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  • Writer's pictureSarah F. O'Brien, LCSW, LCSW-C, CCATP, CTMH

Health Insurance Companies are Big Business...and it's BS! Part 2

Read on to find out more on what practices health insurance companies are engaging in to avoid payment for mental health treatment and all the B.S. providers have to deal with just to get paid

A story about winning a rate increase request, just to have the new rate not honored on the date it was to go into effect...x3 (yes this has happened with 3 different companies!)

In this Part 2 addition of how health insurance companies are slowly causing the decline of mental health for mental healthcare providers, we will learn how negligent companies can be about paying the proper amount for the service provided and never paying out in a timely manner.

Let's start with some background

Health insurance companies set reimbursement rates based on education, level of licensure, geographical region, by comparing rates with like-providers near you, and number of years you have been credentialed with the insurance company. Rarely do health insurance companies raise rates for providers all by themselves but occasionally they do-- we've experienced problems in proper payment when THEY have been the ones to raise the rates for us without asking. And then if you are lucky enough to be granted a rate increase as a result of your own request--we experience problems getting paid the proper amount here, too, even though we and they have signed a contract with a date for the new rate to start occurring. The ridiculousness of the whole thing is really a tragedy of errors and lack of compassion.

Health Insurance Company #1

Health Insurance Company #2

Health Insurance Company #3


Asking provider representatives for a rate increase

I mentioned in my last blog post, the process to request a rate increase (when the company has not provided rate increases in 3, 4, 5 years in some cases) is arduous already. We are told by our provider representatives with the health insurance company that we must "make a good case" for asking for a raise. Okay, I can understand that to some degree. But after 4 years without one?! I need to make a case to receive a livable wage? Umm...

I'm going to provide three examples from three different health insurance companies on how THEY managed to screw up actually paying out on legitimate rate increases for providers (me specifically, these are all personal examples of issues). This one is also a juicy bit, so read on!

Health Insurance Company #1

This Company offered a significant rate increase the year after they completed a rate reduction for all master's level mental health clinicians. The year is 2019. This Company sends a letter to all contracted providers alerting us to a new provider manual with new fee schedule in June. The new manual and new rates will go into effect October 1. They've informed us there is NOTHING we need to do (not even sign the new contract/manual or agree to the new rates) and starting October 1 we will all see the increase reflected in claims processed.

October 1 comes and goes. And so does 2nd. And the 3rd. And the 4th...and then November 1, 2, 3, 4. Nothing. Everyone is still being reimbursed at the old rate. So naturally, I get on the phone to whoever I can get (not my provider rep for THIS insurance company, because this person NEVER returns anyone's phone call, barely responds to email--same person still employed in the same position 4 years later, nothing has changed!). So I'm on hold for an hour, get a customer service rep, get a supervisor, then make this same call to find out the issue several different times with several hour+ long wait times, to eventually learn their "electronic system that reads the claims has not been updated to reflect the new rate, they are working to get everything changed over and claims already filed to be reprocessed at the new rate." Really? Are you %$*& kidding me? YOU told US in JUNE this would go into effect October 1 and YOU COULDN'T UPDATE YOUR SYSTEM TO READ AND PROCESS THE CLAIMS CORRECTLY by the date you provided to us?!? This is ludicrous.

On top of all that, providers went 7 weeks without any claims being processed at the new rate. This was a HUGE problem for practices with staff, because staff got raises and then insurance didn't pay out which left group practice owners in a bind. Okay, 7 weeks pass, we start getting NEW claims processed at the NEW reimbursement rate, good. However, those 7 weeks of claims waiting to be "reprocessed at the correct rate and further reimbursement provided" took months, over a year for some folks to get what was owed to them, some never recouped all that was owed to them because the process of "staying on top" on the Company to fix it and reimburse them properly was too much while still seeing clients. I'm a solo practice owner/operator, 7 weeks of the unpaid portion of the new rate was over $3000 for me. I did not receive all of my adjusted payments for over 6 months! And this was after filing a complaint with the SCC (State Corporation Commission), and hounding my provider rep and their supervisor for updates every 2-4 weeks until I was paid in full (VERY squeaky wheel). No interest was provided for the incredibly late payments and this error was completely the fault of the health insurance company with their own system. We providers suffered the consequences.

Health Insurance Company #2

This Company's provider rep is the one who told me to "make a case" for asking for a rate increase, when it had been over 4 years since I had received a rate increase from this particular company. Okay, so I make the case. I write 4 pages of rationale for why I deserve a rate increase to better match the reimbursement rates from other companies, like Medicare for example. Medicare was paying more for the same service than a nationwide big health insurance company (!!). I set my rates in the rationale and was met with "we can't accommodate your rate increase request, however we can offer 7% over the current market rate in your area" and it took 5 MONTHS TO GET THIS RESPONSE! I followed up every few weeks to a month with my provider rep and nothing, nothing, nothing.

