IMAGINE BEING WORRIED sick, struggling to find a mental health clinician to treat your 12-year-old child who is so anxious that he has not been able to go to school for two weeks. You’ve called dozens of private mental health clinicians and treatment centers, day after day, only to hear that they are full and not accepting new patients.
Imagine being a new mother suffering postpartum depression, unable to care for your infant, and unable to get treatment.
Both of these situations are unimaginable tragedies, yet increasingly common here in the Commonwealth, as affordable access to mental health and substance abuse services continues to decline. Perhaps even more tragic is that health insurance company practices are partially responsible for this situation.
One of the major problems clinicians have to deal with is retroactive claims denials, also called clawbacks. Insurance companies can recoup their payments to a clinician months, or even years, after a therapy session takes place and is paid for. Therapists secure prior approval from health insurance companies before treating their patients, and then have to adhere to billing deadlines (usually 60 or 90 days after each session takes place). No similar deadline exists for insurance companies.
Most of the clawback stories we have heard involve insurance companies discovering months – or more often, years – after the fact that they were not actually the insurance of record when the treatment took place. So, even though the therapist called the insurance to make sure their new client was eligible for service, and even though the insurance authorized the treatment, and even though the therapist was paid for the service by the insurance company – still, months or years later, the insurance company might discover they had made a mistake and demand the money back.
Insurance companies are also able to demand to see all of a clinician’s files for a particular client, and can recoup payment if the files do not follow their particular guidelines. It’s like if your employer could take back paychecks you deposited years ago, just because you forgot to endorse the checks.
Handling insurance for MassHealth members has additional complications, and this makes it difficult to treat those very patients for whom the Commonwealth needs to expand access to mental health services.
One colleague of ours in private practice received a letter in the mail from an insurer, demanding $27,000 back. According to the Bureau of Labor Statistics, that amount is over half of the median salary of mental health practitioners and counselors. Clawbacks have led to gaping budget holes for the more than 80 community-based mental health and treatment provider organizations in Massachusetts. One South Shore center recently reported clawbacks totaling over $137,000.
The fear of an insurance company retroactively demanding such massive payments has a chilling effect on private mental health clinicians and treatment centers alike – many of which are small businesses. When we discuss the many factors driving down access to mental health care in our state, look no further than these business practices. They are effective, subtle ways for insurance companies to deny critical behavioral health care.
Massachusetts must join over half of the country in passing legislation to protect health care providers from this practice of clawbacks. This session, state Rep. James O’Day and Sen. Michael Rodrigues have introduced a measure that would limit insurance companies to a six-month period for recovering payments for services already completed. It is a critical step toward addressing the grossly unfair business practice of clawbacks and leveling the playing field between mental health clinicians and insurance companies. Insurances should have to adhere to the same timelines and rules that they require of providers.
Our colleagues provide crucial mental health and substance abuse services day-in and day-out, in good faith and in accordance with the best insurance information available to them at the time. Insurance companies routinely violate this good faith and the spirit of our laws when they claw back payments from providers.
Massachusetts can and must do better if we are to address the crisis in access to mental health and substance abuse care.
Erica Kirsners, LICSW, is a clinician and social worker in Brookline. She is a Co-Chair of CliniciansUNITED Executive Committee, a campaign of SEIU Local 509.
Vicker DiGravio is the President and CEO of the Association for Behavioral Healthcare, a statewide association representing more than 80 community-based mental health and addiction treatment provider organizations.