Therapist No Longer Covered by HMO

I was dismayed to find that the psychotherapist that I have been seeing for 6 months is no longer covered by my health insurance as of the new year. I felt that she and I were working well together, and that she really understands the stresses that I face as a lawyer. Now I have to decide whether to pay out of pocket. A friend has suggested that self-paying might be just as well, because of issues of privacy, but I thought this was covered by confidentiality. Can you clarify?

It is an unfortunate fact of managed care that HMOs maintain restricted provider lists. This is one of many measures taken to contain costs. The mental health/substance abuse portion of a health care plan is often subcontracted for management by a separate company. Because these companies are constantly undergoing mergers, acquisitions, and restructuring, and because a job change may require an HMO change, many people may find themselves in your predicament. It is worth appealing to the HMO for a single-case exception that would allow you to continue with your current therapist. They may decline, of course, especially if your therapist appears to be oriented toward long-term (i.e., more costly) treatment. When a choice is available, it is often wise to select a now-rare “indemnity” health policy — the old-fashioned type that does not have a restricted provider panel. Next best would be a PPO (preferred provider organization) or POS (point of service) plan, both of which allow subscribers to go “out-of-network” in exchange for a lower rate of reimbursement. The premiums are generally higher for these plans, but it may be worth it. Privacy is another issue. Whenever you utilize health insurance to pay for psychotherapy/counseling services (like any medical service), a diagnosis must be included on claims submitted by the provider. It is impossible to be 100% certain that such information will never leak out, e.g., to an employer, to a national medical database, etc. In many HMO plans, a diagnosis alone will suffice for the first 8 sessions per year. More extensive disclosure — at least on items such as symptoms, suicide potential, substance use, environmental stresses — is required to extend treatment. While it is reasonable to be concerned about privacy, especially for those in high-profile positions, this concern has to be weighed against the cost of treatment. Harmful outcomes seem to be rare. For example, in this writer’s 20+ years of clinical experience, the only known case where disclosure to health insurance had adverse impact was one that resulted in an increased premium. If money is not an issue, the self-pay route is certainly safer. Therapy costs are tax deductible as medical expenses, of course, but one might have to produce documentation (and thus sacrifice privacy) if audited. Services that we provide at LCL, by the way, are free of cost and do not make use of health insurance. As part of our assessment, we discuss insurance related concerns with our clients when referring them to other professionals.

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