quixotic120

am a mental health provider, am listed in several insurance directories that I either no longer take or never took to begin with

It’s linked to another article but they describe why therapists stop taking insurance as a matter of complexity. This is true but another aspect is that some insurances simply pay significantly less than others. It’s a difficult thing to discuss because the low ones typically still pay like $60-80 an hour and on a surface level that sounds like a lot (because it is). But the reality is that doing therapy is complex. For one I typically lose about 30-50% of the good rates just to overhead (lower side is telehealth or home office, higher side is if you rent an office and can go even higher). More so if you’re actually planning for retirement and sick time, which a lot of therapists just ignore. Then you have to figure that we only get that rate for billable hours, which is 20-30 hours a week depending on how good you are. The rest of the time is admin bullshit, case collabs, screening new clients, etc all of which is unpaid.

So I can take the $70/hr insurance that barely covers my day to day, or I can limit myself to private pay and the ones that pay $100-140/hr. Even with the 100-140/hr ones I’m still probably making 60-70k on average because of stuff like no shows and cancellations (which is why more and more therapists are charging very high cancel fees)

But their main point of the complexity is a big one too. In my experience the insurances that pay low are the ones that are most likely to give me grief over payment. They’ll pay me very late (but if I submit billing 10 seconds late they’ll deny), they’ll clawback payments for the dumbest reasons and be the most aggressive about clawbacks (potentially meaning that I’ll suddenly get a note from them that I have to return $1000+ because they decided after paying me they shouldn’t have), and they’ll have the worst systems for submitting billing (requiring me to have hours of wasted time on hold with their shitty customer service)

It’s terrible that this person died and it’s worse that they spent almost $400/month for care that was never able to be delivered. It’s worse that this will probably result in no changes whatsoever. Even if harris’ Medicare for all prop passes it will take ages and the design is that there will still be a “two lane” system, where private supplementary insurance is still available for the rich. This will likely result in tons of providers that don’t bother taking Medicare because it’s more of a pain in the ass and pays less. So the government will finally give you insurance if you have none but it will be functionally useless like this article describes. End commercial insurance altogether

The important takeaway from this is that “supplements” have 0 oversight. The CBD, probiotics, vitamin d, etc that you buy could just be capsules of vegetable oil that does nothing at all. Or they could be asbestos and cyanide for all you know (that probably would lead to an investigation though). There’s also no safety regarding packing and handling, so it might literally be a guy with unwashed hands who just picked his butt loading your gelcaps in a dirty bathroom that someone just took a massive shit in. No one checks and verifies any of this and that’s why shills and hucksters jump onto this shit, it’s a completely unregulated market where can cut corners everywhere and say whatever you want as long as you include *not intended to treat any diseases and not evaluated by the fda

A $1200 thing you buy on instagram that sends “good waves” to your brain? Supplement. The cbd you buy at the gas station? Supplement. Doterra oils? Supplement. No regulation, no oversight, just robbing people based on their desperation to fix chronic pain and mental illness

Bleed in my ass

those bass drum hertas tho

It hasn’t seen a release yet, code is here:

https://github.com/arjpar/WebShield-staging/tree/ldev

I’m not endorsing it, never heard of it before this post, but this was literally the second line of the readme

“massaging tartrazine solution into hairless mouse skin over the course of a few minutes or using microneedling achieves “complete optical transparency in the red region of the visible spectrum”

I know it didn’t happen this way but I like to believe it was someone having their unwashed dorito fingers after lunch, decided to massage a mouse for several minutes, and figuring this out

Then if you’ve met your deductible the big question is if you have a coinsurance after the deductible is met and an out of pocket maximum.

If your coinsurance is 60% or 80% or whatever, you won’t be responsible for the full bill but only that percentage of it.

If you have no coinsurance (a no charge after deductible plan) the service should be covered 100%

If you have coinsurance you should have an out of pocket max, which once hit should end the coinsurance and make services covered 100%. OOP max is typically quite a bit higher than deductible, sometimes 5-7x as much, but not always. It’s plan specific.

