Getting insurance to pay for therapy

Not for the faint of heart. But we’ve got a roadmap from someone who’s done it.

Hey there – 

Does this sound familiar? You want to start going to therapy, and you want a therapist your insurance will pay for. After all, that’s what insurance is for. 

But none of the therapists on your plan’s list are panning out. They don’t take your insurance, or they’re not taking new patients. Or maybe the listed phone number doesn’t work.

This sort of thing happens a lot. Researchers and journalists call these haunted provider lists “ghost networks.” Ghost networks are a problem for many health care providers, but none more than mental health practitioners. And ghost networks make it harder for anyone seeking mental health treatment to get care. 

On a recent episode of An Arm and a Leg, we talked with Abigail Burman, an attorney and health policy researcher. She found one approach to “ghostbusting” – our term for getting your insurance to cough up a therapist who takes your insurance or to cover an out-of-network provider at the same cost to you as an in-network one. 

We started talking with Abigail after she sent us a guide she’d posted online, based on steps she’d recently taken on behalf of a friend. We’re sharing a lightly-edited version below. 

Here’s what you should know before we jump in:

1. Abigail’s an attorney, but this isn’t legal advice. Although she names some legal principles involved, a lot of her guide is about battle tactics when you’re fighting for your rights.  

2. This won’t work for everyone. Your legal rights in this situation are going to vary, depending on where you live and what kind of insurance you have. As Abigail notes, if you get your insurance from work, you’re at a disadvantage here.¹ I know, ugh.

3. This ain’t easy, to put it mildly. As we’ve said so many times, expecting people to do any of this to get care is unfair and unrealistic, especially for someone in the vulnerable position of seeking mental health treatment. 

But until we have the kind of health care system we deserve, being a friend who will share this burden with someone else can really help others.

A broad guide to getting therapy/psych appointments covered when you can't find anyone in network 

By Abigail Burman

This process may take more phone calls than what’s listed here because some of the phone people aren't familiar with the regs/are generally hostile, but if you have the time/emotional energy, it can be worth it.

(If you have self-funded insurance through work, these state regs unfortunately do not apply, but you may be able to leverage your particular plan documents and HR department to get relief. You are also still eligible for marketplace plans, which may provide better coverage.)

1. Google "timely access"+"network adequacy"+[your state]+[medicaid/insurance, depending on what you have].² You will likely find some requirement that plans provide timely access to care or an adequate network to meet enrollee needs. Note these down! There is also likely a requirement that if the network does not provide adequate access the plan must cover out-of-network providers.³ Also note this down! 

2. Call between 5 and 10 of the doctors listed in the directory as taking new patients. They are likely not actually taking new patients, will not answer the phone, or only have appointments more than a month out.
   

   On the off chance one is taking new patients within a reasonable time, great, stop here. If you find someone who is a psych/therapist but does not treat your specific issues or prescribe the meds you need, that does not count as access, so proceed to the next step.

3. Call your insurer's enrollee line and say that you would like to file an administrative grievance for lack of timely access and inadequate network because you cannot find a doctor to make an appointment with. Cite the regulations. They may suggest that you call your PCP, call a crisis line, or call a list of doctors they will provide. Do not do this! Hold the line! You are entitled to timely access and an adequate network, you want to file a grievance. It may take a few tries to get someone who is helpful and understands what you want, but it will happen. Do not let them make you call any more places. You have done enough work.

4. If you can, file a complaint with your state's insurance regulator and/or the state Medicaid regulator. 

You should now receive a call from the insurer's grievance department. Demand that they provide you with an appointment within the specified/a reasonable time frame. Open the call by saying you have filed a complaint with the regulator. Then explain that the regulations entitle you to timely care and that the insurer has the obligation to provide it, so you will not be making any more phone calls. State that if they cannot provide access to an in-network provider they are obligated to provide access to an out-of-network provider for the same out-of-pocket cost and you would like to begin that process. Again, make clear you will not make any more calls.

