Dealing with health care insurance has become more difficult and more of a dilemma. Practicing medicine gets progressively more difficult with more time spent doing less of what I imagined I would be doing to care for my patients and more time jumping through administrative hoops, meeting requirements that do not enhance the quality of care and take up time that could be spent with patients and dealing with obstacles to care.

For over 30 years I have been in the private practice of psychiatry, including psychopharmacology and psychotherapy. I have either contracted with insurance companies or filed claims as an out-of-network provider and then billed the unpaid portion while keeping fees reasonable to maintain a low financial burden for my patients. This has been my personal choice since it is most consistent with my value system of not wanting to exclude from treatment those who cannot pay my fees up front or out of pocket. I have been comfortable with the financial trade-off inherent in this choice. However, more recently this has presented more of a dilemma for me as I have struggled with insurance companies not paying me, proposing to decrease rather than increase reimbursement, and using deceptive tactics to propose lower reimbursement.

One large commercial insurance company with whom I file claims as an out-of-network provider stopped paying me at the start of 2023. Although claims were filed as they always had been for many years, I began receiving piles of rejected claims. After weeks of fruitless attempts to contact the insurance company, it was only after I contacted my state representative that my biller and I were able to connect with an insurance company representative, and then I had to convince him that the problem was with the processing of the claims and not how we were filing them. I did not receive any payment for claims filed for 2023 until the end of May after hours and hours of extra work by my biller. Payment has continued to be very delayed with the same repeated errors resulting in nonnegotiable checks. I am left with the concern that I will never be completely reimbursed.

I reached out to another very profitable commercial insurance company to request a fee increase as reimbursement had been the same since 2019. Its response was to send a proposal that offered modest increases for a couple of procedure codes, but no change or significant decreases for the remainder of the codes. After pushing back very hard and pointing out the huge revenue increase the company had last year, the multimillion-dollar salary of the CEO, and the absurdity of the comparison made to Medicare, I was offered a proposal that rolled back all but one of the decreases in reimbursement and increased the others by $2 or $3. The lower reimbursement was disproportionately skewed toward behavioral health and not evaluation and management codes.

A third insurance company is using another company to repeatedly call providers under the ruse of needing to verify information to process the claims. The company tried to coerce me into agreeing to a much lower fee in exchange for expediting claims. Even though I have never agreed, and I eventually blocked the company’s emails and calls in response to feeling harassed, my claims were processed at its lower proposed fees, and appeals about these claims have been denied.

I have many insured patients to whom I have a continued commitment to them and their treatment. As a physician, I feel caught between that commitment and my own moral standards and feel beleaguered by insurance companies that do not seem committed to ensuring access to mental health care. Accepting insurance as payment should not require having to bear uncertainty about receiving or fighting for payment.

If psychiatrists are to accept insurance more broadly, something has to improve. The issue of how and if patients are able to access treatment is vital. Insurance companies whose practices do not comply with mental health parity and resist reimbursing for behavioral health care have duplicitous ways of reimbursing less and have phantom networks that create barriers to mental health care. More psychiatrists need to be engaged in getting insurance companies to stop these practices and comply with parity laws and regulations; the answer is not simply to stop accepting insurance and thus deny care to those who can’t afford to pay out of pocket. ■

P. Lynn Ouellette, M.D., is a private practitioner in Brunswick, Maine, with a specialty interest and education in perinatal mood and anxiety disorders.