PROVIDER FOCUS--Health Insurance Carriers: Sleeping With the Enemy

The Boil-down: This entry is written with behavioral health providers in mind. This fall, therapists, counselors and psychologists in one of the states where I am licensed to practice are being asked to credential with a new carrier/manager/payer for Medicaid. Many of these providers are young, and even the experienced ones may be so conditioned to the status quo that they are likely to sign a contract with the new company--called a Provider Agreement--without reading the fine print. Doing so could cost them more than they understand. Let's talk about that.

The Details: According to Statista research, total U.S. expenditure for mental health in 1980 was $31.4 billion; as of 2014, they report the number to be $179.3 million, projecting the amount to soar to $238 billion by 2020. How accurate was the prediction? According to NAMI, Statista was dead on at least through 2019 ($225 billion--NAMI didn't have numbers for 2020 in this article). Other sources may have measured total expenditures differently (hospitalization, medications, counseling, etc.), producing lower but still staggering numbers. One in five Americans gets some kind of behavioral health (behavioral health is a term interchangeable with mental health) treatment. Behavioral health accounts for 57% of all health care expenditures.

Embedded in the numbers above are insurance payouts. Despite the steadily rising utilization and cost of behavioral healthcare, insurance carrier (company) profits are up anywhere from 7% ($1.6 billion for Elevance Health) to 70% ($2.8 billion for Cigna) for 2023's third quarter. These numbers represent all profits, broader than profits based on just behavioral health. The same article, Becker's Payer Issues, cites Centene Corporation's third quarter profits at $738 million--up over 26%. We'll get back to Centene in a little bit. Even Humana, who is lamented as having seen a 20% drop in profits over the same period, raked in $1.2 billion. Only CVS was cited with a loss, but they are being sued in a major way. The name of the article? "The House Always Wins." The point driven home in the article is that carriers are thriving, and providers are anemic, referring mostly to the larger medical/hospital systems.

Do insurance carriers profit from the behavioral health industry? I had trouble finding any figures on this. What I did find were articles predictably reporting that behavioral health is still not achieving parity with other divisions of the health industry. Your primary care doctor is qualified to perform and bill for a one-hour behavioral health session with you, and she will get paid anywhere from 20% to 100% more than I would for the same service--even though her training may have taught her nothing more about behavioral health than to listen and educate with statistical information. The thrust of this reference article suggests that insurance companies profit in part by skimping on behavioral health coverage. Qualified mental health professionals get paid twenty percent less on average for providing the same service compared with primary care providers; moreover, between 45 and 63 percent of behavioral health care office visits were out of network for the samples examined. Insurance carrier profit margins increase as a result of the policies creating these outcomes.

We will get back to insurance carrier tactics momentarily. First, I would like to take a closer look at how a behavioral health insurance carrier keeps its own kind of insurance policy in its back pocket; I am referring to the Provider Agreement, a contractual document outlining the rights, expectations and responsibilities of the clinician and the insurance company. The Provider Agreement plays out such that the clinician provides services to insured members according to the terms of the contract, and the carrier "manages" and/or pays the clinician for provided services--ostensibly according to the terms of the contract. Legally binding contracts designed to benefit corporations are the bread and butter of the capitalist world. Well-paid attorneys are predictably crafty at drawing up paperwork which will put the corporations at a gaudy advantage over the signees, sometimes to the point of violating the human rights of the citizens the corporations purport to help. Even cursory investigation of companies in the realms of rental properties, food service, human resources, timeshares, industrial production, and religion easily reveals the myriad ways that powerful people in charge of corporations use contractual agreements to short-change others to the point of abuse and serious harm. Behavioral health provider agreements are wielded no differently; this phenomenon abuses the good faith of talented, ethical providers, and violates the rights of insured members.

What is contained in a behavioral health provider agreement? Some of it is really basic, essential stuff designed to ensure that contracted providers adhere to regulations, laws, and a minimum ethical bottom line. The provider has to agree to follow the legal and ethical guidelines set forth by the industry, and state and federal governments. Be lawful, be truthful, be transparent about the services one has provided, and operate your clinical space safely and confidentially. Keep standardized documentation, protect members' health information, and run an unoffensive, drug-free office. Don't bill for services you didn't provide, because that's fraud. Such contractual structure is part of an insurance company's obligation to back up what it has promised it will deliver to insured members. However, provider agreements are worded in ways that can seem daunting, even threatening to the providers signing them. Admonishment against losing one's credentialed privileges, license, and freedom from incarceration if you do illegal or unethical things is not where the threats stop. Ethical therapists also have plenty to watch out for, and once they've signed on, there seems to be very little they can do to prevent the payer from acting on the privileges granted to the corporation in the contract.

