If it seems clinician finances are more precarious than usual, no, it’s not your imagination. You don’t have an anxiety disorder. The uncertain economy means that discretionary income for self-pay psychotherapy may be disappearing. But if it seems like dealing with insurance is worse than ever, that’s not your imagination either.
Every day, I see audits, pre-payment reviews, and new creative ways being implemented to delay, deny, or claw back payment. Credentialing and contracting seem to be taking longer, with more mistakes being made that take longer to resolve. Payers are quibbling over 90837 use again. There’s talk of reimbursement rate decreases in some locations, with tech platforms such as Alma or Headway not being exempt. If any of this matches your experience, I’m going to explain why.
The major insurers, especially the ones offering government or Marketplace plans, have been disappointing their shareholders. Profits, apparently, aren’t sufficient. (does anyone hear tiny violins playing?)
Make no mistake: the first duty of an insurance company is to the shareholders. Employers who purchase group policies are a distant second. And policyholders? Hah. Not even on the radar. Except as cost liabilities.
On July 29th, United HealthGroup reported 2025 second-quarter earnings results. Despite an increase of $12.8 billion when compared to second quarter 2024, that apparently wasn’t sufficient. UHG’s stocks decreased another 7% following the earnings call, for a total 2025 collapse of more than 44%. A (probably long overdue) Justice Department investigation into United’s Medicare Advantage “upcoding” practices probably isn’t helping things, either.
Other payers have financial “woes” too. Centene, the largest vendor of Medicaid managed care plans, reported a second-quarter loss of $253 million. Molina, Centene’s competitor in the Medicaid managed care and ACA plan market, also cut its 2025 earnings outlook. And Elevance (Anthem/Carelon) reported a 24% loss in profit to date in 2025.
Don’t let the doom and gloom mislead you. These folks are still making plenty of money! But it’s not enough to satisfy Wall Street shareholders, who expect to see hefty year-over-year profits. Which isn’t a model that is either ethical or realistically sustainable in healthcare.
Does stock outlook affect clinician finances?
Yes. Insurers are going to have to do something to increase profits enough to satisfy investors. I don’t think it takes three guesses to determine whose finances will be targeted.
Here’s looking at…us!
Any way an insurer tries to save money will result in systemic changes that negatively impact clinician finances. For instance, layoffs might worsen delays/mistakes in credentialing and contracting – fewer employees to process enrollments. Personally, I’ve never subscribed to the belief that “doing more with less” produces positive results. Seems to me that if you invest less, your results will be, well…less. But hey, they’re saving money in payroll costs!
Who cares if a few clinicians are unhappy or if claims are delayed, right? Recently I had two newly-contracted practices with Aetna report that despite their contract effective dates being more than 60 days in the past, new claims are still processing “out of network.” Aetna laid off over 600 employees in 2024 and 2025. It could be a coincidence. If you believe in coincidences.
Yes, eventually, claims can be reprocessed to pay at the in-network level. But that requires clinicians to call, appeal, dispute – all of which takes unreimbursed time and effort. And if claims are paid 90 days later, then Aetna gets 90 days’ worth of interest on clinician finances. In theory, state “prompt-pay” legislation requires insurers to pay interest on late claims, but often that doesn’t happen. And even when it does, the amount of interest paid is probably nowhere near what the insurance company took in during the time claims were delayed.
Check out this lovely little paragraph I found hiding in Optum Behavioral Health (United)’s provider manual:
No interest or penalty otherwise required under applicable law will be due on any claim which was initially processed timely and accurately, but which requires reprocessing as a result of the untimely execution of a Participation Agreement or amendment; or the inability to align Optum systems in a commercially reasonable period of time. (page 71, version effective Aug 15, 2024)
WOW. Optum is outright saying they can be as slow as they like with no consequences. How convenient for United’s bottom line. And how damaging to clinician finances.
There are too many examples of payer shenanigans to provide an exhaustive list, but here are a couple more. All are systematically designed to be destructive to clinician finances and the survival of practices. When practices fail or go out of network, clients can’t access affordable, competent care – and claims don’t have to be paid.
- Low reimbursements ensure “Ghost Networks“ – which can be literally deadly.
- No standardization in billing. Multiple ways to bill for telehealth. Does the payer require a taxonomy code? Why did this payer insist on contracting me with my Type 1 NPI when everyone else uses my Type 2? Etc. People make billing mistakes because it’s almost impossible to keep up with the varying expectations. Claims payment is delayed, stress increases, and clinician finances suffer as some therapists decide their mental health is more important than fighting to get that $80 owed by BC/BS for a session from 6 months ago. It adds up. Payers profit.
- Unilateral downcoding policies. Cigna announced that effective October 1st, they’re going to reduce 99214 and 99215 claims down to 99213. It will be up to providers to file reconsideration requests with medical records to prove their services met criteria for Levels 4 or 5. Aetna has already been downcoding for a while now. Unilateral downcoding forces a practice to face two awful choices: 1) bill for what you did and fight with documentation on every single claim in order to collect, OR, 2) bill something less, getting reimbursed even less, but without a hassle (presumably). In the non-prescribing psychotherapy world, this is the dynamic that the “you’re billing too many 90837” letters has created for years now.
- No provider customer service. We’re told use portals instead of calling. But when there’s a complex problem to be sorted out, there’s no one to talk to who can help. US-based employees with authority to fix the issues are unreachable. Eventually people just give up out of frustration. (I can help with this!)
What’s causing these “losses?”
People are utilizing their health insurance benefits more than the bean counters expected. How dare they?
Insurance executives use the term medical loss ratio (MLR) to refer to the percentage of premiums spent on claims payment. The Affordable Care Act dictates a medical loss ratio of at least 85%. Historically, payers have managed to stay close, but for second quarter 2025, these were the MLR numbers reported:
Isn’t that a good thing for clinician finances? More claims being paid?
Sure, until they find a way to claw money back. Or reduce reimbursement rates to “compensate.” Or they decide to impose pre-payment reviews and/or unilateral downcoding. In the words of many of the CEO’s presenting the “disappointing” 2nd quarter results, “aggressive provider coding” is responsible for a lot of their “losses.”
Or until payers lay off more employees, complicating your ability to get contracted/credentialed, or changes made to your profile. Fewer people to program/update the systems that adjudicate and pay claims. (Yes, claims are mostly processed by AI algorithms).
Or when the “losses,” together with not-so-beautiful new legislation removing people from Medicaid and the likely ending of expanded ACA subsidies conspire to raise 2026 premiums by about 15%. United has already admitted plans to discontinue Medicare Advantage PPO policies in 2026, which will render about 600,000 seniors scrambling for different coverage that will most likely be both more expensive and with skimpier benefits.
The scariest part of all for mental health clinician finances?
Is that in the flurry of earnings reports, four of the five payers quoted specifically mentioned behavioral health as one of the leading areas of increased costs.
That Wall Street beast must be kept fed.
Need help managing the insanity of insurance billing, or fighting to keep money you earned? I’m here to help!
