Have You Thought of Giving Up Your Practice?  You Are Not Alone

By Barbara Griswold, LMFT (July 8, 2024)

Working as a network provider for multiple insurance plans for 34 years, I’d participated in my share of “bitch sessions” with other therapists, sharing stories of how frustrating it was to deal with insurance, and how it could make you tear your hair out.  But I guess at some level we accepted that while it was not fun, it was certainly doable, and something we were willing to put up with if we wanted to serve clients of different income levels.

But in recent years, something has changed in the tone of many colleagues who are now calling for consultations.

Instead of complaining “this insurance plan is driving me nuts,” more and more I am hearing from therapists that they are thinking of leaving the field all together.  One therapist summed it up when she said, “with all that is happening in the field right now – insurance hassles, Medicare enrollment or opting out, clawbacks, cyberattacks, concerns about HIPAA compliance and risks and always-changing requirements – I’m seriously considering giving up my practice.” And sadly, I hear similar versions of this sentiment every week from clinicians.

How did we get to this level of despair?  Here are some of my observations:

While insurance has always been difficult to deal with, it was much simpler when I started out.   A large number of clients had no insurance coverage for mental health.  Almost all of us did 100% in-person care, and a lot of it was private pay, so payment was usually easy-peasy — they handed you a cash or check.  When working with insurance, client coverage was usually pretty clear:  They would have a limited number of sessions (ex. 15, 20, 30) a year.  We could usually contact a plan fairly easily to check coverage, ask questions, or get a problem resolved.

Then, insurance plans started buying each other up, often “carving out” the mental health portion to another plan, so that it became difficult to determine what health plan was covering a client.  Sometimes therapists who provided services found out their claim was denied since they weren’t providers for the carved out mental health plan.

Then came the Affordable Care Act and the Federal Parity Act.   Thousands more clients gained mental health coverage, and with no session limits, regardless of diagnosis.  Therapists were thrilled!  However, health plans found they still could limit the number of sessions we provided by reviewing our care and deeming it “not medically necessary.” To do this, SOME health plans started doing more frequent clinical treatment reviews (usually by phone), and some started asking for progress notes before paying claims, using those notes to refuse payments. This did NOT thrill therapists.

With the expansion of insurance coverage (a good thing), more clients now had multiple insurance plans.  This has often led to a bad thing: Therapists were often not paid for their services (or were asked for money back) because the health plan that was billed was not the client’s primary insurance plan.

But the biggest change (in my view) came when the pandemic hit.   Overnight, therapists had a million basic and complex questions about telehealth coverage and coding, which was different for each client.  Health plans were COMPLETELY overwhelmed with the number of calls coming into their call centers (a situation that seems to continue to this day).  Plans scrambled to set telehealth policies and coding rules, which they changed constantly.  And in my opinion health plans did a TERRIBLE job communicating any of this essential information to providers (or even to their own representatives), so getting clear answers was almost impossible.

Worst of all, the hold time to talk to a live person at a health plan tripled or sometimes quadrupled from pre-pandemic levels.  In my experience, it was not unusual to have to wait over an hour to reach a live person. And often that person was not well-trained enough to resolve even your most basic questions, or to resolve a payment issue.  And all this came at a time when we were all going through a major learning curve on every possible front without any warning.  We had to learn new Place of Service codes and Modifiers.  We had to learn which plans covered what. We had to move all our clients online overnight, and learn how to use telehealth platforms, to send and receive confidential documents, and to accept payments via the internet.

And the despair is fed by fear about “clawbacks.”  A “clawback” is when a health plan has paid you for a period of time for services and then asks to see your notes for those sessions; if your notes aren’t up to their standards, they could ask that you repay the money they paid to you.  While I believe these clawbacks are not as frequent as most therapists believe them to be (or that online therapist groups might make them seem), they understandably provoke some anxiety.

After reading this article, you might feel even more negative about insurance.  So, why did I decide to write it? 

• I thought perhaps it might be nice to give some of you a much-needed reality check. If you are feeling that insurance has become more difficult to work with, the reality is that yes, that isn’t your imagination.  You are working within a system that has indeed gotten more splintered and crazier and more difficult to navigate with each passing year.  It isn’t you.   And yes, the past few years have been exhausting in all that we have been forced to learn.
• I want to tell you that if you are thinking of quitting, you are not alone. Private practice is very isolating, and we are out there struggling alone.  So sometimes we think everyone else out there is thriving, and that we are the only ones feeling so overwhelmed by the business side of running our practices that we might actually think of quitting.  This ABSOLUTELY is not the case.
• I want to encourage anyone reading this not to give up your practice.  Think of all the years you studied and all the hours of training and experience you went through to get to the position of honor and respect that you hold.  Think of how much you love being with clients.  That is what matters — Keep your eyes on that prize.  Resolve not to give the insurance industry the power to rob you of your passion.
• When you think of quitting, think of it as the caretaker part of you sending you a helpful message, saying that you need to take some steps to take care of yourself, as your frustration is getting high. But quitting is an extreme step.  Are there any less extreme steps you could take?  Here are a few thoughts:
  • Consider cutting down on the number of insurance clients you see, or total number of clients you see..
  • Resign from some (or all) of the insurance panels you are on (see my article on resignations here). Work toward achieving a better balance between insurance and private pay clients.  This can’t happen if you are a network provider on every plan.  Remember, if you did resign from insurance plans, some of your insurance clients – if they have PPO or POS plans—may have some coverage to see you as an out of network provider; others might be able and willing to pay out of pocket to continue to see you.
  • Consider hiring a biller to take on the administrative and billing part of your practice.  You know, the stuff you hate.  It might not cost as much as you think.  See my article here
  • If clawbacks make you too anxious, consider getting off the plans that do the most frequent clawbacks (in my experience, these are Medicare, United Healthcare/Optum, and Medicaid, though of course any plan can do a clawback). And if you stay on these panels, just resolve to write terrific notes so you feel confident in an audit (if you aren’t confident in your notes, check out my webinar “What’s Missing From Your Charts”—click here)
  • Seek out support.  Hire a business coach to support you in creating a thriving practice that you love.  While I no longer do consultations, I have compiled  a list of Private Practice Coaches which I’ve posted here. There is no need for you to have to do this alone.

I do want to end with a message of encouragement.  While working with insurance isn’t right for everyone, I do still feel it is doable despite the challenges.  My practice was always full because of it, and I was happy that  it enabled me to see a wide variety of clients that otherwise could not have afforded therapy.  But if you continue to work with insurance, you may just need more patience than was needed years ago, and maybe you’ll need to think more carefully about how to care for yourself and protect your sanity in the process.