[seventyeight]

(i'm sorry this is so long. i want to get some advice, and i couldn't figure out what to leave out.)

for about the first year and a half of therapy, i was paying completely out of pocket as my insurance didn't cover anything. it was about $14,000 the first year, and $7,000 for the next half (i had a session or two every week).

finally, i found out that my insurance company would do something called a "single case agreement" (SCA) with my therapist. this would mean she would be considered almost like an in-network provider, and my sessions would be reimbursed 50 to 70%. so for about the last two years or so, that's what we've done. the single case agreement involved her filling out a form, and then spending about 10-15 minutes on the phone with the insurance company. then about every 3 months, she'd have to call and speak with someone for 10 minutes to re-evaluate my case.

this plan year, i decided that i would get out-of-network benefits to see if that would cover my therapy instead (sort of like a "plan b" in case the SCA ever stopped working). i continued to submit my claims like i normally did, and my insurance company continued to pay as they had before (50 to 70%). this last month however, they only paid a small fraction of my claims (like 20%). i called and spoke with three different people, and they said they had been mistakenly paying my claims as if i still had the SCA. they said that the correct out-of-network rate was the 20% reimbursement, and that is what it would be from now on. i asked if i had any other options, and they said i could do an SCA again.

i talked to my therapist about all of this. i sent it to her first in an email to give her a heads up, and then talked with her in person at my next session. when we got to the part about the SCA, she didn't say anything. finally, she just said something like, "geez, insurance companies are so screwed up. this is why i hate working with them." i took this to mean that she wasn't willing to do the SCA again, and that was her way of telling me. in fact, i said something like, "yeah. and i know you don't want to do the SCA again.." to try to confirm that this was actually the case. she replied, "no, i don't. we're done with that." the way we left it in session was that i was going to call the insurance company again to see if everything i knew was correct, and then get back to my therapist regarding a plan moving forward.

i emailed my therapist with an update (that nothing had changed re: insurance), and told her that unfortunately all of this meant that i would have to cut back on therapy (from every week, to every other week). she wrote me back saying that that was fine, and we went ahead and scheduled some new appointments. all along, i kept thinking that at some point my therapist was going to change her mind about the CSA. it was sort of like i was in disbelief that i was actually going to cut back on therapy, and that she was actually going to let me.

here's what upsets me about it:

1) i can't figure out why she was willing to do the SCA before, but not now. it makes me feel like i'm not as important of a client anymore.

2) it would greatly benefit her financially to do the SCA as it would keep me coming every week. i don't understand why that wouldn't be worth it enough to spend 10 minutes on the phone four times a year, in order to keep her salary (at least from me) from being cut in half.

i'm not sure how to approach her about any of this. as far as she knows, i'm fine with everything moving forward. however i don't feel like i can go on not saying anything (we have a very open/honest relationship), but i also feel like we're touching on some very personal issues (like her source of income) and i don't want to pry or be offensive.

if you were in this situation, what would you do?

Sounds like you need to ask your T those questions. Only she can answer them for you.

[Eliza Jane]

That sucks. I can't imagine why she won't cooperate.

My one thought is that she actually earns more OON than if she is considered sorta in-network. My pdoc is OON. He charges $170 for an appt. My insurance will cover $60 and I pay $70. He ends up getting his full fee. My T is in network. She charges $120 per hour, but they insurance company limits her to $60. So I pay T my $20 copayment and the insurance company pays her $40. She ends up getting half her fee because she is in network.

Am I being clear? Insurance is so confusing and evil.

Best,
EJ

[seventyeight]

thanks ej, but that's not it. she gets the exact same amount, regardless. i know what the insurance gives her, and then i pay the balance. in fact, before we did anything with the insurance, i told her that i didn't want anything to effect her finances. so we agreed that everything would stay as it was, and i'd pay whatever was owed regardless of what they paid. it makes no difference to her where the money is coming from, as long as she gets the full fee. so if i owe $600 for the month, the insurance would pay $300 and i'd pay $300. now, they're paying $132, and i have to pay $468 - which i can't afford.

i think i'm just really hurt that she'd so easily let me cut back in sessions. i think that's what's bothering me most. i know i should be mad at the insurance company for being a$$holes, but i'm mad at her for what appears to be not caring about not seeing me as often.