In my professional opinion, any entity in power will push for absolute power--or the next closest thing it can achieve. For capitalists, power leads to profit. The goal is the widest profit margin possible, and other considerations, such as ethics, for instance, don't really enter into the model. Oh, there must be the appearance of ethical behavior, morality, caring for the people the company serves--that can be covered with well-written vision points, policy and procedure entries, and some good marketing. But how many companies, insurance companies included, engage in legal, administrative and financial wizardry that ends up looking nothing like the compassionate vision points written into their chicken-soup public relations campaigns? If we refer to concepts described in earlier Eyes Wide Open articles, this integrated paradigm for trauma therapy may help some key things swim into focus. Corporations are systems comprised of subsystems of people, and are therefore susceptible to powerful pockets of unhealthiness; the unhealthy emergent properties include narcissistic gravity and groupthink. Corporations are not really inanimate entities, but they can only exude the degree of empathy (or contempt) possessed and invested by the humans running the organizations. If the agenda is myopic enough to be "profit no matter what it takes," then employees may be encouraged to execute administrative processes which do not reflect empathy for others, and are therefore at risk to disregard the rights of those with whom it serves or networks. In the world of behavioral health insurance, carriers ostensibly serve insured members, and network with providers. Providers represent service utilization, and therefore can easily be seen as a threat to profit margins, and therefore as adversaries. Chief Control Officers and CEOs who stepped on the necks of others to climb the corporate ladder might also implicitly encourage hostility toward any known threat to their profit margins and/or indifference to the people they serve. This does not make them statistical outliers in the world of capitalism; many corporations operate inside this kind of narcissistic gravity, including behavioral health provider agencies.

It is no secret that the goals and intentions of health providers have collided with those of insurance companies. One could write thousands of pages about that. But I want to point out another observation of my own: professionals gathered around those utilizing mental health services (physicians, lawyers, EMS responders, law enforcement officers, social work case managers, hospital administrators, and managed care reps, to name a few) seem palpably averse to the idea of mental health treatment. Normalizing behavioral health needs as part of every person's humanity is non-conforming to the rigid rules of their reference groups, and doing so therefore puts said group members at risk for ostracization. So they seem to be desperately regarding behavioral health issues as "not me," cognitively partitioning behavioral health needs exclusively into some domain for those who are "crazy" or mentally "sick." In the process, behavioral health insurance members who utilize care are easily viewed as outsiders to the group of "normals" who are actually in denial for the sake of conformity. From there, they are viewed as "less than," which leaves them vulnerable to human rights violations. Indeed, many have no ability to fight for their rights in the first place. Treating mental health survivors as outsiders, different, crazy, "less than," and especially as pathologically dishonest, malingering (making up their symptoms for attention), or pathologically delusional when they're not--all of this maltreatment by professionals is referred to as iatrogenesis--harming those we have promised to help. Worst-case scenarios of iatrogenesis are well-documented (although the incidence of iatrogenesis is wildly underestimated by scientific studies and journalistic reports), and include emotional violence, sexual exploitation, and refusal of care. Insurance companies are part of this phenomenon of harming humans with mental health conditions through stigma and neglect in the name of profit, and they go to great lengths to prevent government from deterring their goal.

At this point in today's article, I insert my story of how insurance carriers in my area deny coverage and care to those who desperately need mental health services--by attacking the helpers. These corporations' tactics terrorize ethical mental health providers through authorization and audit processes, secure in the knowledge that the provider agreements the clinicians signed give them full legal and contractual permission to persecute therapists, counselors, and social workers. I understand these abusive practices first-hand, because they did it to me at my practice, and used the same methods on a large private non-profit where I worked fourteen years part time.

