Session 184: FAQ’s About Therapy & Insurance

Session 184: FAQ’s About Therapy & Insurance

Dr. Joy: Hey, y'all! Thanks so much for joining me for session 184 of the Therapy for Black Girls podcast. One of the most common questions we get from the community is, “Why can't I find a therapist who takes my insurance?” There typically isn't a quick or easy answer to that question and we wanted to provide some insight about what mental health benefits look like for insurance plans, and answer as many questions as we could about how to make the best decisions you can when looking for coverage and getting the most out of your benefits.

First, we're joined by Dr. Cara McNulty who serves as the President of Behavioral Health & EAP, Aetna. Dr. McNulty shared great insights about what kinds of services are offered with insurance plans, how to find the plan that might be the best fit for you and she shared more about the services Aetna offers to assist the community with mental health needs.

And then back for another visit is Dr. Ajita Robinson who is not only an expert in grief, but also offers services to help therapists manage the insurance plans that they accept. Dr. Robinson shared some of the reasons therapists might not accept insurance, what's involved in using your insurance for therapy, and resources you can use if you don't currently have insurance. If anything resonates with you while enjoying the conversations, please be sure to share with us on social media using the hashtag #TBGinSession. Here are our conversations.

Dr. Joy: Thank you so much for joining us today, Dr. McNulty.

Dr. McNulty: It's a pleasure to be here. Thank you for having me, Dr. Joy.

Dr. Joy: I'm pleased that we will be able to continue the conversation we had a couple of months ago when we were on a panel together. And I would love for you to just start, Dr. McNulty, by talking about how you have seen people's mental health being impacted during the pandemic.

Dr. McNulty: Happy to do so. We know that people are under a lot of stress and having COVID-19 with all that is unknown, only increases stress and anxiety. And so if we just look at what's happening in our communities right now, the CDC did a report that showed 11% of adults who were surveyed contemplated taking their own life as a result of the pandemic because they had anxiety, depression, they were scared. You see this rise in people contemplating their own mental health and their lives.

And then if you take that down even one notch, we know that a group that is really, really impacted are young adults. And we're seeing one in four young adults (between the ages of 18 to 24) have considered taking their life in the month of June, as a result of isolation, depression, anxiety, hopelessness. We're seeing those statistics rise. The other thing we're seeing, Dr. Joy, is this pandemic has created this uncertainty that is profound for our communities and so with our attempts to keep people safe, we've had the need for physical distancing. Well, that has created a lot of social isolation and that social isolation has grown and impacted communities, and some communities much more than others.

So you see the perfect storm: COVID-19, people unsure what's going to happen, people being isolated and people feeling hopelessness and anxiety and depression. And in many communities, asking for help is really hard.

Dr. Joy: Right, I'm glad you shared all of that information, Dr. McNulty, because that is one of the things that I have been most concerned about. Is people's mental health right now, but I'm also really concerned about how people's mental health continues to either kind of stay afloat or further deteriorate as we continue to kind of live throughout the pandemic. I would love to hear how Aetna specifically has maybe shifted your approach to meeting your members’ needs during this time, especially related to mental health.

Dr. McNulty: Absolutely. One of the things we did right away is we looked at what's happening in communities: what does it mean to have people who are suffering or having increased mental health disruption? First, we just looked at our data: what's happening with our members? And what we saw is people needing support because they were worried about their finances, they were worried about their job stability, they were worried... “I'm an essential worker and what if I go to work and I bring home this virus and my family gets sick? How am I going to take care of my kids? My daycare isn't open.”

The first thing we did was look at our data and say what is getting in the way of people getting care? And then the second thing we did right away is we opened up what we call liberalized, we opened up a resource called Resources for Living. And Resources for Living is open to anyone across the country and the offering we provide is it gives you support for addressing your mental health needs, it gives you support for addressing things like: How do I find daycare that I can afford or daycare that's open? Or I'm worried about paying my rent, what can I do? I've been laid off or furloughed. I am concerned about having enough food to get to my elderly parents.

Resources for Living is a unique resource that we opened up across the country to anyone where they can call in, get the support they need, get the resources they need, and get the mental health counseling they need. And it's free of charge. We did that right away, Dr. Joy, because what we believe is that whether you have insurance or not, now is the time that people need to know they are not alone. So that was the first thing we did.

The second thing we did is we made sure, because we needed to physically distance, how do we ensure that people can get the access to care that they need in their community via telemedicine or tele video? We expanded our relationships with our providers across the country to ensure we had access for anyone who needed mental health services. And we expanded those virtual care offerings literally in every community and we have seen a robust increase of people utilizing those services. So that was the second thing we did.

And the third thing we've done is we continue to check in on our members, on our own employees, to ensure that they are taking care of their own mental health wellbeing. And that we're giving them the access to resources, webinars, materials that help them build their mental health resiliency, get the care they need, so that they can handle this unprecedented situation around COVID-19 and other things happening within our communities.

Dr. Joy: And I appreciate it. We talked about this on the panel before, but this Resources for Living program that you all have that is available to anyone, regardless of whether they receive Aetna coverage or not, anyone can use that line and call in to get support and resources.

Dr. McNulty: Absolutely.

Dr. Joy: We get a lot of questions about the costs associated with mental health care coverage. Can you just share a little bit, Dr. McNulty, about what our community should consider when they're choosing an insurance provider, when they especially know they're going to want mental health care services?

Dr. McNulty: Absolutely. When you're thinking about picking insurance, it's really important to think about, what am I going to need? Or what do I think I'm going to need? Understanding your own health is important. Maybe you're considering having a baby or maybe you're pregnant. Maybe you already have had struggles with mental health and you know you're going to need some mental health support. Maybe you're like, I don't know, I'm pretty healthy.

