The third in a series of stories about mental health parity.

By Yen Duong

Patients often struggle to find therapists, counselors or psychiatrists within their insurance networks—but many mental health providers don’t accept insurance and leave the paperwork for patients to file an out-of-network claim with their insurance companies.

“In North Carolina, we have people who are not able to access mental health services within their provider network,” said Michelle Laws, a policy analyst for the National Alliance on Mental Illness-North Carolina. “That creates another challenge and barrier to access to care and treatment.”

Some providers do accept insurance, which often means taking on additional hurdles.

“I say to people if you have insurance, you paid a lot for it, you ought to be able to use it,” said family counselor Laura Ashford, who practices in Cary.

A national 2014 study published in JAMA Psychiatry showed that about half of psychiatrists do not accept insurance versus about 10 percent in other specialties. The authors surmised this was probably because of low reimbursement rates and treatment restrictions.

This is despite a 2008 law passed by Congress that requires insurers to cover mental health and substance abuse on par with physical health.

Of the 59 complaints related to mental health parity made to the N.C. Department of Insurance over the past three years, 22 were filed by providers who wanted help joining or leaving insurance networks, or appealing denied claims.

Getting appropriate care, at a cost

Though therapists used to regularly charge for an hour of work, United Behavioral Health (which manages mental health services for insurance giant UnitedHealthcare) will only pay Ashford for a 45-minute session. With a few minutes to warm up and a few minutes to wrap up, she said 45 minutes is not sufficient to make progress.

“I’ve heard concerns like ‘it’s not worth my time to drive across town to be with a therapist for only 30 minutes,” Ashford said.

Ashford can get around the 45-minute time limit if she requests a special pre-authorization from the insurance company, which eats up hours of her week that she could be spending with patients.

“The issue is that [the insurance companies] decided that everyone, except the few you want to fight for, needs to have a lesser amount of time,” Ashford said. “They have lesser sessions for young children, but often you do a half hour with the child and a half hour with the parent.

“I’m doing play therapy with a child for 15 minutes, then meeting with the parent for 15 minutes. That’s not enough time to do anything or get anywhere.”

Shorter sessions mean that patients need more months to get the same number of hours with their therapists, Ashford said.

“I think it gives them the feeling that they’re sicker than they really are because they’re like ‘I’m never gonna get well because I’ve been in therapy for six months,’” she said.


Stephen Wyatt, the medical director of addiction medicine at Atrium in Charlotte, said he commonly sees insurance companies pushing patients toward outpatient programs before they head to an inpatient residential program.

“They’ll want you to do a lower level of care and have them fail it before you move them to a level of care that you feel is appropriate,” Wyatt said. “They want to tell you, without seeing the patient or knowing what’s going on, that the patient should be at a lower level of care.”

Jack Register, a Greensboro therapist and the former head of NAMI-NC, worries that patients lose out in the shuffle between insurance restrictions and provider recommendations.

“I wonder whether or not practitioners actually will shape what they might do for a vulnerable person who needs care based off of what the reimbursement stream is,” Register said. “Do we put somebody with severe schizophrenia into a support group because that’s the only service we can get reimbursed, versus the idea of the intensive therapy that they might need?”

Joining the insurance panel

Even if mental and behavioral health providers want to accept insurance, they may not be allowed into the insurance panel, or group of in-network doctors, Register said.

“Insurance panels get closed all the time for really stupid reasons,” said Register, whose practice includes providers in the Blue Cross Blue Shield NC, Medicare and Cigna networks, according to his website. “I have 20 years of experience and four licenses behind my name, and they tell me I’m not specialized enough, in some cases, to get into an insurance panel.”

“Blue Cross and Blue Shield says we have X number therapists and X number of people with your credentials, and if we have enough therapists to meet the need, then we won’t let you into the market.”

Insurance companies negotiate discounted rates for providers in exchange for joining the network and gaining more access to potential patients.

In North Carolina, the average rate for services by behavioral health specialists is 12.2 percent lower than what Medicare pays, according to a report by government consulting firm Milliman. In contrast, primary care providers are paid about 30 percent more than Medicare.

For example, Ashford said the going rate for an hour-long therapy session in Cary is $150, but United Behavioral Health only pays her $60 for a 45-minute session. According to a federal database, Medicare pays $86.82 for the same 45-minute session and would pay $130.19 for an hour-long session.

What’s the disparity in North Carolina?

According to a 2015 report, North Carolinians on PPO plans used out-of-network behavioral health services much more often than out-of-network medical or surgical health services.

Another way to measure the disparity is how much health plans pay physicians for various services, compared to the amounts that the Medicare Fee Schedule offers.

These statistics come from a disparity report by the consulting firm Milliman, commissioned by a subsidiary of the nonprofit Bowman Family Foundation. Graph credit: Yen Duong.