[ECHOES]

as far as she knows, i'm fine with everything moving forward.

seventyeight, she needs to know how you really feel about this. Only then can she decide about doing what she has to do to continue the SCA. She may just have wanted you to confirm that you can do the SCA again, even though the insurance company has started paying the out-of-network rate. She may have wondered if it was possible to go back to the SCA arrangement again. Now that you've confirmed that, you could let her know that since it is an optioin available to you, you would like to use it, that you don't want to cut back on your therapy sessions. Then ask her if she is willing to do her part again for the SCA. She will appreciate knowing how you feel and what you want.



.

[seventyeight]

hi echoes. yes, i told her in the email that we had two options: to do the SCA or to cut back until i figure something else out. when she didn't say anything in response to my talking about the SCA in person, that's when i tried to figure out what she was thinking about it. that's when i said something like, "i know you don't want to the SCA.." to see if she'd confirm or deny. she confirmed, unfortunately. she knows it's an option, she just doesn't want to do it. and i have no idea why.

part of me is wondering if we did the SCA longer than she wanted to in the first place. maybe she's been wanting to stop all this time, and i never knew. the odd thing is that had i not decided to switch to out-of-network, we'd still be doing the SCA! the whole thing is so frustrating. and very upsetting.

it makes me want to quit altogether.

[ECHOES]

emails are easy to forget the details of. I would still talk to her about it. She has the option of speaking her mind and stating if she doesn't want to do the SCA now.

When you said you knew what she was thinking about doing the SCA, that is very different than asking her if she is willing. There was a question there that wasn't asked directly. She may have chosen to not read your mind to acknowledge the hinted at but unasked question. This is important to you, and deserves its place in your therapy session.

...tell her you do not want to cut back on sessions and you need her to do the SCA OR CSA (whatever its called), because you cant afford it otherwise and that you are very appreciative of her efforts at helping you with this because you understand its a hassle. But its what you need right now.

[rainbow8]

I'm sorry this is happening, 78. I hate insurance companies!! I agree with the others that you need to be totally direct with your T about the SCA. Tell you that you do not want to cut back on your sessions. I know it is a sensitive issue, but it's something you need to clear up. Since she's your T, she'll be understanding and answer you honestly and compassionately.

I'm sorry this happened, 78. Like everyone else, I HATE insurance companies, but I also go a bit nutty when clinicians aren't willing to go the extra mile for long term clients. I get it that people don't have copious amounts of time to wrangle with insurance company people who are invested in NOT paying out any more money no matter what. But the reality is, if a clinician truly believes that an individual needs and requires support and guidance in a therapeutic environment how can he/she not ethically do what is required by the insurance company. As someone working in education with special need children, I can't simply say, ". .. We're done with that!" If someone is truly committed and believes in the services that she is providing, they she needs to ADVOCATE that that service continues! Just my take on things.

I would definitely talk very frankly with her about this issue.

[wotchermuggle]

Your therapist might change her mind about things depending on how you present it to her.

One way might be to say that you've thought about what it would really mean to cut back to half the amount of sessions and was wondering if she would consider following the previous protocol because you've decided you really don't want the fewer amount of sessions.

Just try and bring it up in a non-confrontational/judgmental manner. I've found raising issues this way makes it much more likely you'll get what you want/need because people are less likely to go on the defensive.

[unaluna]

you might offer that the ten minutes come out of your session, ie that she call while you are there? I don't know what's going on here. she is being pretty cavalier about your ability to pay. I hate to remind her, but there is a lot more supply than there is demand right now.

[Eliza Jane]

Originally Posted by hankster

you might offer that the ten minutes come out of your session, ie that she call while you are there? I don't know what's going on here. she is being pretty cavalier about your ability to pay. I hate to remind her, but there is a lot more supply than there is demand right now.

