State of Therapy: Why Therapists Feel Trapped by Insurance: The Power and Control Wheel, Reframed

A colleague we have known for years, since right before the pandemic, hopped on a call with us recently and said something that stopped us in our tracks. He had been listening to the last several episodes of our podcast, and he told us he missed our laughter. He missed the fun we usually bring. And he was right. It has not been feeling very funny lately.

We still get the giggles. But lately it is the kind of laughter that shows up in dark places, the kind that comes out when something feels so absurd you either laugh or you come apart. There is real fear underneath it, real protectiveness, the mama bear that comes out when something is not right, and you cannot look away. So we want to talk about why the laughter has gotten harder to find, and about a framework that has helped us name what we have been sitting with.

When the framework fit too well

Both of us come out of domestic violence work. It was our training, our internships, the groups we ran early in our careers. So, the Power and Control Wheel is not new to us. It is the tool used to map the patterns of coercion and abuse that keep someone trapped in a relationship, the wedges of financial control, isolation, minimizing and denying, using the children, coercion, and threats.

The idea came up almost as an experiment: what happens if we take that wheel and hold it up against what therapists are experiencing inside the insurance system right now? We pulled up an old Power and Control Wheel and started going wedge by wedge. It got uncomfortable really quickly. Really, really uncomfortable.

That discomfort is worth paying attention to. When we work with victims of domestic violence, there is often a moment of minimization or denial, and then a moment where someone sees it written out on paper and cannot deny it anymore. We had that same reaction to our own wheel. Not because we were blind to how insurance companies treat clinicians; we have been talking about that for a long time. But seeing the pattern laid out, wedge by wedge, made it impossible to look away. This is what that is.

To be clear about what we are and are not saying: we are not equating the trauma of physical or sexual abuse with a billing dispute. We are using the same model, the same framework, to look at patterns of power and control operating inside a system.

The cycle that keeps speeding up

One of the things that struck us most is how the cycle works. In an abusive relationship, there is the tension building, then the explosion, then the honeymoon period, then back into tension building. Over time, it can speed up. The honeymoons get shorter. And when you are inside it, bouncing back and forth, it becomes so much about survival that it is hard to step back and see the cycle at all. It is hard to have the energy to make sense of what is happening because all of your energy is going toward safety.

That is where a lot of therapists are with insurance right now. The financial control has been there for a long time, but it is speeding up. It is not two blowups in year one and ten in year ten. It feels like it does not stop. A claw back arrives, so now you have to work extra hard and put more money in to make up for it, because otherwise you cannot pay rent, or your health insurance, or feed your kids. That is financial control, and it is running at a pace that makes it genuinely hard to safety plan, to figure out whether you can exit, or when, or how.

The wedge we thought would not fit

When we first started, there was one wedge we could not place: using the children. And then our clients told us exactly what it was. Using the children is using our clients.

We are in this because we care so much about the people we serve. And that care is exactly what gets used against us. We feel manipulated into signing contracts, extending them, taking pay cuts, doing all kinds of gymnastics, because we care so much about our clients and about getting their needs met. The parts of the wheel we thought would not translate turned out to translate perfectly. The therapists doing this work around the country are not blind to it.

The No Surprises Act, or a case study in blaming

If you want a single example of minimizing, denying, and blaming, look at the No Surprises Act. It exists for a good reason. People were going to in-network hospitals, getting emergency care, and then getting surprise balance bills from providers inside that hospital who were not actually in their network. That is a real problem and we needed a law to fix it.

It passed in 2021. As of 2026, the enforcement measures intended to stop that specific hospital billing problem have not been implemented. What has been enacted is that private-pay therapists, people with nothing to do with insurance and no ambiguity about their fees, are now writing good faith estimates trying to predict what a person they have never met, whose diagnosis they do not yet know, might pay for therapy over the coming year.

So the people who got hit are the people who were never the problem. If that is not a bait and switch, if that is not taking an issue and using political power to move it somewhere else, we do not know what is. Our associations tried to push back and say this makes no sense. There was no exclusion for us. We think that is because insurance companies have far more lobbying power, more money, and the ability to point that power exactly where they want it. That difference is enormous.

