My Provider Experience Reviewed: Private Insurers vs. Medicaid
My earlier post on retaining accessible providers in the addiction field mentioned insurance as a primary problem. That is, dealing with insurance companies is so burdensome and unpredictable that at this point many providers only take private pay– which places their care out of reach for most patients. I wrote that despite well-known administrative hassles associated with Medicaid, I actually find it easier to deal with, in some respects, than private insurers. By reader request, this post will elaborate.
First, some important caveats: Medicaid, here, is MaineCare. My experience with MaineCare does not necessarily reflect how Medicaid operates in any other state, and in some cases I know it's quite different. Especially for my international readers– it's an honour to have you!– be aware that Medicaid is administered at the state level with lots of variation.
Additionally, it is hypothetically illegal under US antitrust law for providers to discuss amongst ourselves our fees, costs, or payment rates by insurers. If we are all businesses competing with each other, anything like coordination or collective bargaining theoretically amounts to price-fixing.
Whether that threat, which is really just about language in the contracts we sign, has any teeth, is unclear. It certainly benefits insurers in that they privately retain all financial information about this market. It even enables them to discriminate against providers in legally protected classes. When all communication about rates must stay strictly between the insurer and each provider, individually, we have no way to uncover such discrimination. But with all of that said, I am not looking to make my newsletter a target on this technicality. When I'm vague about reimbursement rates, this is why. (Who knows what I say unrecorded?) I have found some data on reimbursement rates nationally and by state, but even from my limited knowledge I see major errors in it, which is why I'm not linking to it.
So here is my comparative review of the provider experience, broken down by task:
Credentialing / Paneling
This is the process of joining a network: becoming a "paneled," "credentialed." or "in-network" provider (all synonyms). Paneling was pretty straightforward for all private insurances that I accept. MaineCare, on the other hand, took 3 years of attempts for me to join! I'm finally in now, but I posted earlier about this long journey if you want to know more.
Rosalie Genova
To MaineCare's credit, however, after I joined I was offered an individual meeting with an administrator. She taught me everything I'd need to know and answered all my questions. She treated me like someone whose work is worth paying for. With private insurers, you're on your own to learn all their systems, and you're treated like a nuisance if you get any contact at all.
Verifying Benefits and Securing Authorization
I don't verify benefits for private insurance; I ask clients to do this themselves before we start meeting to find out any copay or deductible they'll have to cover. However, you never really know until you've heard back on the first claim, because sometimes it doesn't match what the insurer said. MaineCare verification, by contrast, is very simple: I search for the patient on the provider portal, and it tells me whether their membership is active, and for what dates. There are no further details that can vary by person or plan; it's all the same for all members.
Authorization means pre-approval from a payer to cover a member's treatment. Private insurers require authorization for the higher levels of care I used to work in, like intensive outpatient (which is at least 9 hours per week), but so far I have not encountered any that require an auth for regular outpatient counseling. MaineCare, on the other hand, has to authorize absolutely everything. This includes the initial assessment, which means submitting a diagnosis for someone I've never met 🤡. From there, I have to get authorization for up to 72 15-minute increments of counseling at a time.
Submitting and Tracking Claims
For private insurers, I use Office Ally to submit claims. It's an affordable option, though it used to be free before so many insurance companies opted out of "partnership" with OA. As for tracking, they all have different provider portals, and claims may be trackable within a few days, or sometimes not for a month or more. I think this is a major reason that more clinicians do not work for themselves: there's so little predictability as to when you may be paid for work already done.
I'm told I could submit claims to MaineCare through Office Ally as well, but it's much simpler to submit them directly through their portal. Some kind of decision status shows up within a day or so on a tab that they maintain (and private insurers do not) where I can view all my submitted claims.
Rates and Payment
I set my own fees, like all fully independent providers. Private insurers pay me moderately less than those amounts, and MaineCare pays me even a bit less than that. Low Medicaid reimbursement rates are a glaring systemic problem across all health care: they lead many providers not to take Medicaid, while those who do sometimes can't meet their expenses and go under as a result. Either outcome reduces access to care for Medicaid members. In some rural areas of Maine this problem rises from frustrating to life-threatening, and everyone ends up losing access, not just MaineCare members.
MaineCare's reimbursement rates, for the codes I bill, are actually close enough to the rates I get privately that I'm not making much less per session by taking Medicaid. Or, not much less than I'm already making less by taking insurance at all. MaineCare payments are all electronic, and usually arrive within 2 weeks, where private insurers sometimes pay by check and vary widely in timeframe. Occasionally I have also had insurance companies try to pay me with gift cards, LOL. You have to painstakingly "opt out" from this payment method and get the amount reissued in, you know, money. I think games like this should be banned (and hear some good folks are working on that).
Communication and Transparency
I'm always confused when instructions to providers begin "Contact the insurance company"– as if that's a basic first step. Insurers make it extremely hard for providers to contact them, having no phone line for provider questions or else multiple lines that each tell you to call one of the others. You have to enter in numerous identifiers just to get past the robots, and even if you do you will rarely get someone who understands and will answer your question. Patients, in my experience, have better access, but only to information directly affecting them. Even if they want to ask questions on my behalf, they can't; they're told I have to use "the provider line" which may not even exist.
MaineCare has a provider support line, clearly posted along with its operating hours. Every time I've called, I've reached a human immediately, and my problem or question was resolved. But with MaineCare, I have far fewer questions to begin with because hundreds of dollars don't mysteriously go missing– which brings us to transparency!
When private insurers make a mistake, I'm lucky if I can even reach anyone to call attention to it. When MaineCare makes a mistake, they usually catch it themselves, or will work with me once I bring it up. If MaineCare won't pay me for something, I can see for myself why not (and usually rectify it). If a private insurer won't pay me for something, I may never get an explanation. There are all the logistical hurdles above to even making contact, but additionally, I suspect that sometimes there is no answer. These companies are so large and diffuse, with numerous contracted entities performing different parts of their functions, that I don't think even they necessarily know what they're doing. That said, these unsolved mysteries have never once gone in my favor: money only ever goes missing. It never spontaneously appears. So opacity seems to be working very well for private insurers.
Overall, I find MaineCare is better to work with on every point except reimbursement rates (though not by much), and authorizations. "Waste, fraud and abuse" can show up anywhere, but based on my first-hand experience, state-run health insurance for all sounds just peachy to me. The fact that people are being kicked off Medicaid in droves– a trend accelerated but definitely not started by Trump– is all the more infuriating when you see how well Medicaid can serve both patients and providers.