I want to begin by providing adequate context. Factor number one: in the geographic area where I practice, clinical evidence of corruption leading to severe human rights violations hangs in the breeze, usually adequately perfumed by public denial. Anyone who searches literature and mixed media about it will discover that this part of the Midwest has a pretty clearly written history of high-profile, far-reaching scandal, with meticulously documented evidence of phenomena too "unreal" to believe child trafficking, pedophilic Satanism, government human rights violations, and politicians, bankers, and university officials robbing innocent people blind without any consequences. Many of the pages of this history have been burned like so many copies of Huckleberry Finn. Thousands of damning legal documents and journalistic articles remain available for public consumption, and yet our mainstream society seems content to pretend they aren't there. In the contemporary climate of morality-free politics abetted journalism, the sources of these stories can be quickly discredited as conspiracy theorists, and therapy clients with disclosures of being severely traumatized by organized harm, for the few who might go public with their histories, can easily be explained away as attention-seekers, survivors of psychotic delusions, or even lying money-grubbers. The good people of the Midwest are busy working very hard, lending time and money to charity, lobbying for human rights, going to church, hunting, fishing, and golfing. They also spend a lot of time shopping online, binge-watching their favorite shows, staring at their phones, digesting fake news, tailgating in support of their favorite sports teams and keeping the second most dangerous drinking habits in the country. The takeaway is this: by history, the populace in this part of the country have been innocent, unquestioning and distracted enough to allow a really unsavory corporate element to take hold unabated. Even though midwesterners have experienced a degree of awakening to join powerful movements toward change, there are still many issues about which we are still in the dark or over which we are not ready to lower our shield of skepticism--or which we just don't have the energy for. Unethical insurance companies are more than willing to take advantage of this kind of environment, and in the process they harm the most vulnerable citizens--those with mental health conditions, those in need of Medicaid-funded services.

A second contextual factor overlaps with the first, as all levels of government in this geographical area have had a lot to do with the behaviors described in the preceding paragraph. Now I will tell a story that I don't believe has ever been written by any journalistic source. We can pair this true story with the tales of regional insurance companies engaging abusive managed care practices and legal scandal which I will share in a moment. This first story involves a powerful six-armed agency funded by the federal Substance Abuse and Mental Health Services Administration (SAMHSA), as well as the state's health and human services behavioral health division. This agency oversees service delivery to hundreds of thousands of people in need, providing often well-designed humanitarian care to individuals who would not be able function without this help. Citizens' tax dollars should always be transparently used in this positive manner to assist the public. Well...in 2013, representatives of this same agency got their picture in the paper smiling and shaking hands with contractors who had agreed to take control of the now-privatized community mental health system. This publicly funded agency had promised (out loud and in writing) to allocate $270k to help these contractors with their startup. After the contracts were signed, the parade was over, and the news photographers had all gone back to their desks, this agency quietly revealed to the contractors that they would not be providing assistance in the amount of $270k; actually, they were offering only $30k. To my knowledge, this news never made the papers; neither this powerful agency nor its desperate contract victims ever held a press conference to disclose the adjustment in funding. The agency had told a two hundred forty thousand-dollar public lie. Who was ultimately going to suffer from this lie? Midwestern humans who needed full funding in order to receive adequate community mental health services. This story epitomizes government iatrogenesis against survivors of mental health conditions.

Contextual factor number three: insurance carriers have always been at odds with health care providers. As a young and inexperienced clinician, fresh out of graduate school and still quite wet-behind-the-ears, I experienced this tension first hand by attending a public meeting between providers in my state and the managed care company poised to assume oversight of Medicaid behavioral health services back in the mid-1990s. I was instantly infused with the understanding that in order to make a living as a mental health therapist, I would have to acquiesce to sleeping with the enemy. Sadly, some providers have behaved like the bad guys, earning a reputation for fraudulence. This gives insurance companies and the federal government license to declare open-season on all health providers, which in my experience they do without apology. Twenty years ago a practice management article warned me about the United States Department of Health and Human Services gunslingers, the OIG (Office of the Inspector General). The article cautioned that these cowboys claim their only aim is to protect weary travelers (mental health services consumers) who hold much-needed tickets to ride the Medicaid Express. But they do more than just keep train robbers away; they strong-arm the porters who are on the train as paid help to mental health passengers. That twenty year-old article wrote that the OIG "Fraud, Waste and Abuse" unit (that's not what it was called back then) boasted recovering an average of $4k per audit, even though the vast majority of audit survivors were not charged with fraud or otherwise sanctioned. Many were just counselors or psychiatric nurses who were overloaded enough that they were behind on paperwork or kept records faithfully but in minor ways that were out-of-bounds according to the OIG. The federal government had begun systematically bullying tired and underpaid mental health providers into giving money back--money which had often been earned "fair and square" for legitimate, helpful provision of services to insured members who benefited greatly from those services.