After I FINALLY received notification my request was "approved" to some degree, now comes the contract, and at least this Company sent me an updated contract, with updated fee schedule, asked me to sign, they signed, and set a date for 2 weeks later to go into effect. Out of curiosity, I asked the person who finally responded/informed me I was approved why it took 5 months and a lot of follow-up from me if I was just going to be approved anyway. And that employee told me "Honestly, it got lost in my mail inbox and I didn't get to it until I was alerted this week." Cool. Let's not forget, I followed up with my provider rep SEVERAL times, to be told "these things can take a while." Okay. Now the 2 weeks has elapsed and I expect to see the increase...Welp. You know where I'm going. That 2 weeks came and went I was NOT seeing the agreed upon new rate being reimbursed in my claims. This goes on for 4 months! I have to collect information for every single claim already submitted and paid out incorrectly for that time period, add ALL the information to a spreadsheet for my provider rep and he had to resubmit them for correct payment and get the rate adjusted, since it seemed to not have been UPDATED IN THEIR SYSTEM FOR OVER 4 MONTHS AFTER THEY APPROVED ME!

Is this ridiculous enough for you yet? Keep on reading, I got one more story for you.

Health Insurance Company #3

I sent this Company the same "make a case for it" rationale I sent to Company #2 to be met with a similar response, but it took less time to get. Maybe 2 months instead of 5 months. The response: "We cannot accommodate such a high rate increase request at this time (let me remind you, I requested the equivalent of $50 or so BELOW my current set rates and they still refused to accommodate), however, we can offer 10% from the current market rate in your area, here is a new contract and fee schedule to sign." Great, I'll take it! There was confusion with the business name and doing business as name which was not communicated or clarified well by the Company's employee which resulted in many back and forth emails which felt frustrating, but at least someone was responding!

Now, this new rate came again with a new contract, and a set date for the new rate to start... over 3 months from when I, and they, signed the contract. Really? We are all agreed and now it's going to take 3 months to execute it? Whatever. I accept my fate and move on. Almost completely forgetting that I am supposed to be getting more money for this Company's claim submissions, and guess what? Yep. You know. June came and went. In fact, it was June 27 when I go double checking all of my reimbursements to realize NONE OF THEM HAVE BEEN PAID AT THE NEW RATE. I'm about to blow a head gasket at this point. I have waited nearly 4 months for the agreed upon rate that took 2 months to get approved for in the first place to get to the start date and for that entire start month it still has not been executed in their system to pay me properly, and I have to outreach them AGAIN to ask why I'm not being reimbursed properly. It has already taken SO MUCH FREAKING WORK to even get the rate increases (all in all for Company # 2 and Company #3 it took a year and 3 months to get approval and I'm still waiting for Company # 3 to adjust the rate and start paying what they agreed, now 5 weeks after the effective date) and then the big bad health insurance companies making hand over fist in profits cannot simply do the work they agreed to do on my behalf to get the rate increase 1) approved 2) schedule effective start date 3) get new rate in their electronic system by the effective date 4) reimburse me in a timely manner with the new rate. What is the deal? Is no one required to do their job at said health insurance companies? Everyone else can just be neglectful of their duties, to my detriment no less.

The span of these stories is nearly 5 years of the 7 years I have been in private practice. And this doesn't even cover other health insurance issues I've experienced as a small business/practice owner. Money already paid for a claim has been redacted time and time again for "duplicate payment" when I know with my meticulous record keeping the claim has NOT been paid out twice, but it's too much to fight for every dollar so sometimes I just let them take this money back without fighting it. Still, some insurance companies pay me less for a psychotherapy hour than hair stylists charge and collect for a cut and style. On top of it all, EVERYONE is asking healthcare providers, and especially mental healthcare providers, to keep giving, giving, giving. Give your time, give your energy, give your emotional capacity, give your money back even and BE RESILIENT too, and just keep doing it. This expectation and the egregious practices of health insurance company's is nothing else than bullying and exerting power and control over smaller voices, and straight up taking advantage of healthcare workers across the board.

I'll say it again, being a mental health care provider in today's landscape is brutal. We're taking hits from all sides and we have little support. It's not all about money, but we are people too, with families, homes, pets, and responsibilities that cost money. We live in the same place as everyone else, where money is a necessity to survival, at least here in the West. We have to make a livable wage, and without having to fight to get properly paid that livable wage every month or every year, if the public continues to expect us to show up and give give give. We like giving, we like helping, we don't like being taken advantage of because we like help. We want to be VALUED, APPRECIATED, SUPPORTED, AND COMPENSTATED for the healing work we do.

*BONUS* Follow me on instagram and drop me a message about which health insurance companies you think I'm referring to in this post. I'll let you know if you are correct! @TimelessTherapist

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