When the AI gets overwhelmed, deny it

Some doctors have started recording themselves on the phone with insurance companies, and one recent example says everything. A physician was calling for a peer-to-peer review, asking why a procedure was not covered. The reviewer said she did not see a certain history in the file. He pointed out that he had detailed it in the second paragraph. Her answer, roughly: the AI gets overwhelmed if you give it too much information, so it just denies it. Then she approved it and apologized. [confirm source: recorded peer-to-peer call]

Sit with what that reveals. The technology exists to read the second paragraph. But it costs less to run the AI with limited bandwidth. It costs less to have a peer skim it after the AI denies it. And it costs even less if we, on our end, do not have the time or energy to get on the phone and fight it. They are banking on us being worn down, being quiet, being complicit. Which, again, is exactly what an abusive relationship counts on: you need me more than I need you.

And here is a question worth sitting with. These companies are determining what is medically necessary. They are practicing healthcare. Yet there is no malpractice liability for denying it. Nothing happens to them.

What the numbers say

If it feels like denials are going up and getting more complex, it may be because the system is working exactly as designed. A 2024 analysis found that 19% of in-network claims and 37% of out-of-network claims submitted to healthcare.gov plans were denied. For 36% of all denials, over 28 million claims, the reason listed was simply "other reason not listed." Less than 1% of denied claims are ever formally appealed. Of the appeals that do get filed, 40 to 75% are overturned.

Look at what that combination does. If you can deny at scale without most people appealing, and 99% of denials mean nobody bothers you again, imagine what that does to a bottom line across 28 million claims. It is wild.

When we turn on each other, the system is working

Here is the part that stings. Go on social media, and you will find clinicians minimizing what other clinicians are living. "You clearly do not know insurance like I do." "I get a great reimbursement rate. I do not know what your problem is." People gaslighting colleagues they have never met, whose math they have never seen, whose state and cost of living and contract they know nothing about, assuming everyone has the same scenario they do.

And then it turns into clinicians angry at each other instead of at the system. That is how you know the system is working. When we are turned toward each other fighting, we are not turned toward the actual problem, asking where it lives. The problem is not between us. But if we stay distracted by each other, we never look at the real issue.

Safety planning, for those not ready to leap

As coaches, we hold a hard line here: the decision has to come from the person in it. We can sit with someone in the place of indecision without pressure, without telling them they have to go. We learned that in domestic violence work, and it matters just as much here. And honestly, we have had to check ourselves lately, because the growing fear and frustration make it tempting to push. It still is not ours to push.

Not everyone is ready to take the leap. So the question becomes: what do you do until then?

A lot of it is protective documentation and clear eyes. Keep track of what is happening. Understand your math. Stay on top of your billing. Keep a record of every rejection and denial. Understand your contracts, and understand what happens when you click a box on one of these platforms: what happens to the client's data, the session notes, the information, where it goes, whether it is de-identified and re-identified. We are the guardians of our clients' care and their information, because the corporations are not going to be. If we are going to operate inside that system at all, we still have to protect the client.

We saw this play out with a client recently. They had done all the right cash-pay marketing, and it was working; people were finding them, calling, having a great consult. And then those same clients would say, great, I want to book with you, but I am going to go through Rula. So the clinician sits in that stuck place: keep going this route, or cut it out and take the leap. There is no single right answer. There is the next informed step.

Go roll down a hill

Our colleague was right that the laughter has been thin. And working alongside people in abusive situations, you learn it takes real effort and intention to hold onto joy while you are still in it. So this is also a genuine question for you: are you still finding joy? Are you still playing? Are you taking care of yourself, or are you sitting at the computer all day just hoping the work works?

You have to have a life, too. The way we get there might look different right now, with everything happening in the world. But the levity is not optional, and it is not frivolous. It is how you stay in this for the long haul.

So read the hard thing, then go watch some comedy. Call it balance. Go dance, or go roll down a grassy hill and get covered in dirt. Match your humor to the ridiculousness out in the world; sometimes the only move is to one-up it.

