The Hidden Struggle of Using Insurance for Mental Health Care

If you’ve tried to use insurance for psychiatry, you already know what “coverage” can look like in real life: a directory full of ghosts, numbers that ring to nowhere, clinics that quietly left a panel years ago, and staff who kindly explain they’re full through next season. You start with the number on your card and finish hours later with a page of crossed-out names and nothing booked, which is demoralizing when the whole point was to feel better, not more defeated. Even when you do land an appointment, the process behind the scenes rarely resembles the clean abstractions in benefit brochures. Claims ricochet through clearinghouses, prior authorizations stall, and the money owed to practices moves like cold molasses. In 2024 a single clearinghouse outage froze revenue for tens of thousands of clinics, forcing teams to re-enter claims by hand while rent, payroll, and medication management continued without pause. “In network” reads like a promise; on the ground, it often behaves like a maze.

Denials turn the maze into a grind. Patients imagine a clinician reading their chart and deciding, with judgment and context; increasingly, the first pass is software built to move decisions at machine speed, rejecting in seconds what took hours to document. Families discover this only when a letter arrives with language opaque enough to feel like satire: medical necessity affirmed in one sentence and unmade in the next, requests for information already provided, deadlines that expire while you wait for a portal message to open. Add “ghost networks” that regulators keep catching—lists riddled with wrong numbers, closed practices, and prescribers who left years ago—and you get the quiet truth behind so many failed searches: on paper there’s access, by phone there isn’t. Every no has a human cost. Treatment plans stall. Symptoms stretch across another month. People who finally reached out start to wonder if the effort was a mistake.

Even when payment does arrive, it can move in reverse. Practices receive “overpayment” notices months after the fact—clawbacks that pull revenue off the ledger long after care was delivered and rent was paid. One large clawback can erase a margin for an entire quarter and turn a stable clinic into one that is suddenly negotiating with landlords and halting hires. Small details compound: portals that crash mid-submission, contradictory instructions from different departments at the same insurer, appeal windows that are too short for the volume of charts requested. Staff who trained to support patient care end up spending days resubmitting claims and writing appeal letters, while phones keep ringing and refills still need attention. It isn’t bureaucratic theater; it’s the quiet way a system transfers time, risk, and cash-flow burden onto the clinical side and calls it “process.”

The predictable consequence is attrition. Psychiatrists, already in short supply, look at the hours lost to denials, recoupments, directory inaccuracies, and multi-month payment delays, then look at the financial reality of running a safe, attentive practice, and decide to step off panels. That choice is often framed by outsiders as greed; from the inside it is survival—an attempt to practice in a way that still leaves room for thinking, follow-through, and the administrative staff required to do both. The downstream effect for patients is simple and brutal: each departure becomes another dead end in a directory, another week of calls, another person who gives up before care begins. The pressure this creates is not theoretical. In the last year, public anger toward insurers has spilled into headlines in ways no one should ever excuse and everyone should understand: when people experience a lifesaving service as organized obstruction, fury looks for a face.

Zellig lives inside this reality. We know what it costs to stay with insurance: benefits checks that require three calls for a straight answer, prior authorizations that ask for the same document twice, payments that land months late, and sudden recoupments that force a second pass at bookkeeping you already finished. We also know what it costs if we step away: more patients left to the directory lottery, more people weighing rent against cash-pay, more untreated illness accumulating quietly in households that have already carried too much. So we choose the harder path. We stay in network where we can and we carry the administrative load that comes with it. We verify benefits before you sit down. We help navigate prior-auth hoops. We resubmit and appeal when claims go sideways. We set clear expectations about out-of-pocket exposure so a surprise bill doesn’t become the last straw. It is slower and it is harder, and we do it because access matters in a way spreadsheets can’t measure.

None of this is a claim that the system is staffed by villains. Most people working inside insurers are doing their jobs under rules they didn’t write. But rules shape outcomes. When directories don’t match reality, when algorithms can deny in seconds what takes weeks to correct, when payments can be pulled back long after care is given, the incentives tilt away from availability and toward attrition. Patients learn to lower expectations. Clinicians learn to harden their schedules. Trust erodes. The fix won’t come from slogans; it will come from basics done well—accurate networks, timely payments, transparent criteria, and a fair process for dispute that doesn’t require a second full-time job to access. Until then, our commitment is simple: keep showing up inside the mess, keep doing the paperwork that opens doors for real people, and keep the path to care from collapsing into a search exercise that only the luckiest can finish.

We don’t pretend this work is glamorous. It is often tedious, sometimes maddening, and always worth the effort when a person who was stuck in loops finally gets through and starts to stabilize. The system may continue to insist the map is accurate; we will continue to meet people on the roads as they are—uneven, slow, and, at times, blocked by design. Insurance makes care harder than it should be, but we stay in network because it keeps care reachable for more people. It isn’t easy, but it’s necessary — and we’ll keep doing it.