Many art, music, drama, poetry, dance and other creative arts therapists in New York State, now that we have Licensing (thanks to the tireless efforts of NYCCAT: the New York Coalition of Creative Arts Therapists) want to know more about how health insurance works in NY, especially those in private practice, so this post is some clarification about what I know in my experience since I got licensed in 2005, when we first got licensing.
Before getting my license, I was operating a private practice without a license and not able to take any insurance from patients, so I was naturally more than excited to be recognized finally as equal to social workers and other psychotherapists. The license was far more meaningful in terms of respect for our work and for the creative arts therapies than about insurance reimbursement, but money is a big part of respect.
Having the license gave art therapists working in hospital and other settings the chance to be paid equal to other clinical practitioners. Those in private practice were able to use the license to get reimbursed by SOME health insurance companies.
At present, Cigna, Aetna, and United Health/Oxford are the health insurance companies which I have had good experience with, in terms of getting any reimbursements and having the ability to take on patients who wanted to use their insurance for therapy. There is only a small percentage of such patients who would be willing to come to a therapist if their particular insurance would not reimburse, so this is pretty important for those who want to take insurance and want a large bulk of their practice to involve health insurance reimbursement. The reason a therapist chooses this is for building or keeping their caseload to a certain amount, not because it is easier!
Taking on patients with insurance brings many challenges. First of all there is the difference between in network and out of network reimbursement. Many people think it’s good to get on “panels” otherwise known as being an “in network provider”, which means that people who have that particular insurance can pay you a copay for each session, which is usually the part on the member’s insurance card that says “Specialist” and then an amount, which usually ranges from 0-$45, sometimes $50. People with the same insurance can have a range of copays, so if you are in network with Cigna, for example, you may have a patient who has no copay at all and no deductible in network, in which case, you usually have to fill out the 1500 claim form and submit it to Cigna and wait to get paid. You may have other patients with copays. With Cigna, if it isn’t 0, it ranges from 25$-45$. The advantage of a patient having a high copay is simply that you get paid quicker, as the fee you get per session is exactly the same no matter what the copay. A patient got the mistaken idea that when her copay went up, at least I was being paid more, but I explained to her that I get the same $67.93 per session no matter what amount she pays. This brings up a big disadvantage with being an “in network provider” with an insurance company. The fee is set and you have no say about how much it will be per session. For every individual session you get paid the same amount. Most insurance companies don’t seem to raise the fee properly every year to account for adjustment in cost of living. In the many years I have been in network with Cigna, and paid $67.93 per session, this year was the first year Cigna raised the individual therapy session fee to $71!
So one advantage of being in network is that most people do not have mental health or medical deductibles in network. However, this seems to be changing a lot, and is an important thing to check out when you get a new in network patient. The reason for this is the following: a patient comes and only has one or maybe 5 sessions. They pay you the copay as it says on the card. You submit the claim to the insurance company, only to find out that the person has a deductible of $600 if you’re lucky, or maybe $2000. This is most problematic with someone who comes one to 6 times and then stops, as you get stuck chasing an ex patient for money they now owe you. I have two of these situations going on. In one case the first session which insurance companies pay more for, Cigna pays $150 for the initial session, so I’m stuck texting and leaving messages with this patient that came once. It’s been at least 6 months now and she still owes me $150. In another case, the patient came about 5 times and owes me for those sessions. Through numerous emails and texts, I finally got this patient to start a vague payment plan which is already imploding. I don’t remember how much the patient owes, but it is probably about $300 or more, and I still don’t have it.
