Why It's Such a Struggle to Find an In-Network Therapist
Which, by the way, is the last thing you want to do when you're depressed.
There's no worse time to find a psychiatrist than when you really need a psychiatrist. In my case, this winter I finally confronted a potent double shot of anxiety and depression that I'd tried to overcome by working myself into the ground. Acknowledging that my brain chemistry wasn't at its fighting weight was big. Good news: I had insurance, a New York state marketplace plan, and I was eager to get back to myself. I logged onto the online database, typed in my zip code and began sifting through the hundreds of psychiatrists who could help.
Except. Except some providers didn't actually take my plan, despite being listed. Some accepted my plan through their hospital affiliation, but only offered the service I needed through their private practice, which didn't participate. Some were simply wrong or disconnected numbers. Even when I checked in with the insurer's customer service, they gave me names that turned out to be no good. They weren't using a different or more accurate database than I was. I called about a dozen practices and nearly gave up before I found even one that fit my needs.
This wasn't my depression telling me I wasn't worth the trouble, or even an unusual problem overall. And it doesn't stem from skullduggery, as one weary doctor who suspected companies padded their networks told me. In fact, the insurance industry and regulators are knee-deep in a multi-front struggle to do something very simple: keep their provider databases up to date.
No one could ever accuse the American health care system of elegance, but it's almost impressive how frustrating and costly this issue can get for everyone involved. Patients, of course, can have trouble finding doctors; not only that, but they can also get smacked with huge bills after a procedure they thought was fully covered—for instance, the surgeon may have participated in the insurance plan, but the anesthesiologist did not. Doctors rely on these directories to make insurance-appropriate referrals. And regulators expect insurance companies to police these databases so consumers have accurate and transparent product information.
Some states and federal Medicare plans have instituted hefty fines to ensure compliance. Last year, California found that more than a quarter of providers listed on two companies' directories had out-of-date contact information or weren't enrolled in those plans. Drill down into specialists and it can get even more absurd: Families USA cited a 2013 study that found one-third of New Jersey psychiatrists were listed incorrectly; in Maryland, that number rose to 57%.
One sort-of good piece of news? It's not screwing over one group of people any more than another—this is a problem across the board. "I'm not aware of any evidence that suggests there's a correlation between the cost of the plan and the accuracy of the directory," says Justin Giovannelli, an associate research professor at Georgetown University's Center on Health Insurance Reforms. The insurance companies corroborate that. "There's been a great deal of effort to make sure that everybody understands what the expectations are and what the rules are, and that consumers have the ability to get actual information and accurate information," says Leslie Moran, vice president at the New York Health Plan Association.
This gets tricky when even doctors aren't entirely clear about which plans they belong to. That isn't always a physician's fault; contracts with insurance companies can be as complex as you can imagine, and doctors often outsource that work as much as possible. "We had a lot of stories at the very infancy of the New York state health exchange with doctors saying, 'I didn't even know I was on this plan network, or I didn't know I was a participating provider,'" Moran says.
That the solutions lie in better communication seems promising, but don't get excited yet. As Moran puts it, "Plans can only keep their directories as up to date as providers provide information." In New York, providers need to notify a plan within 15 days if they're joining, leaving, or changing their contact information. Elsewhere, there are proposals for monthly or quarterly updates.
In theory, the directories get an overhaul when providers reapply to a plan each year. "In practice, [in 2014–2015] relatively few states actually had specific requirements saying that insurance companies had to keep their directories up to date within a period of time less than a year," says Giovannelli, despite federal requirements for state health exchanges through the Affordable Care Act.
Some in the private sector are trying to smooth the way for all parties. Companies like LexisNexis Risk Solutions, as well as the trade association America's Health Insurance Plans, are developing software and networks to better coordinate and centralize multiple provider directories. Giovannelli highlighted efforts by states like Georgia, Maryland and California to require insurance companies to offer a way for consumers to report inaccurate listings. "If you are someone in one of those states, and frankly even if you're not, you can still potentially reach out," he says. "There's a way to contact the insurance company and make them aware of inaccuracy, and then they in these states are duty-bound to look into it and to correct it."
So, if this has ever happened to you, it's not a scam or a personal failure. The system really is trying to fix something broken. How did it all work out for me? I almost cried when I found a psychiatrist who took my insurance and could even see me quickly. Unfortunately, it turned out to be a bad fit. I tried again with my provider directory, but after two or three days of calling around and mapping out onerous public transit routes and weighing unsatisfactory online reviews, I threw up my hands. I couldn't wait any longer.
I'm lucky: I'm getting better, but only because I'm now paying out of pocket. It's not an unusual solution, though it is a privileged one: Given the industry's struggle simply to organize lists of doctors, much less pay them, it's no surprise a 2013 study found that only 55 percent of psychiatrists take insurance at all.
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