As my private practice found traction, I used my accruing wisdom to develop ongoing processes to arm my office against the legal but unethical payment clawbacks described above. Much of this wisdom came from the part-time work I did for a private non-profit organization providing mental health services to fifteen counties in the state where I was licensed. That agency held semi-annual in-services and periodic internal audits with substantive, clearly delineated checklists for complying with all manner of oversight--and for an agency like that one, there were many regulatory bodies to answer to. Any bureaucrat in charge of funding, licensing, or accrediting a non-profit agency reserved the fairly unobstructed right to command that we serve up made-to-order stacks of paper for inspection. The non-profit's executive director calmly modeled a mantric attitude about being prepared for oversight by powerful regulators: we were going to do our thing, and do it very well. Putting this into practice kept us two steps ahead of auditors, payers and inspectors.

So I adopted similar practices at my solo office. Documentation was complete, and in place on time. I kept professionalism and ethics as priorities. I conducted in-house audits of my own clinical files and claims records. When there were deficits, I made corrections, which on three or so occasions justified voluntary repayment. Back in the days of manual paper claims, there was a slightly higher risk of billing errors. For instance, during one internal audit of several thousand dates of service, I found two paid dates of service with missing documentation or paperwork insufficient to justify my being paid, even though I was paid. So I wrote the insurance payer a refund check out of ethical transparency and fairness. My quality improvement practices were not identical to my office's non-profit big sister, but they were competitively comparative. There were three ways, however, in which being a small solo practice put me at a disadvantage. First, I could not afford to employ an office manager and did not want to leave my precious money to a billing agency; this meant I had to wear all the office management "hats." Second, the large non-profit had the resources to design its own electronic documentation software with included staff-user training nearly two years before it was required by law beginning 2014; I could not afford customized software and had to train with free software by the seat of my pants. Third, I did not have my own team of specialized lawyers hanging around. Based upon what I know now, I tell myself that behemoth insurance carriers might view tiny solo mental health practices as weak members of the credentialed herd. I also had to solve certain mysteries on my own, because I was not worth preying upon in mere dollars; there had to be other reasons I was drawing fire. I promise to let you in on the conclusions I have drawn.

By the time I had opened my own practice and started work for the non-profit, the Medicaid contractor who had invited grumpy physicians to that mid-90s meet-and-greet was already gone. The newly appointed contracting corporation was really not that big compared to the insurance carriers we have to work with today. For the first several years, this new Medicaid representative only managed behavioral health care, interrogating providers in person or on the phone before doling out therapy sessions with an eye dropper. In eight to twelve weeks, provider offices would have to call back in and beg for more visits. This company was only authorizing care; the State was still writing the checks for services delivered. But that did not keep the contractor from exercising one of the rights it had written into all provider agreements: the right to conduct audits, which were called Treatment Record Reviews (TRRs).

Every couple of years, my office was "randomly" selected to copy a few hundred pages of client records and either stand by the fax machine for several hours, or carefully hand-deliver these document stacks to a heavily-secured, unfriendly office downtown. While the years of being selected may not have lined up perfectly, the non-profit was typically responding to its own TRR requests by the same insurance company at about the same time of year as I was at my private office. The other therapists and I helped to internally audit and gather file documents toward compliance with these requests. External audit scores with a breakdown of compliance needs usually arrived from the insurance carrier within a month of our agency's submission; requests for written "Corrective Action Plans" (CAPs) were customary, but any audit receiving a score of at least eighty percent passed, meaning that provider would be spared an audit the following year. The non-profit virtually always passed audits with adequate scores, getting away with polite CAP responses stating "we're going to keep doing what we do, and doing it well."

