Even though psychotherapy is beneficial to treating depression in adolescents, more than half of the children that are taking antidepressants do not receive psychotherapy, according to Thomson Reuters research published on October 2008. For your reference, I am attaching the full report here.
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I thought it might be helpful and perhaps relevant to add to what to what you wrote by speaking a bit to the difficulties that people typically face in accessing their employer-sponsored mental health insurance benefits, and then to offer some ideas on how to minimize the stress of the process. I am quite familiar with these difficulties, because I often attempt to help those who cannot afford to see me in my private practice by locating a suitable in-network therapist for them. I also used to work for the second largest managed mental health care company in the U.S. for one year and then spent some time on an insurance panel myself for a brief period.
By the time most people decide to enlist the help of a professional, they’re often approaching fever pitch in terms of discomfort. A call to the toll-free number on the insurance card starts an often frustrating process, especially for someone who is anxious and depressed. The first call to the company that handles the mental health benefit, which is often a different entity than the main insurance plan itself, can have a person waiting up to 15 minutes to reach a customer service representative—particularly on a Monday, always the busiest day for them. This representative typically does a quick and half-hearted search to offer up the names of three providers—not six or more.
So, the typical scenario looks like this: Our depressed and anxious person calls, and it soon becomes apparent that this list of, say, three providers might not take geographic proximity into account at all. That means that the distressed person would have to call back and ask for additional names with this criterion as a filter. He or she now has the name of three additional providers, one of whom doesn’t return the call, and the other two aren’t accepting new patients at this time. A third call to the company’s representative, whose calls are being timed by the company, mind you, yields yet three more names, this time with location considerations addressed once again. The first clinician of this third set of providers offers appointments for 10:00 or 11:00 a.m. or a 2:00 or 3:00 p.m.—Unless the provider works solely with insurance company panels, these hard-to-fill appointment times become the only options for those patients, particularly if the therapist’s office is in a popular, high-rent location. Why? An in-network therapist earns roughly half of the going rate for other therapists in the same area, and the balance of this low fee (after receipt of the patient’s copay, I mean) is often hard won from the insurance company, which will deny and delay a claim based on just about anything. (I have seen it all, believe me.) The second hypothetical clinician in this final set is no longer on the panel, despite his or her name’s continued existence in the insurance provider’s database. And the third provider? You guessed it: “I’m sorry, I’m not taking any new patients right now.”
So, here is how to get the most out of your efforts when you call your toll-free number and access your mental health benefits:
First, know your first and second choices for location—perhaps one near your job site and another near your home. Some representatives can search by zip codes, which is very helpful when looking for a provider in a large city.
Second, make sure to ask for the names of at least six providers. A solid referral from a friend or coworker, who has accessed the same insurance plan, would be invaluable.
Third, if you have a PPO benefit, which would enable you to see clinicians outside of the insurance plan’s panel, it’s important to know the right questions to ask to get a complete and accurate explanation of benefits. The best way to do this is to have what are known as CPT codes, which stands for current procedural technology, in front of you. These are the codes your physicians and mental health professionals use to record the type of service or procedure that you receive. In this case, your codes will almost always (psychological testing and medication management excepted) be 90801 for an initial assessment and 90806 for a standard, 50-minute session with a psychotherapist of any sort with the initials LCSW, LCP, Ph.D., or Psy.D.
Your impatient representative will then tell you something like, “We cover 60% of the fee of an out-of-network provider, and your portion is 40%.” Sounds good. The problem is that, in most instances, she is talking about 60% of what are known as “usual and customary fees,” which means the rate that their in-network providers get. For a Master’s-level clinician, this is $65-68 per session between your co-pay and what the insurance company sends them. For a psychologist, it’s somewhere in the order of $75-$78.
An out-of-network provider in a typical city, however, charges anywhere from $110 to $200 per session, depending on trends for the mental health discipline, the rents for the area, and years of experience. You would be responsible for your 40% of the “usual and customary fee” plus the difference between that and the therapist’s actual fee. In essence, you’re paying the full fee to the therapist, whose receipt for services will get you back somewhere in the order of $35 per session. Yes, that’s a much higher payout for you than a $25 or $40 co-pay, it’s true. (There are darn good reasons that out-of-network therapists charge what we do, but that’s a discussion for another time.)
Often one has to be fairly persistent to find out what the insurance company considers the usual and customary fee. Essentially, you would need to specify what is known as a CPT code, or current procedural technology code. You would tell them it is for a 90806, which means either a 45-minute or 50-minute psychotherapy session. Again, there will be a slight difference if you’re asking about a Master’s-level clinician vs. a Psy.D. or Ph.D. Also, you might be charged a little more with respect to the co-pay for the first visit, which is referred to as a 90801, or initial assessment, because it is supposed to be a longer session.
In my opinion, it would serve people well to look into their list of available in-network providers, because it is indeed possible to find a good one from time to time. If the employee has signed on for an HMO option, this would be the only choice, of course. If this turns out to be more trouble than it’s worth, those with a PPO option can get some reimbursement with an (often much more experienced and better trained) out-of-network provider. Choice is a good thing.
In the meantime, I wish all of you the best of health.
Karen J. Osterle, LICSW, is a licensed psychotherapist, providing marriage counseling/couples counseling in Washington, DC.