One, you want to think about your health and what you think you'll need. You also then want to look at what is my insurance going to cover? Most insurance plans cover both physical health and mental health. That is often misnomer that they don't, and so really making sure that your plan covers both physical and mental health services. Then you're going to want to think about what kind of preventive care is offered? Are flu shots offered for free? Can I get my annual physical exam? What about I need a mammography or a colonoscopy or maybe I need a cervical exam? Making sure you understand what's the preventive care offered.

Then what's the cost to you? So understanding how much will this cost me and how will that payment be made? Will I make monthly premium payments? Quarterly? And then finally, ensuring that access to care is where you live, so are the services available within your community? And we know it needs to be really easy to seek those services. Right now, I would say the healthcare community, we've done a great job in providing virtual care. But not always and not forever will we want virtual care, and so making sure you have access to those providers right where you live and work so you can get the help you need when you need it.

Dr. Joy: I'm really glad you’ve mentioned the idea of preventative care. I think we often think about that a lot as it is related to physical health but I don't think that we think about it as much when we're talking about mental health. It seems that there is a bit of tension that exists, especially with insurance, related to preventative mental health care. Because usually, you have to offer a diagnosis code when you're working with someone on the mental health side. And so for a lot of people, therapists and potential clients, they may resist either using their insurance or that may be a barrier for them even seeking out working with a mental health professional, because they're worried about having to get a diagnosis code. Can you talk about are there any efforts being made to maybe kind of talk about mental healthcare being preventative in the same ways we think about physical health?

Dr. McNulty: Absolutely. Across the clinical community, we are looking at ways to embed screening tools and preventive care screening tools around and through mental health. Right now, we do screening tools to look at your heart health, to look at your sexual health; it would be embedding screening tools that look at your mental health. How have you felt in the last week? Are you feeling hopeless or hopelessness? It's basic questions through a simple survey-style assessment.

One of the things we're doing at CVS Health Aetna is we embed these preventive care screenings within our care management programs, within some pilots we're doing in our minute clinics, where we're screening for anxiety and depression. So you see health care providers starting to build these in (these assessments) into regular preventive medicine. It doesn't matter what you're being seen for. Maybe you went in for your annual physical, we're seeing the screening starting to take place around mental health. Because what we need to do is make sure we're not looking at someone's mental health separate from their physical health.

Most of us, as you know, Dr. Joy, didn't wake up and say, gosh, today, I'm just going to focus on my physical health. Or today I'm going to focus on my mental health. We got up and we thought, okay, what do I have to do? How do I get my kids out the door? What about this, that...? It's really the healthcare community's responsibility, to address people holistically. So you do see us looking at preventive health measures aligned around mental health and physical health.

The other thing I would say is we know, as a healthcare community, we have to be working on mental health resiliency when our kids are young. Teaching them how to handle stress, how to manage feelings of anxiety, what it looks like to be proactive, to understand how we feel when we feel good and how we feel when we don't feel good. Teaching our kids, our young adults (us as parents and community members) that it's okay not to be okay because we can't just wait until there's an issue. So really working on those prevention efforts, those interventions, and then what we do when somebody needs care and support.

Dr. Joy: Thank you for that. Something else, and I'm sure that you have experienced this or answered lots of questions related to this as well, there are so many letters associated with insurance plans. HMO versus PPO versus EPO. Can you talk about some of those distinctions and what it means to have those different types of plans?

Dr. McNulty: Sure. It's really important to go back to what do you need and what is the coverage for you as an individual or for you as a family. Is the coverage for someone with a chronic condition (so has ongoing medical needs) or someone that's just interested in the basic preventive care?

A couple of definitions. A PPO is a Preferred Provider Organization and it's just a type of insurance where you have a certain set of providers you can go to. A health maintenance organization or an HMO, is like a PPO (so like a Preferred Provider Organization) but it usually has less options. And then you have things called High Deductible Health Plans or HDHP, and those are plans that you normally can go to many, many, many different providers, but you have a different way of paying. You pay for the upfront cost up to a certain amount and then anything after that, your insurance covers.

Dr. Joy, all these get very, very confusing. What I would say to the listeners that is most important is to look at: What am I trying to do, trying to make sure I have basic coverage? What will this insurance cover? What is in my plan? And where are the providers? Are they providers that are convenient for me and my family to get the care and service we need?

Dr. Joy: And I would imagine that some of that also, especially if you're getting benefits through your employer, there would need to be some conversations with HR about like the kinds of different plans that are offered as well.

Dr. McNulty: Right. And so if you get insurance through your employer, your employer (at open enrollment) will share the enrollment information about your plan. And often, those enrollment information sessions or materials have maybe assessments that help you look at what plan is best for me. But it's going to ask those basic questions: What am I trying to accomplish? Is it a basic plan or do I need something broader? Who is it for? And where are those providers so I can ensure I get easy access to care?

Dr. Joy: Something else that comes up quite often and we get this a lot in the community is people really struggling to find therapists who are in-network with their insurance. It seems like people do a reasonably okay job finding medical and physical health professionals who are in-network, but a lot of therapists are not in-network. Can you talk about why that might be?

Dr. McNulty: Sure. When you think about physical health providers, there are really large provider systems that handle the physical health, often of communities. When it comes to mental health, we don't have often those big provider systems so you have a lot of individual providers that open up their services and so maybe they can only handle so many patients. Maybe they can only cover a certain group of insurance because they can only handle... Again, they’re one or two providers so they’re small provider practices.

What we have seen and what we at Aetna are doing is we're helping those small practices with their administration services and with their ability to take on more patients, and we're working to expand the reach of those small providers and partner with larger mental health provider organizations to ensure we have coverage. Because, absolutely, finding people mental health providers that are in-network, can be hard.

