Dr. Patricia Farrell on Medika Life

Inadequate or Unqualified Therapy Because of Low Medicaid Reimbursement?

Attracting qualified psychotherapists to provide treatment is not accomplished when reimbursement is undeniably abysmal.

Reimbursement rates shouldn’t determine whether or not someone receives adequate treatment for anything, including mental health therapy. But, too often, rates are so abysmally low for Medicaid patients that they find psychotherapy as easy to find as hen’s teeth. And the need for Medicaid assistance to pay for therapy is great.

Medicaid is the single largest payer for mental health services in the United States and is increasingly playing a larger role in the reimbursement of substance use disorder services. Individuals with a behavioral health disorder also utilize significant health care services — nearly 12 million visits made to U.S. hospital emergency departments in 2007 involved individuals with a mental disorder, substance abuse problem, or both.”

Eighty-two million-plus people are served by Medicaid each year. If the need is so great, and it is admittedly the case, what is the reason reimbursement rates for Medicaid patients are so low? Don’t low-income individuals or families deserve to be on equal footing in terms of any healthcare with other families who live above the poverty line? States determine who is eligible for the program, and it can be quite wide-ranging and daunting for any individual to figure out what services they have available to them.

What are the current rates in a state like New York or New Jersey for Medicaid reimbursement for mental health services? Figuring out the payments and co-pay isn’t for the faint of heart. As usual, it’s convoluted and requires billing experience, and that’s the reason that career may receive a bump in persons needed.

Medicare pays covered providers about $77.81 for 30 minutes of individual therapy. Not everyone will use that 90832 code. Higher billing rates are a prime issue here and . billing is left to ethical and legal issues. But Medicaid, for the same session, could pay less than $60.

In some cases, previously, the rate was about $50. When many psychotherapists are charging over $100/hr (and in NYC it could be $300/hr.), who is going to accept a Medicaid patient? Therapists have a right not to accept patients and some will do so if the individual doesn’t have “adequate” reimbursement.

It is a disturbing fact of life that, when potential patients call for a therapy appointment, they will often indicate they have insurance coverage. How demeaning for them. The bottom line is that money can be a major issue for care. One woman, who indicated she believed every therapist was qualified, wrote a book on her experiences.

I heard of a case where a therapist, in a large practice run by a psychiatrist, was in a session with a Medicaid patient when the door suddenly burst open. The psychiatrist told the patient to get out and never come back again.

It was an unwritten rule in the practice that Medicaid patients would not receive services. The therapist, not knowing of this practice, had agreed to see the patient, a young man with HIV and prior drug addiction.

One of the major problems that lead to quality differences must be considered. Anyone who has a thriving practice and sees a few pro bono cases, may not accept Medicaid cases. Who will accept them? Money is a great temptation and knavery waits for its opportunity.

Although we do hear of occasional whistleblowers reporting unethical and fraudulent Medicaid cases, many who receive the care either don’t realize the care is by unqualified persons or would be reluctant to report. Just as there are pill mills, there are Medicaid/Medicare mills run by unscrupulous therapists who reap the profits and care little about anything other than filling appointments.

Some practices book patients for multiple sessions, one after the other, for additional therapy during one day with other therapists. Ever notice those “hot boxes” outside the doorways to offices?

I also heard of a master’s-level licensed therapist who accepted Medicaid and provided therapy for children who were sexually abused. After more than four years of therapy with one boy, the therapist, when questioned, admitted that he had not received any advanced training. Where was management in this case? He works at a local mental health center.

The boy was not making progress in this therapy, but the mother felt she had no recourse to obtain therapy with someone else. Everyone she called refused services once she indicated it was a Medicaid case.

But it’s not only in psychotherapy that the lower-income patients receive care from an unlicensed, neophyte, or inadequately trained individuals. A highly experienced ENT physician admitted to me that he was no longer doing surgery because “I get about $3 for an operation that costs $1,500,” he said. I think he was engaging in hyperbole because I’m sure Medicaid pays more than that for ENT surgeries.

How Medicaid can be made more equitable in terms of reimbursement is a question for everyone, but especially the politicians in each state. Services to anyone must be done on need, not payments, but that’s where it stands now. As they say, money talks. Does your state offer charity care for those in need?

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Pat Farrell PhD
Pat Farrell PhDhttps://medium.com/@drpatfarrell
I'm a licensed psychologist in NJ/FL and have been in the field for over 30 years serving in most areas of mental health, psychiatry research, consulting, teaching (post-grad), private practice, consultant to WebMD and writing self-help books. Currently, I am concentrating on writing articles and books.


Medika Editor: Mental Health

I'm a licensed psychologist in NJ/FL and have been in the field for over 30 years serving in most areas of mental health, psychiatry research, consulting, teaching (post-grad), private practice, consultant to WebMD and writing self-help books. Currently, I am concentrating on writing articles and books.

Patricia also acts in an editorial capacity for Medika's mental health articles, providing invaluable input on a wide range of mental health issues.

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