If your employer pays 50% that is an arrangement they have worked out and the specifics will be tied to your companies contract. This could mean they would pay 50% of any bill (unlikely as this is not a fixed cost they can plan for. Maybe if you’re like a ceo or some shit) or it could mean that up to your deductible they’ll pay 50%.

Also keep in mind even if you’re in a “covered 100%” scenario there are some instances in which you would still get billed:

Differential vs contracted rates - if the hospital charges $5000 for your procedure but your insurance only pays $4600 the hospital can sometimes bill you for the difference. This is not always the case; some contracts require the servicer (doctor) to accept the contracted rates and not charge more. Most common reason you’d get a bill in the above 100% scenarios and also the reason the math might not work out in coinsurance scenarios. Eg in the above surgery example your bill would probably be $1320. It should be 920 as that is 20% of the $4600 paid, or even $1000 as that is 20% of the 5k billed, but you pay the 920 as 20% of what your insurance paid plus the $400 difference, so $1320

Out of network providers - these can often have a separate deductible and sometimes in hospitals a provider can be out of network even though the hospital itself is in network

Non covered services - if the procedure involves a service that isn’t covered (uncommon)

Billing errors: if a bill looks wrong contest it and if your insurance isn’t reimbursing providers properly complain to them. Sometimes a medical office gets your info wrong and assumes your deductible or coinsurance is active when it shouldn’t be. Sometimes your insurance makes similar mistakes.

one of the most frustrating aspects of being a therapist in america in the past 10 years is the hand waving of the ethics involved in the financial renumeration of our relationship with those we serve

I would say a significant stressor for the overwhelming majority of the clients I have is financial woes. And because the system is backwards, those with high paying jobs well into their career tend to have the fancy PPO plans with no deductible where seeing me (or anyone) is only $10 despite the fact that they could much more easily afford a 5-10k deductible. Meanwhile the people who are making 20-50k a year on the other end of the spectrum almost always have those high deductible plans with sometimes massive deductibles and rarely have employer funded hsa.

I’m not an idiot, I run my own practice and I do the books for it. I can do the math to figure out how much take home pay someone has with those salaries. I can also conceptualize the cost of housing, food, phone, transportation, etc because I am also paying these things. So when I meet someone here and their appointments are $140 per meeting I am in a tough spot. I am asking them to take on a burden of $560 per month (assuming weekly sessions). That’s immense. And if the deductible is 5k, 7.5k, 10k, it will take ages to meet especially if they’re younger and not really making contact with many other medical providers.

I am contractually obligated to charge what your insurance pays me in these instances. If your insurance pays me $140 for the hour I have to charge you that until you hit the deductible. I could be dropped from the network if I modify this for you and get caught.

I can ask you to skip using your insurance and charge a lower out of pocket rate but this is complex. For one, many therapists can’t adjust their rate much lower. I have flexibility here because my practice is entirely telehealth so my overheads are much lower. But if you see them in an office? They are paying about 40-50% of that just in rent most places.

Additionally even with telehealth I have to be careful with adjusting rates. Insurance only pays me for specific timed and coded sessions. If you and I have a phone call for 25 minutes? Not covered. If you ask me to collaborate with your psychiatrist and I talk to them for 40 minutes? Not covered. The time I spend dealing with billing and this system, which works out to an average of 20-30 minutes per session? Not covered. So the 25% of my week doing billing shit and the overtime hours doing phone check ins, case collabs, etc. has to be covered by that.

This is why many therapists give fee schedules and charge you for all of these things. If you want paperwork from them it’s $1 a page, phone calls are $75/hr, etc. I can make it work without this because I’m not paying for office space but if I was I would need to do this to keep myself afloat.

This is also part of why many, many therapists simply don’t take insurance anymore. Just pay me the $140 directly. I can collect it via square or whatever and your billing is done. I no longer spend 5-10 hours a week on billing nonsense like fighting retracted payments, finding out why claims were denied, etc. You can submit receipts for out of network reimbursement and you deal with them.

