my insurance company "cut back" coverage

[dazed&confuzed]

My therapist called me today after my session to say that my craptastic insurance company had asked for a review of my case...he assumed it was flagged because I have been going twice a week, but he said he hadn't been asked to do one of these for quite awhile. Anyway, so we discussed what he would talk to them about (my general anxiety, OCD, impulse control-I shop WAY too much, and how my mom died 1.5 years after being chronically ill since I was a little kid). After speaking with them, they refused to cover more than one visit for me per week... :mad: I have been seeing the same therapist for 6 + months at two visits a week. I am guessing something changed with my policy as of this year tho, since I needed an authorization # at the beg of this year, and I never needed one before. I did verify when I called and got this number that I was allowed an UNLIMITED (bull crap) number of visits and just had to get prior authorization again in August. Anyway, the insurance person told my therapist that 2 visits a week are really just for people in a crisis (suicidal, etc.), and that they want to review my case with him again in a month. Um, for WHAT? To cut me back even more?

My therapist also told me that insurance companies don't like it if you aren't doing CBT...psychodynamic (which we are doing) is seen as questionable. I can't believe that an insurance company who knows nothing about therapy can decide what might or might not work for me.

So here are my questions...does anyone know if I have any recourse about trying to get my 2 visits a week covered? I want to call them and point out that I was told unlimited visits anyway.

I asked my therapist about going out-of-pocket for one of my visits per week, and he said he was concerned about how that might look if the insurance company wanted to pull my chart and review my case after this next month. But damnit!! It's MY therapy. If I am paying out-of-pocket for one visit a week and they cover the other, is it any of their business and CAN they use it against me?

Any advice is appreciated. I feel like my support structure has been yanked out from under me and I am really really scared. I was just starting to feel normal and now I don't think I can go to work tomorrow because I hate pretending like I am "ok" in front of other people when I just am not at all...

D&C

[Guest ASchwartz]

Hi D and C,

Now you know why I no longer accept any insurance companies or their reimbursements. They are intrusive and have money as their only concern and not the best interests of the patients when it comes to the field of mental health. I am sure they would rather not have to deal with mental health at all.

No, you have no recourse with regard to your insurance company's decision. I am sure you can appeal their decision but, in the end, they will come to the same decision.

As for why your therapist will not accept your payment for one of two sessions per week, I am mystified. The insurance company does not care. As long as they do not have to pay it makes no difference to them.

This is why I tell all new patients that I will lower my fees rather than deal with insurance.

Hope this helps,

Allan:)

[dazed&confuzed]

Hi Dr. Schwartz,

Thank you so much for your response...

I called and talked to the department of insurance for my state and they are sending me some information on appeals...they said I might have a right to an external appeal even if my appeal with the insurance company is rejected, which you are right about, I am sure they will reject it. However, my therapist, who I talked to this morning, wants me to put the appeal idea on hold until we talk next week...he thinks if they look at my chart duiring the appeal, they could want to reduce my visits even more based on the psychodynamic approach we are taking. Its so ironic that after 6 months of psychodynamic vs. 5 years of unhelpful (well, for me) CBT (which the SAME insurance company paid for) I feel NORMAL. Well until now. Now I just feel awful.

And I am sorry to mislead you. My doctor will certainly accept my payment, but he is afraid if the company wants to look at my chart when they do another review in a month, they will make some issue with me coming a second time during the week (again, I think the concern is that they could choose to even more closely monitor my "progress" or, as I mentioned above, reduce their coverage of my visits even more), even if I am paying out-of-pocket. Although I feel like they are going to do whatever they want to do anyways...and I would rather fight for my rights than not fight at all.

Thanks again for your response.

D&C

[David O]

Hi Dazed,

Allan is right... the insurance company has little if nothing to do with how you pay as long as they only pay for weekly visits. In addition, like Allan, I refuse insurance... many of us in the field do as it deeply sacrifices treatment. Interestingly, patients/clients are far more motivated when they're paying out of pocket and tend to make quicker improvements when they see the money going out of their own pocket.

I'm afraid I would have to side with insurance company on 2 things, 2 visits per week is not generally common unless there is a crisis at hand-- I rarely would see someone more than weekly, and I see mostly individuals with the most persistent and severe cases of mental illness (schizophrenia, Bipolar Disorder, etc.). Secondly, the cognitive behavioral therapies have established themselves as effective therapeutic interventions for your issues whereas psycho-dynamic treatments have not.

This is not to say psycho-dynamic is not effective as much as it is to say that they have not conducted the requisite research to support the efficacy of treatment. In many cases, as Allan will attest to, it is far more effective than the CBT model-- much of this depends on the condition/issue and how good your clinician is. In the hands of a seasoned and competent clinician, most therapies will be highly effective, in the hands of a non-skilled, less competent clinician, even the most evidence based approach will be ineffective.

Good luck with this minefield of frustrating insurance BS-- that alone is enough to drive me to seek treatment.

Good luck,

david

[Lindamomof7]

Thanks for bringing this topic up. I hear similar stories from others on medicare/caid?

well then I guess I am one of those "severe" cases for therapy. I see a LCSW 2 times a week, well thats when I am not shutting her out, but since I have the bipolar diagnosis it is a "medical" condition and I do not tap into my mental health benefits so I have unlimited visits.

The hospital benefits are the same way luckily for me. And it is very discouraging to pay insurance and I'm sure with 7 kids you can figure how much that is as a small business owner but then to search for a Dr and find out they don't even accept insurance is very discouraging as well.

Good luck to us all......