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…
Ok. I’m interrupting my attempt to get deeper into the issues around money and therapy because I have until the end of May to do my part in raising awareness around mental illnesses and the paths to mental health and stability…
I think this is too great an opportunity to pass up. On my personal Facebook I pledged to post at least once a day a fact or question to do with this subject. Then I decided to do the same on my LinkedIn “share” with connections. I am in too many professional LinkedIn groups to post on all of them! Then I decided to post about it on my public Facebook Artist Page. In fact after I’m done with this post I will announce it on my Artist Page.
I confess as a therapist and human who works closely with people on their very personal paths towards health and real soul fulfillment, feeling myself to be, or at least aspire to be, a sort of modern times Shaman or Doctor of the Psyche, I am really excited about this discovery that May has been Mental Health Awareness Month for over 50 years! How dare they not tell us in grad school or at our jobs and internships! How many therapists know about it??? Check with your therapist and/or psychiatrist to see if s/he knows about it! Spread the word! Thank goodness for the Internet and social media, as they help us raise awareness of such an important topic. There is just too much stigma out there about mental illnesses and so much ignorance. Why do health insurance companies still limit outpatient mental health treatment to 20 or 32 visits a year!?? How dare they set a limit on something so important in such an arbitrary manner! I’ve never had a patient with a mental illness who was invested in his or her therapy, who thought 20 visits or 32 sessions was enough per year. That has to change. What would people with one kidney do if they limited their dialysis visits per year? Unthinkable…
To get back to the point, though I don’t think I’ve strayed that far, in this post I will do what I’m doing daily on Facebook and LinkedIn: I’m going to make a list of ten questions or lesser known facts about various mental health issues. By mental health I include addiction, eating and personality “disorder” issues as well as trauma of various kinds and healthy positive behaviors related to this topic…
1. The relatively new phenomenon of personal blogs about how a person is living day to day with his or her symptoms and feelings about having some type of mental health issue is a wonderful way that people can see up close the courage and strength it takes for people to face their life day in and day out, struggling with staying healthy. It’s also a great testament to how far we’ve come with medications that work for people and with diagnostic criteria that help people come to terms with and manage their daily self care. Of course there is a lot more to improve with medication and treatment, but these very raw personal and honest blogs out there are a great way for people to feel less alone with their particular struggles. For some, the blogosphere is the only community they have and place they feel safe discussing such personal issues and struggles. So I start with a very positive aspect of mental health awareness by saluting all you people out there blogging about your struggles and triumphs. I follow many great blogs of this type and hope to find many more…
2. Schizoaffective Disorder: how many of you have heard of it? I first learned about it at an internship at a Continuing Day Treatment program long ago, so I have worked with individuals given this diagnosis. The term was first coined in 1933, but I have a feeling most people haven’t heard of it unless they have it, know someone with it, or work in the mental health field. You can find very particular detailed explanations of it on the Internet. I would describe it as bipolar and mood disorders meets and marries schizophrenia types of symptoms. What a challenge to be dealt this card! You have some sort of mood instability, whether primarily depressive, manic or both, as well as possible psychotic episodes, paranoia, hallucinations and delusions. For a really up close and personal account of it, read the memoir “The Quiet Room” by Lori Shiller. There’s still a lot of controversy about this diagnosis, and it comes up in this very moving book. In my experience, I think this diagnosis can be helpful to people suffering from such a confusion of symptoms because usually Bipolar Disorder and Schizophrenia thankfully now are seen and recognized and treated as very different because they are completely distinct. In the past people with either of these illnesses were lumped together , but we know a lot better now. However, there are some people who suffer from symptoms described by this “cross sectional” type of disorder. In my experience it really does exist, and the diagnosis is helpful, as people can be treated with both a mood stabilizer or anti depressant and an antipsychotic type of medication that people dealing with schizophrenia take, and they can have potential relief of their mix of symptoms and also begin to experience themselves as functioning at a much higher “level” in their lives which can be greatly improved and a lot less painful and confusing…
3. So, on the topic of mood stabilizers and “anti psychotic” medication, otherwise referred to as “psychotropic” medications: In contrast to what I said above, it can be confusing for people suffering from Bipolar Disorders, Schizoaffective Disorder, or other schizophrenia related disorders on terms of the wide variety of medications currently used to treat such illnesses. On the one hand, modern medicine has put to rest the confusion of what used to be called “manic depression” and “schizophrenia.” We all know now how different these are, but some of the medications treat both types. The difference is in the dosage. Old fashioned medications like Haldol, as well as the newer “anti psychotics”, such as Geodon, Risperidol, Seroquel, Zyprexa and many others, are prescribed for any form of psychotic episode, as well as being maintenance medication for schizophrenia and related “schizo” type disorders. To make matters more confusing, people with Bipolar Disorders, for whom a typical mood stabilizer like Lithium or Depakote, just to name 2 main ones, does not help enough to stabilize moods, can now take such medications as Zyprexa or Seroquel as mood stabilizers, usually on lower doses than for schizophrenia type symptoms. Some people with a kind of Bipolar Disorder take a typical mood stabilizer, as well as one of these other meds, and as well as an anti-depressant and other medications such as those for anxiety, which are in a totally different classification. So we’ve come all this way in distinguishing Bipolar type symptoms from those of schizophrenia related illnesses, and yet the same medications may be used to treat both. A little confusing. However, it is great that these other medications were discovered to have mood stabilizing properties, as some people need to take them instead if or alongside their regular mood stabilizers. Seroquel is also considered to have anti depressant properties, so probably some of the others like it also do.