It is getting better. Every state has resources that will outline where your mental health providers are, what insurance they take, and what to do if you don't have insurance. So every state has that available. Also nationally, the SAMHSA–which is Substance Abuse and Mental Health Service Administration–has a hotline that you can call 24/7, 365 days a year, to get referral information in English and in Spanish, for individuals or families seeking mental and substance abuse care.

Dr. Joy: Thank you for that, we'll make sure to include all of that in our show notes. And so, Dr. McNulty, I know you mentioned earlier that we don't necessarily anticipate needing virtual services forever. But a lot of what we've heard in our community is that more people are using services because they find it easier to talk with a therapist or it can fit into their schedule better, now that they don't have to commute. And so are telehealth visits typically covered through Aetna’s insurance?

Dr. McNulty: Absolutely. We cover telehealth visits and many, many insurers cover telehealth visits, especially now it is becoming the norm. And when we think, Dr. Joy, about mental health, one of the great things (if we can say) that have come out of COVID-19 is we've gotten, all of us, more used to what it would be like to have a virtual visit. And sometimes when we're talking about our own mental health and wellbeing or whether we're talking about our substance use or a plethora of issues, what we know is when we're doing a virtual visit or a phone visit, it's easier to tell the person on the other end, hey, this is how much I'm really drinking. Or this is impacting my life and here's why. It's easier, and what we see is that people are willing to share more and ask for more help because it's easy to remove the barrier of having to sit with someone face to face.

Dr. Joy: Mm hmm. Yeah, I've heard that a lot as well and therapists have shared that it is a very different experience to see clients in their home environment. That you get even additional information that you would not necessarily get with them sitting in your office.

Dr. McNulty: Absolutely. And we see young adults absolutely gravitating towards using these virtual options and staying more consistent with their treatment plans because it's easier. It's time wise easier, it is easier to tell someone (for some populations) when you're not face to face and it's easier to say, “You know what, I'm not okay and I really need some help.”

Dr. Joy: Mm hmm. Dr. McNulty, are there any kinds of session limits related to mental health services being covered?

Dr. McNulty: Sure, it depends on your insurance. If you have insurance through your employer, you also have something, most likely, called EAP–Employee Assistance Program. And an EAP does quick, short-term counseling visits to address a situation that isn't going to take long-term counseling. Maybe you're having an issue with parenting at home and trying to figure out how to manage your kids and their school and keep up with your work, and it's really stressful. That might be a great conversation to have with an EAP provider.

Usually employers offer EAP sessions in bundles of three to six, we even see some employers offer sessions up to 12. It is these short burst sessions (so usually it’s 30 minutes, sometimes 45) where you can have a confidential conversation with a therapist to talk about your issue and get the support you need. For example, with Aetna insurance, let's say my first issue was this parenting situation. I worked through in three sessions with my counselor and then let's say a couple of months later, I have an issue with my manager. I'm really struggling, we're not connecting well, I find it really stressful. That's a new issue so it would be a new set of three sessions.

For Aetna, each issue is its own set so it's not like you've run out. Now, if it's something like the parenting that continues on and it's causing increased, let's say, anxiety or depression, then we would transfer you over to utilize additional behavioral health benefits other than EAP.

Dr. Joy: And are there any session limits for your regular mental health benefits?

Dr. McNulty: No. Because the goal is that you get the support and care you need but we're going to make sure that we're helping you get to the right place at the right time with the right provider, because that's how we get the outcomes that are best for you as the individual.

Dr. Joy: Mm hmm. That really brings me to my next question, Dr. McNulty. People really experience, I think, a lot of frustration in finding the right provider for them. We know, again going back to that alphabet soup we talked about, therapists have all kinds of letters behind their names. And so we know what that means but the general public doesn't necessarily know what all of those letters and certifications mean. For someone who maybe has decided I do need some additional support, I need some help right now, what is the first step that they should take in trying to find the provider that's going to be a good match for them?

Dr. McNulty: It's so spot on, Dr. Joy. One, we're asking people to know why they don't feel okay (and maybe some people do) but then also know what they should do about it, who they should see, is it covered under their insurance, and then making an appointment. We're working really hard at CVS Health Aetna to remove those barriers and so one of the first things to think about is, if you have insurance through your employer, is to contact your EAP or employees’ assistance program. That is a perfect place to start because that EAP is going to help you look at what's the issue, what kind of support do you need and who might be most ideal for you to see in getting that support. Because it might be a licensed social worker, it might be a psychologist, it might be a psychiatrist, but that EAP resource can help you do that.

For anyone who doesn't have insurance or is like, I don't know how to navigate this, you can utilize and call our Aetna free line Resources for Living and we'll help you do that. We'll have a clinician help understand: What is it you're trying to solve? What is the issue? Do you have insurance or not? And if you don't, we'll help you with resources. And who would it be best for you to see in your community? That's a second way to do that.

And the third is to contact, if you do have insurance and it is through your employer or you've gotten it off the local marketplace, you can contact your primary care provider or your nurse that you have seen, and ask them for resources available within your community.

Dr. Joy: Dr. McNulty, can you give us the number for the Resources for Living?

Dr. McNulty: I can. For information, you can contact us at CVSHealth.com/SecondCurve. Or for our Resources for Living line that's open to anyone (no insurance needed) you can contact Resources for Living at 833-327-2386.

Dr. Joy: Perfect, and we will be sure to include all of that in the show notes. Something else that we know comes up quite often is that the people in our lives are able to tell we're struggling sometimes before we are. What kinds of things would you say to someone who maybe has someone in their life who may be struggling with a mental health concern? How might they be able to get them connected and what kinds of questions should they maybe be asking?

