The health care industry has changed dramatically over the past twenty to thirty years. Today's typical health insurance company is a very aggressive business looking to save money in the interest of increasing profits. When computer manufacturers or barbers or car mechanics or restaurants cut corners, reduce quality and quantity of services and increase consumer cost, consumers react by spending their money elsewhere, forcing these businesses to change their practices. Unfortunately, these same market forces have not impacted the health insurance industry as it continues to increase costs to you even while eroding the quality and quantity of service.

No matter the larger socio-political-economics, the day-to-day reality is the same. Your health care is no longer a private matter between you and your health care provider (physician or therapist, for example). In all but a few instances, for-profit managed health care corporations stand between you and your health care provider's recommendations. Managed health care employees who will never meet you, who will never examine you and who may even refuse to talk to you commonly have the ability to deny you the care that highly qualified health care providers recommend.

Managed health care companies restrict your care and thereby increase their profits in a number of specific ways. It may be important for you to learn which, if any of these business models may some day influence who can care for you and how:

1. Indemnity insurance is how all health insurance was fifty years ago. Under an indemnity policy, the patient sees whatever provider he or she prefers, receives whatever care the provider recommends for however long it is recommended and is reimbursed for most or all costs with no questions asked, up to a reasonable per-year or lifetime benefit maximum. 

2. Preferred Provider Panels are typical of PPO (Preferred Provider Organization) managed care plans. A PPO makes its money, in part, by allowing patients only to be seen by providers who have contracted to work within the PPO plan. In a PPO, providers  agree to accept lower payments per service in exchange for a higher number of referrals through the plan. This means that providers must see more patients per day to maintain an income level, often compromising on the quality of your care.

3. Health Maintenance Organizations (HMOs)  are closed networks of providers intended to meet every health care need within a single organization. Patients who participate in HMOs typically enjoy relatively low premiums, copayments and deductibles but may find that they have no benefits outside of a more or less limited group of providers. (Click here to learn which companies offer HMO plans in New Hampshire ).

4. Point of Service (POS) plans may cost more in preemiums, but offer you more, as well. Most POS plans invite patients to see providers on a preferred provider list (as above) with minimal co-payments and deductibles and allow patients to see "out of network" providers (those who are not a part of the preferred provider network) for somewhat higher co-payments and deductibles.

5. Capitation shifts the profit-loss dilemma back to the provider. Under a capitated health care arrangement, an insurance company pays a provider a fixed amount of money to meet the health care needs of a specific population for a specific period.

For example, Alpha Insurance pays obstetrician Dr. Smith ten thousand dollars to deliver all of the babies born in Metropolis in a calendar year. If no babies are born, Dr. Smith banks ten thousand dollars for no effort. If ten babies are born, he is effectively paid one thousand dollars per delivery. If one thousand babies are born, he may work non-stop through the year and be paid ten dollars per delivery, no matter whether every delivery is a life-threatening C-section or a fifteen minute uncomplicated labor. Under capitation, providers must consider their own pocketbooks every time a test is ordered or a procedure completed., creating  one of the many unacceptable conflicts thrust upon patients and providers alike under managed health care.

Health Insurance in the State of New Hampshire

You do have rights. You have a right to appeal any healthcare decision directly to the managed care or insurance agency. Appeals based on a provider's unique services in your geographic area or on a patient's pre-existing relationship with a provider regardless of network status are sometimes granted.

Click here to

Reach the New Hampshire Insurance Department

In New Hampshire, you may also appeal any healthcare decision or complain about any insurance-related healthcare practice (denial, limitation or payment) to the state insurance commissioner:

Roger A. Sevigny (2006)
603.271.2261 or 800.852.3416

BUT ... what does the law say about your effort to appeal an insurance denial? US Supreme Court Ruling 6/2004

Health Insurance and Mental Health Care

Your health insurance very likely imposes restrictions on the type of psychological services you are eligible to receive and on the allowable duration of such services.

  Your health insurance likely requires that the confidential matters which arise in the course of participating in psychological interventions be reported to uninvolved and often clinically naive third parties (e.g., managed hwealth care case reviewers) and that the identified patient (yourself or your child) be categorized and labeled using medical terms suggesting the presence of an illness. These inflammatory and often misunderstood labels are recorded as part of the patient's electronic file. Even the 1997 federal HIPAA laws very likely do not adequately protect this data. 

Your health insurance or managed care company requires that participating providers complete reauthorization review procedures on paper, by phone, e-mail or fax which are often very time consuming and highly intrusive, hurdles which can stand between you and the continuation of psychological services.

For these reasons, Dr. Garber withdrew from participation in all managed care, preferred provider and other third party health insurance reimbursement entities effective September, 1999.

In order to maintain the freedom to provide the highest quality psychological services and so as to not compromise patient confidentiality, Dr. Garber will not bill your insurance carrier or managed care company for services rendered. Payment is requested in full at the time of service. A flexible fee schedule can be arranged at your request.

If your insurance carrier or managed care company will accept your claim for reimbursement, Dr. Garber can provide you with the necessary claim information at the time of service.  At your written request, Dr. Garber will provide you, the patient with any reasonable documentation that might facilitate your request for reimbursement.

Depending on your health insurance or managed care policy, its details and limits, you may have the option to submit a claim for reimbursement directly to the company yourself. If you are seeking reimbursement for the cost of psychological services, please contact your insurance company or managed care organization as soon as possible with the following questions close at hand.