Carter J. Carter became a therapist to help young people who are battling with their mental health. Rosanne Marmor wanted to help survivors of tragedy. Kendra F. Dunlap wished to serve people of color.
They studied, refined their abilities, and opened practices, joining health insurance networks to make their services available to people who couldn’t afford to pay for sessions alone.
More than 500 other psychologists, psychiatrists, and therapists spoke with ProPublica about their experiences.
This report is from ProPublica, a nonprofit journalism organization that examines abuses of power. Sign up to receive their top stories as soon as they are published.
But one after another, they encountered a system designed to squeeze them out.
Although federal law compels insurance to give equal access to mental and physical health care, these businesses have been discovered repeatedly shortchanging clients with mental illnesses by limiting coverage and delaying or denying treatment.
These patients, whose diseases can be chronic and costly, are detrimental to business, according to industry sources.
“Looking at mental health treatment through the lens of insurance, I don’t want to attract those individuals. “I’m never going to make money on them,” said Ron Howrigon, a consultant who previously managed contracts with providers for major insurers. “One way to get rid of those people or not get them is to not have a great network.”
There are far too few available therapists in insurance networks to assist all of those seeking care. Despite the fact that practically all Americans have health insurance, almost half of those suffering from mental illness do not have access to treatment.
The repercussions can be disastrous
To better understand the forces that push even the most well-intentioned therapists away from insurance networks, ProPublica delves into a subject that is typically studied through statistics and one-off perspectives. Reporters interviewed hundreds of providers in nearly all 50 states, from rural areas to major cities.
The interviews highlight how the nation’s insurers have quietly, and with no pushback from politicians and regulators, taken on an outsized role in mental health treatment.
Insurance companies, rather than therapists, frequently decide who can receive treatment, what type of treatment, and for how long. More than a dozen therapists reported that insurance pressured them to cut care while their patients were on the verge of damage, including suicide.
All the while, mental health providers struggled to stay in business as insurers withheld payouts that arrived months later. Some people spent hours each week following down the tiny payments, listening to hold music, and sending faxes into the void.
Several insurers told ProPublica that they are committed to ensuring access to mental health doctors, highlighting that their policies comply with state and federal regulations. Insurers also stated that they have policies in place to ensure that reimbursement rates reflect market value and to support and retain providers, for whom they are constantly recruiting
They have waived denied payments. They’ve taken second jobs. They sought treatment for personal assistance.
However, hundreds of people who talked with ProPublica claimed they all had moments when they felt compelled to leave the network.
Why I quit the network: Insurers interfered with my patient’s care
Melissa Todd’s moment came when she was forced to limit the care of a patient in crisis.
Todd, a psychologist from Eugene, Oregon, was treating a young woman who had experienced trauma and whose father had died abruptly.
When the patient first came to Todd, she had been unable to sleep for more than an hour or two for days. “She described it to me as maddening,” Todd recalled, recognizing a variety of symptoms consistent with bipolar disorder.
Todd assisted her in developing safety plans when she felt suicidal and was available after hours, including in the middle of the night.
“I was giving her almost daily updates,” the patient told ProPublica, “because that was what I realized I needed to do if I wanted to survive.” (Her name has been withheld to preserve her privacy.)
Longstanding practice standards advise clinicians to explore a combination of therapy and medication when treating patients with bipolar disorder, so Todd sought out a psychiatrist who could handle the young woman’s prescription. Despite the fact that the patient was covered by UnitedHealthcare, America’s largest insurance, Todd was unable to locate anyone with openings. Her patient had to spend hundreds of dollars on out-of-network psychiatric appointments.
Then, six months into treatment, UnitedHealthcare began to wonder whether therapy was actually essential.
Todd led an insurance reviewer through her patient’s delicate condition. Todd explained that even when the woman was quiet, she was aware that the illness was unpredictable. She was concerned that her patient would try suicide if care was taken off at the wrong time.
The reviewers answered that the patient required to be actively having significant symptoms to continue with treatment, and they believed that the therapy was ineffective.