My solo practice did not receive the same audit process treatment or results. Even though I crafted my intake paperwork, pre-treatment assessments, treatment plans and progress notes after those used by the non-profit, I believe my first-ever audit score was 80%...at least my work had passed and I got to skip a year. However, each subsequent audit came back with a suspicious score of 79%, and the accompanying demands for promises of corrective action. Based upon my understanding of regulatory terms set forth in that company's provider manual or similar handbook, as well as things I was told on the phone by treatment record reviewers, was that I could only make improvements to my documentation going forward. Going back in the client file to add or amend anything was considered falsification of records. Such accusatory language was already floating around in this company's lexicon, and had begun to include the collectively used words"Fraud, Waste and Abuse." For case-building purposes, it seemed suddenly important to this and many other insurance carriers to cluster the regulatory terms "waste" and "abuse" next to "fraud"--the one that was certainly a felony leading to forfeiture of one's license and possible prison time. We providers may have all been suspected fraudsters, guilty in the minds of some Chief Control Officer until proven innocent by passing one of their clerically and orthographically fetishistic record reviews. One private sector colleague of mine was on a call asking an authorization reviewer about how to proceed with an issue; she made an innocent suggestive inquiry to the reviewer, who accused her of potential fraud. The colleague finished the call, hung up the phone and decided to stop seeing Medicaid clients altogether. The abusive climate created by the holder of power, the insurance carrier, was harming insured members (through therapist attrition) while also battle-fatiguing their providers.

My persecution by this Medicaid contractor reached an unthinkable apex by the first quarter of 2016. More than a half-dozen times I had received my unsatisfactory audit scores, and each year I had responded carefully with questions followed by ridiculously thorough CAP plans. These too, it seemed, were unsatisfactory, exemplified by my 2013 CAP in which I responded to a new complaint that notes were still handwritten, by proudly announcing I would be on-schedule in the conversion to all-electronic, clearly legible documents including progress notes. No more handwritten notes like the ones they had to sift through from 2013! For the 2014 audit they requested MORE documents from 2013, knowing I could not have improved them (lest I "falsify" records). Moreover, the reviewer stared directly at typed 2014 treatment plans chock-full of measurable objectives and declared that there were no objectives in the treatment plans. And so on. My non-profit executive director personally noted during a phone conversation with me, that this insurance carrier was targeting agencies who treated individuals with intellectual disabilities and individuals in nursing homes, and was doing so in a boldly discriminatory manner. The non-profit and my office had those client populations in common. But for about eight years, my office had also been treating individuals who needed long-term intervention for recovery from severe trauma and dissociation. This Medicaid managed care contractor was now also the payer; empathy-free capitalists, I tell myself, do not want even a sliver of their profit margins squandered by high-utilizers of any kind, and had apparently decided there was no need to even try to hide their assault on therapists who give medically necessary treatment to these three vulnerable populations.

They did directly persecute two of my clients with disabilities by deauthorizing their cases. This meant those two individuals would no longer be able to seek covered counseling services at my office or any other office. It's illegal for a Medicaid-credentialed provider to charge an insured Medicaid member money for services, so these individuals would have to search for a provider who didn't take Medicaid, pay the new providers out of pocket, and start their therapy connections over at square one (or, as so codependently urged by the defecting payer, I should continue providing services "with care and skill"for no pay--which is tail-covering legal double-talk; I might need to keep delivering medically necessary services, even though the payer deauthorized care under the guise that treatment was not medically necessary). As an alternative, an authorization for medication management was opened in lieu of therapy. The powerful psychiatrist signing this authorization for the managed care company had a large practice in direct competition with my tiny practice, and had stolen my clients in the past. He was in charge of this decision...conflict of interest, anyone?

The aforementioned apex had a head-scratching twist to it: this insurance carrier put me through a gauntlet of clerical punishment, probably aware that as a low-volume provider I had no secretarial help and would have to shoulder all the work myself. The persecution was very stressful and reappeared year after year. But although this Medicaid contractor inundated me with audit burden under an agenda clearly unrelated to any desire to guide me into streamlined record-keeping compliance, and although they did manage some unethical savings by snatching away two innocent people's treatment authorizations, they never asked me to repay a single dollar. If that didn't already make it difficult to assign logic to the company's actions, in the first quarter of 2016, the auditor charged with reviewing my treatment record filed a complaint against my license on behalf of the insurance carrier. The body of the complaint was a strange rant about my progress notes containing too much ongoing information and being difficult to understand. The reviewer had selected five files for review, and in this case four of them belonged to high-utilizing clients who were recovering from severe childhood trauma and dissociation.