Another problem with being an in network provider is that insurance companies have all kinds of strange deals with agencies and schools, which may not be obvious until you have submitted a claim. I have a terrible situation going on because one of my patients had a very confusing plan with Cigna due to the school the patient is affiliated with. I am used to submitting claims to one Cigna fax number and then following up with a phone call to make sure the claim is processing. (Another part of the annoyance of dealing with insurance in network and out of network, paperwork, submitting claims and following up to make sure the claim is processed and paid, a very frustrating and time consuming activity that basically sucks and makes you want to scream at the poor customer service people who have the terrible job of dealing with irate providers all day. So in this weird case, it took a few months to even figure out that I had submitted the claim to the wrong place and faxed it to another place which was incorrect as well, or sent it in the mail. I finally through a few frustrating phone calls and looking again at the patient’s card, found an address to send the claims to. These claims now represent about 18 sessions from January to June 2013, and I have not been paid a cent by Cigna. Through more phone calls to different numbers and getting claim statements in the mail that my claim was being processed, I found out that the institution that handles the claims is waiting for a price quote from Cigna. I won’t go into further detail about this, as it is obviously incredibly frustrating to imagine not being paid for about six months of sessions! The only way to avoid this kind of disaster is to look very carefully at the patient’s insurance card the very first time s/he comes to a session to make sure you have all the info, not just the ID number and the usual stuff but look at the address and contact info and see what kind of Cigna or whatever insurance it is and what it is called, as the companies are huge and have all kinds of subsets of different arrangements.
Also, if you have longterm in network patients, watch out for the new year, which is when their plan could change drastically; the copay could go up or down, and there could suddenly be a large deductible, which, depending on the patient, could drastically change whether or not s/he even is able to continue therapy. Also in July, some employers change things around and have their fiscal year start over, so that is another time when you could suddenly find out your in network patient got their insurance switched to another insurance. It just happened to me with a patient, but luckily I take the other insurance out of network, the deductible was low enough and the patient is invested and ok with these changes…
OK: Out of network, advantages and disadvantages…: As an “out of network” providor, you set your own fee, which is really great, believe me! It means I can finally charge my full fee! The insurance company, if they pay your particular type of license, will pay you a percentage of that fee, and the patient pays a “coinsurance” fee which is the rest, and can range from 50%, not so great, to lower. Of course the more the insurance company pays, the better, and the more likely your patient is to be ok with having you as an out of network provider. Most therapists have these patients pay the fee in full and then they submit the claim to the insurance company, and the insurance reimburses the patient. Of course, being in NYC, and being a “nice” therapist when it comes to these things, as most of these out of network patients tend to be students, often either Aetna or United Healthcare, and as such, they cannot pay up front unless I am lucky enough to get a student whose parent pays me directly, anyway, I usually end up just submitting to the insurance and then either having the patient pay part of it or none of it until the insurance company sends the check to me directly for their portion of the fee. So this can be tricky, as there are many patients who don’t really want to have to pay up front, and given the choice, would just find an in network provider so they could simply pay a low copay. As an LCAT, I am paid out of network by as I mentioned above, Aetna and United Healthcare/Oxford. Blue Cross Blue Shield and GHI do not pay LCATs otu of network, so you cannot bill them. I have some patients who have Blue Cross, for example, who are committed to working with me and just pay me on my sliding scale. This is one of the good cases of not being able to take someone’s insurance. You get paid by your patient and don’t have to submit claims and waste time with insurance companies.
In addition, you don’t have to figure out a diagnosis for the patient, which in some cases is a big relief, as it can be tricky figuring out the right diagnosis for some patients. Not everyone has an obvious depression or anxiety disorder, which is most common for private practice, and some people present with symptoms that do not fit any particular diagnosis very well, so putting down the number for the diagnosis on the claim form is another big important potentially headache making part of taking insurance. Luckily in most cases with insurance the diagnosis is obvious; it is especially helpful when someone comes in who already takes prescribed psychotropic meds, though that is not always an obvious pointer to the diagnosis. There are no particular meds usually for such disorders as the skin picking or hair pulling disorder, which are now included in the chapter on Obsessive Compulsive Disorders; it could take a long time to even find out that your patient has such types of symptoms.
Anyway, I digress. All this is to say that people are wrong when they say to wait until your patient walks in the door to discuss fees. This is an old fashioned out dated point of view. It is actually much easier and usually you have no choice about it, to figure this out in a phone conversation or by email before your patient comes to you. I had someone come in only to find out that I did not take her credit card which she was using for all medical fees with Cigna. I was not sure she would find many therapists who would take her credit card, but maybe some therapists out there have started taking credit cards. Anyway it was a waste of her and my time. Sometimes it is clear that the person will not be using their insurance and in most of these cases I do wait to meet them to discuss fees. However, it is much easier to figure out what’s going on with insurance payment right away, especially with non Cigna patients.