By this point, you will hopefully have reached someone accommodating and they will find you a doctor. The key is to be a giant asshole. [Editor’s note: you may feel like an asshole when you’re calmly asserting your rights, but you are unequivocally Not The Asshole.] You know your rights, you will not settle for anything less. No matter how much the people say they are trying to help, anything that is not them calling doctors’ offices or filing a grievance is not actually helpful.

Do not accept any suggestions for other places to call, especially if those places are your PCP or crisis lines. You did enough work with your initial calls to 5-10 places. At this point, the statutory/regulatory responsibility passes to the plan. Just keep repeating that under the regulations they are required to provide you with an appointment within X time.

Whoever you are on the phone with may try to get you to file a complaint rather than a grievance, or say that a grievance can only be filed against a doctor. Again, hold the line. Complaints don't have to be reported to state regulators, but grievances do. You want to file an administrative grievance, although your plan may have a different name.

Also, state regulators get astonishingly few complaints. It may feel like it's pointless, but 3-5 complaints are typically enough to launch a full-blown investigation.⁴ So there is a high likelihood your complaint will actually result in some pain for the insurer.

---

OK, Abigail is completely awesome. And this all sounds completely exhausting.

But as I learned when we talked, Abigail actually had to go even farther in the ghostbusting process than the steps she just laid out. 

After working her way all the way up the tree at the insurance company, she talked with someone who could authorize payment to an out-of-network provider. 

That person flatly refused to do so, even though Abigail had the law on her side. 

“I read them the regulation over the phone,” Abigail told me. “It did not, did not, change their position.”

The secret trick

Here’s what worked: Abigail got the state rep’s office involved. 

“This is the secret trick for any interaction you are having,” she told me. “Largely with government agencies, but also sometimes with private companies.”

“All of your elected representatives from local through to Congress have staffers whose only job is to make your interactions with these systems easier,” she said. 

Abigail worked for a member of Congress once upon a time, so she's seen this all from the other side.

(And you don't have to be a former Congressional aide to call your state representative's office. In most cases, a state rep doesn't even have THAT many constituents, so their offices are usually pretty accessible.) 

When she called, someone at the state rep’s office gave Abigail the email address of a person at the state insurance regulator’s office who could lean on the insurance company to cover Abigail’s friend. When Abigail emailed that person, they responded almost immediately. 

And within a couple of hours, Abigail heard from somebody else. 

“We got a phone call from the health care plan’s lobbyist for the state, saying that, yeah, she was personally going to fix this, [and] promising an appointment within the next two days.”

Yep. And Abigail’s friend got the care she needed.

I love two things about Abigail’s story:

1. There’s an actual victory of some kind, as well as lessons some of us can use.

2. It reminds me: We’re in this together. Abigail did all of this on behalf of a friend.

I’m starting to think of First Aid Kit as less of a self-defense manual, and more as notes on ways we can take care of each other. 

So I want to ask you: If you find any of this helpful, pass Abigail’s guide around. 

And if you’ve got more to add, please bring it on in the comments below or privately here. You’re my best source.

Catch you soon,

Dan

Additional Listening + Reading

• Again, you can hear more details about Abigail’s story and her fight in the latest episode of An Arm and a Leg. I recommend it. She’s really good company.

• For a little explanation about “self-funded” insurance from employers, here’s an episode we did about it (and here’s a transcript for skimming). And from our pals at KFF, here’s an explainer about how states don’t regulate that kind of insurance.

• For a dose of confidence, maybe: Law professor Jacqueline Fox used to fight insurance companies as an attorney. She called it “easy.” Here’s our episode about her. 

1. The rights Abigail refers to are part of state insurance regulations, and state regulations exempt insurance from most big employers. (It’s regulated, lightly, by the Department of Labor.) It’s a whole thing called “self-insurance,” and it limits a lot of folks’ rights, which sucks. However, as Abigail notes, there may be some language in your insurance policy itself that’ll give you some similar rights.

2. Some states have more definitive laws around these terms than others — the right to an adequate network and timely access to care.

3.  Note: And it might define what ‘timely’ means.

4. This figure comes from Abigail’s work as a public policy researcher! It’s in her paper “Laying Ghost Networks to Rest,” published by the Yale Law and Policy Review.