4. While in my experience with working with people who suffer from very serious mental illness, mood stabilizers and medications like them can really be miracle workers for those suffering from Bipolar type issues in that, once the right medication or combination is found, people who take their medications daily can experience a great relief of symptoms and a sudden experience of real stability, those suffering from “unipolar” depressive illnesses such as dysthymia and major depression, tend to have more struggles with their medications. There are the lucky people who find the right anti- depressant and get relief; unfortunately of those people there is the group who after 6 months to a year find the medication no longer works, and they are plunged into a depressive episode and have to try some other anti-depressant(s) to see if a different one will work. For others, none of the different types of anti depressants out there seem to work. Some women in the latter group find a doctor who decides to try the more innovative treatment of using hormone medications to treat their depression. I read an interesting article about this a few years ago which really amazed me, as many people I know who suffer from mood disorders tend to complain that they can’t take birth control pills because it sets off depression. Others take hormones for birth control alongside their other meds without any trouble. Thankfully now there is a small group of women who take only hormonal medications to relieve their depressive symptoms! What a great medical breakthrough!
Ok. I have not yet reached number five and this post turned out to be much longer than I expected. So, the above is my food for thought on this topic thus far. I pledge to reach number 10 before Mental Health Awareness Month is up!!!
I have talked about several memoirs of mental illness that I’ve found to be absorbing and brave. I just in fact read two by Marya Hornbacher, in reverse order of when they were written: “Madness” about her struggles with severe bipolar disorder and alcoholism, and “Wasted”, her first book about her serious long bouts of “bulimarexia” before she found out about the bipolar illness.
However the constant battle to stay stable and healthy, to keep up all the self-care required to keep illness at bay, that requires a dedication and perseverance of a rare sort. As these memoirs show, it isn’t enough to just be taking your medications as prescribed, although that is a big step forward, but usually, there needs to be some sort of consistent therapy and/or peer support group or group therapy. Along with that, people taking meds need to be aware of mixing them with alcohol and other substances. Part of regular self care involves regular exercise of some kind, engaging in soothing and relaxing activities, and eating healthily. Soothing self talk is key, especially for people hearing mean voices and those who have a running judgmental commentary going on in their brains. Many mindfulness meditation techniques are very useful.
For others, it is quite the opposite. For example, for many people with eating disorders “under control”, there is a daily battle with the mind obsessing about body and/or food intake, and it can be frustrating to have mastery over the self destructive behaviors but not over the “sick” thoughts. For these people each day is a battle with their demons.
In my last post, I touched on the topic of medications and mental illness. This post will attempt to address some of the issues connected with this vast topic…
Psychotropic medications have always been a controversial topic in many different societies. I have had much experience working with people on all kinds of medications, as well as working with people in the midst of going off their medications, starting to take medications for the first time, and many who tried out medications and then stopped them without finding a medication that was helpful. In addition, I have encountered people suffering from various emotional and mental difficulties and disorders who were vehemently opposed to taking any form of medications but were willing to try alternative forms of healing instead of medications.
I try as a therapist and person to be open to all points of view about this topic. What one chooses to put in one’s body is a very often private and vulnerable personal topic. While psychiatrists that I have talked to about this admit that we know very little about what makes a medication work and why and how, we also know a lot more now than ever before, and there are a lot more choices of meds than ever before…
As I mentioned in my last post, I have found that people struggling with and suffering from such issues/disorders as schizophrenia, schizoaffective disorder and bipolar disorder (both 1 and 2 as they appear in the DSM), really benefit from regular medication for an extended length of time. Often the reason for a re hospitalization or “relapse” with one of these serious disorders is caused directly by the person stopping taking their medications, usually because the person feels a lot better and thus thinks, “Oh, now I can stop taking these medications,” which makes some sense, as very often when our suffering is relieved by medication, it makes sense to stop taking it. But these disorders are more like diabetes. You don’t stop taking your insulin because you feel better. When I worked at a Continuing Day Treatment Center for adults and also at a residence for emotionally disturbed children, I saw how the medications really helped people with these serious types of disorders. Almost all the adults at the CDT were taking some kind of psychotropic medication, and a lot of but not all of the children I worked with at the residence were also on medication. The topic of medication and diagnosis and children is a complicated topic better addressed in a separate post. Suffice it to say that I saw children also helped by medications, especially those with ADHD and other behavioral disorders.
