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Therapist calls for 'open, honest dialogues' between various players in behavioral health

April 11, 2014
by Thomas A. Peltz, MEd, LMHC, LADC-1, CAS
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Letter to the Editor

Thank you for the article titled Healthcare: ‘Too Important to be left to politicians.’ Recently, I was thinking of issues in my private practice which seem to overlap with Jeffrey A. Lieberman, MD’s points.

To add on to his excellent points in this article, I’d like to offer some additional thoughts. These, of course, are coming from me, a LMHC, LADAC-1, CAS level therapist. There are many similarities between our two perspectives.

  • Often the more skilled and seasoned clinicians have left the clinic settings after their schooling ends, in order to become independent community-based providers in the delivery of care. However, it then becomes more difficult to work with the insurance system because once on your own, there is no ‘loud voice’ to be heard.
  • The antitrust laws have prohibited discussion of fees, expenses, or operational costs amongst clinicians. Our professional boards are as bound by this as independent practitioners are.
  • Addiction treatment was the whole topic of the Vermont Governor’s State of The Union this year, yet finding appropriate and affordable care for addicted people is still extremely difficult. The medical care model treats addiction as an acute illness with insurance, yet it is a chronic model needing a long-term care approach. Already short lengths of intensive IOP/PHP or inpatient stays exist, with sometimes daily monitored insurance reviews for coverage. So too, emphasis on pharmacological care is increasingly the standard of treatment now, rather than abstinence. Bed space is limited, programs get full quickly, and admission into appropriate care is more difficult. This leaves the outpatient, independent, non-prescribing therapy provider struggling for ongoing care coverage sometimes.
  • Unions can collectively bargain, and individual clinicians are not allowed to do so, due to the antitrust act. However, individual clinicians can not receive full membership status in the union – at least the MA SEIU 509 – only Associate Membership status.
  • Insurance companies set their reimbursement rates – they don’t negotiate them with independent providers. Thus, rates have been declining, and there is little recourse for the provider.
  • E. Fuller Torrey’s book, American Psychosis: How the Federal Government Destroyed the Mental Illness Treatment System, offers a six decade historical insight to the shifts of care from inpatient to community-based mental healthcare, how Medicare affected the funding for treatment, and how police are becoming armed social workers now.
  • Medicare lowered the payment rates in 2013, and changed the length of an outpatient billing session to 45-50 minutes for a CPT code of: #90834. DSM-V is new and the billing codes of ICD-9 and ICD-10 are now included and to be required soon.
  • Levels of required paperwork documentation have gone up and the length of sessions has decreased which creates less potential time to be spent helping the patient.
  • The standards for each insurance company are different with the methods of reporting to them, and payment by them to the provider. Call time hold, requests for information, contract requirements can be very long, complicated, and frustrating.
  • It seems unclear if competition helps or hurts the practitioner, and what the advantages or disadvantages of single vs. multiple insurance payer systems will be – such as the Vermont proposed idea?
  • There seems to be no statute of how long after delivery of care occurs, that an insurance company can require the clinician to repay funds deemed inappropriate, yet the clinician only is given a set period of time to submit the payment request.

Perhaps it boils down to a need for places to establish more open and honest dialogues amongst providers, insurance company representatives and politicians, where fear, restrictions and intimidation are removed.


Peltz has worked in the mental health field since 1973 as both a therapist and an administrator. His private practice office is located in Beverly Farms, MA. He works with adults and his areas of specialty include: alcohol and addiction treatment, mental health counseling, spiritual issues, grief and trauma therapy, and men's issues. His website is