In most cases, the patient does not know much about their mental health benefits and needs to be guided to contact Aetna or United or whatever and ask the following questions and then call you back if they find out they can work with you or figure out what they want to do about the fee:
Do I have out of network benefits for outpatient mental health providers? Is there a deductible? How much is it? What percentage of the providers fee does the insurance pay and how many sessions are covered? The last question is very important, as some companies only cover 20 sessions. The average used to be around 32, but now it can be as low as 20. Supposedly, insurance companies are not allowed to limit sessions if the patient has what is called a “biological disorder”. As far as I have found, that only refers to a few diagnoses, depression and bipolar disorder, schizophrenia and maybe a few others, but no anxiety disorders are included. I’m not sure about PTSD. However, even this “rule” seems to not be followed by all health insurance companies…
In addition, Medicaid and I think Medicare patients get no reimbursement for LCATs, so you either have to charge Medicaid patients a super low fee and consider them to be your “Pro Bono” patient, which I have done in rare cases. In my experience, it is worth it to do this when you have a very interesting kind of patient and the work is extremely rewarding and different from any other kind of work you have done. One of my most transformed patients is such a person, and it is one of the most rewarding experiences I have had recently in my private practice. As they say, great things come in small packages, ie. low fee!
Also, with art therapy groups in private practice, check with the insurance company what the rate is for that, because it is usually much lower than for individual therapy. Cigna pays only $40 per group session, for example.
Note to LCATs out there: as far as I know, Blue Cross, Medicaid and other insurance companies that limit their reimbursement to psychiatrists, psychologists and social workers do not care about the benefits of art therapy or other variants of creative arts therapies and there seems to be nobody to contact who would have any influence whatsoever on whoever decides what professionals to reimburse or not in NY state, so I would not waste time with individual companies trying to convince them to start paying us. Probably the more politically active among you may know which politicians or other organizations to work with to lobby or promote paying LCATs, so that is a great thing to do, but the insurance companies themselves do not care and are such huge beaurocracies, you might as well bang your head against the wall rather than waste any time trying to change their policies…
A Big Money Topic – Raising one’s fee:
Therapists out there – how often do you raise your fee? Do you raise it by the same amount each time? If you have a sliding scale, do you raise the fee differently depending on what your patient is paying you? Do you sometimes raise the fee with most but not all of your patients, or do you raise it with everyone?
Therapist/Supervisors out there: how often should one raise supervision fees? I have a supervision group that I started four years ago, June, 2008, and it still costs the same per month per person. The economy was worse then. In addition, I pay 30$ more monthly to my own much more experienced and well known supervisor for the supervision group I attend. Should I be charging the same to my supervisees as what I pay? I now have three new people in the group which consists of 6 members, so of course it is my excuse that it is not good to raise the fee when half the people in the group just joined it in part because they figured into their budget that they can afford it.
Art therapist supervisors: I have an art studio supervision format, which means a lot of art making and processing through art takes place in the group. Should I charge a separate materials fee, say every three months an extra 5$ from each group member? So far, I’ve never done that…
Since starting my private practice many years ago, I have raised my “full fee”, the regular amount I charge that very few people can afford and that one insurance company actually pays me, so I’ve raised that fee two times in about ten years! When I write that, I think, it’s time to raise my fee. However, in reality, most of my patients whose insurance does not pay me or who don’t have insurance, are stretching their budgets just to pay what they are paying me now… So I know this is not a good time to raise my fee. Another thing about this topic, it makes sense to raise one’s fee at the beginning of a new year. Somehow people are more able to accept it and it seems less random…
There is the big problem of the economy; I think I raised the fee more regularly before 2007; I don’t even remember exactly when the economy got very bad. However, it is hard these days to raise a fee that hardly anyone can afford on their own. There is also the philosophy I discussed in another post. Basically some people believe there is a fee ceiling to therapy, meaning, therapy should not cost more than about $125-$150 per session hour (50 minutes). I believe that to be true, that there is a limit to how much a session should cost. I even think a reasonable fee is probably a little lower than my “real” fee. Partly I have this “real fee” for people on the sliding scale to recognize to what extent I have “slid” down to meet them where they are at financially. I now won’t accept anyone who can’t pay at least half my regular fee. Most people would think this is too much of a sliding scale, but I remind everyone, this is New York City, meaning that, yes, I have to pay New York City rent on my studio office, but my patients are paying too much of their salaries on their own rent and other New York priced necessities like food, and don’t have much cash left over to pay for therapy.