While Bipolar Disorder is a serious and sometimes even deadly illness, it is amazing how much medication taken regularly can really transform someone and their ability to function, such that people who continue to take their medications on a regular basis can function and thrive. Sometimes one or sometimes a combination of medications, and there are now many different mood stabilizers whereas a while ago it was mostly lithium, anyway these meds can really help balance the fluctuation of moods from manic to depressive. Most people have to learn the hard way that they need to accept their biology and that they suffer from Bipolar Disorder, by going off their medications, having a relapse or even two or three, and then accepting it and staying on the medications that work for them. Luckily there are now a variety of mood stabilizers, and these medications don’t all take away a person’s creativity and liveliness; they just help an individual to manage their mood disorder.
Schizophrenia and schizoaffective disorder are much more debilitating than bipolar disorder. However, I witnessed many of my patients healing with a combination of therapy, day treatment which provides structure and socialization, and medication. This combination of approaches really help people with severe symptoms, such that the voices they are plagued by can disappear, or at least subside to the extent that the individual can function on some level and receive some relief. It is very unusual for an individual suffering from these illnesses to be able to not take any medications. There are many good medications out there that work; unfortunately many of these st cause weight gain, and I saw my patients suffer with the side effects of weight gain as well as worse side effects. Some people manage to be careful with their diet and are able to take these very potent medications without experiencing weight gain. However, I saw many of my patients at the program who were on Medicaid and had poor dietary habits; still for many to be able to socialize with others, even to be able to leave their house or residence and attend the program was a big step towards healing. The medications were only one part of this; therapy, groups, meeting others with similar issues, having a structure to their day — all of this was necessary for some or partial recovery.
Depression, including both major depressive disorders and other less serious depressions, is much trickier in terms of medication management. I have certainly seen people with bipolar disorder take medication for depression along with a mood stabilizer and be helped by the extra medication. I have also seen people get out of a terrible depressive period with the help of anti-depressants. Some of these people were helped by taking some kind of anti-depressant for several months to a year and then were able to stop their medications and use other means for their daily self care to avoid slipping back into a depression. I have also seen people with depression who continue to take their medication even when they are not depressed, and these people find it helps them to combat the return of depression. Any person taking anti-depressants temporarily or permanently is greatly helped by having some form of therapy, as well as a support group or yoga or regular exercise or any other number of “non medications” that help with healing. In fact, sometimes the medication helps the person to be able to be motivated to do these other things that they were too depressed to do for themselves before taking medications.
On the other hand, I have seen some people struggle with taking anti-depressants, even to the point that they are willing to try a few different ones, looking for one that works, only to be defeated. These people sometimes can find no medication that works for them ,and they often make a valiant effort to find one. However, the good news is that there are other ways to shift depressive brain chemistry. Art therapy is especially effective in that the act of making art and being creative in the moment does have a positive effect on the brain. With the support of the art therapist or the group therapy, a person with depression can begin to shift his/her mood towards feeling better. Regular exercise has been proven to help with depression as does yoga. With good support from friends, family, a therapist, a support group or therapy group, some people are able to combat their depression without the help of any psychotropic medication.
Of the people who refuse to try any of this kind of medication for their depression, many do self medicate and even are aware they are doing so. Some use drugs or alcohol, which of course actually physiologically contribute to depression, but the slight lift or high at the beginning of injesting substances can outweigh the crash for many people caught in a cycle of addiction or dependence. Even limiting food intake to an extreme is known to produce a high, so restricting food intake can be another form of self medicating. The challenge for this group of people is to become aware that they are self medicating in an unhealthy way and after that to change these behaviors.
There are people who do not self medicate with unhealthy behaviors who believe alternative medecine is the way to go. These people really work hard to combat their depression with positive self caring behaviors such as regular yoga, massage, reiki, some kind of creative endeavor or creative arts therapy, as well as writing and using some of the cognitive behavioral therapy techniches as well as creative visualization, acupuncture, and even being careful with their diet, as it is true that certain foods contribute to depression. Often it can become a vicious cycle where depression leads to eating unhealthy foods or bingeing on unhealthy foods, then becoming more depressed and continuing to take bad care of oneself. So changing one’s diet can really help with depression.