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Key points
- Mental health providers almost never receive yearly cost of living adjustments.
- BCBS forces clinicians to sift through 75 pages of codes to find only one or two have slight adjustments.
- Mental health therapists are leaving the field for better work-life balance and pay increases.
- Insurance companies must raise their reimbursement rates and reduce red tape for mental health providers.
“The current state of mental health care in the United States is troubling,” according to the cover story in the May 2023 edition of Counseling Today, published by the American Counseling Association. Agencies understaffed. People are unable to access or afford care. “Counselors are overwhelmed with high caseloads, and many are leaving the field in search of better pay and work-life balance.”
The Coronavirus pandemic amplified the clinician shortage. Access to mental health care and helping those in dire need is at a crisis level itself. Few solutions exist, but one is a literal no-brainer: Compensate providers commensurate with education and experience.
“Despite federal laws requiring health insurers to reimburse mental health and medical services at the same rates, the unfortunate truth is that many insurance networks have terrible coverage with outdated provider directories and unintelligible benefits,” wrote Katie Jennings for Forbes in 2021.
The National Alliance on Mental Illness (NAMI) published “Health Insurers Still Don’t Adequately Cover Mental Health Treatment” in March 2020—that warning was prescient given the global catastrophe that evolved.
Inadequate Reimbursement Is the Root of Clinician Shortages
Two years ago, I covered this in The Frustrating Financial Realities of Therapy. Mental Health America posted Fix the Foundation: Unfair Rate Setting Leads to Inaccessible Mental Health Care earlier this year. “There is not much of an incentive for providers to take insurance if they aren’t guaranteed adequate payment,” wrote Mary Giliberti, MHA Chief Public Policy Officer. She concluded her report with: “Until the foundation is fixed, everything else is just window dressing.”
Colleagues in various parts of the country agree. While some insurance companies are the exception—and they are revered for this—most fall behind in how they deal with mental health provider pay.
Aetna, ComPsych and Magellan Behavioral Health historically paid low rates to mental health providers. Blue Shield, HAI , Meridian and Tricare (which serves military families) were named among lower payers as well. Third party administrators (TPAs) handle the processing of claims for self-funded health plans. Some of these pay providers with a VISA card. Yes, they expect providers to incur fees to get paid! That's like saying "pay me to get your paycheck." It's incredulous. More time gets spent to opt out of this insane way of disrespecting providers.
Those providing employee assistance programs (EAP), such as Aetna, ESPYR, and Magellan, are often similarly low. An EAP offers counseling services through employee benefits, usually between three to six sessions, but sometimes 10 to 12 are covered. Few EAPs offer more provider payment for management referrals, but they should. Management referrals require additional paperwork and additional check-ins with EAP personnel because a client’s job status is affected.
In any other field, more time typically garners additional compensation. It’s amazing how mental health providers receive sub-par remuneration, often regardless of time spent. Therapy is, after all, a profession that supports practitioners and their families.
When providers make assertive cases for slightly higher rates, they may be summarily rejected—and what’s worse, those who decide often haven’t worked a day in mental health care. Most who decide what mental health providers get paid do not possess a master’s or doctoral degree, clinical training, or mental health licensure. Ms. Giliberti outlined about rate setting guides that insurers use.
No Cost-of-Living Adjustment (COLA) with Insurance Companies
When I entered private practice in 2008, Blue Cross Blue Shield (BCBS) in Maryland (Carefirst) had two tiers of reimbursement—a higher rate for PPO plans and a lower rate for HMO plans, which back then, got outsourced to Magellan. HMO members could not easily find therapists or psychiatrists even though the database boasted hundreds.
Magellan reimbursed providers abysmally. To stay in business, providers got paneled with several insurance plans to make their ends meet. Magellan plan members competed for the few spots on any given caseload.
When Carefirst BlueCross BlueShield brought all mental health in-house and evened out rates, things improved, for a few years, at least. Sadly, compensation for master’s and doctoral level mental health providers in Maryland, which includes the densely populated Washington DC suburbs, has returned clinicians to a road once traveled.
For the average person, it is: You work for a company, and after years of waiting, your boss tells you via letter you’ll receive an increase. You’d like to know how much you may expect.
First, you must wade through 75+ pages of codes and descriptions of, let’s say your job tasks, to find that increase, and when you do, you discover that two or three tasks get a few cents to a little over a dollar boost, but that most of your daily duties do not merit an increase.
It’s not that you’re working less, you’re working even more. Your performance is good; it’s not about quality. It’s not about quantity because you're literally slammed with inquiries for therapy services.
This goes on for months, even years without so much as a cost-of-living adjustment. In the meantime, groceries and living expenses have increased, as continuing education, professional journals, license renewal, supplies, computer and telephone costs, record storage, and more—ordinary costs of doing business certainly do not decrease.
A few tasks at your job get compensated a tad more, yet the vast majority of duties, that have led to burnout, go ignored.
If you’re a clinician, you substitute the word duties for CPT codes.
Welcome to mental health care. Clinicians in all parts of the US face these struggles. Colleagues reported that Blue Cross Blue Shield (BCBS) in many states is not regarded as provider-friendly in the payment realm. There are indeed insurance companies who increase rates across the board, not just piecemeal.
This dissatisfaction trickles down to employers who select plans for their employees, often switching when from one carrier to another when necessary.
Who Makes These Reimbursement Decisions?
It’s impossible to know who exactly decides provider compensation, but in the case of one regional insurer, a recent graduate with a bachelor’s degree in psych or economics was the liaison between therapists and executives to plead the case for rate increases.
Lacking the minimum credential for state licensure—master’s degree, clinical hours, board exam, and licensure—how could this new college grad, who had never worked a day in mental health, make a coherent case for therapists?
If this was your line of work, how might you feel? And do you think this will go away on its own?
“At the least, insurers should include more providers who treat behavioral health and pay them as much as providers who treat physical health,” wrote Kate Woodsome in a July 2023 Opinion in The Washington Post. “To attract more mental health and addiction specialists to underserved areas, insurance companies should raise their reimbursement rates and reduce red tape such as the authorizations to see certain providers.”
Woodsome’s approach seems sorely needed with a broken mental health system, that some days feels like it forces providers into retirement or other livelihoods. Until the root of the dysfunction gets addressed by insurance companies, their members will face difficulty using their plans and finding treatment. Fix the core problem—low provider payments—and the populace will benefit.
Copyright © 2023 by Loriann Oberlin, MS
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