I understand why my peers do what they do. But ethically it’s a mess. I signed up to help people and what I have become is a gigantic cash sink that puts a tremendous amount of pressure on the people I serve and is counterproductive to our work.

At the same time I deserve a fair salary for my work and this is the only way to get it. And if I protest the system by leaving it because it’s so broken then the end result is that there’s 1 less mental health provider who takes insurance. If I stop taking insurance altogether I alienate a ton of people with high need who can’t afford to pay out of pocket forever and/or don’t know how to navigate out of network reimbursement.

I cannot tell you how many times I do a screening call with someone and they say “this sounds like what I need”, they tentatively schedule, and then once I run their insurance and give them the actual numbers of what treatment will cost they simply ghost. It is a system that actively deters people from seeking assistance because it is so cost prohibitive

And the insurance lobby has its fingers so deep into the framework of america that this will simply never be fixed. It will only be changed. Look at Kamala Harris’ proposed Medicare for all: it still allows private plans. That will be a movement in the right direction because it will end the idea of someone being “uninsured”, which is great, but it will also create a two lane system in which many practitioners will do whatever they can to avoid taking basic Medicare patients in favor of the commercial plans. Commercial plans, at least in my area, simply pay more. Significantly more. Like $80/hr vs $140/hr. And in the end I will have the same problems because the unnecessarily complex private insurance system will still exist and be very powerful. I will just have one more insurer to add to the web of complexity. But no politician will ever remove the private health insurance industry. To do so would alleviate so much spending waste, so many wasted administrative dollars and man hours, but it would also result in layoffs of hundreds of thousands, if not millions, of americans whose jobs rely on processing the complex bullshit of this system

Speed or mallrats depending on what kind of vibe you’re going for

edit: upon reflection I will change my Sandra bullock movie to “the net”. Terrible, but strong 90s vibes

your scenario is either worded incorrectly or very atypical (which is very possible, there are a lot of different insurance plans in the us

typically high deductible plans work in a way of “meet your deductible and then we cover x% after that”

eg I am a therapist, I bill your insurance $100 for an hour session. You have a $1000 deductible with 80% coinsurance.

Our first 10 sessions will cost you $100 out of pocket, which goes to me directly. I submit billing for these sessions but get no reimbursement from the insurer because you have already paid the full amount. However, my submission of billing indicates to the insurer that you paid $100 for a medical service on whatever date for whatever diagnosis.

After the $1000 deductible is met your insurance splits the bill with you 80/20. Now you pay me $20 per meeting and when I submit the billing the insurance (hopefully) pays the other $80 to give me the $100 per meeting I am owed.

This of course assumes no other medical spending goes on for the duration, otherwise you would hit your deductible faster. If you saw me 3x and then had a surgery that cost $5,000, you’d pay $700 for the surgery to settle your deductible plus an additional $860 (20% of the remaining $4300) and then sessions would be $20 under the 20% coinsurance.

You should also have an out of pocket max, this is kind of similar to a deductible but it is different. This is a tally of your total spending and once you hit it your coinsurance usually drops and you pay nothing.

Also important point is that deductibles reset every plan year. This should have been made abundantly clear to you but I still encounter many who do not know this

Additionally your insurance may have certain services covered that don’t cost you anything or where the deductible doesn’t apply (eg you’d only pay 20% even if it’s the first appointment of the year). Typically this is preventative care, things like physicals and vaccinations

That is the most typical. But like I said it there are many plans and variations. It’s possible you have a plan that prior to meeting the deductible you pay 50% of billing and then have a 0% coinsurance. This would be really great insurance.