I had already easily defended a half dozen previous complaints against my license, all of which were frivolous and contemptuous, initiated by the likes of: a tire-slashing divorced dad whose lawyer wanted me to examine the man's daughter and declare her mother unfit; a coke-recovering non-custodial father alleging that all of his son's health providers were trying to convince him to kill himself; and in one case a professional couple (including a well-known therapist/home host for kids with disabilities) who were in the process of successfully stealing a prepubescent boy from his current caregivers. At the risk of sounding like a social media video graphic, I "destroyed" the two billion-dollar corporation's complaint by wielding a one hundred-page response, complete with discreet breakdowns of client treatment (clients authorized the release of this information) and client attestations to the value of my medically necessary work. In my written response to the complaint, I vocalized this question for the board: were my accusers hoping the state would join them in sanctioning me for using psychotherapy to successfully treat survivors diagnosed with bipolar disorder (a "mental illness" which the psychiatrists that I know believe one cannot recover from), chronic posttraumatic stress disorder, borderline personality disorder, and dissociative identity disorder? (I was later informed that this latest managed care reviewer was a licensed therapist who did not perform therapy, the chronically prescription-abusing husband of the second most power psychiatrist in the city; her practice remains notorious among survivors for treating clients with trauma and dissociation as though they were malingering, "borderline" or psychotic, heavily medicating them via polypharmacy, and setting the expectation that they would always be "ill" and never "recover.") Defending myself took many extra unpaid hours, but the result was the licensing board's swift dismissal of this laughable complaint. Third-party oppression ceased for the next five years, but unfortunately it was not over, and what made further persecution possible was once again due to the language included in provider agreements I knew I would have to sign in order to keep treating Medicaid clients.

Within that year, the audit-happy Medicaid managed care contractor and payer withdrew its oversight of behavioral health and all but disappeared from my professional landscape. Replacing them were a trio of carriers to which providers smilingly referred as "the three-headed monster." Having been credentialed with third-party pay in the private sector for two decades, my increased awareness of the potential consequences of operating a practice motivated me to carefully read the terms of the Provider Agreements offered me by the new Medicaid trifecta. Even through the chewy "legalese," the bombastic corporate entitlement built into these heavily stilted contracts was a palpable weight which settled right on my chest. Even so, I recognized these unfair but common-practice contractual terms as far from uncommon; all the other third-party provider agreements I had ever signed contained similar language. To this point, no carrier/payer had carried such contractual terms to an abusive conclusion. For me, the most egregious stipulations in the contracts were the ubiquitous non-disclosure clauses (I was agreeing that I could be legally punished if I told anyone what was in the Provider Agreement; this is a feature of legal documents which, in my opinion, should be against the law and therefore forbidden in legal contracts, especially when it unfairly protects the narcissistic interests of the corporation), and the clauses stating that many of the features of the agreement would remain in force even after the termination of the contract...in perpetuity. Again, corporate attorneys were using the law to generate such narcissistic gravity that even if they or I terminated the contract, in the following months they could audit my office, and five years eleven months later they could still legally request client records from me. They stopped short of laying claim to my first born and calling dibs on a "bag of nuts." Indeed, about five years after I signed these Provider Agreements, a trusted colleague was audited by a completely unrelated insurance carrier in the year after it had "gone under" and ceased to offer benefits or third party pay services.

Professional life under the three-headed monster was almost refreshing at first. There were no preauthorizations required for outpatient therapy services. Claims processes were smooth and payments were mostly hassle-free. The most friendly, fairly toothless monster-head did transparently explain that it would conduct clinical reviews for clients utilizing at least twenty sessions in a six-month period. I doubt I need to explain all the very personal diagnostic and pragmatic client information providers have to cough up during clinical reviews; I think most therapists have had to do a number of those. In this situation, the gentle monster-headed carrier renewed open authorization for my clients every time. So in 2021 when I received an audit request from the unrelated, (rumored) zombie-spawn of the original nefarious Medicaid contractor, I simply paid my dues with a good attitude, turning over four hundred pages of protected health information, awaiting their response with a wholesome curiosity about what they would ask me to improve. I heard nothing for eighteen months; you know what the trouble with that is? If my office is practicing anything non-compliant and I don't get timely feedback, I will have unwittingly maintained those same non-compliant habits for another year and a half. But it soon was clear that zombie-spawn did not care to help me nudge my already ship-shape record-keeping procedures toward compliance with their standards. They had salted my clients' information away for a day when their own highly questionable practices would make a profit-taking power play. They were in it to get rich and were willing to victimize an intellectually disabled trauma survivor, an anxiety-disordered graduate student, and a sex-trafficked foster care minor child with brown skin to get richer.

