Why Pivotal Counseling Isn’t “In-Network”
Also see our page on
How To Ask My Insurance About Out-Of-Network Coverage
Many clients are confused by our not taking insurance. Some have even asked if they can give us the paperwork from their insurance so we can join their network. We certainly understand clients wanting to make the most of their insurance. However, there are several reasons why Pivotal Counseling chose to not directly accept or bill insurance. Some of those may also be reason for you to reconsider attempting to use your insurance for counseling.
Who Is The Client?
When it comes to insurance, there can only be one client. For an individual client, this may not be much of an issue but for couples or families, this can be a problem. It means that we have to identify someone as “the client,” the one with the problem. The other person can be there as a support according to the insurance records (coded as “family therapy”). However, only the one person is listed on the insurance claim.
Couples or family issues are best seen as something that the pair or group of you are addressing together, and even subtle notions that someone’s diagnosis can be blamed for all of the issues can create difficulties in therapy. Therapy is about everyone coming in and owning their own parts in the problems within the bigger system. Having an one person as the “identified patient” can get in the way of that.
How “BAD” IS YOUR ISSUE?
Insurance companies only pay for what they see as “medically necessary.” In other words, they want to make sure that your mental health issue is so severe that it impacts your everyday functioning at work, school, social situations, or daily living such as bathing, eating, etc. When billing your insurance, your therapist needs to make a strong justification for what your diagnosis is and how it impairs you from being a functional individual.
This can be a big problem. First, many clients come in to work on issues that aren't mental health disorders. They seek treatment before their issue would meet the criteria for diagnosis as a mental health disorder (and that is a good thing). Rather than being supported in taking a proactive approach to dealing with their mental health, clients are penalized and by their carriers because what they are seeking help with is not “medically necessary.”
This becomes even more complicated with couples. Most insurance policies don’t cover marriage or couples counseling. It is diagnosed as a Z-Code, a code that indicates an issue that may come up in therapy that does not qualify as a mental health diagnosis. It is this code that most insurers will simply reject. Some therapists will bill insurance for couples counseling by diagnosing the “identified patient” with a mental health diagnosis. The problem is that if they then do marriage therapy, they are not actually treating the diagnosis that is being billed for. This does not fit with our therapists' ethical standards.
The Impact of a Diagnosis
The other issue with insurance requiring a diagnosis is simply that you now have a diagnosis. Every clinician has more than a few clients that get caught up in their diagnosis and see it as part of their identity. Rather than dealing with an issue they are facing, they become their issue. We don’t see our clients as disorders and symptoms and we don’t find that they benefit from seeing themselves that way either. Our clients are whole and complete people who, like everyone, struggle at times to adapt to what life brings them. We believe that they benefit the most when they are able to take this perspective also.
Your Diagnosis, Your Privacy, and Your Choice
Once that diagnosis is reported to the insurance company, it will remain on your medical records for the rest of your life. Many people don’t realize how that can impact them and how they lose control of access to that information when that file is shared with those who need access to it. A diagnosis says nothing about who you are now, how you have adapted and grown, your strengths, and what actual symptoms you experience. And yet, a diagnosis will say a lot for those who read it and may negatively impact you in the future. Your diagnosis can follow you around in school or college and be a barrier to doing certain things such as working with the military, being hired for federal jobs, obtaining security clearances, working in aviation, and any other jobs requiring health-care related checks. In fact, many schools and healthcare institutions are now employing policies to screen out employees who may be unstable or cost too much money in mental health care and lost work days. Your choice in who knows your diagnosis disappears once that diagnosis is provided to your insurance.
Further, insurance companies require clinicians to reveal diagnoses, symptoms, behaviors, and treatment plans that itemize the issues we are working on and the goals we have set. We are unwilling to reveal confidential, potentially damaging information to the insurance company to justify our clients’ needs for emotional support. Avoiding interactions with insurance companies protects the confidentiality of our clients.
Insurance companies also limit the number of sessions they will pay for a client. Your treatment method, approach, and length is decision is between you and your therapist. We do not believe it is appropriate for healthcare decisions to be determined by insurance screeners and treatment to be decided based on production pressures from a corporation whose operating philosophy is based on attempting to increase profits and minimize payouts.
Insurance and the Therapist
It would be disingenuous to not acknowledge that there are personal reasons we have for not wanting to take insurance. Accepting insurance demands a significant amount of time and patience to fulfill paperwork demands, pursue reimbursements, re-authorizations for treatment, etc. Additionally, insurance companies pay what they believe a provider should be paid, sometimes as little has half of a provider’s session fee, and make it increasingly difficult to get paid. This means your clinician spends more time working in order to get paid less. This time spent trying to get paid a portion of our fee would detract from the clinician's time spent on better things such as engaging in consultations and research on your case, broadening their expertise in order to provide higher quality services, seeing other clients, and taking the time they need for self-care so that they can be focused, energized, and refreshed when they sit with you.
Is There Any Way to See You and Use Insurance?
Possibly! Some insurance carriers will reimburse for out-of-network mental health services. In those cases, we are able to provide clients with the documented information you need to request reimbursement. You’ll want to check with your insurance company for specific details. Read our webpage on How To Ask My Insurance About Out-Of-Network Coverage for specific questions you can ask them.
Please be aware that all of the concerns listed above about privacy, diagnoses, and your medical records still apply when a super bill is submitted.
Conclusion
Counseling or therapy services are an investment in your and/or your relationships overall wellbeing and health. You’re looking for help because you are ready for your life to be better. Investing in solid counseling services is one of the best things you can do for your ultimate success in life, for your loved ones, and, most importantly, for your own happiness and wellbeing.