“I felt all this pressure to say the right thing to be able to keep giving my client what she needed,” Todd told me.
Finally, the reviewers sought a date when therapy would no longer be necessary.
Todd exited the network so that she could treat her patient without interruption. The patient was able to pay out-of-pocket due to a minor compensation following her father’s unexpected death. According to a ProPublica study of government survey data, people are more than twice as likely to pay the entire cost out of pocket for visits to mental health specialists as they are for primary care physicians.
While United declined to comment on Todd’s experience, spokesperson Tony Marusic stated that the insurance company is “committed to ensuring members have access to care that is consistent with the terms of their health plans.”
Many clinicians, including Todd, told ProPublica that insurers regularly interfered with patient treatment. In addition to discontinuing therapy, they are urging clinicians to limit the length of their sessions to 45 minutes, even if patients demand longer. Therapists told us that when insurers refused to fund treatment, their patients fell further into despair, experienced worsened panic attacks, and ended up in emergency rooms.
ProPublica spoke with 44 doctors who said they left networks because insurance questioned the necessity of care.
Why I left the network: Due to dysfunction
Last summer, Daniel Clark, a New York psychologist, evaluated a college student for attention deficit hyperactivity disorder. According to the student’s plan, Cigna was meant to pay for practically the whole evaluation, which cost more than $1,400. However, the corporation declined and instructed Clark to bill the patient. Clark instructed his patient not to pay until he fought the claim.
When Clark first called Cigna, a customer service agent informed him that the insurer had made a mistake. However, the corporation did not quickly remedy the issue, so Clark filed an appeal. He assumed it would be faster than sending it by snail mail, which, in 2023, was his only other option for contesting a coverage decision.
When he received no response, he contacted again and told the same tale to a new customer care representative, who informed him that the claim was still being processed. Clark kept making calls from his office, car, and home but stopped tracking them after he reached 20. Clark finally received payment from Cigna last month, more than a year after seeing the patient and making what he believes to be 45 calls. He estimates that the time he spent on customer service lines cost him more than $5,000 in revenue that he could have made by seeing more patients.
Anneliese Hanson, a former Cigna manager, told ProPublica that the bad customer service can be attributed in part to a decision made some years ago to outsource the calls to the Philippines. Hanson, a therapist who was employed as a manager at Cigna, worked in the mental health department during the changeover period. She stated that abroad personnel do not have access to the entire claims system and are often confused with complex medical terms in English.
After quitting the insurance industry in 2022, Hanson started her own private therapy practice. She has direct experience with being on hold for more than two hours and unsuccessfully searching for pertinent addresses and fax numbers. She has decided that the byzantine process is not an accident.
“The idea is if you make it so frustrating for providers to follow up on claim denials, they’re just going to give up and the insurance company is not going to have to pay out,” Hanson told me.
Cigna did not respond to ProPublica’s inquiries
ProPublica interviewed over 100 clinicians who have left insurance networks due to red tape.
In 2022, Donna Nicolino, a therapist from Connecticut, was treating a Ukrainian woman for posttraumatic stress. Her condition worsened after Russia invaded her own nation, endangering her family’s safety and resulting in the death of her friend’s son.
Just before the disagreement erupted, New York-based Healthfirst disallowed almost a dozen of Nicolino’s therapy claims.
“Documentation does not support services billed,” the note stated. According to the insurer, her claims lacked a physician’s signature and did not have enough information to identify the patient or proof of permission for telehealth.
Nicolino was perplexed; her notes did not require a doctor’s signature. Her records described the patient’s progress and included a signed consent form.
Nicolino posted images of her handwritten notes, and her patient called to confirm that the therapy sessions had indeed taken place. But Healthfirst continues to refute the accusations without explaining why.
Nicolino treated her patient often for free as she attempted to reverse the denials. She was concerned that the stress of dealing with insurance was exacerbating her patient’s distress.
However, after nearly a year, Nicolino became dissatisfied with the network’s instability and quit. The patient was unable to cover the charges and had to discontinue treatment.
