As COVID Overwhelms Mental Health Availability, Providers Move to Self-Pay


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Joy Zelikovsky expanded her therapy practice — Nourish the Heart Counseling — from a part-time, side hustle to a full-time job with four employees during the COVID-19 pandemic. 

“We are completely full and I have a waiting list,” Zelikovsky said. “I get anywhere between two and five referrals a week.” 

While that’s great for job security, Zelikovsky said, it makes the process of finding a therapist for anyone suffering from mental health disorders incredibly challenging. 

“It is a serious problem ranging from available beds for residential eating disorder treatment and psychiatric problems to outpatient therapy,” she said. “We are starting group therapy in order to offer an alternative solution, but a lot of people don’t want to do group because they think it’s second-rate therapy.”

According to Anthem Health Insurance, mental health care costs for its fully-insured members in 2020 were up 20 percent compared with 2019. And according to a report based on 500,000 Anthem-affiliated health plan claims, the rate of behavioral health diagnoses in young children and adolescents rose by seven and 12 percent respectively in 2020. For older adults, the diagnosis rate increased by eight percent. 

And while it is true that mental health care costs have been on the rise year to year for more than a decade, said James Michael, CEO of Access Health CT the state’s health insurance exchange, the cost increase for 2020 was far higher than anticipated.

Michael said insurance carriers have increased the number of in-network mental health providers to meet the increasing demand, but this year there was no way to anticipate the increase that would have been needed. 

“Simply put, no matter what you did last year, it’s not going to be enough,” Michael said.

Between 2019 and 2021, Anthem increased its HMO behavioral health providers in-network from 15,600 to 19,042 and its PPO behavioral health providers in-network from 15,499 to 18,933.  But that number will likely begin to drop as many therapists, including Zelikovsky, consider switching to a self-pay model.  

Many therapists are leaving insurance behind

Although Zelikovsky has built her practice by accepting insurance, her goal is to stop accepting insurance within the next five years.

“Rates are all over the place,” Zelikovsky explained. 

In Connecticut, reimbursements range from less $50 to more than $100 for the equivalent session.

“United is one of the best payers right now, Aetna and Husky are next, then Cigna, and Anthem is down at the bottom,” Zelikovsky said. “Anthem’s rate is honestly insulting.”

That sentiment, if widespread, is significant given that Anthem is the largest insurer in the state, with 1.5 customers, provides coverage for all state employees, and is one of just two carrier options available on the Access Health CT marketplace. 

In addition to offering the lowest reimbursement rates in the state — less than half of what Husky pays — Anthem is not paying in a timely manner and their customer service lines have been slow and difficult to use, according to data collected in a survey and submitted to the State of Connecticut Insurance Department by the Mental Health Clinicians Action Network of Connecticut.

Victoria Massey, a licensed marriage and family therapist, said she has already taken steps to end her contract with Anthem and is planning one day to transition to a self-pay practice. 

“I unpanneled with them because I’ve had it,” she said. “They’re my lowest reimburser and for two of my clients they’ve come back asking for medical records to prove that they need more sessions which is substantially more work on my part.” 

In addition to requests for medical records, the Mental Health Clinicians Action Network survey noted many instances of Anthem requesting that providers repay their reimbursements months later after a review determined a service was unnecessary. 

“MHCCAN-CT indicated that Anthem is recovering claims for more than a third of the behavioral health providers. Whenever payment has been made in error, or in excess of the maximum amount of payment necessary to satisfy the provisions of the member’s health plan, Anthem will have the right to recover such payment from the member or, if applicable, the provider or otherwise make appropriate adjustments to claims,” according Juna Ferguson, Risk Analyst for Anthem, in a letter in response to the survey and complaints submitted by the Action Network to the state Insurance Department. 

“Insurance is dictating too much of treatment at this point,” Massey said. “A lot of plans have such a high deductible anyway that people have to pay out of pocket to meet that deductible. If I were just self-pay with a sliding scale it might end up being the same price or less.” 

But if more therapists transition away from Anthem, and eventually all insurance carriers, that would not only reduce options for those who can’t afford to pay out-of-pocket, but also the number of available therapy slots.

“If I were self-pay I could cut my caseload in half,” Zelikovsky said. 

For Massey and many others, the stress of the pandemic and the telehealth-only style of care has already caused her to reduce their caseload reducing the number of spots even further. 

According to Anthem, the reimbursement rate for mental health providers, like Massey and Zelikovsky, will be updated later in 2021. 

“The scope of changes and determination of revised rates are currently under thoughtful consideration,” said Alessandra Simkin, spokesperson for Anthem.