How insurance companies fill their networks with ‘ghost’ therapists
January 24, 2024 4:03 PM   Subscribe

Oh thank god someone is doing actual reporting on this.

I have been seeking mental health care for about a decade, and it has been basically impossible. Even setting aside the concept that insurance up until quite recently might offer coverage for mental health care, if you DO have that available to you, this article is all about why you can't find a therapist.

Nobody is taking new patients. People who are taking new patients aren't in-network. People who are listed as being in-network aren't in-network.

I once spent every lunch hour of every day for a month calling therapists in my area who were listed as in-network, so 30 hours going down a list and making phone calls, and across that entire month the end result was I had zero appointments.

The one time I did get help through insurance was when the company switched to a new insurance provider and they had this list of "enrollee special benefits" one of which was counseling. I got hooked up with a women who was actually doing a practice that I needed, but she was a terrible fit for me personally and I only got 6 appointments in a calendar year [GREAT special benefit!], and when it ran out I didn't pursue it further.

What I have discovered is... if you need mental health care... quit your job for long enough to get onto Medicaid and then suddenly you get all the mental health care you want. I'm even living in Washington, that state about which this article is written, and I get that they're focussing on these major insurance providers, but I wonder what they would discover if they added Apple Health into the mix, because that's an ACA marketplace insurance that CAN be bought into.

I just don't know if the Apple Health insurance that can be purchased has the same mental health care coverage as the Medicaid insurance. If you CAN buy into it... then that's the way to go because I got a referral to a large practice and have had three appointments already, all since shortly after Christmas.
posted by hippybear at 4:14 PM on January 24 [15 favorites]

So, on the one hand you have BetterHelp, which can probably find you someone to talk to, even if they're not particularly well-matched to your needs or at all helpful, or you can wardial the yellow pages. Great system!

I had some luck with a smallish psychotherapy group practice, but one day my therapist either left or was summarily dropped from the practice with no warning, no explanation, and no proper "goodbye" session. It was extremely weird and I didn't go back to the practice.
posted by BungaDunga at 4:19 PM on January 24

I'm so upset.
posted by grobstein at 4:24 PM on January 24 [2 favorites]

I have a suspicion that those who can pay out of pocket are taking available spots. Why would a provider want to hassle with insurance when they could get paid in cash? Like so many other things, mental health care has been gentrified.
posted by larrybob at 4:48 PM on January 24 [13 favorites]

Usual, Customary, and Reasonable is the tools of the devil here. Even when you have a PPO 90 or other godlike insurance, do get a good therapist out of network, and you've meet your deductible, and you understand the coinsurance you still have to pay most of the bill because usual, customary, and reasonable are based on their own payout rates that NOBODY TAKES and hasn't budged since 1993. Can you find that amount in advance? Not on your fucking life. Can you contest the amount? Don't be ridiculous!
posted by Your Childhood Pet Rock at 4:53 PM on January 24 [6 favorites]

Ran into exactly this issue, with United in particular. My wife ended up doing a mini version of this investigation with similar results.

She also happens to be a (formerly) practicing social worker. Here’s the reason nobody takes insurance: they wildly underpay relative to market rates, AND they require documentation that increases the overall time investment per client by 50%, they don’t reimburse for that time, they can reject the claim for legalistic/made up reasons, and even when they do pay it takes months. I don’t blame therapists for not wanting to deal with any of that. It’s not just an annoyance; the unpredictability and overhead undermines the business model.

The solution is for insurance companies to be far, far better regulated. Or single-payer (that is also better regulated). 🤪
posted by techbasset at 5:13 PM on January 24 [18 favorites]

A friend of mine worked in a well-known experimental psychiatry-psychology lab, at a well-known psychiatry facility, and needed help for profound depression for years. As he said, "it's ironic to have a condition that magnifies every barrier and the only way to get help is from a system that has nearly insurmountable barriers to overcome." At his worst he'd know he needed help but couldn't get it, at his best he'd think "maybe that was the last time" and didn't think he needed help. And that was for a person well educated in the needs, system of care, and consequences of lack of followup. "What do people that aren't like me even do?" he asked.

In a moment of doing well, he finally established care. Every day I see him now I think "WOW... it's wonderful to have the best version of my friend here. The person I know."