“She was making some progress,” she stated, “and we had to just pull the plug.”
Healthfirst representative Maria Ramirez declined to comment on Nicolino’s payment concerns, but she did say that the insurance had “processes to verify that claims accurately reflect the services provided and are coded with accuracy and completeness.”
Why did I leave the network? It was financially unsustainable
Many clinicians struggled to make ends meet as in-network therapists.
Reimbursement rates remain essentially unchanged and notoriously low. Commercial insurance pays therapists an average of $98 for a 45-minute session, while out-of-network colleagues might earn more than double that amount. Dozens of providers told ProPublica that their reimbursement rates have barely changed in years.
The costs of running a private business can be high, including malpractice and health insurance, billing and administrative services, office rent, and utilities. Insurers only pay for time spent in session, not for writing notes or chasing payments.
Mental health professionals’ reimbursement rates are also lower than those paid by insurers for comparable treatments. Consider two in-network clinicians: If you spend an office visit discussing depression with a psychiatrist and then have the same conversation with a physician assistant, an insurer may pay the physician assistant roughly 20% more than the psychiatrist, despite their medical school training. This is according to Medicare rates, which insurers use to calculate their own rates.
Despite federal regulations guaranteeing equitable access to care, there is no requirement to equalize provider payments.
Providers may band together to push for higher pay, but antitrust rules and insurer contracts prohibit them from collectively setting fees, limiting their ability to communicate about their earnings.
Many people refused to share their pay rates with ProPublica for fear of violating a law or causing insurers to withhold payments.
More than 130 providers reported leaving insurance networks due to inadequate payment rates.
Almost every state has a statute requiring insurers to promptly compensate for treatment claims, although the strength and enforcement of those rules vary widely. Providers reported that they sometimes had to wait years for payment.
Companies can also reclaim money even if they were the ones who made the mistake. Many jurisdictions generally prohibit insurers from taking back payments more than two years after a claim is settled. However, about 10 states have no limits.
ProPublica spoke with over 60 providers who said they quit networks after insurers delayed or attempted to take back payments.
After nearly a decade of delivering therapy to children with severe autism, psychologist Anna DiNoto heard that Premera Blue Cross was withdrawing more than $11,000 in compensation for services she had already provided.
The company claimed that her large Washington-based practice occasionally used inaccurate billing codes and maintained notes that were insufficiently thorough to substantiate the services delivered.
Instead of requiring providers to remedy specific problems, such as failing to note start and stop times for sessions, it subjected the entire practice to a prepayment audit: payments were delayed for months since a reviewer had to first deem the paperwork appropriate.
“We just kept being told that our notes weren’t good and we needed to spend less and less time with our patients,” according to her.
After taking out loans to pay their employees, DiNoto and her business partner warned patients that they would soon be unable to supply services. In the end, she estimated that the insurance company had neglected to pay them $1.5 million.
“And they also stole my heart,” she added. “I felt like I was going to have a heart attack every day.”
A spokeswoman for Premera stated that the business was “transparent, responsive, and made every effort to ensure our responses were clear and straightforward.” The recoupment process, according to the spokeswoman, assures “proper fund use to support access to quality, affordable care.”
DiNoto, who took satisfaction in enabling children who couldn’t walk or talk to move and communicate, said her patients had few options. Several families went months without being able to locate another provider. Some never did.
Desperate parents called her as their children regressed, with one returning to punching walls and fleeing the house.
When she told Premera she was quitting the network, she got an email that astonished her almost as much as the audit
Premera asked her to stay
But she’d made up her mind: she was finished.
This report is from ProPublica, a nonprofit journalism organization that examines abuses of power. Sign up to receive their top stories as soon as they are published.
Tony Luong contributed photography for ProPublica. Alex Bandoni of ProPublica handles the art direction. Kirsten Berg and Jeff Ernsthausen of ProPublica contributed reporting and investigation, while Agnel Philip provided data analysis. Brent Jones of NPR and Mhari Shaw created the visual design for NPR.