Dr. McNulty: Oh, it's so important because we all play a role. All of us, not just providers, but we as parents and community members and spouse and partners. We all play a role. One of the first things I would ask is that people really start to listen and notice the health and wellbeing of those around them. We often, when our mental health is suffering or struggling, give off warning signs. And those signs might be that maybe your appearance isn't as it normally is, maybe you just haven't had the energy to take care of yourself. Now, you might say I'm not seeing so-and-so or people as much, but maybe if you see him over Zoom, etc.

Or you hear it in their voice. Their voice is maybe sounding hopeless or less than engaged or someone is backing away from commitments, they’ve decided not to join in a group activity or seem disinterested. A person might be sleeping a lot or not sleeping, we see people become agitated or angry or not able to be consoled. And we find people that when they're really stressed, often say statements like: You know what, I don't think this is worth it; I don't feel like I add value; I don't know that I want to live. It's any of those.

Sometimes it's not as blatant as “I don't know that I want to live,” but if any of those things can be signs. And what we need to do as a support community is to have bold conversations and have the courage to say, hey, I noticed you seem really agitated and I'm asking out of care and concern: How are you? I mean, how are you really? I want to know. And when we do that with an open mind and empathetic and really showing up, what we see is people will tell you. And then we help people if they say, “You know, I am not good,” we help them get those resources. And I know it's hard for people to have these conversations but what we know, Dr. Joy, is these conversations save lives.

Dr. Joy: Mm hmm, yes. That's valuable information and I agree with you, Dr. McNulty. It is all of our responsibility to make sure that we are paying attention to and really listening when we ask people how they're doing, especially right now.

Dr. McNulty: Absolutely.

Dr. Joy: You've already offered such incredible information, is there anything else you feel like you'd like to add related to how our community can get some additional mental health support right now if they need it?

Dr. McNulty: What I would say is I would encourage, if you yourself need support, or someone you love, please check out Resources for Living. We have great clinicians, local community resources and support materials for you to help with the struggles that you're experiencing now as a result of COVID and other civil unrest. Check out those resources for living.

Number two is to know that you're not alone and it is okay not to be okay. We're not all going to feel great all the time, we are going through a really hard pandemic, a lot of social unrest. And there is support–you do not have to do this alone. And finally, it's really important to remember that you are essential to your family, to your community, to your loved ones, and so we need to take care of our own health wellbeing as best as we can. Because when we do, we add so much to the richness of the communities which we live, work and play.

Dr. Joy: Wonderful. Thank you so much for that, Dr. McNulty.

Dr. McNulty: It's my absolute pleasure. Thank you for having me.

Dr. Joy: Thank you so much for joining us again, Dr. Robinson.

Dr. Robinson: Thank you for having me.

Dr. Joy: In addition to being an expert in all things grief and supporting your clients there, you also have an entire agency dedicated to helping therapists with their insurance claims. Can you tell us a little bit about that?

Dr. Robinson: Absolutely. Mastering Insurance for Mental Health Professionals, I created to address this issue that many therapists have on whether to take insurance or not take insurance. Really how to master that process so that they can make the best decisions for, not only their practice, but how to help clients (who either have insurance or don't) navigate access and care.

Dr. Joy: Yeah, the entire insurance topic, I think, can be frustrating for both clients and therapists. It is the number one complaint that we hear from people who even try to use our therapist directory, is that they are searching through therapists and they may find one that they think they'd be a great fit with and then the therapist doesn't accept their insurance. Can you tell us about the whole process of whether a therapist decides to accept insurance or maybe is even eligible to accept insurance?

Dr. Robinson: Sometimes, depending on the licensure type or status of the clinician, they may actually not be recognized as an approved provider by the insurance company. Now, this does not mean in any way that they're not a valid healthcare provider; it just means that some insurance companies have certain licensure requirements. And so, for example, Medicare does not accept licensed professional counselors, which I am, and so I would not be able to accept Medicare. That would be a potential barrier for someone wanting to use their insurance.

But other things that may impact that process, other than licensure type, might be networks sometimes are closed in certain areas. And so some insurance companies might say, “We have enough providers who are in-network, we're not currently accepting new clinicians to provide services for our clients,” so that could create an act where your provider might be interested in joining a network but the insurance company’s panel to join isn't open.

Other things that we hear quite often might be the reimbursement rates. This is what your insurance company will pay that clinician for that clinical hour, or whatever the session length is, and sometimes those rates just are offensive. Sometimes, to be quite honest, it feels offensive for therapists trying to run a sustainable business and being able to provide really good care.

And then there are some limitations that we experience when we are in-network such as there's some plans that only allow us to see clients for 60 minutes if they have certain diagnoses. And there's a lot of hoops that we might have to jump through in order to get those sessions approved, which as you can imagine, takes a lot of time. And so sometimes it's the administrative load that does cost, that creates a barrier on whether or not a provider can acceptance a certain insurance company, a certain insurance plan or not. And so many providers may choose to be out of network because there are access issues if you are an in-network provider, as well as the administrative load of just managing and maintaining those contracts.

Dr. Joy: Yeah, and I think that that is often what happens, especially for therapists who are in a solo practice or maybe working in a practice in addition to a full-time job. Is that I often hear that they just don't necessarily have the bandwidth or the resources to be able to keep up with all of the administrative pieces related to accepting in-network insurance.

Dr. Robinson: Yes, it can be quite challenging, as I have the entire agency dedicated to it. It really can be a full-time job in and of itself. And so that definitely is a barrier when we just want to do the thing we're really good at, which is really help clients heal. And so if you're on the phone trying to check benefits and following up on claims and picking out all the interesting denial codes, that can be a barrier to clinicians being able to actually work with clients.

