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The last time this article was published I almost posted a reply to this but didn’t. Now I have time so I will. The denied claims are tragic, obviously, and this behavior is insidious. But something this article only touches upon at the end is what this system is really designed to do: extract previously paid monies from providers
This is such an important issue. I get why they lead with denied claims, because to the average person that is the issue that impacts them. But the above issue destroys mental health care systematically by burning out providers, slashing their income, and shuttering practices. And United is the worst, for sure, but they are not the only offender
What the article describes is what happens, generally. Something in the insurance providers “system” gets flagged. So they audit on their end. Then they may audit on your end. Or they may not even need to. They may find that an error in their system resulted in them paying you for months of sessions that someone wasn’t actually covered. Now they want their money back. They want it all, now. Or they do what United does, they audit you, and they find something that justifies not paying. They almost certainly will because the regulations are extremely complex.
Now you have a hell of a decision: do you spend a ton of time appealing? Remember: many outpatient mental health practices in the us are independent because attaching to a healthcare network means losing 50+% of your income. So if you appeal it means you’ll spend 5-10 hours a week on phone calls and paperwork, for free. Not to mention if it’s in reaction to an audit you may need an attorney so now it’s costing you money, and a significant sum at that.
Do you give in? If you run a medium sized practice and this included a handful of clients you could be on the hook for 20, 40, $50,000 or more. Do you even have access to that? Would a line of credit like that cripple your business?
Do you penalize your staff? You’ve already paid them, do you tell them what’s going on and ask them to pay back the funds? (no, this is unheard of, they’re all not making terribly much money usually)
Do you penalize your clients? In some cases this is genuinely what the insurance company expects you to do. If it’s a case where the policy was not actually active and they paid out in error but didn’t catch it for weeks or months they will claw back their money, guaranteed, and tell you to bill the client $3800 or whatever.
I had a client who was on permanent disability and they didn’t process his disability paperwork for some reason. By the time this was caught by his insurer it was 4 months after the time it should have been. 15 sessions had occurred, they asked for 1767.90 returned immediately. Now what am I supposed to do, demand he turn over two entire disability checks? Turn him into collections when he can’t pay because his (subsidized) rent alone takes up over 60% of his income and destroy his already wrecked credit? I’m here to help him improve his mental health, not destroy it, fuck that. So now I eat that 2 grand. What am I supposed to do? How do I balance that? That’s a 3% pay cut in a day because once again it’s put upon me to subsidize my clients care when the system fails.
I run a lean practice. It’s only me and occasionally I’ll bring on one supervised staff who is in post grad that I give a very fair fee split too. I still keep a secret savings account of 15,000 for clawbacks.
The reason is because I’ve had colleagues with medium practices, roughly 10-12 people in the group, go out of business because they get hit with a 40+k clawback that they simply weren’t prepared for. Or they just burn out dealing with that shit. Or they stay in business but now they no longer accept insurance at all, have ridiculous policies ($125 missed appointment fees! 48 hour notice required!) and inaccessible to anyone who makes less than 150k/yr
Then overnight a practice with 12 clinicians is gone and the community, which is desperate for clinicians, has 10 or so scrambling for new jobs and the 1-2 who ran it considering just getting a manager job at target or something. Then my inbox gets that many more emails even though my psychologytoday says “not accepting clients” because my waitlist is already months long.
Don’t even get me started on commercial rental prices
