Today’s episode of health insurance companies are bad and they should feel bad

By | December 28, 2023

Several years ago, we urgently needed to find a therapist for a member of our family I’ll call Pat (not their real name, obvs). Pat had been diagnosed with specific conditions and we needed to find a therapist qualified to treat those specific conditions, which certainly were not unusual conditions for which one would need a therapist, though they were on the severe end.

At the time our insurer was Blue Cross Blue Shield of Massachusetts. For the record, I’ve been the customer of many insurance companies over the years, and in my opinion BCBSMA is actually among the better ones, so this posting isn’t so much a condemnation of BCBSMA in particular as it is a condemnation of the health insurance industry as a whole.

Despite a huge amount of effort, we were unable to find an in-network therapist qualified to treat Pat and accepting new patients. This story has played out many times for many people over the years, and you can find article after article about it in the mainstream media.

[begin long aside about why things are this way]

The two primary theories about what’s going on, and you can choose one based on how much of the benefit of the doubt you want to extend to the companies, are:

  • Insurance companies’ reimbursement rates for therapists are too low and their paperwork burden too high, so many therapists opt not to join their networks and instead only accept out-of-pocket payments.
  • Insurance companies keep their therapist networks small on purpose to make it harder for customers to obtain in-network therapy because so the insurance companies don’t have to pay for it.

It doesn’t help that there is a huge therapist shortage in this country, i.e., there really aren’t enough therapists for all the people who want and need therapy, so there’s no market pressure for therapists to join insurance company networks; they can easily fill their schedules with people willing to pay out-of-pocket.

Some states are trying to do something about this, e.g., the Addressing Barriers to Care Act enacted into law by Massachusetts in 2020. But problems like this take many years to fix, and the pandemic has made things even harder, so I don’t see this problem going away any time soon.

[end long aside about why things are this way]

However, I had the advantage of knowing that if there was no qualified therapist in the BCBSMA network, they were required by law to allow us to select an out-of-network therapist and reimburse us for their treatment as if they were in-network. Therefore, I contacted their “case management team,” one of whose jobs it is to help customers find qualified in-network practitioners, told them what my family member needed, and asked them to find someone qualified and in-network. After two weeks they were unable to do so, at which point I invoked the aforementioned requirement that they approve reimbursing an out-of-network therapist at the in-network rate.

At first they were like, “OK, we’ll approve that for 30 days and then try again to find an in-network therapist.” And I was like, “No, uh-uh, that is not how this is going to work. Therapy for serious conditions is only successful when the patient is able to form a stable long-term working relationship with their therapist. If we have to go out-of-network to start Pat in therapy because there is no in-network therapist qualified to treat them, then we expect Blue Cross to keep paying their therapist at the in-network rate for as long as they continue to see them.” The person I was dealing with didn’t explicitly agree to that, but he did continue to process the subsequent claims as in-network long after the 30-day cut-off he had originally suggested.

(By the way, I am not exaggerating about the importance of a long-term relationship with one’s therapist. It’s now several years later and Pat is still regularly seeing the same therapist they started seeing when all this went down.)

From that point forward, once a month the therapist would send us a “superbill” listing the total cost of all the therapy sessions for that month. I would submit that bill via email to a specific person at Blue Cross for reimbursement. I would usually receive no acknowledgment of any sort from the recipient. If I was very lucky, I would receive reimbursement within 60 days, but most of the time I would have to reach out repeatedly in subsequent months demanding reimbursement in increasingly strident terms, CC’ing other people at the company and threatening to file complaints with the state, before finally being reimbursed. Blue Cross says they process reimbursement claims within 30 days of submission, but that certainly was not the case for me most of the time.

Fast forward to June 2023, when I started a new job, so I left Blue Cross and switched to another insurance company as of July. In mid-July, therefore, I submitted the final superbill to Blue Cross, showing just one therapy appointment for June, asking for reimbursement for that one appointment, and stating that I had switched insurance companies as of June so this would be the last one. As usual, there was no acknowledgment of my email, nor timely reimbursement. I emailed again in October; no response, no reimbursement. I emailed again in November; no response, no reimbursement. I emailed again on December 6, this time CC’ing other people and threatening to file a complaint with the state and a small-claims lawsuit. Again there was no response, but I a couple weeks later I finally received a reimbursement check dated December 12, five months after I first requested reimbursement.

These reimbursement delays aren’t just an amusing story. My family is lucky enough to be financially comfortable, which means that we can afford to pay hundreds or even thousands of dollars worth of therapy bills and then wait months to be reimbursed for them. But somewhere around 20% of American families can’t afford a $400 emergency expense. If one of those families experienced what Blue Cross put me through, they would either have to rely on the kindness of the therapist and their willingness to trust them to pay their bills after several months’ delay, or forego the needed therapy. That’s not acceptable.

Incidentally, when I switched jobs in June I opted for a high-deductible health plan (HDHP). My premiums are much lower, I’m allowed to use an out-of-network provider, and I can take the large difference in premiums, deposit it into a Health Savings Account, and use it to pay the therapist tax-free without any more fighting with the insurance company.

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