Dr. Joy: And Dr. Robinson, can you talk about when you use your insurance as a client? Is the therapist required to give you a diagnosis with something in order for the claim to be approved? Is that true or not?

Dr. Robinson: It is true. All insurance companies have a process or a procedure called medical necessity. This is true whether you're going to urgent care or a primary care doctor, OB-GYN, and mental health. There has to be a medically necessary reason that services are required and so sometimes this is challenging because you might need support to navigate the stress, the overwhelm, whatever you're experiencing, but it doesn't meet clinical levels of disruption in your quality of life. That's what makes it medically necessary.

So could you benefit from support? Yes. Based on the standards that we have to adhere to, most commonly referenced under the DSM-5, it doesn't meet the criteria for a clinical disorder. But if it does, that's what we have to decide. Is there a mental health diagnosis that better explains what you're experiencing, such as depression or anxiety or PTSD, that would necessitate intervention and treatment? And so a mental health provider has to be able to justify billing an insurance company for the services provided.

And so it does render a diagnosis. Sometimes it's adjustment disorder that many people perceive as rather mild and it could be bipolar or some other diagnosis, but everyone that's using mental health or benefits, billing insurance *[inaudible 0:40:06] diagnosis.

Dr. Joy: And does insurance cover V codes or V codes in the DSM-5? Or things like bereavement or phase of life, is the one that I think I hear most often. Will insurance dictate that as a medical necessity?

Dr. Robinson: Most insurance companies do not. There are a few exceptions, they are a few and far in between. This is actually the challenge that we have with individuals seeking couples counseling. Insurance companies actually don't recognize couples, there is no code to bill for couples, it's billed under family therapy. Some insurance companies don't consider couples family therapy and most couples don't actually have a clinical diagnosis. And so what do we list? We have to pick one person in a couple, identify if they have a diagnosis and bill under that person.

And so that gets really tricky because we might be toeing the line there on whether or not we're forcing medical necessity, because a Z code or a *[inaudible 0:41:05] code now, is what they're called, is a better fit. But we know that the *[inaudible 0:41:09] code is going to be denied and so some therapists... Again, this may be very valid, but in certain ways is still an interesting line on are we forcing medical necessity so that we can create access to care? And so that's a big debate in billing for couples, why many therapists do not bill because most times a *[inaudible 0:41:28] code is the better fit and most insurance companies don't cover those services. Because they're not considered medically necessary, which again, many therapists do not agree with but that is not our decision in many cases.

Dr. Joy: Right. And the other thing that I have heard from people who maybe want to use insurance, but are afraid of things being on their record. Do you know of any cases where having a diagnosis of maybe like a depressive disorder or a bipolar disorder or anything, has stopped people from being able to get a job or qualify for things?

Dr. Robinson: Yes. I wanted to preface and say this is not as pervasive as I think we believe it might be. But there are some situations in which this could be very relevant and have an impact and so I'll start with the ones that are most common. If you have a federal clearance, so if you work for the federal government and you have federal clearance, it is not the fact that it's on your medical record; it's the fact that you are often required to submit and release the information if you’ve had psychiatric or mental health care. And so it's not that you're receiving treatment alone; it's the conditions in which you are employed.

And so our military, traditionally, have always had this as a potential thing. Although there are some laws that are supposed to protect them, we know that laws are upheld by people who don't always honor those things. And so that can continue to be a potential barrier. An employer could ask, especially if you have a position where... usually it's federal clearances where those are most likely to be requested.

The other way in which an employer might find that information, let's say you work for a small company. The insurance company each year sends an aggregated report, so it doesn't have your individual information on it, but let's say you are the only person of a certain demographic. I could be the only black woman and so it may include things such as age, demographic and diagnosis, frequency of use. What they're trying to understand is what is the risk profile of your employees and those things factor into how much your insurance premiums cost. So, in those cases, if you're at a very small company or you are a unique demographic, your information could be identifiable because there's enough markers that single you out, but your name wouldn't be listed on that report per se.

Other instances in which I've seen this occur is when individuals apply for life insurance and most commonly when it's life insurance over a certain threshold. Often, I see a trigger, sometimes that's a $300,000 mark and above, they may ask. It's less common in states that have a suicide writer (so if suicide itself isn't a condition that invalidates your life insurance). And so that may be an instance in which you're applying for life insurance and they request a release of mental health records. So those are the scenarios in which it's most common to occur.

Dr. Joy: Got it. So that, I think, is the reason why we will hear some people who have maybe federal jobs or other jobs like that, even if they have insurance, will decide that I don't actually want to use my insurance and will just pay out of pocket.

Dr. Robinson: That's correct. Or even folks without those conditions, work type place settings, if they believe that they have a psychiatric or a personality disorder, they won't want that on their record, regardless of where they are, so they may still opt out of the process. And so, yes, I agree.

Dr. Joy: Mm hmm. And so we hear about this record, and I don't know that we always know what that means. Where is our medical record stored? Like who has access to that?

Dr. Robinson: It depends on your therapist, your provider. We use an electronic health record, which means our information and all of our patients’ information is stored in an electronic encrypted cloud. And so that's what we use, but some therapists still take paper notes. And so you have a file, whether it's digital or paper, that has your name on it, that is kept in a confidential space, usually behind a locked cabinet. And everything that has happened that is clinically relevant, might be in that file. So your intake, your emergency contact information, notes from your individual sessions, things of that nature. And so we're required to maintain those notes for however many years. In Maryland, it's seven to 10 years, depending on if you're under 18 or over 18. Each state has their own requirements about how long a provider has to keep that medical record.

Dr. Joy: And the only reason anyone else would have access to that record is if you signed a release for us to be able to release some parts of that information for whatever reason you decide you want to have it released, correct?

