beyond that, she learned that these community mental health centers, despite being nonprofits, are still aiming to constantly reduce costs; in her first six months, she saw many support structures for both clients and clinicians cut. This included laying off most of the case management staff, expecting the counselors to pick up the slack. She rarely even had time to keep her (legally-required) notes.
She lasted less than a year before quitting. She's not sure she'll ever go back.
Counselors are being squeezed from both sides here: They either burn out early, or the insurance companies fuck them over in perpetuity.
When I was a student the rule was you had to do a year in community mental health type setting during school as an internship prior to graduation. I forget the exact hours requirement. It was supposed to be a learning experience but almost all of us were just put to work with a full caseload from day 1, paid $0 and hour, and the agency billed on our behalf. It was very burnout inducing to be making nothing working in the setting you describe. Then you’d graduate and get to have the honor of making $15-25/hour, the low end of which was offered over at target.
It’s also why I don’t understand how those programs struggle so much. AFAIK the practice continues to this day and it means they have a sea of interns providing free labor. The interns don’t get the same session rate as a fully licensed therapist but at the same time they literally cost $0/hour, they are slave labor. Medicaid and the community mental health system is built on it. It’s why low SES individuals are by default used to never having the same therapist for more than a few months or so; the turnover is crazy
Going through the listings for any kind of doctor in your health plan is a nightmare. When I needed to see a primary care physician, it took two hours of calling 10+ listed offices to find one that was actually a primary care physician, was still practicing in the geographic area, was accepting new patients, and still accepted my health insurance (apparently dropping plans is common?). And the earliest they could see me was in 6 weeks.
It was the exact same type of experience when I needed to see a particular type of specialist, except the earliest appointment I could find was in 3 months.
The insurance companies just don't update their lists for any type of doctor, as far as I can tell. Whether this is due to sheer incompetence or deliberate deception or some combination of the two, I couldn't tell you.
Insurance cos can still compete on the merits of their networks and, in theory but sadly I think not in practice, these schemes could work in favor of the patients if the insurance company uses their network to balance cost with service quality.
A very dominant one could effectively rule a region as a cartel, though.
Lobbyists
The answer is on some of the other comments on this page. Insurance companies make reimbursement so difficult that some doctors do not want to accept the insurance.
As many other comments point out, insurance companies pull many tricks to try to not reimburse.
I've submitted claims directly to insurance before and had the same issue.
- Your claim gets rejected for missing information, but they dont tell you what is missing
- Your claim gets rejected for being a duplicate, but the previous claim also got rejected, or both got rejected
- Your claim is "not received" there is no record of a claim
- Your re-submitted claim gets rejected because 90 days have passed, but of course, it is because you were forced to resubmit over and over
Some people don't like not having choices for doctors, but I would much rather just have one system to deal with. I don't have to print out medical records like I have to for my wife and kids (they are on a different plan), or call a bunch of different providers to find care, or go back and forth as two different providers say the other side is the one that has to do anything. I never have to argue with my insurance provider about paying for something, I never have to wonder if something will be covered.
For example, a therapist is a very personal thing and I'd imagine you might have to try many to get it right. Psychiatry is as much an art as a science, so it's not like they're fungible.
Or what if, say, your internist dismisses your heart problems as anxiety, but you'd like to see a specialist because you know the difference and it's not just anxiety. That's it? Not allowed?
You don't always have a choice to see a different specialist if you live in a smaller town, but in larger cities you can request a different one.
In general you can't make direct appointments with specialists on your own, you need to be referred by your primary care doc. Once you have seen a specialist, though, you can make direct appointments with them.
You can also call and tell them why you think you need to bypass the normal system. They have staff who are there to help navigate those situations. I have never had to do it personally, so I can't vouch for how accommodating they are.
I will say, though, that in my experience I have a lot more say over my care than my wife does with her traditional insurance provider. She has had to fight to get things paid for and been rejected way too many times.
