06/30/2025
How to Become a ‘Bad Actor’ in the Eyes of an Insurance Company
By Lisa Tieglman-Koepp, MSE, LPC, NCC, CEDS
There was a time when our relationship with insurance companies, while often adversarial, still reflected a shared mission: to prevent unnecessary hospitalization by increasing access to effective outpatient care. We were encouraged, sometimes even pressured, to adjust our session frequency and length to manage acute crises in the least restrictive environment.
However, the landscape has shifted dramatically. We now find ourselves under scrutiny, unnecessary audits, and clinic-destroying claw-backs. What once reflected a meaningful, 53-to-60-minute psychotherapy session is now considered 'excessive', despite clinical rationale and necessity. Perhaps most alarming was being docked for not discharging chronically suicidal patients because they’ve ‘met the maximum benefit of treatment.' These directives contradict everything our licensing board standards, mandated reporting laws, and the ethical oaths we took to protect those in our care demand of us. Discharging patients who remain at risk, who are still in need of support, simply because the system no longer deems them financially “worth it,” is not just unethical—it’s dangerous.
Then the day came when I learned about the ‘Preclusion List’ - a list of providers and entities considered 'bad actors' and 'threats to the integrity of the Medicare program'. Medicare had created another category for these folks, right alongside those who have been convicted of a crime or accused of fraud. Calming anxious clients about loosing coverage for their mental health care with me was not an easy task. I first needed to make sense of it myself. It sill remains unclear what other actions CMS has determined meets criteria to land on this list of 'bad actors' and entities that pose 'threats to integrity' of the Medicare program.
So, I fought hard! I devised emails, made daily calls to CMS, consulted an attorney, even called the insurance commissioner. After persistent effort, the error was confirmed, and CMS promptly requested the insurance company send retraction letters. Righting the wrong of being slandered would take more than a letter and an apology. We hired lawyers to represent us in a countersuit, until it became financial unsustainable to continue. We waved the white flag of surrender and bowed out, with no accountability on the insurance company, or payments on monies still owed. It was devastating financially and therapeutically and completely unjust!
This insurance strategy will backfire eventually. However, I know If I go down before that happens, it will not be because I failed my patients. It will be because I refused to abandon them. To all my colleagues in the field, here's my unfettered advice. It may feel like 'The 'Road Less Traveled' but take it anyways. Be choosy when it comes to your contracts. Do not be bullied, belittled, or blindsided. Align yourself with honorable entities. Know the road ahead, especially the higher one, because there's a lot less traffic there!
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Lisa has been a practicing psychotherapist, professional mentor/consultant/coach, clinical supervisor, author and professional speaker since 1993; She is the visionary founder of LTK Counseling Associates and SpiritWings Productions, a speaking company honoring holistic truths. She currently provides professional counseling, professional mentoring and consultation services through Northshore Clinics & Consultants in West Bend, WI. Lisa is part of the adult inpatient therapy team at Aurora Psychiatric Hospital in Wauwatosa, WI. She has always been a passionate advocate for social justice causes and empowering people.