It’s also possible that you have a benefits package from your employer that is basically paying 50% of your deductible in a roundabout way. this is far more commonly done by the employer funding an hsa/fsa account which would be a payment card that you use on medical spending and not the insurer. However, I have encountered plans where the hsa and insurance were rolled together and joint companies, where the hsa would pay all or part of billing prior to deductible on the patients behalf

Using the same examples above you’d pay me $50 until you met your deductible, then nothing once the deductible is met. If you had a $1000 deductible, saw me twice, then had the 5k surgery you’d pay me $100 and $900 for the surgery. If you have one of the situations where the employer is covering 50% of the deductible it would be the same but the surgery would be $400 because ultimately you’re only paying $500 of the $1000 deductible and your employer is covering the other half. This is not a situation I’ve ever encountered

Another important point is that deductible status is dependent on your providers doing timely billing and your insurance processing said billing in a timely manner as well. This does not always happen. As a result you may meet your deductible but my billing verification shows that is not the case. The examples I used above were clean and easy but it’s never that simple. Most people have a deductible around $2500 (and many 2-4x this) and see several different healthcare services.

I submit my billing at the end of each day but some places are sloppy and will take weeks to submit. This can lead to situations where you are charged money because I was under the impression you had a deductible but you should not have been. Eventually the insurer will pay me once things sort out. If I am good at record keeping (I am great at it for this reason) I will catch the double payment and send you a refund. This is why it is important for you to keep track of deductibles and medical spending. Not all offices are managed well. I’ve personally had money stolen from me (because this is literally fraud, to not refund the double payment) and I don’t believe it was ever intentional, just offices with shitty management. Let your providers know if you’ve met your deductible. I will always hold off on charging you if you tell me this, submit billing, and see what the insurance reimburses. If they reimburse me in full then you were right. If they don’t I send you a bill and if that is incorrect you need to call your insurance to complain

You should be able to track deductible and out of pocket spending on your insurances consumer portal (eg go to Aetna.com or whatever and click “for subscribers” and make an account, if you haven’t already). This should also give you an explanation of plan details.

Most importantly you should be able to call the office of the place (or billing dept if it’s a larger health network) doing the procedure to have their office manager check what you will be expected to pay for the procedure both at time of service and expected cost total. This takes only a minute but be forewarned it is essentially an estimate and not a guarantee. Billing can change last minute depending on how the procedure goes (eg added complexity allowing them to add another cpt code for something)

There’s a lot more to it than this unfortunately. Some plans have tiered deductibles, sometimes a staff member in a hospital isn’t personally enrolled and then are considered “out of network”, which is a whole other thing, sometimes you are still responsible for a certain services that the provider requires but the insurance refuses to pay. That last point especially: every time you establish with a medical office or get a procedure you sign something that says you are financially responsible for services not covered by insurance (I guarantee this, every time). So if you get bloodwork with like 30 tests and 2 aren’t covered even if you’ve met your out of pocket max and have the best insurance in the world you’re getting a bill (and potentially a hefty one, some blood tests are extremely expensive)

Sorry this is very long and complex but that is kind of how insurance is? To boil it down to a “eli5” 2-3 sentence explanation would either require your specific plan information in much more detail or to overgeneralize and potentially mislead you.

I mean like running their hypothetical control software/framework within a docker on a local server. Is that illogical? I do the same for the software that runs my ip cameras with my home server, instead of them needing to connect to some external server.

You’re ultimately right though, when it comes to docker I am at the proficiency level of “can deploy other people’s images” and not so much on the “have bothered to make my own”

You’re both wrong for speaking in absolutes. It could be pica but it’s impossible to fully assess such a situation based on a literal sentence description, you would need to know the context, frequency of behavior, occurrence with other items (eg is it solely soil). It could be soil eaten out of desperation to alleviate symptoms related to iron deficiency but again, impossible to know from a single sentence but a child eating soil would be grounds to evaluate for pica unless the child was specifically instructed or something (eg folk medicine)

brought to you by someone who spent 5 years doing neurodevelopmental evals of autism and intellectual disability in children, where pica came up a decent amount of the time (especially for the kids with ID)

US laundering stolen taxpayer money into “eco” contracts thanks to nepotism and buying off politicians