Acknowledgement of bias: this describes the system of care in the USA.
posted by rubatan at 5:14 PM on January 24 [20 favorites]

If you think finding a therapist that takes regular insurance is hard (and it most definitely is,) try finding one that takes Medicare. Good lord, is it rough. In my area, no psychologist (that I can track down) takes Medicare. The few therapists I found that did take it are all of these letter-salad-after-their-name therapists. Pick one and hope, I guess.
posted by Thorzdad at 5:27 PM on January 24 [2 favorites]

Thorzdad, until very recently, Medicare would only pay for licensed clinical social workers.

I know someone in the same boat, and I finally mentioned it to my own therapist, which is how I learned about the LCSW requirement. More therapists (with different credentials) should become available for Medicare users at some point, theoretically, anyway.
posted by Archipelago at 6:07 PM on January 24 [1 favorite]

quit your job for long enough to get onto Medicaid and then suddenly you get all the mental health care you want.
It is awesome that Medicaid met your needs, but I don't think this is a common experience. I had a friend just south of you in Oregon who struggled to find providers who took Medicaid.
posted by mrgoldenbrown at 6:24 PM on January 24 [3 favorites]

I do know that Medicaid is executed differently by every state, and I do probably live in one of the better states as far as what is provided through Medicaid.

It is awesome that Medicaid is meeting my needs. We need universal Medicaid of this quality for all US people.
posted by hippybear at 6:28 PM on January 24 [3 favorites]

The woman in the photo was our therapist for a while. Very weird to see...
posted by Windopaene at 6:29 PM on January 24 [4 favorites]

Yeah no. Medicaid didn't get expanded in how many states?

I've had luck with a bigger practice, but even then, I'm looking for my 4th therapist.
posted by Chrysopoeia at 6:31 PM on January 24

Medicaid didn't get expanded in how many states?

Well, and even if Medicaid did get expanded, how the program is structured is done on a state-by-state basis, so even if Oregon might be considered a fairly progressive state in a lot of ways, they might have a very different set of what they offer in their Medicaid vs what Washington offers.

Honestly, I had no idea it was even possible to get mental health care in this area because I had been trying for so long. Is the difference that I had a referral whereas before I was looking on my own? Is the difference that the Medicaid that I have is proactive about mental health care, and there are other programs I could have signed up for that had different focusses?

I honestly have no idea why I'm suddenly having a good health care experience when for literally decades I've felt like the system was treating me like I shouldn't dare seek out help even while paying for what was pretty great health insurance through my work. But I wish this could have been my experience all along this struggle, and I wish it could be available for everyone.
posted by hippybear at 6:37 PM on January 24 [1 favorite]

Years ago I joined a free program where you could see students who were still working to complete their therapy degree, and the first two people I saw (because they would quickly exit the program) were great. The third person, absolutely terrible. And that's my sum of experience in this area.

...I should add that since they were students, people with really severe issues weren't recommended to use this program. So it was like, therapy for people who could have also benefited from other kinds of programs like mentoring, life coaching...
posted by subdee at 6:40 PM on January 24

I have a suspicion that those who can pay out of pocket are taking available spots.

Likely to be the case, in no small part. My neighbor across the way is seeing someone, while covered by one of the insurers mentioned in the article, and it's a strictly submit-for-reimbursement affair. Literally none of the APA people in the entire county were willing to deal with insurers -- every single one was pay upfront, pray for reimbursement later. The best you can hope for is to find someone whose accounting software will auto-generate invoices that the insurer software finds to be acceptable.

...but, in defense of the therapists, this is what the American People have very repeatedly, very loudly (and occasionally with threatened violence), demanded must always be the case. So you can't really blame the therapist for doing what society demands.
posted by aramaic at 6:53 PM on January 24

Years ago I joined a free program where you could see students who were still working to complete their therapy degree, and the first two people I saw (because they would quickly exit the program) were great. The third person, absolutely terrible. And that's my sum of experience in this area.

I tried this! I showed up to one session and talked to a 22 year old who pretty much sat across from me and mumbled "Wow, that's messed up" every few minutes. Later I received a bill for $110.