And if this reframe did something for you, we want to hear it. Does seeing it this way help, or does it shut you down? Does it give you more compassion for your colleagues, more clarity about what to ask for, more clarity about where your vote goes? Or is it just overwhelming? Every one of those reactions is valid. This is one imperfect iteration of a way to conceptualize what is happening, and it is a work in progress.

Mostly, we want you to know you are not carrying this alone. If you need a place to feel heard, to not be gaslit, to be validated, let us be that spot.

Transcript

Kelly Higdon, LMFT (00:01) Welcome back to the Starting Counseling Practice podcast. The success stories that we normally share are going to be replaced today by yours truly, Kelly Higdon and MIranda Palmer, LMFT she/her (00:13) Miranda Palmer. Kelly Higdon, LMFT (00:15) We're gonna talk on our monthly kind of talk about what's going on in the field, how are we feeling, what are we noticing. We just came off of a sprint with our clients, which means we got to do a lot of deep dives into the private practices of people all around the world, which is really fun and enlightening. And there's a lot of emotion happening in our industry. So we thought we'd talk about it today. MIranda Palmer, LMFT she/her (00:45) And it was really interesting. we have a a colleague that has known us for years, since I think right before the pandemic 2019, this amazing human Don Crowther, and knows us really well, but we hadn't spoken in a couple of years. And so we did a little catch up today. And he said, you know, it's so interesting. I last I listened to your last few podcasts and Like 'cause we're we're like in a Zoom together and talking and laughing. And he was like, he's like, That's what I miss. I miss your guys's laugh. He's like, You guys, like the fun that you bring into this into this world and into everything that you do. He's like, But can I tell you, like listening to your last like several podcasts, like I don't hear the laughter. I don't hear the fun. And we're like, Yeah, no, it's not feeling funny right now. Like we're Kelly Higdon, LMFT (01:22) Yeah. Ha. MIranda Palmer, LMFT she/her (01:42) Like sometimes we get the giggles, but like in a really like weird way. Like in like a whoa, this is real dark. And like we've had some dark conversations. We have another day that I will not recount on here. But like the the silliness of like this feels really absurd, what's happening in our profession. There's certain things in the world that feels really absurd. And like trying to find the balance of Kelly Higdon, LMFT (01:52) Yeah, MIranda Palmer, LMFT she/her (02:11) Of being in our humor humor, but also feeling feeling some fear for ourselves, some definite protection, like the protective, like mama bear comes out in both of us of like this isn't right. And like, what can we do? And we're like, let's get into action. And like there's some like righteous anger or some just some social justice anger kind of stuff. I guess so much to like balance. Kelly Higdon, LMFT (02:28) Yeah. Yeah, yeah. I know, and when he when he said that, I was like, well, I think it's just like there's an urgency I feel, and it's like this urgency to get out information. And I will say, like it or not, I refuse to entertain on social media. So most of my hilarity is just behind the scenes or with clients, maybe, and less like doing dances and memes and things like that. But We are funny and we do laugh a lot, but there has been a lot more information and like, okay, pivoting and how do we help people navigate these changes and it's just constant to the point that you have to laugh at it because it feels ridiculous, I guess. MIranda Palmer, LMFT she/her (03:25) If I mean it's this space of like again, because I I I'm really glad to be informed. There's so many great things about staying informed. Like that is part of my job. But to like open up your email and say, like, we're trying to fast track licensing for AI doctors, and you just go like, Did I just I must have misread that. Like I must be misreading that. Like, what is happening right now? And then again. Kelly Higdon, LMFT (03:33) Right. Yeah. MIranda Palmer, LMFT she/her (03:53) We're like we're still on the on the the other pieces of you know AI therapists. If if they're ready to give a physician a license to an AI physician, then w I don't say like what are we, but like in the in the pecking order that shouldn't be there, but the pecking order that is in our society in the system, like, are they even gonna require a license? Like what do we it's just been wild! I don't feel like there's a day that I haven't opened up my email or opened up my TikTok and there isn't something big that's happening that feels important, that feels like something that like, well, people need to know that, but then there's also this space of like, or do they? Is it creating more fear? Is it creating less action? Is it just this overwhelm that becomes too much heaviness to carry. Like what is the what is it? You know, I