Is paying a therapist the difference between their rate and what insurance covers reasonable?
December 19, 2011 4:25 PM   Subscribe

I see a therapist on a regular basis. I have health insurance with a small copay for these visits. Some time ago, my therapist asked that I pay the difference between the fee they bill for (their full rate) and the negotiated rate that my health insurance pays to them. This increases my out-of-pocket costs dramatically. Is there something odd about this arrangement?
posted by anonymous to Health & Fitness (24 answers total) 3 users marked this as a favorite
The negotiated rate that your health insurance pays them is a contract rate that they accept in return for the benefits of being in that provider's network. If your therapist doesn't want to accept that rate, they should leave the network.
posted by mkb at 4:28 PM on December 19, 2011 [14 favorites]

Yes, they are likely breaking their contract with your insurer by asking you to pay this difference.
posted by nat at 4:30 PM on December 19, 2011 [16 favorites]

Nthing that this is not ok, and that your insurance would likely drop him as a provider if they knew this. If your therapist "asked" that you do this, say no.
posted by supercres at 4:33 PM on December 19, 2011 [5 favorites]

Not only that, but it's pretty shitty to involve you, the patient, in what's clearly some tension between him and your insurance network. His financial issues (assuming that everything is square in your insurance and that you always have your copay) shouldn't enter the therapist-patient relationship.

It would be unethical to borrow money from you, or ask for a tip, and this isn't that far off. By having MH insurance, you've already paid for his services (less the copay).
posted by supercres at 4:39 PM on December 19, 2011 [6 favorites]

This was the arrangement I had with my therapist, but she made it clear at our first session that this was how she did business so I was free to find a different therapist if I was not able to afford her.
posted by prefpara at 4:51 PM on December 19, 2011 [1 favorite]

would this be acceptable for any other medical treatment? NO.
posted by cupcake1337 at 4:57 PM on December 19, 2011

Yeah, this is not cool. I'd be tempted to inform the insurance company
posted by St. Alia of the Bunnies at 4:58 PM on December 19, 2011 [7 favorites]

I am a psychologist who sees people in-network for a couple of insurance companies, and I agree that this is unethical and completely unprofessional. I know a lot of therapists who do this, however. It is extraordinary that they think it's fine, justified by the fact that the insurance company doesn't pay them as much as they think they should be paid (which they refer to as "my usual fee").

Nobody forced them to sign a contract with the insurance company. They're just trying to get "good" referrals (like you) without paying the price of a reduced fee for service. There was a time when therapists were quitting the insurance companies like crazy because the therapy biz was booming and therapists resented the lowish fees, increased paperwork, surveillance and control of the insurance companies, etc., and there were enough self-paying customers coming through their doors. Now, however, because the therapy biz is declining (because of increased use of psychotropic medications, the recession, and other factors), a lot of therapists are trying to get back into the networks. However, they then feel ripped off that they're getting paid $80 or something per session instead of the $150 or more they're "used" to getting.

Well, too bad.

I really HATE when therapists do this. I'd say absolutely NO to the therapist, and if he doesn't like it, leave. You are paying insurance premiums for the privilege of choosing a therapist from the company's panel AT THEIR NEGOTIATED RATE, not some made-up rate the therapist dreams s/he "deserves."
posted by DMelanogaster at 5:00 PM on December 19, 2011 [34 favorites]

I agree that this is unethical (breaking a signed contract, god it even feels a tad "extortiony" to wait until you have a client with a good relationship and then ask for more money) and one of the major things I would look for in a therapist is a strong moral compass.
posted by magnetsphere at 5:04 PM on December 19, 2011 [7 favorites]

Balance billing is not OK.
posted by madstop1 at 5:05 PM on December 19, 2011

I work for a national insurance company and this would be a violation of the provider's contract with the insurance company, as long as they were truly part of the network to begin with and not just honoring a rate as a courtesy.

Also, there could be a change if their contract or your plan have changed recently.

As an FYI, for plans that are now governed by the Mental Health act which the TARP legislation was tagged onto, most of the separate mental health limits are waived, as they must be the same as the medical benefits.

As an additional note, the same contractual language which prevents them from balance billing also prevents them from waiving your copayment. Under the terms of their contract, they cannot bill the insurance for costs which you aren't obliged to pay and, if they are going to waive a copayment, they couldn't bill that to the insurance in the first place. Most states consider "fee forgiving" a form of insurance fraud. Payment arrangements are fine though.
posted by slavlin at 5:18 PM on December 19, 2011 [1 favorite]

This is potentially a form of fraud and is not just breaking their contract with the insurance company but actually illegal in many states. Your state may have a truth-in-billing law that this person is violating.