So this post was meant to focus on fees and fee scales as well as the issues of raising fees and how often to raise them. The questions I’m trying to bring up, besides the ones I already asked are:
Therapists and patients: how do you feel about raising your fees? how do you feel when your therapist announces to you that s/he is raising his/her fee? same question for therapists in supervision with their supervisors raising fees for individual and group supervision.
Therapists and patients: do you believe that there is some kind of fee ceiling for therapy, ie. therapy just should not cost more than somewhere in the neighborhood of $125/session? That there might be a fixed value for the therapy session, especially given the unique aspect of therapy: most people see their therapist once a week, and thus pay about four sessions per month. There are no other doctors you see that often, unless you are going to physical therapy or other forms of therapy, such as yoga therapy, hypnosis, acupuncture, Reiki, etc. When I pose questions about fees I include all these forms of healers in contrast to regular physicians and medical specialists.
Most patients are quite respectful and do realize that most therapists are very dedicated and invested in their work, but they are running a business and have expenses like rent, electricity, insurance, advertising/internet marketing, and for art therapists, a lot of art supplies. In my studio I aim to have a really wide variety of materials, so I do spend quite a bit on supplies as I think it is important for patients and supervisees to see when they come in that they have a lot of creative options. I also have a sandtray and figurines for it, as well as extra sand because a lot of sand ends up on the floor. This is a special kind of sand called moon sand, which costs quite a bit, but it’s totally worth it! The subject of Sand Tray therapy with children and adults is fascinating, and I intend to write a whole post about it soon…
So yes, therapy involves an intimate form of paying money and being payed. There is a conversation at the beginning of therapy that involves fees and cancellation policies. When the sliding scale is discussed, the patient is required to actively think about his/her budget, how much s/he can afford for weekly therapy, and the patient usually takes into account what the therapist’s regular fee is, and usually wants to respect that the fee needs to somehow be reasonable for the patient and respectful of the therapist’s experience, skills and business.
In some ways, a lot of these issues are circumvented by the existence of health insurance. I do have a lot of patients who pay through insurance. However, I have a soft spot for “starving artists”, meaning actors, musicians and performers and visual artists out there who don’t have health insurance. There are also patients who have health insurance, but often the insurance won’t pay out of network or won’t pay a Licensed Creative Arts Therapist. In those cases, I know my new patient is very invested in working with me because s/he chooses to pay out of pocket, when s/he has the option of finding someone else whom the insurance would pay. In those cases, even if the person is paying on the low side, I feel very grateful for their investment in working with me in particular and that we have a strong therapeutic bond, even after just a few sessions.
This last example shows how the fee can really express a lot. It can be the patient telling the therapist, “I really like working with you; I don’t even want to choose the economically easier option of just finding someone on my insurance and paying a low copay.” That to me is much more valuable than anyone, insurance company or person, paying me my full fee. It involves someone choosing an option that is worse for them economically because they really value the therapeutic alliance or what their gut is telling them about working with me. A lot of people can tell pretty quickly that they have a good fit or not with their new therapist, and this is one of the most fulfilling votes of confidence one can receive from a patient. Money can communicate a great deal. And money does matter. It means a lot of different things to different people, but money is about value, and how much you value the service you are seeking out and receiving…
I just wrote a long draft for this post, and it disappeared, so I am very frustrated. I will try a shortened version of what I had in mind.