There wasn't a second session.
posted by Pope Guilty at 8:44 PM on January 24 [13 favorites]

The solution is for insurance companies to be far, far better regulated. Or single-payer (that is also better regulated). 🤪

FWIW single-payer is not a panacea for mental health because the treatment is so individualized. If I hurt my knee the surgeon is all but fungible. That's not the case with mental health. In Australia the reimbursement rates for a therapy session is A$137.05 (about $90 USD) when the prevailing rate is A$200+ an hour. Oh and you only get 10 of them per calendar year. Oh and you need a GP referral which you also need to pay for since three quarters of GPs charge above the Medicare reimbursement rate.

I don't know if this is a problem specifically in the anglophone world where protestant ethics rule the day and mental health problems means you've sinned so fuck those people but it's fucking bad everywhere I know.
posted by Your Childhood Pet Rock at 8:47 PM on January 24 [6 favorites]

Well, if anyone is interested in the perspective of someone working in the therapy field, I'll raise my hand and share (between the comments on the recent Betterhelp posting and now this one, I just can't hold my tongue in defense of therapists anymore, so here goes):

Imagine... a bright-eyed, bushy tailed college kid who has big dreams to help others and make a difference, so they decide to go to graduate school for counseling. "Just take out loans," people tell them, "that's what everyone does and you just pay them off eventually!" So they sign on the dotted line to pay for their $80,000 counseling degree, work part time to live on, and work even more for free at internships, doing unpaid labor in exchange for the prospect of learning (which happens at some placements, but not all).

Finally, after years of hard work, they graduate! They get a job working in the community, spending their days working with people who are shouldering enormous trauma, who are depressed, suicidal, hopeless. People who have mood and personality issues and sometimes are explosive towards them, threatening, demanding. People who are homeless, addicted to drugs, in abusive relationships, but still manage show up to do the work with them. Supervisors who add more and more work, caseloads of 55+ clients for one person, demand more billable hours and productivity while also telling them to do "self care" to avoid burnout, as if it's another task they and they alone are responsible for. Their wage for this job? In some states, barely more than minimum wage. But hey, those loans at 7.6% interest are on an income-based repayment plan, so their monthly payment is zero - no big deal! Just 10 years of this and those loans will be forgiven, right?

Unless they can't survive for 10 whole years on community mental health wages and burn out conditions. Unless their agency is bought by a for-profit company. Unless they need to take a sabbatical to recover from burnout and pause their loan repayments. Unless the loan servicer doesn't keep track of your payments. Unless unless unless.... Careful though, turns out that interest is capitalizing every year!

But maybe that therapist eventually finishes their 2-3 pre-licensed supervised years, passes an extremely difficult clinical exam, and gets licensed! Maybe they decide to seek greener pastures in private practice. Control over their own schedule and caseload, sounds great, right? Except... no benefits, no safety net, no healthcare, no PTO. And insurance rates haven't kept up with inflation in decades, so those reimbursement rates are insufficient to earn a living. And require so much paperwork and hoop jumping to claim them, and then can be CLAWED BACK at any time, even years later, for any reason the insurance company deigns to use.

So maybe our hero therapist decides to go with an in-between solution: a tech-driven middleman startup like Betterhelp, Talkspace, Headway, etc etc etc... They advertise better solutions for both clients and therapists, right? Nope, no better: not only does our therapist friend get only a fraction of the revenue they generate for that company, they also get pressure to respond to clients within a certain time frame, pressure to message clients with a high word count or high frequency of contacts, pressure to deliver measurable outcomes in a field that research still struggles to measure, where relationship building and therapeutic alliance is the real value but can't be quantified with a dollar sign despite capitalism's unending attempts to do so.