When I finally got an adjudication statement from the company's Fraud, Waste and Abuse "Special Investigations Unit" (it's acceptable here to react to their title with either an eye-roll or a panic attack) in an audit covering a sixteen-month period of service provision for the three clients in question, I absolutely had to take a moment, just sitting back in stun-gunned awe of their brazen insolence. These auditors were not asking for a five-page Corrective Action Plan detailing how I would restructure the layouts of my progress notes or enhance the content of my pre-treatment assessments. They were not just accusing me of "upcoding" or insufficiently documenting ten or so sessions and asking me to partially refund them for shortened sessions and fully repay them for the so-called poorly documented visits. No. They had pored over the hundreds of pages of properly coded, fully documented session notes, assessments, treatment plans and demographic files, and rejected the diagnostics, the time-stamps, the symptom descriptions, the in-session interventions, and the between-session plans as non-compliant. Then they treated me the way I would expect them to treat a provider who had refused the audit or produced no records at all: they asked for one hundred percent of the money back. I had provided competent, skilled, medically necessary services to their insured members for sixteen months, and this carrier's audit team was declaring that I should have worked for no pay all that time. They were trying to reclaim fifteen thousand dollars. I could repay the full amount now. Or I could appeal, which would permit them to audit thousands more pages of client files and as I understand it, even visit the practice location site to apply the same made-up observations and unfair application of rules, burying me in red tape. If I did not repay, any future payments for services provided to any of their insured members would be garnished and applied toward the company's reclamation of $15k. Even though I did not repay a penny of it, they still had what they wanted. They would never have to pay me again, and they made it appear as though I deserved this outcome.

I think back on how early experiences in my career, and my own recovery via therapy, prepared me to receive these unthinkable challenges without shame, panic or rage. I recall using a consultant to review the prepared audit response before sending it, and using the same consultant to re-check our copies of the documents and confirm that the auditors were grossly exaggerating or confabulating their findings, or just leveling an egregious ruling based upon their own internal errors. I remember contacting other therapists to learn that they had been audited and required to face similar prejudice or sloppiness. I remember how difficult it was to find an attorney to advise me when my own attorney was too busy to counsel me in the case; inconveniently, my accusers had enlisted the services of at least three law firms in the metro area, and so those three firms could not take me on due to conflict of interest. Most often, I wonder how many scared young therapists and even experienced but isolated clinicians just forked over massive sums of money in response to these abusive auditing practices. I also notice that I almost never hear health professionals talking about it, and I hope that most of them are well-enough connected to be able engage in trusted discourse about toxic practices that are definitely present in our environment and can strike even prepared clinicians with a stressful, perhaps devastating amount of force.

Unsure of whether any justice will come from what I am sharing with readers here, I lean steadfast on the belief that silence is paralysis and awareness is power. While brazenly immoral corporate practices suggest that the top brass of companies like the ones I had to face off with fear nothing; they might believe that no power on earth can or will make them answer for what they have done. But again, firmly anchored in my own principled convictions, I think that shedding a growing light on what they're doing and opposing these practices might be a way to effectively deter such practices. Bound by the non-disclosure clauses ensconced within maybe two dozen Provider Agreements I have signed over the years, I could see my adversaries accusing me of contractual violations if I state whose practices are abusive or whose contracts contain which terms. So rather than identifying the crooks who left me shagged (refer to the Cambridge Dictionary, not the Urban Dictionary), let me tell you about a third-party payer I found in the news. These capitalists exemplify the kind of bravadic apathy toward ethics and humanity that I have repined throughout this article.