Dr. Robinson: Yes, mostly. Your therapist or if you're seeing an organization like my own, there's very limited pieces of information that, let's say *[inaudible 0:46:28] has access to, but it wouldn't be the details of your session. But outside of that, you would have to consent or provide a release of information. Unless we're talking about children and then, of course, the parent has the right to access that file.

Dr. Joy: Right. I'm guessing the health insurance plans themselves have a database when like the therapists are sending in their claims. They have a database of like the diagnosis and the dates of attendance, but they don't necessarily have access to your entire files, correct?

Dr. Robinson: Oh, that's a wonderful question. Technically, when you consent to use your health insurance to cover services, the health insurance company can come back and say, “We want to audit that medical record to ensure that the service provided meets medical necessity.” And so the way that that clinician documents medical necessity, and it starts with the very first session... That intake all the way through every single session, must document medical necessity consistently. Or the insurance company can come and audit that file and say, “Well, you said this person meets the criteria for bipolar, but nothing in the way that you were documenting treatment and progress indicates that you're treating bipolar, based on the standard that we have.” We're not capturing symptomology, we're not capturing changes in functioning, things of that nature, so we don't have proof that you are providing medically necessary services.

The insurance company may come back and say now that therapist owes money from all of the sessions they paid for because medical necessity isn’t evident. This is another reason that therapists may not want to accept insurance because audits can happen. And sometimes a therapist feels like they don't exactly know what insurance companies want, what medical necessity actually looks like from a documentation perspective, and that they can just recoup the funds. And so if that therapist is receiving EFT or direct deposits for their payments, the insurance company will just come back into that account and take the money and so that that can feel very disruptive to someone trying to provide therapy and knowing that this could happen at any time. It can be a big deterrent for many therapists. And so because you consented to use your insurance to pay for those sessions, in your contract with your insurance company, it says that they have the right to review any notes from treatment. And so technically, the insurance company, you've given them legal right to review that note.

Dr. Joy: Wow, I don't think I knew that.

Dr. Robinson: One of the things that we do as therapists to kind of protect and safeguard that information is although the insurance company has the right to ask for that file, we often will come back... One, we’ll notify a client that hey, the insurance company has asked for this information. At that time, they can choose to go back and pay for all of those out of pocket and withdraw that claim for coverage so that we don't have to release the notes but oftentimes, therapists can submit a treatment summary. So instead of releasing every individual note, we will write a summary of treatment thus far. And that might include the diagnosis, how many times we've seen you, the changes we've noticed in symptomology, what instruments we're using to capture those changes, and progress that's been made and future plans.

But again, think about that. That's additional time that the therapist has to take to write that letter. And our goal is to continue to keep your information confidential, but it's another thing that the therapist does have to kind of tackle and make time for, which again can be a barrier.

Dr. Joy: Mm hmm. And do you know if there are any certain things that would happen that might trigger an audit? Or is it kind of just random?

Dr. Robinson: One thing that I want to add about that other point is that, because this is a big myth, people think because they're out of network, that they're not subject to an audit. Because the contract is actually truly between the client and the insurance company and so let's say you come to me for out of network services, you pay me directly, but you seek reimbursement by submitting a superbill, a medical receipt for the insurance company to reimburse you. That also opens the gateway for those notes to be released.

The only way to truly protect them from an insurance audit is to pay out of pocket and not seek reimbursement. I just wanted to close the loop on that because it's an area that therapists who are out of network think that their notes can’t be audited, and that is not the case if that client seeks reimbursement.

Dr. Joy: Got it, okay. So anything in particular that might trigger an audit?

Dr. Robinson: From a therapist’s perspective, the overuse of an adjustment code. If you have majority of your clients that you diagnosed with adjustment codes for an insurance company, that will trigger an audit. For certain insurance companies, utilizing the CPT Code 90837, you will get a utilization review. They're calling it utilization review, but it's an audit. And so they're wanting to review why you are holding sessions, all sessions at that length, because they're wanting you to hold shorter sessions, maybe that 45 minute code. Some insurance companies want that longer code, that 90837, reserved for more severe cases, so individuals who have high suicidality or PTSD, things of that nature, or recent hospitalization. So those might trigger an audit.

And then the other ones are generally just random. Federal insurance companies (such as Medicaid and Medicare) do periodic audits and so if you're in-network with them, you should expect to be audited. Commercial insurance companies, they're usually rarely done. Unless, unless a client has complained, and then that can put you on the audit list as well.

Dr. Joy: Okay. And so something else you mentioned earlier is that a claim could be denied if they don't see that what you've said actually meets the criteria for medical necessity. Are there other reasons why claims might be denied when, let's say, you are a therapist in-network, you kind of checked it all out ahead of time, but then you file a couple of claims and then you get information that these have been denied? What are some reasons that the claims might be denied?

Dr. Robinson: Mm hmm. One of the big reasons that claims are denied is because clients have another insurance plan that's actually primary. And so it's so important that clients tell us that you have more than one plan. They may have, let's say, their own plans with their job and they're under their spouse's plan. Well, we need to know that both plans exist, whether we're in-network with both plans or not. Let's say for example, you have Aetna and you have Blue Cross Blue Shield. And Blue Cross Blue Shield is secondary but I'm not in-network with Aetna so you only give me the Blue Cross Blue Shield card. Blue Cross Blue Shield is going to come back and say we're not primary, you have to submit to Aetna first. Aetna might deny it and then Blue Cross Blue Shield will pick it up, but you have to send it to the primary before a secondary to pick it up. That's one of the pretty consistent reasons that denials happen, is that we submit it to the wrong company first.

The other reason might be that, for whatever reason, let's say a plan does not cover a certain diagnosis. There are some plans that do not cover family therapy or couples counseling. They do not cover adjustment disorder as a medically necessary diagnosis. These plans usually tend to be self-funded plans (they might be funded directly by the employer) and those plans, they do not have to adhere to the Affordable Care Act provisions treating mental health as parity. So those are reasons that it might deny.