Sure, she could make an appointment with any specialist she wants... but will insurance pay for it? In your example, if you have another doctor who has said the problem is just anxiety, will insurance pay for your second opinion?
If insurance isn't going to pay for it anyway, it doesn't really matter if you have Kaiser or a traditional insurance provider. Both of us can make any appointment we want if you are going to pay it yourself.
That person was actually a nurse at the local high school.
Only PT available to me? "Sure, I can see you in 10-12 weeks from now..."
We have the technical means to provide a decent life for everyone. And I mean everyone, including illegal immigrants sneaking across the border. And we could do all that while everyone struggles less.
So yea. Most jobs are fake and stupid and don't need to be done. The ones that need doing could be given more support, distributed more evenly.
This was a mainstream economic viewpoint less than a century ago. What happened?
Everyone is worried that automation is going to steal people's jobs, and jobs won't exist anymore, but that has already been happening in full swing for 100+ years. 'Useless' jobs are and will continue to be the solution to that problem.
(And I am using 'useless' rather tongue-in-cheek. The jobs do have real functional value, even if they're in higher parts of Maslow's hierarchy)
For most families with two parents who work, it would be better for one to stay home and tend to life and children. It's inefficient, alienating and demoralizing to have both parents forced into specialized wage labor that amounts to a useless make work.
Put another way, if society allocates more resources to people who work outside the home doing useless things, then fewer resources are available to people staying in the home doing useful things. One way this manifests is inflation, ie, higher COL.
As for "purpose"...wow. Ask the next GrubHub employee that comes to your door if it gives them purpose.
Working less should be a social goal, a targeted outcome of public policy.
> As for "purpose"...wow. Ask the next GrubHub employee that comes to your door if it gives them purpose.
I bet they have enough purpose in their life that they aren't committing violent crimes for shits and giggles.
Doctors' offices employ people whose only purpose is to be experts at navigating the byzantine insurance system. Arguing that these jobs should be preserved is the broken window fallacy. These jobs do not have real functional value. They are compensating for something that is destroying value.
Even worse is when it's not even someone's job, as in the case of individual people fighting with their insurance company to get paid what they're owed.
I wish that people in this country could get over the idea that 'jobs programs' are a bad thing. Some of the best BS jobs are artificially created, the ones that capitalism produces naturally tend to be of the rent-seeking variety.
You don’t need a very high proportion of the population to poison the well with bad behavior enough that everyone just accepts that as regular behavior and then even the ethical portion of your society starts engaging in the bad acts.
One of the main benefits for having a government is to go in and regulate bad behavior away that would never occur organically because each individual actor in society loses far too much trying to fix the situation on their own to rationally try.
No thank you.
The answer to government created problems isn't a government created department.
All you have to do is look at all of history to see the results of increased government power. Look at the lies of the unaffordable care act. look at the fact that things the government promises as "free" become unaffordable and worse.
What we had when this country had great healthcare options.
You know... the stuff that was replaced with "Keep your Doctor", "keep your plan", "save $2500 a year" and other lies used to pass the unaffordable care act (and similar).
There's a reason "Free Healthcare" can only pass with lies - and it's because government options/UHC/etc are lies for those who don't look at... well... history.
Funnily enough, speaking of lies and kool-aid, when you talk of ObamaCare to supporters of that political party, they are vehemently opposed.
"What if, instead of ObamaCare, there was, say, an Affordable Care Act that did X, Y and Z?" (where X, Y and Z were actual features of the ACA)
"Oh, that would be much better! I'd love that!"
But you don't need to worry, it's politically impossible to get rid of the healthcare industrial complex which is 5x the size of the more frequently cited military industrial complex.
And even then, I've experienced NHS care and it's 1000% better than the experience I've had with american care. It's not perfect by any means, but it's insane how much better it is than what we have here.
Calling it a dumpster fire when the US system exists is laughable at best.
This is literally happening under the current system now. My cancer treatment plan, should I ever get it while I'm living in America, is to blow all my cash and buy an exit bag on credit.