So, where does this leave our therapist? Now $100,000+ in debt, burnt to a crisp, criticized for taking only private pay clients in order to make enough income to pay bills, pay loans, and maybe take a few weeks off for vacation. As if it's their fault for wanting to earn a living commensurate with an advanced degree. As if it's their responsibility to single-handedly fix a broken system. But still, holding safe and non-judgmental space for people's deepest and most painful traumas. Still, showing up everyday with unconditional positive regard for their clients, who they admire every day for the work they're doing and the strength they show. Still, going to continuing education trainings and learning new theories and techniques and honing their clinical expertise. Still, supervising new clinical interns and trying to encourage them to see the good in the field even when it feels like a dumpster fire. Still, nurturing that flame inside that burns just a little bit brighter when a client looks at them on the way out and says, "you know, this was really helpful, thanks."
posted by carlypennylane at 9:02 PM on January 24 [72 favorites]

I seriously got lucky finding my new therapist. Admittedly this is because (a) my work offers an alternate insurance option for that because my HMO can't do regular therapy, (b) the alternate insurance option will literally track down potential people for you to call. I went through 3 out of 4 recommendations--the first refused my insurance, the second refused me personally--and here I am on #3 until I lose this job. Once I'm out of this job, there goes the therapy, of course.

Moral of the story: if you have Optum as an option, it's fucking great. Of course, I've never heard of them otherwise until recently.
posted by jenfullmoon at 10:38 PM on January 24 [1 favorite]

Meanwhile, China is so far ahead of the capitalist West that they actually have centers for the prevention of mental health.

posted by Aardvark Cheeselog at 8:58 AM on January 25

Optum is basically just rebranded United Behavioral Health (it’s actually more complicated than that, but ultimately not really) which is just United Healthcare. I’m glad you’ve had a great experience with them jenfullmoon, but they are pretty much one of the main actors in making behavioral healthcare a shitty minefield for both patients and therapists.
posted by flamk at 9:51 AM on January 25 [5 favorites]

Years ago I joined a free program where you could see students who were still working to complete their therapy degree, and the first two people I saw (because they would quickly exit the program) were great. The third person, absolutely terrible.

Yep. The best therapist I ever had was a PhD candidate at my local university's practicum clinic. It isn't even a close call. Hands-down amazing, and exactly the kind of therapy I need (which you just can't get via anyone who takes your insurance. I find they all are more-or-less following some sort of CBT manual.) And, then they graduated and the next person wasn't very good and I dropped out.

Anyway...If you live in D.C. and are seeing therapist named Sam, tell him Jim says "hi."
posted by Thorzdad at 10:12 AM on January 25 [1 favorite]


The two times I've sought out therapy, it's been a helpful and beneficial tool. In both instances I've needed to stop going because the out-of-pocket costs are too burdensome for my budget. Therapists deserve to be paid for their services, obviously, and mental health should be taken seriously!

Unfortunately, Kaiser –my current insurance option– has an abysmal track record, which is full of class action lawsuits and fines. Kaiser must have decided long ago that the lawsuits and fines cost less than actually providing adequate mental health coverage and care.
posted by nikoniko at 11:34 AM on January 25 [1 favorite]

Yes, literally they did do that, decide that the fines were worth it. That said, for the most part I've actually had a pretty good experience with Kaiser during my mental breakdown, they just don't do weekly care. They do crisis care, is what they've told me, and since I'm in crisis, that's mostly gone well except for the whole diagnosis thing in that other thread.

they are pretty much one of the main actors in making behavioral healthcare a shitty minefield for both patients

Is there literally ANYWHERE that doesn't have a shitty minefield? I ask this seriously. Literally I've seen articles of "Kaiser is the most blatantly worst, but NO ONE is good."

That said, didn't know it was United, which is the company everyone tells me to get and pay more out of pocket for, so hmmm.
posted by jenfullmoon at 1:42 PM on January 25

As a therapist, I feel fortunate to work for a company that pays me a salary AND accepts a variety of insurance plans including all of my state's Medicaid contractors, so I can accept as many Medicaid clients as want to see me (many, since I primarily see children and teens) and not worry about my paycheck. Not having to do my own billing is a delight. Also, my student loans were forgiven when I was disabled for a substantial period of years (I thought forever, but divorce forced me back to work), so I only have substantial credit card debt caused by my disability to pay off.

All this said, my first job in mental health was providing in-home behavioral skills help and family therapy to children and families. I had a master's degree and was making just about $35k/year. When I interviewed for my current job, I interviewed at a nonprofit organization that wanted me to see more clients per week for $15k less per year.

As always, insurance companies are making out like bandits and both providers and clients are getting screwed.
posted by epj at 3:19 PM on January 25

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