A Delaware corporation named Centene has been the subject of almost innumerable complaints and lawsuits. During fiscal year 2010, they eclipsed a net worth of $1 billion. Peaking at over $55 billion in August 2022, the managed care and specialty healthcare company's worth has dropped by more than a third since then, possibly due to lawsuits over their questionable practices. A Reuters article states that shareholders (which include the members of several blue-collar pension funds in Illinois) attempted to sue Centene for withholding information about the $6 billion acquisition of Health Net--although the 8th Circuit Court of Appeals disallowed the suit. The State of Ohio sued Centene for a complex scheme of fraudulent practices which the Attorney General asserted the deceptive practices were "deeply concerning" and would have a "direct effect" on Ohio's most vulnerable citizens, those on Medicaid--with whom Centene most commonly contracts. The seemingly endless stream of complaints and legal actions against Centene target their deceptiveness about costs and profits, billing third-parties for services already paid, and a vast sea of instances in which they promised points of coverage to insured members, which they then refused to provide. But the complaints most pertinent to the point of this article look like the one posted by a Texas psychological services provider with breast cancer. She alleges that Centene either never paid her or reclaimed payments post-audit on a significant amount of work in the Houston area. Centene would not accept in digital format the loads of additional documentation they demanded of her when she decided to appeal; she reportedly spent $1k on shipping hard copies to Centene, and thousands more in legal fees. Centene's billions in profits grew out of the pain they caused by deceiving or strong-arming insured members, providers, and smaller carriers via takeover. They have committed record levels of iatrogenesis against those with behavioral health conditions, deceiving and burglarizing the money purses of state offices, taxpayers, shareholders and innocent health providers along the way.

What You Can Do: Even though there is a principled fury with which I morally support every honest, hard-working clinician who eventually faces the challenges that come from insurance carriers and third-party payers who abusively wield audaciously unfair contractual terms to immorally reclaim squarely earned funds, or just to scare everyone "straight" so they don't commit "fraud, waste and abuse," the current answers may seem more like a bitter pill than just deserts. To whom should we report abusive third-party pay practices? It remains a riveting question without satisfying answers.

The most obvious advice might be moot for new providers who are desperate to build a caseload and generate income: be very careful about contracts, read everything before deciding to sign, and consider not signing any contract with lopsided or risky terms (in my experience, all third-party pay contracts hold such terms). I clarify here that I am only a professional survivor of third-party pay, not an expert in matters of ethics, law or practice management, possibly evidenced by my own results. I kindly refuted what my adversaries were charging, contacting my own existing attorney and close to a dozen other attorneys before being offered a sit-down that would lead to helpful advice. I inquired with my state's Medicaid office and the insurance commission. The Medicaid provider liaison acted as though she was not aware state contractors were behaving abusively, but helpfully pointed out that if a provider is willing to complete the appeals process, they are entitled to a State Fair Hearing in front of an ostensibly impartial board, who may reverse the auditor's decision. I denote this with a bold asterisk, because I want you to know your options as a contracted provider, but it behooves you to understand, especially as a low-volume provider, what you may have to endure throughout an audit appeal, including demands from the auditors clearly designed to punish providers for choosing to appeal.

If you are like practically everyone else and need to sign Provider Agreements with credentialing insurance carriers to launch your career or grow your practice, then the best prevention from that point is to do what you do, and do it well. Keep disciplined, informed record-keeping habits in line with processes used by experienced clinicians and successful clinics--which will also align with the expectations spelled out in your Provider Agreements with insurance companies. Stay prepared for an audit by keeping paperwork up to date and conducting internal audits of your files. Perhaps even sign an agreement with a trusted colleague or two for interoffice peer review. Either way, meet with said colleagues to talk about the climate of the industry, regulations, and the behavior of third-party payers in your professional community. Get to know provider representatives from the insurance companies who pay your practice; the amount of "intel" they are sometimes willing to share can be surprisingly advantageous. When you find yourself in unknown regulatory territory, be willing to pay a reputable, specialized attorney for advice--but locate them before crisis hits, so you don't spend months in a pressured search the way I did. Continually work to diversify your caseload so your clients have varied and evenly-distributed health insurance payers (fifteen years ago seventy percent of my clients had Medicaid; five years ago only fifteen percent had Medicaid; and since the $15k abusive audit, Medicaid clients comprise only five percent of my private practice caseload). For many private practitioners, the hallowed goal remains attaining a purely cash-paying clientele; it's nice work if you can get it. Above and beyond all this, any activism you can muster to raise awareness and centralize solutions for the provider community may prove invaluable to someone a lot like yourself. The therapists in my region who organized to eliminate regulations requiring that doctors sign off on our diagnoses and treatment plans succeeded; there have also been strides of progress in the fight for parity. Whether it be via establishing an advocacy group, fighting for legislation, and/or even mustering our own class-action lawsuit, our standing together to oppose dirty corporate tactics in the world of health insurance might prove to be the stones sufficient to slay Goliath.