Sometimes it denies because the client has a marketplace plan. They went on the Affordable Care Act, the marketplace website for their state, they signed up for insurance, but for whatever reason, there's a delay. So let's say their payment declined one day and technically they don't have insurance. The insurance company could deny it because in their system, it hasn't caught up that that second time they ran your card it went through, so it's still showing that you're inactive. Those are the three common reasons that claims might be denied. Is that the type of service provided isn't covered, or you don't have insurance or if you have another plan that should be billed first.

Dr. Joy: This all really sounds like it is important and I think this is a large part of why it can be so frustrating as a consumer to try to figure all of this stuff out. Like a lot of this is written in terminology that is really, really complicated. Are there tips that you have for people about how they can kind of do as best they can to advocate for themselves? And like, what kinds of things should they be considering if they're looking for a health insurance plan?

Dr. Robinson: One of the number one things that I will say for folks signing up for health insurance plans is if it is any way feasible, financially or otherwise, for you to choose a PPO or an open access plan, I would choose that over an HMO. Although that may give you a lower premium, it also restricts your access. One of the things that HMO plans do not have that PPO and open access plans do, is more robust out of network services or reimbursements. So if your therapist doesn't take insurance on a PPO or POS plan, the plan is more likely to pay more for those services, which reduces your out of pocket costs for those services that you might be paying out of pocket.

You also increase the likelihood that if it's a PPO plan that you're going to find more therapists who are in-network. Because you're sharing in that premium cost which means their reimbursement rates for the providers are more likely to be acceptable, so more providers are more likely to be in-network in that regard. The other piece is that you really want to understand what your plan covers. And so although your therapist might verify your benefits, you want to understand what to expect. And so things you want to ask about is if your plan has a deductible, does it apply to in-office mental health services? Because sometimes we think that it doesn’t because you see a copay for specialists. But sometimes, because they're specialists, they treat us as specialists and the deductible is more likely to apply to us and our services. So that means that until you hit the deductible, you have a higher out of pocket cost as well. So pay attention to that.

You may also want to just ask if they cover family therapy or if they cover adjustment disorder. They will give you that preliminary information. They always will say “we can give preliminary information, there's no guarantee,” but they will tell you no if they don't. And so I just encourage everyone to call for yourself and ask those questions. That piece is really important.

Dr. Joy: And do you have resources for people? I know most people, if they have insurance, probably get it through their employer; are there resources that you will suggest for people who may be self-employed or are looking to just kind of get insurance on their own?

Dr. Robinson: Absolutely. The Marketplace is a good place. The Marketplace will also connect you for free with an insurance broker in your state. It doesn't cost you anything to work with an insurance broker and so they often can meet with you and talk about what your unique needs are and they will filter through the plans that meet those needs. And so instead of you looking at the 75 plans that the Marketplace will say is available, your broker can narrow that down to maybe the top 10 for you to review and can really help you understand the coverage limits, again, that are important for your unique needs.

And so they can look at things such as the pharmacy formulary. So if you take a medication, I have asthma, I want to know whether or not my inhaler, something that I get every single month, is going to be considered a higher copay on the formulary or a lower copay, because that affects my overall day to day costs. Your broker can help talk you through those different things and really find plans that meet your needs and it's 100% free for you.

If you are self-employed like I am, you may look at going through your payroll software. I use Square for payroll, they have plans or access to plans that are built in that they're able to leverage their size as an organization to get you better rates for both you and your employees. You also can look at your professional organization. I belong to American Counseling Association, they have some life insurance and other things that I can leverage because I'm a member of their association. And so those are places that I would look. Outside of those places, your Department of Health and Human Services is always a great source of information.

Dr. Joy: Perfect, thank you so much for that. Is there anything that we haven't covered that you think is important for people to know about health insurance and using their benefits?

Dr. Robinson: I think that covers it. That was pretty thorough. I just want to say to not be afraid to use your benefits. I know that it can be convoluted, *[inaudible 0:59:07] insurance, but to do your best to inform yourself about the process and stay in communication with the therapist if anything changes. I think that piece is really important to keep in mind.

Dr. Joy: Yeah, and I think we may want to kind of spend a little bit of time talking about the frustration of not being able to find somebody in-network. Do you have suggestions for people who may be kind of doing this search and they find all these therapists, but nobody's in-network? What should they maybe then do after that?

Dr. Robinson: I might reach out, again, understanding what your out of network benefits are, because you still can utilize that to decrease your out of pocket costs. There are also therapists who may be on websites such as BetterHelp or Talkspace, that have already agreed to offer a sliding scale. You may just reach out to the therapists themselves; they may have a built-in sliding scale for you. I also think I don’t buy into this notion that you would pay for it if you value it, because some people truly cannot afford $200 a week for the care that they need, although they understand that it's important. But you may want to look at where you can move things in your budget.

If you have a health insurance plan that has an FSA account, so flexible spending accounts or health savings accounts, those accounts can be utilized to pay for the out of network services that you are looking for. The other place is that you can look at the insurance directory for a list of in-network providers and so that's a wonderful place to look. The challenge might be that in-network providers might also be full because we accept insurance and so just continue to reach out. When we are full, we often refer the colleagues that we know have availability that are also in-network. Don't be afraid to reach out to therapists. If they can’t help you, many of us will try and connect with someone who can.

Dr. Joy: What about group therapy? Does health insurance tend to pay for group therapy?

