For Melissa Todd, that moment came after she was pressured to limit the care of a patient in crisis.

A psychologist from Eugene, Oregon, Todd was treating a young woman with a history of trauma whose father had died unexpectedly.

When the patient came to Todd, she was often unable to sleep more than an hour or two for days on end. “She described it to me as maddening,” said Todd, who recognized an array of symptoms that fit a diagnosis of bipolar disorder.

Todd helped her devise safety plans when she felt suicidal and was available after hours, even in the middle of the night.

“I was giving her almost daily updates,” the patient told ProPublica, “because that was what I realized I needed to do if I wanted to survive.” (Her name is being withheld to protect her privacy.)

Longstanding practice guidelines recommend that providers consider a combination of therapy and medication when treating patients with bipolar disorder, so Todd sought a psychiatrist who could manage the young woman’s prescription. Although the patient was covered by UnitedHealthcare, America’s largest insurer, Todd was unable to find anyone who had openings. Her patient had to pay hundreds of dollars for out-of-network psychiatry sessions.

Then, six months into treatment, UnitedHealthcare began to question whether therapy was even necessary.

Todd walked an insurance reviewer through the details of her patient’s fragile state. Even when the woman had periods of calm, Todd said, she knew the disorder was unpredictable. She worried her patient could attempt suicide if care was cut off at the wrong time.

The reviewers responded that the patient needed to be actively experiencing severe symptoms to continue with treatment and suggested that the therapy wasn’t working.

“I felt all this pressure to say the right thing to be able to keep giving my client what she needed,” Todd said.

In the end, the reviewers demanded a date when therapy would no longer be needed.

“I felt all this pressure to say the right thing to be able to keep giving my client what she needed.”

Melissa Todd

Psychologist

Eugene, Oregon

Todd left the network so she could treat her patient without interference. The patient could afford to pay out-of-pocket because of a small settlement after her father’s sudden death. People are more than twice as likely to pay their full bill out of pocket for visits to mental health providers than primary care physicians, according to a ProPublica analysis of federal survey data.

While United did not respond to questions about Todd’s experience, spokesperson Tony Marusic said the insurance company is “committed to ensuring members have access to care that is consistent with the terms of their health plans.”

Like Todd, many providers told ProPublica that insurers frequently interfere with patient care. In addition to cutting off therapy, they are pressuring providers to cap the length of their sessions to 45 minutes, even when the patients require more time. Therapists told us that they have seen their patients sink deeper into depression, suffer worsening panic attacks and wind up in emergency rooms after insurers refused to cover treatment.