I would actually just report him/her to the state insurance commission.
posted by Eyebrows McGee at 5:21 PM on December 19, 2011 [2 favorites]

[comment removed - question is not "what do you hate about therapists and money"]
posted by jessamyn (staff) at 5:28 PM on December 19, 2011 [4 favorites]

Agree that this is balance billing and is porbably not allowed by her contract with the insurance company.

Whether or not you stay with her depends on your comfort level with her and with the whole situation, how our therpy is going otherwise, etc. At a minimum, you should be able to talk about it with her. If you don't feel comfortable doing that, she is probably not a good match for you.
posted by SLC Mom at 5:45 PM on December 19, 2011 [1 favorite]

Check your explanation of benefits from your insurance company. it should have a column labeled "patient responsibility." The amount in that column is what you are responsible for paying- no more than that.
posted by dogmom at 6:03 PM on December 19, 2011 [2 favorites]

Yup, this is balance billing. Check your insurance plan for this term; most likely it will say they don't allow it. By going along, you are enabling a breach of contract. And also going to a therapist with questionable ethics, which is something that would bother me a lot.

Report them to your insurer (and the state board if you like) and find a new therapist.
posted by emjaybee at 6:37 PM on December 19, 2011

I'd concur with the majority of respondents on this one if, as slavlin writes above, this provider really is a part of a network and negotiated a rate. Do you know that for sure? (I ask not to undermine you, but because health care and health insurance are really complicated. It's easy to be wrong about these things.)

I have been a patient in a situation where my provider was out of network, and I paid her the copay my insurance plan required. Then she billed the company directly for her fee minus that copay. But what the insurance company was willing pay was an amount they define as "reasonable and customary" for the service. That figure is in many cases--as it was for my provider--far lower than the provider's fee.

Charging you the difference in this case is totally appropriate, though a giant bummer.

Before you report the provider to the company or an insurance regulator, just make sure that the insurance company's figure really is an agreed-to rate between your provider and the company, and *not* something else, like a "reasonable and customary" rate.
posted by celilo at 6:53 PM on December 19, 2011

Definitely not ok. How is your relationship generally with this therapist? It might be time to move on, honestly.
posted by sweetkid at 7:11 PM on December 19, 2011

It should just take a phone call to find out if your therapist is in-network (has a contract with the insurance company) or out of network. If he is out of network, then the balance should also show up on the insurance statement as patient responsibility.

Out of network professionals have not agreed to accept the insurance amount - they are entitled to collect their full fee. However, the fee should be specified at the first meeting. It is unethical (and possibly illegal) for them to retro-actively change the fee. However, you would have to check the small print in your informed consent - you have already agreed to pay whatever the insurance doesn't cover.
posted by metahawk at 7:35 PM on December 19, 2011

I concur with people saying you should report them to the insurance company and also the state board. This behavior, besides probably being illegal, is manipulative and takes advantage of you and your trust in your therapist. I'd find a new therapist right away if I were you.
posted by dovesandstones at 7:47 PM on December 19, 2011 [3 favorites]

This is balance billing, and in some jurisdictions, such as Connecticut, the law prevents it, *even* if the healthcare provider is not "in network" but agreed to take you on anyway. In such jurisdictions, submitting the claim (actually, "accepting assignment") is implicitly considered to be accepting the terms of the network's payments.
In CT, only if the provider bills you, and *you* claim from the insurer, can they bill the full rate.
See this article, for example.
Check what the situation is in your jurisdiction. It can vary wildly.
posted by blue_wardrobe at 8:17 PM on December 19, 2011

Wow, I had no idea this Wasn't ok, but I guess that explains why my therapist and my friends' therapists (I can think of at least 3) all were very careful in explaining why they were doing this and that we were free to not pay the difference and find another therapist.

I was fine with paying the difference because the insurance companies really were paying ridiculously low rates, and my therapist went to bat for me multiple times when the insurance company was trying to cut off my sessions. So while it may be unethical, depending on your location, you may have a hard time finding a therapist who Won't ask for the difference.
posted by ldthomps at 8:23 AM on December 20, 2011

"free to not pay the difference and find another therapist. That's an explanation?" Sounds like my way or the highway.
posted by Obscure Reference at 4:29 AM on December 21, 2011 [1 favorite]

No, you don't have to pay it.
Also if you report her to the Insurance they might drop her from their network of providers.

"she made it clear at our first session that this was how she did business so I was free to find a different therapist if I was not able to afford her"
You should have just reported her to the Insurance company. Then she's free to find patients that pay out of pockets. She can't have it both ways.
posted by WizKid at 1:17 PM on December 22, 2011

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