Dr. Robinson: It depends. It really depends on the type of group that is occurring. And so there are *[inaudible 1:01:12] psychotherapy groups, insurance company covers those, and then there are support groups. And so it really depends on the type of group that's being offered. Therapists need to understand this as well, because I get this question from them a lot. I want to run this group, I'm in-network, do I have to take insurance? And so it really boils down to what's happening.

Things that we want to consider about whether or not your insurance might cover it or whether or not you have to take insurance if you're the provider, is who's facilitating the group? I don't mean, yes, the therapist is going to be there, we're going to be holding the frame and maintaining confidentiality or a safe space, but are group members able to lead conversations and discussions or activities? Is all of the focus coming from and the planning happening from the therapist? If it is, it doesn't really matter that you're calling it a support group, because you're running a psychotherapy group.

We also want to think about how are we screening for people who are eligible for the group? Are we using diagnosis as a factor? If we are, we're running a group that insurance, if we're in-network, we should be billing them for? There's a few other things, but it really depends on what's being offered and who's eligible. Because those are usually criteria that may or may not be based on things that we use to determine diagnosis. The more we're likely using those measurements, the more likely we are running psychotherapy groups, and those are covered by insurance. If insurance covers groups, and most of them do.

Dr. Joy: Got it. I think that that's an additional way that a therapist who has a full individual caseload may be also running a group that you can ask about. So that's another alternative, and
usually it's cheaper (in a lot of cases) for a group than it is individual.

Dr. Robinson: Absolutely, and that creates access. We do that a lot for people who otherwise would not be able to afford individual but want the support and community. And you're right, it also can free a clinician who's otherwise full up because they can run a group and serve more people that way.

Dr. Joy: I know that therapists are looking for alternatives, so a lot of therapists are using Zoom or other virtual avenues to meet with clients. But some therapists are offering walk and talk therapy, and a lot of therapists actually were offering this even before the pandemic. Is something like that covered by insurance?

Dr. Robinson: Yes. So that's the modality. That's the method through which therapy is provided and that part, if there’s evidence that it is effective, insurance isn’t regulating that. And so the piece that's important, prior to COVID, was that you started the session, so you met at the office, you did your walking and you end the session at the office. In that case, you could put your office as the location in which services were delivered. Because we're now in this COVID space and most of us providing services virtually, you just put the telehealth service. That is the place of service code would just be telehealth. You no longer have to start and stop at the office and so that piece is really important.

And yes, I get that question all the time. It is really, really important that clients sign a consent form for walk and talk therapy, because unlike being in the office or being virtually at your home or wherever you are, we can't help maintain confidentiality. We might be walking and you see someone that recognizes you and they see you with us. And you may not want to tell them how you know us or what our relationship is, but we can't prevent those things because we are out in the open. We just want to know and understand the different types of confidentiality or things that change when we use walk and talk therapy, but it's very effective. Nothing changes about, you know, really the way that we intervene; we just have a different vehicle to deliver the service and so, yes, insurance companies cover it.

Dr. Joy: The other thing that I have heard some colleagues talk about is parking lot therapy. Like they will be in a parking lot and the client will be in the parking lot, too, and they're kind of talking on the phone. They can still see one another but it's in the safety of their own cars.

Dr. Robinson: Yes, very innovative.

Dr. Joy: People are just getting very creative right now in the ways that we're trying to serve our clients.

Dr. Robinson: Absolutely. So that brings up this caveat. Telehealth is covered pretty universally with COVID. That was not always the case for every insurance company prior to that. Walk and talk therapy is happening. It is important to understand (and this is for therapists and clients to really understand) that it is important for telehealth that most insurance companies have a requirement that we can both hear you and see you. So phone therapy is generally not covered. There have been some exceptions made because of COVID but the standard is that it has to have both audio and visual.

And that's important because body language tells us a lot about how clients are doing, how they're responding to certain things. We need those visual cues and we'd love to see you. But it really does inform our work and our practice. And so to the extent that that is possible, we really want to make sure. And so this car therapy makes sense because it gives me the visual as well as the audio and keeps us all safe. I love how innovative we are being at just making mental health the norm and accessible and I just hope that we continue to do this, to engage and to be creative and innovative in the way that we serve.

Dr. Joy: Yes, yes, agreed. Dr. Robinson, tell us again where we can find you. And also let us know, for any therapist who may be listening, who may want to use your agency to support them in taking insurance, can you give us the information for all of those?

Dr. Robinson: Absolutely. Everything that you would possibly want to know about what it is that I do and how I serve, you can find at AjitaRobinson.com. There is a lovely tab that says Therapy for those of you seeking services for yourself or your loved ones. And for therapists, if you're interested in support regarding credentialing and billing, whether you're in-network or out of network in your own company, under that same tab that says Work With Me, is the Mastering Insurance Company. It will take you right to that website. We have courses, we have done-for-you services. We also have a membership program that gives you access to life support. And so that is where you can find me. AjitaRobinson.com has all of that information.

Dr. Joy: Perfect. Thank you so much again, Dr. Robinson.

Dr. Robinson: Thank you for having me.

Dr. Joy: I'm so glad Dr. McNulty and Dr. Robinson were able to join us for today's conversation. To check out the resources they shared, visit the show notes at TherapyForBlackGirls.com/ session184 and please text two sisters right now and tell them to check out the episode. If there's a topic you'd like to have covered on the podcast, please submit it to us at TherapyForBlackGirls.com/mailbox.

And if you're looking for a therapist in your area, don't forget to check out our therapist directory at TherapyForBlackGirls.com/directory. If you want to continue digging into this topic and connect with some other sisters in your area, come on over and join us in the Yellow Couch Collective where we take a deeper dive into the topics from the podcast and just about everything else. You can join us at TherapyForBlackGirls.com/YCC. Thank y'all so much for joining me again this week. I look forward to continuing this conversation with you all, real soon. Take good care.