Maybe it's not the best of both worlds, but it's at least a far better safety net than the US provides, and that's the most critical piece. Both for the most affected individuals, and society as a whole (even in terms of cost! An ounce of prevention is worth a pound of cure, and all that.)
In Bulgaria where I have many friends and family, the system has always been nationalized, barely funded by the government. I don’t know a single Cancer survivor there.
We already ration care, it's based on what you can afford. We already underpay doctors and nurses like crazy, just go talk to one. We already drive them to burn out, because the current health care system is prioritizing admin pay over quality care.
The hellscape you imagine is the american system. It literally could not be done worse if we tried.
Average nurse salary in California (where ~10% of US population lives): $124,000
Average nurse salary in Spain: €29,277
My sources are probably junk, but even with insurance companies out of the picture what is the math that would make the US healthcare cheaper?
This is without tackling the earning rates for specialty MDs, like vascular surgeons, who are not that numerous to begin with.
Yet https://www.wfla.com/community/health/coronavirus/florida-ha...
2. Medicare was not allowed to negotiate drug prices until this year. Drug comonies basically got to wr8te themselves checks. In some ways the Us taxpayer subsidizes drug development for the whole world.
The amount of money we spend on healthcare in excess of the OECD average is more than we spend on the military. 10% ish of that is the entire yearly profit of the healthcare industry. The other 90% is raw inefficiency. And where does that 90% go? Mostly to salaries. Eliminate our inefficient system, and you eliminate millions of middle class jobs.
No politician will do it. They may talk about it and campaign on it knowing it won't happen. But they will never pull the trigger because it would be political suicide.
Also, if you want to know more than you ever needed to about the US healthcare system and why it is so expensive I highly recommend this report: https://www.mckinsey.com/~/media/mckinsey/industries/healthc...
The only way to really change this is voting for progressives when possible, though it's hard to convince others that this is what you need to do.
If you are in a blue state, vote in the primaries for the progressive candidates. If you are in red states, that's voting for democrats in general and the most centrist republicans in the primary.
The absolute worst thing to do is to not vote and let the most conservative candidates run wild.
That 6.9% of GP is supporting millions of jobs, and to remove an inefficiency like that would put them all out of work. It is not possible to do that in a democracy.
I think the government could make progress by focusing on just cutting costs or just reducing inefficiencies. When the two are conflated and attempted at the same time, the incentives don't actually line up so nothing happens.
It's not like any individual reform is going to suddenly end all that waste and put everyone involved out of a job. Iterative small improvements make a real difference in people's lives, and won't provoke an immediate giant supply-side shock.
I don't pretend to have the answers to the question of "what reforms should we do?" but throwing our hands up and saying "nothing!" is not the answer.
How do you reduce inefficiencies and cut costs without compromising care?
You cut jobs that are redundant. America spends an insane amount of money on administrative overhead. 4x the average of other wealthy nations [1]. This is largely in part because our fragmented insurance system leads to excessive redundancy in administrative roles
So meaningful reform means cutting jobs. Or you do the shitty political move and preserve these useless jobs for the sake of keeping people employed because our social safety net is a joke and the cost cutting you do make is at the expense of compromising care and vulnerable populations (eg cutting Medicare and Medicaid benefits). Then you get more clinician burn out and struggle to fill key clinical roles/staffing issues, scheduling issues and longer appointment waiting periods, more deaths and complications from a lack of preventative care, more mental health issues and drug abuse in communities, etc. all of which is happening in the USA.
[1]https://www.pgpf.org/blog/2023/07/how-does-the-us-healthcare...
I've got no love for drug company lobbyists, but drug companies do actually manufacture real things.
Health insurance companies are different.
Once it becomes a government benefit, there are no more lobbyists. There is no market actor to lobby on behalf of, because the market ceases to exist.
With "platinum" healthcare, my out of pocket for dealing with an (admittedly complex) kidney stone was $8,000.