“They’re making it so the only people that will serve their clients are new therapists right out of the gate, because everyone else is saying no,” Ashford said. “Someone like me with 30 years of experience either settles for $60 for the 45-minute session or [limits to] clients that can pay cash.”

If out-of-network providers don’t charge patients upfront, they risk never getting paid, as networks often send the reimbursement check to patients instead of to providers.

“Suppose you are somebody who is addicted to opiates, and you go in for a 30-day treatment,” said Scott Leshin, who founded SJ Health Insurance Advocates, which writes appeals to insurance companies for patients. “Let’s say we’re successful in getting you $30,000 reimbursed when you leave treatment; you’re now going to get a check for $30,000 in your hand. What do you think an opiate addict is going to do?

“It’s cheaper for them not to have opiate addicts, of course,” Leshin continued. “But the reason why they do it is because they want to drive out of network providers either in network or out of business.”

Ensuring access

Though many behavioral health specialists offer sliding scale fees based on income, appropriate therapy remains out of reach for almost 60 percent of American adults with mental illness, according to a handout from the National Alliance on Mental Illness.

Ashford offered an example of a child whom she wanted to see twice a month, then taper down to once a month. Instead, because of insurance limitations, he saw her only once a month from the start.

“I think the hard part is many insurance companies don’t reimburse much, so it’s making it less and less accessible to people who pay for insurance but can’t get what they need for mental health,” Ashford said.

If patients want to access behavioral and mental health care, providers need to stay in business, Ashford and Register both said.

“I can’t make a living and I can’t be a viable business if [insurance reimbursement] is the only income stream I have,” said Register.

Register said he’s offering more support groups and workshops to make up for the losses of accepting insurance.

The future of health care

Different metrics for successful hospitals, such as numbers of emergency department admissions and hospital readmissions within 30 days of discharge, could change the perceived value of behavioral and mental health care providers, Wyatt said. He said Medicare will focus on these two criteria in the future, which means insurance companies will follow.

“It’s ironic that behavioral health including substance abuse problems are major drivers to those two factors,” Wyatt said. “Anyone treated for anything, if they have a significant anxiety, depression or certainly are a regular drinker or user of other drugs, their compliance on leaving the hospital is terrible.

“The very idea that [behavioral health] is not well serviced is one of the ironic and crazy things about the health care system.”

Leshin said more legislative solutions are necessary to support providers.

“North Carolina is definitely one of the states that is on the forefront of treating mental health and substance abuse,” Leshin said. “You have a lot of fantastic people in your state doing some great work. It’s just a fight. As great as the service providers are, it’s still a fight.”

Insurance companies respond:

UnitedHealthcare spokesperson Tracey Lempner wrote in response to NCHN’s queries: “We have a broad network of providers that members can access for their mental and behavioral health needs and we pay providers based on the market dynamics and network need.”

From BCBSNC spokesperson Austin Vevurka: “[We] are working closely with the Kennedy Forum to be a model health plan, ensuring adherence to parity and increasing transparency for our members and the general public.

Blue Cross North Carolina is committed to increasing access to effective behavioral health treatment across our state, leveraging telehealth to extend reach.  We are building capacity to integrate behavioral health treatment with our members’ other health services, thus improving access and quality of care.”

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Yen Duong covers health care in Charlotte and the southern Piedmont for North Carolina Health News.

2 replies on “Mental health providers struggle with disparities in the system”

  1. I got paid 30 cents on my billed hours as associated with seeing a United Health Care end stage client IN THE HOME. I got paid 30% of what Medicare wld pay me. Yes, house calls. Client can’t drive and barely walks.

    AARP sponsors United Health Care. What’s with THAT? Why do people choose these “Advantage” companies? Cheaper. They have reps that are assumably (?) paid to go to their homes and they offer them unbelievable services. Like mental health services, which they then don’t pay for.

    After literally dozens of calls to UHC and reference numbers that meant nothing I told the end stage client I gave up. UHC demanded I sign documents to keep me frm billing the client in order to merely CONSIDER my complaint. The NC DOI did NOTHING. Manximus Federal Services which oversees Medicare “Advantage” ( oxymoron) companies did nothing. There’s no other place to take up my complaints.

    We need a one-payor system and that’s Medicare.

    A NC Psychologist

  2. So many mental health providers are no longer in network with UHC that clients have fewer options. Yes, there is the 45 min. restriction with UHC but they also reimburse at one of the lowest rates compared to other insurance companies and clinicians get fed up with having to do twice and drop off the panel. Every time I field a phone call from a potential client covered by UHC they describe how hard it is to find a mental health clinician who accepts their insurance. I do my best to give them options and provide referrals but the small pool of choices continues. I have tried to give feedback to UHC about this situation and I have not seen any change to their authorization or reimbursement structuring.

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