I was thinking along those lines too. Maybe offer to pay her for the 10 minutes? I almost think offering that might make her realize how unreasonable she is being and how desperate you feel.

I also agree with others above that you need to discuss the emotional impact of her statements. I would be really hurt too.

Good luck,
EJ

Originally Posted by hankster

you might offer that the ten minutes come out of your session, ie that she call while you are there? I don't know what's going on here. she is being pretty cavalier about your ability to pay. I hate to remind her, but there is a lot more supply than there is demand right now.

I don't want to seem disruptive or obstructionist, but I have to say that I think that your therapist responsibility to call your insurance company OUTSIDE the parameters of your therapy session. The reality is, if a person states that they provide 50 or 60 minutes of therapy for such and such amount of money, then he/she needs to provide that amount of in session contact. Anything outside that 50/60 minutes of session time is negotiatable.

I believe that if a counselor thinks that he/she needs to be compenstated for additional time (eg. out of session contact and/or coordination of services . . .including insurance calls, then he/she needs to talk to the client and contract for that additional time/payment). I DO NOT feel that this is the responsibility of the client to talk about, "bring up" or contract for. It is about financial responsibility and that is the job of the therapist. If she feels that she needs more compensation than she needs to bring it up in a very direct and upfront way.

I say this because I think that many people in therapy feel guilty or responsible for dealing with the "business" portion of therapy. It isn't our responsibility. It is the therapist's responsibility. It is her job. It is her professional responsibility!

[KazzaX]

All I could really think of here is (and I have no knowledge of how the system works in the USA) maybe she has a lot of clients that are on this SCA thing? At first I thought "well a 15 minute phone call, filling out a form and a 10 minute phonecall each month isn't a huge deal", but then I thought to myself "what if she has 40 clients she has to do this for?". Maybe she wasn't thinking in terms of not wanting to put you on the SCA thing, but it was more along the lines of "oh no, more paperwork and phonecalls". IE it wasn't about you, it was just a bit of "uhhhgg paperwork".

Either way, its not your problem and an upfront conversation would probably do the trick to clear the air. I know it will feel a bit akward but in these situations I usually just go in and blurt it out before I have a chance to censor myself, lol. Embarrassing, but I get the answers to my questions! The not knowing is the worst bit.

[Nightlight]

That response would have hurt me as well. Your help means so much to me, but your not willing to help me to be able to afford your help? Maybe she didn't understand you correctly? Either way I think you need to be really clear. It's a big hassle and a pain for you too, but you really think you need to stick with weekly appointments, so would she be willing to help you makes this work? I think you need to tell her how it made you feel when she seemed to be so unwilling to help in this situation.

I stopped for financial reasons, well, I cut back to once a fortnight. It was dreadful. I went downhill so quickly. I felt abandoned. I'd advice you strongly to not just do this because it seemed her position was made clear. You really need to be heard, so you can understand what is happening and why, and if it's avoidable.

My therapist does often use my appointment times do deal with that sort of stuff, and if that would help in a situation like this, I do think it's worth using appointment time (if you can't pay extra) to sort it out, if at all possible.

[Miswimmy1]

Talk to her about it. That's all u can do... Ask her why she isn't willing to cooperate. She may not see how u are really feeling. This happened to me a lot before my t and I got close. I would come off like it was all ok, so she didn't see how bad things really were.

[seventyeight]

i really can't thank all of you enough for such great feedback. it's amazing to me that i could be struggling so badly with a problem, put that problem out there, and get such thoughtful and helpful responses. i've been feeling very alone with all of this, but you all are giving me great comfort right now. thank you.