don't know. Kelly Higdon, LMFT (04:57) And then I, you know, this aspect of the constant retraumatization or exposure to really challenging world events and things happening. You had this idea of applying the power and control wheel, right, to what's happening in our country's healthcare insurance system. And I think about you and I both come from working in domestic violence. That was my training and my internships and things. And you and I both run groups and all sorts of stuff. And we're very familiar with this wheel. And thinking about like when people are in situations of oppression and constant abuse, you know, where does the laughter go? So I I, you know, looking at this wheel, it's like, okay. that balance of we're in a situation that's that is abusive and we're still trying to create a life with levity and enjoyment and connection, it's challenging. MIranda Palmer, LMFT she/her (06:06) It's really really challenging. I think that's the piece that I was always struck by in the in the work in that part of the of the clinical work was the space of a how the how that cycle of violence the like tension building and then there's this explosion then it sort of goes into this like sort of honeymoon period and then back into the tension building and then the explosion and the honeymoon and then over time maybe it speeds up a little bit more. Maybe there's the honeymoons get shorter. And how when you're in the midst of that, bouncing back and forth, it becomes so much just about survival. It's really it's hard to step back and to see the cycle. It's it's hard to have the energy to make sense of what's going on because it's just about safety. And I think when we started like, and it's not that this is this is new to be looking at it from this perspective, but when when we started actually like going like wedge by wedge in the power and control wheel and looking at the well how how does this show up? in the way that things are happening in the insurance industry, it got really uncomfortable really quickly. Like really, really uncomfortable. And it and it so connected in with what we're hearing from therapists, I think especially in the United States. Like the what's happening in insurance, I'm not seeing it in other countries, especially countries with single payer healthcare. This is this is not a thing. what we're experiencing with this for-profit healthcare middleman, however you want to middle person, third party, fourth party platform stuff, like this is uniquely so far a United States issue. It is it really is people going from well. Kelly Higdon, LMFT (08:13) Mm-hmm. MIranda Palmer, LMFT she/her (08:27) I just have to make sure my next paycheck comes and like, wait, I well, I can't do this because they might pull back my last paycheck or wow, I already got a claw back. So now I have to work extra hard and put more money into this to like make up for this piece because otherwise I can't pay rent or you know, I can't pay my health insurance or I can't eat or I can't feed my kids or all of these other pieces. Like the kind of like financial control that has like sort of like that's been there for a long time, but it's like speeding up, speeding up, speeding up. And it's not like, in the first year of of marriage or the first year in the relationship, there was like two big blow ups, and now we're in year 10 and there's 10 blowups or it's happening every four weeks or every three weeks or every two weeks or it feels like it doesn't stop. Like it feels like we're in that place in the cycle of like It's it's really hard and it makes it hard, I think, especially when we're in such a I wanna say like an active phase of the cycle to like safety plan or to to determine whether you can exit or when or how you can exit. Like like it feels it it just feels hard. Kelly Higdon, LMFT (09:52) And to your point that when this was being worked on and the discomfort that started to arise from it, kind of the shock, I remember I felt more like shocked of like, shoot, this is this is actively happening, and I'm I'm in this with a bunch of other people. And I think about when working in MIranda Palmer, LMFT she/her (10:17) Hm. Kelly Higdon, LMFT (10:20) domestic violence and victims of domestic violence and sometimes that like minimization, the denial. And then when you point I remember distinctly this happened a few months ago. A friend was getting out of a relationship and I was explaining financial control, financial abuse, and they were like, what? And like showing them how that worked. I had the same reaction looking at this wheel modified for the insurance system that we're in and going like, my gosh, that is what that is. But I wasn't seeing it as power and control, specifically in this abusive way. We're not equating. Like the the traumatization of like physical sexual abuse and those kinds of things, but we're using this same kind of model and framework to look at patterns of power and control in the system. And I I am Mm, not surprised, surprised by my reaction of like, my gosh, this is impacting in this