Well… it seems many of you had some strong reactions to my previous article on 45 minute sessions.

That article was actually the second of two.  The first article looked at Aetna’s decision to reimburse 60-minute sessions (CPT 90837) at the same rate as 45-minute sessions (90834) for clinicians utilizing the billing platform Alma.  

The second article explored whether it made sense to shift from routinely offering 60-minute sessions (technically 53+ minutes) to 45-minute sessions (38–52-minutes).  That is, if some health plans were not paying more for 60-minute sessions, and others were more frequently auditing these sessions, did it make sense to shift to shorter sessions? 

I expected this discussion to spark some strong reactions, and let’s just say my inbox was… lively.  

Your reactions 

Some of you passionately pushed back. You felt I was implying that clinicians should simply accept insurance company demands for shorter sessions, instead of standing up for what’s best for our clients.  You said we must not comply,  but instead strongly protest, and fight not to be swept up by this era of “instant everything.”  

Some pointed out – rightly so — that shifting to shorter sessions could reduce any future incentive for health plans to reimburse longer sessions, and might even encourage future coverage cuts.  

Others lamented that if a health plan didn’t pay more for 60-minute sessions they  would have no choice but to resign from the plan, as 45-minute sessions would not allow for the type of specialized treatment they provided, or would not be appropriate for the type of clients they served.

And still others felt that it was simply a numbers issue — that these insurance plans, which already required clinicians to accept a sharply discounted rate for sessions, had now created a policy that was financially unworkable for their practices.

A few of you wondered — could I possibly be suggesting that all clinicians should switch to 45-minute sessions with all clients?  They clearly felt I was clinically “selling out” clients everywhere.  

So, what do I have to say for myself?

So let me be clear:  I think this industry-wide push toward shorter sessions is despicable.  Paying the same rate for 60-minute sessions as for 45-minute sessions is just the latest example in a larger pattern of a healthcare system which focuses on increasing profits by decreasing provider time with clients.

It isn’t fair to our clients.  It isn’t fair to us.  And these types of financial policies chip away at clinicians’ decision-making power.  When health plans limit the length and type of treatment that they will reimburse, it doesn’t allow for us to consider the individual needs of the client that is sitting in front of us, or to be compensated appropriately for whatever care is needed for them.   

I am NOT advocating for shorter sessions for all clients, for all clinicians.  How you choose to structure your practice is your call.  I AM saying that it is one possible and valid response that I know many of you are considering due to current reimbursement trends and the financial reality many of us are facing.  

And I would never support passively giving insurance plans whatever they want. I definitely believe we need to push back on health plans on these issues.  But the changes we would like may not come, or may take time, so we may need to take intermediary steps.

While I can’t tell you how best to respond, my goal is to lay out the considerations so you can think through your options, and make calm decisions that are financially right for you, ethically grounded, and in your clients’ best interest. 

I admit, I do have an agenda…

But I’ll admit it: I do have an agenda here. I don’t want to see large numbers of therapists leave insurance panels in a wave of anger. And believe me, I understand the anger. Insurance plans are giving providers plenty to be furious about right now. Aetna’s decision was foolish and short-sighted, and I expect it will push many therapists to seriously consider resigning. 

Before we get there, though, I want us to pause and think creatively. Are there ways we can continue to serve clients through insurance while also earning a sustainable income? Because if therapists leave panels en masse, access to therapy will get worse for clients—and some therapists may find it harder to keep their practices full. So whatever you decide, my hope is that you make the decision thoughtfully, not reactively.

Things to keep in mind before resigning

So before resigning, remember:

• Many plans continue to reimburse routine 60-minute sessions without question and without record requests.  You might consider continuing to provide longer sessions with those plans
• Check rates.  One therapist shared that one plan reimbursed 90834 at 90% of the 90837 rate, another paid only 50%.  This helped her decide which clients she could consider treating with 90834 sessions.
• If you are an Alma member and the income loss is too steep, you might resign from Alma’s Aetna contract, and independently credential with Aetna (the rate reduction seems currently limited to Alma).  But remember that independent credentialing can take months and isn’t guaranteed.
• And if 60-minute sessions are going to be reimbursed at 45-minute rates, then yes—push back on the health plan, and have your client do so.  In the meantime, look at each client individually.  Could some benefit from 38–52-minute sessions? And if so, can you use some of the strategies from my last article to make those shorter sessions work well?  For some clients, 38–52 minutes of therapy is still far better than no therapy at all from a trusted therapist because that therapist had to leave the network.

So:  Should you switch to 45-minute sessions?  Here’s help deciding

 I’ve created a visual decision tree that I hope will help you, called “Should I Switch from 60-minute to 45-minute Sessions?”  Download it here