All I could really think of here is (and I have no knowledge of how the system works in the USA) maybe she has a lot of clients that are on this SCA thing? At first I thought "well a 15 minute phone call, filling out a form and a 10 minute phonecall each month isn't a huge deal", but then I thought to myself "what if she has 40 clients she has to do this for?".

no, she doesn't have any other clients on SCA. she's told me explicitly that she doesn't work with insurance companies (at all), and that i'm the only client that she's ever done anything like this for before. also, the form was a one-time thing, and the phone call is once every four months.

there was a point at which she was the one submitting the claims though. we thought it best to do it that way as she was the one getting reimbursed. i guess i just didn't feel comfortable being responsible for "her" money. when i asked her if it was a hassle for her to fill out, she said no not at all - that she had the form saved online and all she had to do was change the date and hit print. i still felt bad about it, so i gave her a bunch of pre-addressed envelopes with stamps, so that it was even easier and that she wouldn't be spending any money or anything. but at some point, i became the one to send in the claims, so she doesn't do that part anymore. and the main SCA form is done with, so she doesn't have to do that either. so it's basically 40 minutes a year on the phone. yeah, i'm certainly hurt she's not willing to do that, but it's not my decision.

you all are right, i'm just going to have to talk to her. i really can't seem to figure out how though. and there's definitely a part of me that's afraid she'll just say, "nope, it's not worth it to me to do this for you."

i should state for the record that we have an otherwise incredible relationship. she's the first therapist (out of like 7 or 8) that i ever connected with, and we've been working together for four years now. we've gone through a LOT together (for instance, i almost died last year) and she has told me on a number of occasions how special i am and what i privilege it is to work with me. she has also told me that she loves me. i know a lot of therapists say these kinds of things, but i really do feel it from her.

to think that this isn't really working out, is devastating. but that's just me spiraling out about it. ugh.

[Nightlight]

I really get how hard it is. I'd been with mine for well over three years when this happened to me. The relationship had always been so solid, reliable and supportive. Yet she was willing to leave it just like that. My therapist does also have a tendency to agree with me. If I say "we just have to space out the appointments because I can't afford it" she will say "okay, that's fine". She is still willing to work with me though, if I actually stop and talk to her about it, she just seems to have a thing about me calling that shots like that and if I offer something like that she just says yes.

I know bringing finances into a special relationship like this, and to risk losing something so supportive and helpful because of something like money is just a really, really tough thing to face. Do try to be honest with her when you see her, and explain how you've been feeling.

[quote=seventyeight;2702911]no, she doesn't have any other clients on SCA. she's told me explicitly that she doesn't work with insurance companies (at all), and that i'm the only client that she's ever done anything like this for before. also, the form was a one-time thing, and the phone call is once every four months.]

Okay, you've mentioned that she's a wonderful and responsive therapist. She GETS you. Then what's the problem with her spending a few minutes every few months explaining to the brainless and stupid insurance companies what she does with you as a therapist???? I'm sorry but in my book that isn't a lot to ask of a therapist. If you were asking her to spend hours on the phone or endless emails related to your treatment than I would agree that her commitment was overboard, but obviously that is NOT the case!

When an individual contracts to provide services it usually doesn't mean a confined amount of time. If a therapist says that they provide 50 minute of therapy time for say . .. $95.00 an hour. . that can NOT mean that that is the ONLY service provided. Even physicians know that they are RESPONSIBLE for providing ongoing care for their clients outside of their actual appointments. I get that if a client is requiring 2-4-6 contacts or phone calls outside of the regular appointments that the caregiver needs to "talk" about the fee but that is the CAREGIVERS responsibility NOT the clients! I get that most clients realize that they are over stepping their fee schedule, but it is still the provider's responsiblity to bring the topic up and to negotiate!!!

[seventyeight]

tomorrow i'm seeing my therapist and will FINALLY get to talk about this issue. i think i'm starting to get nervous! i just want it to go well.

thanks again to everyone for all their input. i'll let you know how it goes..

[Nightlight]

Good luck! I know it's a hard topic to discuss.

78. i will be thinking of you... i really hope things work out like you need them too. sending safe hugs

Good luck for tomorrow, Please let us know how it goes

[WikidPissah]

good luck 78