way. Like, I obviously, you know, like we've been talking about insurance companies and all of this kind of stuff. But just like those victims that I've worked with that were just like, wait, kind of that shock feeling of like seeing it on paper, seeing it kind of written out and being like, I can't deny this anymore. MIranda Palmer, LMFT she/her (11:41) Yeah. Yeah. I I think there is like a I mean, we've been talking about like being empowered for the last, you know, fifteen years or whatever regarding insurance companies of like, hey, if these programs don't work for you, you can move over. But it's often been around like just the basics of does this financially work for you and do the the regulations work for you? Right? Like or do the the contract, the contractual obligations. Right, what they're expecting of you, what they're requiring in terms of medical necessity, does that match what your clients need? Like just like clinically, like, is this a fit? Like, are you needing a steak dinner and like going to Wiener Snitchel and like being confused as to why your client can't get a steak dinner at the 69 cent wiener snitchel? Like these are not the these are not the same thing, right? So there is, but this like ramp up over these last few years. Like one of my favorite examples, and and it was like a it's something that I knew, but I hadn't like fully looked it up because it just makes me angry every single time was like the No Surprises Act. And the whole thing was hey, this is because the No Surprises Act was there because people were going to an in network hospital. Kelly Higdon, LMFT (12:50) Mm. MIranda Palmer, LMFT she/her (13:14) And they thought, hey, I'm in the in-network hospital. It's where my insurance company told me to go. I got care for emergency. And then after the K, after the fact, I'm getting these weird bills from people who are working inside of that hospital who weren't actually in my network. And I'm getting surprised balance billing for that. Right. So they put this law in place, pushed it through. Fantastic. We need that. And how much of that has actually impacted or or put put in place for the insurance companies? It passed in 2021. Zero in 2026, zero of the things to help fix that from happening have actually been enforced. But what has been enacted is that therapists are putting together good faith estimates to try to tell people that they've never met. That they have no idea what their diagnosis is, what the what they possibly could pay for therapy over the next year, even though their fees have always been very clear. And if and it's specifically private pay therapists that have nothing to do with insurance. So the people who got impacted were the people who were not in the hospital, who there was no ambiguity about it. Like there was no ambiguity. But they're the people that are impacted. Like that, like if that isn't like a bait and switch, if that's not like a a denial, a blaming, well, the here's the problem, or again, using political power to like make the problem go over here, because there's there's no reason. And all of our associations, right, that we paid a lot of money to, like they did, I mean, they tried to say, hey, this doesn't make any sense. But Guess what? That there was no exclusion for us. Why? Because I think it's because insurance companies have a lot more lobbying power and they have a lot of money and they want to focus the energy where it goes. And that lobbying power, it it makes a difference. It makes a huge difference. Kelly Higdon, LMFT (15:29) So on this this power and control wheel, some of the things that are covered are like looking at coercion and threats, corporate and political power, emotional abuse, how isolation is used, minimizing, denying and blaming. Yeah. MIranda Palmer, LMFT she/her (15:45) Okay, pause for a second. So one of the ones, like when I first started ha like, we had this idea and I was playing with it and I literally put up an old power control wheel and I was like, I can see how a lot of these things work, except the using the children. And our clients specifically go, my gosh, no, the using the children is just like using our clients because we Kelly Higdon, LMFT (16:11) Mm-hmm. MIranda Palmer, LMFT she/her (16:13) Are in the space where we care so much about our clients and getting their needs met that we feel manipulated into signing onto these contracts and extending them and taking pay cuts and doing all these crazy things and these crazy gymnastics because we care so much about our clients. And it was just like, my gosh, it is it is all there. Like even the parts that I was like, I don't see, like it wasn't like I was blind to it, but our clients aren't the therapists around the, you know. Kelly Higdon, LMFT (16:39) Mm-hmm. MIranda Palmer, LMFT she/her (16:42) Around the country doing this work are not blind to it. Kelly Higdon, LMFT (16:47) Yeah. There's a lot of use of our clients and weaponizing our work against us. There's patriarchy at play, economic abuse at play. It's I encourage y'all to go and check