I started by describing a lot of potential scenarios (in private practice as opposed to clinics or training institutes or agencies) for therapists and patients to raise questions such as the following:
In the world of many therapists the whole topic of the fee and sliding scale and how to handle the negotiations of it is hotly debated. Some say if you don’t pay attention to the fee and how it is paid you are avoiding a lot of important issues. Others have a philosophy of really using the sliding scale fee and accommodating people other therapists would never work with. I confess I fall in the category of those, the ones who lower their fee to accommodate patients with little money and at times I accept a patient coming only twice a month. In most cases it is a patient who has been coming weekly for a long time but not always. There are other reasons I have accepted this type of patient besides money issues though I agree with most therapists’ opinion that much more can be accomplished with the regularity and structure of weekly sessions. I also would never run a supervision group that did not meet weekly as I think the group process works with weekly meetings and consistency and keeps the group functioning for support as well as clinical issues.
Many years ago I read in the New York Times magazine a profile of a British therapist. I don’t remember his name or why the article was on him but I do remember him saying, ” I strongly believe that therapy should not cost more than (don’t remember the amount but it was equivalent to about $80 which these days might be around $120 as this was written around ten years ago)…” anyway I was really struck by his point. He actually thought there was a limit to a decent fair fee for his services despite his education, training and experience. Sort of like saying an ice cream cone from a truck shouldn’t cost more than 3$. This was and is very unusual in our profession to actually say that it’s indecent to charge more than a typical amount such as $100-$120 per session as your highest rate. Putting a limit on the value of therapy. Most therapist’s focus much more on the difficult issue of, can this particular patient afford to pay my highest fee and if not what can they afford. On the patient’s side, I have seen people say I don’t want to pay you less than such and such as I don’t want you to feel disrespected so this is what I could afford to pay you.
I admit I had a conversation with someone about couples therapy and how insurance companies often pay too little for it. Yes, some therapists charge more for couples than individuals. The reasoning is that couples therapy is much more difficult to do, which I think is definitely true. In addition, most couples don’t stay in therapy that long with some exceptions. While it is not unusual to have a patient in therapy for five years or more, the average couple dies not remain in therapy that long. I could diverge into a discussion of couples therapy but that is for another post. I will add that it’s not unusual for a couple to go to a couples therapist and end up with one partner continuing with the therapist individually and thus stopping their couples sessions. It is one way people kind of accidentally find a therapist they like for individual…
Back to money. The idea of going to someone’s office to share intimate details of your life and expose your self in various verbal and nonverbal ways is hard for some people to wrap their head around. Usually the boundaries of not knowing much about your therapist helps with this scenario and makes the whole money transaction make more sense to most patients. I am going to a doctor of the mental, emotional and spiritual body so of course I am paying as I would for a doctor of the “physical” body. This is how I would explain the process to a curious and puzzled Martian.
People may notice they are sometimes treating their therapist like their mother (transference) but it helps to have the distance and strangeness of the personal information mostly flowing one way, from the patient to the therapist.
I admit or confess to sometimes wracking up a large bill with a patient who is on a low fee and having a very hard time confronting the patient about it. It certainly would be easier if the patient brought up the topic. Confronting someone who has a job they work hard at and are paid little for who has loyally stayed my patient when s/he could have found someone in network on their limited health plan and now owes me for quite a few months if therapy is not easy. I also have a patient who left therapy suddenly owing me about $300. She has paid off most of it but still owes enough that I need to chase after her every once in a while.
The majority of my patients not using their insurance pay me some fee lower than my regular fee and pay it on time.
The one insurance company I am in network with pays me a little more than half my regular fee. What does this mean? Probably that the insurance company undervalues my work in a much more insulting way than any patient is capable of doing. It says with your license, level of training and experience we agree to pay you almost half your fee. If course experience usually doesn’t mean much to the insurance companies nor do they raise your fee according to inflation and cost if living.
Raising your fee is another big topic which a lot of therapist’s struggle with.
Money and therapy: big topic to be continued in the next post!