For nine days hospital stay for gout (oof) in Australia, I paid $38 out of pocket... because I wanted premium TV channels.
Insurers are incentivized for you to not seek out healthcare, but not die. Or seek care, but pay out of pocket. They need those premiums.
I had bad insurance once (Unicare), and an office lady I worked with who used to work there shared many horrifying stories of things like employees putting claims in plastic bags and hiding them above the ceiling tiles.
I'd say there is still a difference in how the ghosting is likely to affect the person seeking care. Somebody seeking help with plantar fasciitis or urinary troubles might not appreciate being ghosted, but it could be a major roadblock to someone with executive dysfunction, or devastating to someone with social anxiety. There's probably also a bit of a difference in terms of finding someone actually good. Do you know whether you might be better served by a different dermatologist? Your sense of that is probably much less strong than that of someone currently seeing a therapist with the wrong approach for them. I agree that this does happen in all medical specialties and that it's bad everywhere, but it's even worse for therapists to do it.
Why not? They're the ones who are gatekeeping the product (their network) at the same time as they're selling access to their network (this is considered one of the "features" on which insurance companies compete and sell their product).
Not to mention that, as mentioned in the article, insurers are legally required to maintain a sufficiently large network to enable their patients to receive care in a timely manner.
If insurance companies want to restrict patients and limit them to seeking care from providers within a preapproved, artificially limited network, then it's totally fair to criticize them for not ensuring that their network is sufficiently large and accessible to be practically usable by patients.
Some people still think it is like One Flew out of the Cuckoo's Nest but really you can be suicidal and still spend 48 hours in the emergency room before getting to spend another 96 hours in the psych ward, get a depot injection of Haloperidol decanoate and get discharged.
Never mind trying to see a talk therapist.
And all too often it "can't" be provided because the insurance provider chooses not to provide it ("that provider is out-of-network, sorry").
Additionally certain insurers may pay terribly. Most insurers in my area pay about the same but one pays about 65% less than the average. It works out to less than minimum wage after I pay my overhead. No thanks, not joining that network.
you have a right to be free. Right to self defense. Right to free speech.
You don't have a right to the services of others.
No I am not a Silicon Valley bro, with the amount of kids I have I’m practically 200% above poverty line. I have “great” insurance and still do this. It can be done.
I know insurance intimately and it’s a terrible deal with poorly aligned incentives (for patients). I think removing any and all possible middle men will significantly decrease the corruption factor and waste factor. I don’t need 3 levels of coding reviewer bosses, support staff, adjusters, Blah blah blah to check my visit codes when I am the one responsible for ensuring what I ordered is what is delivered.
I also participate in an HSA and have been appreciating this idea and if anything think it should be increased, more tax breaks and more money directly to people.
No the fuck I don’t. How can they get away with charging more for someone with coverage than without? What exactly is the point of my insurance if that’s the case?
“That doctor hasn’t been at this office in ten years” “Not taking new patients”
I was making phonecalls and sending emails and logging in to weird web portals with two different insurance companies, Cobra (which was managed by some mysterious other entity??), two different HR departments, and the finance people at the hospital for months trying to deal with this stuff. The hospital we were at was in-network for both insurance companies, but no one was communicating with each other (and apparently one doctor involved was not in-network, so there were extra charges, which is such bullshit).
Why is my employer involved with my healthcare costs anyway? It's genuinely a Kafka-esque nightmare.
Anyway, any presidential or congressional candidate that opposes universal healthcare doesn't get my vote, ever. Sorry Biden, but you don't automatically get my vote just because I disagree with the republican platform.
Maintaining a list of professionals is challenging. There are very simple input problems with this kind of data.
The professional, in this case a therapist, but it really doesn’t matter what they do, just isn’t going to keep their portal updated on the insurance network aggregator.
The insurance companies can’t make the anyone update their listing, and the professionals don’t have incentives. They’re full up on work so there’s no real need for them to do anything to get clients.
This is a bog-standard supply and demand problem.