Have insurance? Good luck finding an in-network mental health professional.

And be prepared to pay a bundle out-of-pocket.

As a psychiatrist, Dr. Andrew Popper wanted to see lower- and middle-income patients who often face the greatest mental health challenges. He also thought taking insurance was part of a well-rounded practice. But years of hassles to get insurance companies to pay routine claims wore him down.

For Popper, who practices in the Boston area and volunteers as an instructor at Harvard Medical School, the last straw came in 2022. Suddenly, an elderly patient he’d been seeing for more than a decade was getting her weekly claims turned down.

The amount was just $30, but the money mattered to the patient. Popper said he made about a half-dozen calls to the insurance company – often more than 30 minutes each when the prompts and time on hold were factored in. Each time, the company’s representative agreed there’d been a mistake – but the claims were never paid.

“I don’t want to throw away $150,” Popper said, referring to the five visits at issue, ”but every half-hour call I’m thinking, ‘This is ridiculous – I could have been seeing more patients.’” Such rejections and bureaucratic roadblocks had him spending too much of his time on paperwork and similar calls.

“I’m helping fewer and fewer people and turning more of them down – it’s heartbreaking.”

Soon Popper joined the growing wave of mental health providers who’ve stopped accepting insurance. Now the psychiatrist fields dozens of calls from would-be patients desperate for help and seeking anyone who’ll take their health insurance.

Popper’s insurance woes – which he recently detailed in an op-ed for STAT News – are part of a much bigger crisis: The failure of America's private insurers to address a post-pandemic national emergency around our fragile state of mental health.

A spike in suicides (up 40% in just two decades), a simultaneous rise in “deaths of despair” from drug and alcohol abuse, and a spate of mass shootings are symptoms of an era when wider availability of mental health treatment, including therapy and medication, could help million of potential patients. But experts say the insurance industry has adopted an array of dubious practices that boost their profits while denying patients the care they would be getting for their premiums.

A recent comprehensive report from the mental-health advocacy group Inseparable found that while nearly one in every five Americans will face a diagnosable mental-health condition in a given year, more than half of these – or roughly 27 million people – do not receive care. And close to half of these 27 million report that they tried to get help, and failed. The numbers are even higher for teenagers experiencing depression.

“The thing that got me is that roughly 55% are covered by a commercial insurance policy with a mental health benefit, and yet only 20% of the people paying for these policies are getting any care,” Bill Smith, the founder and CEO of Inseparable, said in an interview.

How insurance companies make it hard for patients to get the care they need

Inseparable has been cataloging the ways that large insurance companies confound their policyholders and providers or deny their claims for legitimate care with practices that save these large corporations billions of dollars while their customers suffer. For example:

• When many policyholders reach out for help for themselves or a loved one, they are confronted with what critics call a “ghost network.” This is what looks on paper (or a computer screen) like a robust network of mental-health care providers, from psychiatrists to licensed therapists, only for would-be patients to learn that many of those listed have actually left the network, or are duplicates, or are overbooked and not accepting new patients. Many who are seeking help give up, despite the high fees for out-of-network care.

• The process for getting patients’ claims approved and paid, which logic suggests might have gotten simpler and more streamlined in the digital age, has instead become a labyrinth of delay and denial. As in other types of health care, mental-health treatment claims are increasingly subject to “prior authorization” scrutiny that occasionally triggers outright rejections or – especially with expensive medication – a “fail first” regime in which cheaper, and less-likely-to-work, drugs are approved instead of what’s prescribed.

• Those official rejections come on top of everyday bureaucratic bungling that infuriates providers like Popper. Mental-health providers complain that large insurers apparently haven’t invested in the technology or the staffing to process routine claims or handle common occurrences, such as when a patient has both Medicare and private coverage. 

A psychiatrist like Popper doesn’t need to see the statistics compiled by Inseparable to sense that would-be patients aren’t getting the mental health care they need, The Massachusetts clinician says he can tell there’s a crisis from the dozens of calls he receives from people anxious to see if he still takes insurance or just to make an appointment.

Popper said he often gets remarks like, “You’re the 14th person I’ve called.” He said he feels either a sense of enormous relief when he can take them on. “It tears your heart out when I can’t see them…There’s a begging, a pleading.” He said he’s not sure how many of the calls come because insurers are still listing him in their “ghost network” of physicians though he’s left their plans, but he suspects that’s some of the problem.

“There’s zero accountability,” Popper said, referring to the ghost networks. “That’s because the whole time the patient is searching for care he’s still paying the premium.”

“When we pay our health insurance premiums, we expect them to be there for us with necessary and lifesaving health care,” a 36-year veteran psychiatrist named Julie Pease told the Maine Beacon last fall. Taking part in a protest outside an Aetna Health Insurance office in Portland, Dr. Pease told a reporter she was fed up with the hours she’d been spending on the phone with insurance claims reps, only to see mental health claims rejected. (I tried to reach Pease for this article but none of at least five different numbers listed for her on the internet was correct – the same frustration patients endure.)

The research by Inseparable shows that the growing number of mental health professionals refusing to accept insurance as well as the mounting frustration of patients means many are paying out-of-pocket rates for an hour-long psychotherapy session that in 2021 averaged $174, and continues to rise. Those costs are a significant barrier for Americans seeking mental health care.

Inseparable’s Smith said the insurance crisis is also demoralizing the nation’s mental health professionals. “Insurance routinely underpays providers so that people can’t have a living wage. Reimbursement rates are set artificially low, they make paperwork so cumbersome – and then the difficulties with routinely denying insurance coverage,” he said. “All these things combine to crush the workforce.”

Popper noted that he’s always offered a sliding-fee scale to ensure that his practice treats middle- and lower-income patients – something that he’s always seen as part of his mission.  While he’s doubled down on those efforts since deciding to decline insurance, it can only go so far. “Nobody goes into psychiatry for the money,” he said. “Nobody thinks like that,” but the insurance morass makes his altruistic ambitions more difficult.

So what is to be done?

Popper said it would reduce the bureaucratic hassle for both providers and insurance companies if the insurers would allow a more automatic approval process for smaller claims like the $30 dispute that caused him so much stress. “No one is going to commit fraud for $30,” he noted. The psychiatrist also suggested that big insurers need to start giving preferential treatment in processing claims to the small, independent mental health professionals who bear the brunt of the bureaucratic nightmares.

“Why isn’t there a format?” asked Inseparable’s Smith, referring to the idea of a universal online claims form. “If you have a 1040-EZ for taxes, why not some version where the therapist fills in the form and the burden of proof is on the insurance companies, not the provider.”

The problem with asking Big Insurance to voluntarily make these changes is that the barriers they erect to reduce the use of health care goods and services are in place in large part to boost profits. Critics agree that legislation may be the best, or only, way to rein in these abusive practices. Smith noted that federal legislation that would clamp down on ghost networks has been introduced in Congress, but given the gridlock on Capitol Hill advocates have also been looking to friendly state legislatures to rewrite the rules for state-regulated insurers.

Popper said that despite his longstanding beliefs in capitalism, he’s beginning to think a much more sweeping health care form, such as a single-payer solution like Medicare for All, might be the only way to address a private insurance system that’s not addressing the basic needs of its customers. Right now, he said, “We have a feudalistic system with a handful of lords who hope to throw enough pennies to the peasants to make sure that the peasants don’t revolt.”