Santa, Bring Me Fair Health Insurance This Year: A psychologist view from inside the system

If adults wrote letters to Santa, mine this year would be very simple.

 

Please bring me fair, honest health insurance.

 

Every December I sit with two sets of worries. One is about my clients and the people on my waitlist who are trying to figure out how to use their benefits for therapy or psychological evaluation. The other is about my own family’s coverage, the renewal notices, and the increasing cost of staying insured.

 

I hold both roles at once. I am a licensed psychologist who provides therapy and comprehensive evaluations. I am also a person on the marketplace trying to keep up with rising premiums, deductibles, audits, and rules that seem to change every year.

 

On the surface this looks like a problem of billing codes and policy language. Underneath it is about something more fundamental. Who gets to decide what careful psychological work is worth. Who defines what is medically necessary. And why the organizations that are supposed to advocate for our profession so often adjust to insurance company rules instead of challenging them when those rules conflict with clinical standards and basic fairness.

 

Most of what I describe here comes from an assessment lens. Therapy work is also devalued and delayed. I have waited months to be paid for sessions I provided long ago. But the sharpest ethical tension for me shows up around psychological evaluation, where the gap between what is required and what is reimbursed is especially stark.

 

 

How health insurance became the main character

When I was growing up, I do not remember anyone talking about deductibles or prior authorizations. Many families paid the doctor directly or used whatever coverage a job happened to offer. Insurance sat in the background. It was not the main character in every decision about care.

 

Over time that changed. Employers began using health benefits to recruit and retain workers. Public programs were created for older adults and some low income groups, but they largely paid through contracts with private hospitals and plans. Nonprofit insurers gradually transformed into larger corporate entities. They merged, bought up regional plans, and expanded into pharmacy and other health services.

 

Insurance stopped being a simple agreement to help pay for care. It became a giant industry in its own right.

 

Today some health insurance companies are among the largest corporations in the country. Their executives receive compensation in the millions. From a corporate standpoint, that is how the system was designed to function. They take in premiums, manage risk, control what gets paid out, and reward their shareholders.

 

From where I sit as a clinician and a consumer, it feels very different. We pay them so we can use care when we need it. Then they decide if we can, how often, at what rate, and under what conditions. They decide whether a psychological evaluation is medically necessary. They decide how much of my hour is allowed and how much simply does not count. They decide how high your deductible will be before anything is covered at all.

 

There are regulations around the edges, but inside those rules the system often feels unbalanced and unfair to the people who actually give and receive care. The audits, the underpayment, the denials, and the unpaid labor are not random irritations. They are predictable outcomes of a structure that has gradually given insurance companies enormous financial and decision making power over our health care.

 

What a real psychological evaluation requires

Against that backdrop, it is important to be clear about what a genuine psychological evaluation involves.

 

A real evaluation is not a quick screening or a single checklist. When I evaluate someone for ADHD, a learning disorder, autism, or a complicated mix of symptoms, I am often trying to answer questions that have followed them for decades.

 

Why has school always been so hard for me. Why do I work twice as long as everyone else and still feel behind. Why have past diagnoses never really fit. What is actually going on with my brain.

 

To do that well, I take a detailed history and listen to how problems have shown up over time. I review records. I select appropriate standardized tests. I administer them carefully, often across several hours. I score them. I look at patterns, not just individual scores. I integrate test results with life history, observations, and symptom ratings. Then I sit down and write a report that is both accurate and understandable.

 

After that, I meet with the person and we walk through the findings together. We talk about what the results mean for school, work, relationships, medication decisions, accommodations, and long term planning.

 

Most of this work happens outside anyone’s view. Scoring and interpretation can take hours. Writing a report that truly fits the person, instead of sounding like a template, requires time and attention. The ethical weight is high. These reports influence diagnoses, access to medications, school services, disability determinations, and how a person understands themselves.

 

At the same time, definitions of medical necessity for psychological testing have been narrowed by professional guidelines and insurance policies. Comprehensive, multi method evaluations are often treated as optional. Simple rating scales or basic screenings are framed as enough, even when clinically they are not.

 

If I followed that logic, I would be rewarded for doing less. I would be paid more per hour to stay in the therapy lane than to step back and do the deeper assessment that might finally bring clarity and relief.

 

 

When the hardest work is paid less

As a therapist, one hour of psychotherapy is typically reimbursed around 150 dollars. That hour is emotionally demanding and clinically complex, and there is documentation afterward, but at least the basic rate acknowledges that this is skilled professional work.

 

For evaluations, the numbers look very different. When I add up what I am actually paid for a comprehensive assessment and divide it by the total time spent interviewing, testing, scoring, interpreting, and writing, my effective rate is closer to 80 dollars an hour. That is before subtracting the cost of test kits, protocols, scoring programs, and other tools. Once those are factored in, the real hourly rate is even lower.

 

So something I love to do and am very good at, something that is technically harder, more detailed, and more consequential for a person’s life, is the part of my work that the system consistently pays less for.

 

Then layer on what each insurance company decides that same hour of work is worth. I might set a fee of 150 dollars for a standard billed hour. For that exact same code, same doctorate, same ethical responsibility, different insurers pay very different amounts. In my contracts for that 150 dollar billed hour I may see one plan allow 142 dollars, another 138, another 135, another 125, and another 107.

 

Nothing about my work changes between one claim and the next. Only the name on the insurance card changes. With it, the assigned value of my time and judgment can swing by more than 40 dollars. Over time, this is not just a math problem. It is a quiet, constant message that the value of my work is a negotiable number on someone else’s spreadsheet.

 

 

Most of us join professional associations with the belief that these organizations will advocate for fair reimbursement and defend evidence based standards. We pay dues expecting that our associations will push back when policies ignore clinical reality.

 

From where I sit, it often feels different. Professional bodies and insurers work together to define what counts as medically necessary testing, which codes can be used, and how much will be paid. Those definitions tend to shrink what is covered. Comprehensive evaluations for attention, learning, or spectrum concerns are discouraged, sliced into narrow billable pieces, or treated as excessive. Brief screenings are treated as enough.

 

The result is that individual psychologists are left holding the ethical tension. We are expected to meet high clinical standards while working inside rules that reward doing the least amount of assessment possible.

 

None of this is covered in graduate school. No one sits you down and teaches you the language of billing, the logic of audits, or how often the rules change. You learn it while you are already running a practice and trying to keep up clinically.

 

Billing itself is like learning another professional language. Codes, modifiers, authorizations, recoupments, appeals. Each insurer has its own rules and those rules shift. Trusting someone else with your billing can feel like handing over a newborn infant. You know you need help, but you also know that if something is done incorrectly, you will be the one held responsible.

 

People sometimes say to me, why not just stop taking insurance. My response is immediate. Would you pay out of pocket for my services if you could use your insurance. Most people cannot. Many would not even make the first call if they did not see the words in network.

 

So the ethical problem does not disappear if I walk away from insurance. It just shifts. Who gets left out. Who never gets assessed. Whose ADHD, learning disorder, or autism never gets formally recognized because they could not pay privately for a full evaluation.

If you are a therapist, psychologist, or small practice owner reading this and thinking, “this is exactly what I am dealing with,” you are not alone and you are not the problem. I would invite you to share this piece with colleagues, use it to start conversations in your peer groups, and name out loud what is happening in your own practice. Our distress is a realistic response to a system that was not built around ethical care, and it will take many of us speaking up to change it.

 

In the next part of this series, I will describe what happens when the insurance system decides to look backward at years of work and label it overbilling, and how that kind of audit lands in a psychologist’s nervous system.