it out. this will be up on a blog on our site. Because when you see it like this, it's very hard to deny, and then you think about okay. Well, when someone is in these kinds of situations, right, that there's a this pattern that's happening, we've identified the pattern, and then it's like, how do we get to safety? And and I think a lot of that was to came out in our sprint too, of like talking about the safety planning with our clients, of like, how do you get out of a situation that you feel very much, very much trapped in? And until you can get out, how do you s protect yourself as best you can while you're in that kind of relationship? MIranda Palmer, LMFT she/her (17:56) It's interesting because I did have, like I've talked about f if you've listened to this for any length of time, bless your heart if you have, 'cause this has been going on for a long time. But I've talked about the like I loved working with domestic violence victims. Like I can hang with somebody in the place of indecision, in the place of this is where I need to be, like without any pressure, without any force, without saying like you need You gotta go. Like I can just have the real conversation and leave them in an empowered place. And which is really interesting is that over the years I have noticed myself with clients who are like stuck in these, and we've been talk talking about like abusive relationships. Like this is a toxic relationship. This feels like a bad boyfriend. Like we've been talking about it from these perspectives for a long time. But I've noticed myself feeling more of a sense of like pressure and having to really check myself because even as a coach, like I feel it's really important. Like this has to come from my client. But I've been noticing more of this, like, my gosh, this is getting really bad. Like this is really getting dangerous. Like this is like, can you really do this? Like, like noticing more in myself of Kelly Higdon, LMFT (18:55) Mm. Yeah. MIranda Palmer, LMFT she/her (19:17) Of like a growing frustration, maybe a growing fear, and also like more anger when I'm on social media and somebody is minimizing denying and denying what's happening. They're blaming clinicians, saying, Well, you just clearly don't know insurance like I do. Insurance is fine. Well, maybe it is fine. For your program in your state, whatever the thing is, that they're just like gaslighting these clinicians when we go, no, this can be a no, well, I'm getting paid a great reimbursement rate. I don't know what your problem is. And like all of these crazy things and like me feeling like like, this is like kind of anger coming up of like, no, like you ha you don't know this person from Adam. You haven't looked at their math. You have no idea where they live, the cost of living, or what the reimbursement rate is. Like you may just you just assume that everybody has the same contract and scenario that you do. And then it's this back and forth too, where people are like, Well, they're coming for you too, and then they're mad at that other per it is just like we're we're looking at each other instead of the problem. Kelly Higdon, LMFT (20:25) Yeah, well that's when you know the system's working when we're turning to each other fighting and not turning to the system being like, Hello, where's the problem? It's not between us as clinicians here just trying to serve. But if we get distracted and we focus on that, then we won't be really looking at MIranda Palmer, LMFT she/her (20:43) Yeah it's Kelly Higdon, LMFT (20:45) The issue. MIranda Palmer, LMFT she/her (20:47) Yeah. Kelly Higdon, LMFT (20:48) I agree with you, like that. I feel that too of like, how do you as a coach hold the honoring and sovereignty of the other it person? But when you see the writing on the wall, it's like hard to not project and just to allow for and to continue to empower and educate and give options. you know, we had a client last week talk about. They've been doing all of their cash pay marketing and it's working, but those clients are still going to Rula. They find them, they call, they have this great consult They're like, Great, I want to book with you, but I'm gonna go through Rula. You know, and the you know, the clinician's like kind of in that stuck place of like, well, we could keep going this route or we cut out Rula and we like take the leap, you know. and and I I do remember I was a victim's advocate at the organization I worked. With and you know, not everybody was ready to take a leap. And so it's like, okay, what are we gonna do until you leap? And some of the things that we have talked about are like keeping track of what's happening, really understanding the math, understanding keeping up on your billing, keeping track of all the rejections, everything that's happening. It's really good paperwork skills that are important. And you know. finding being the advocate for protecting the mental health, right? Information of our client. So you really have to understand your contracts. You really have to understand when you click a box on some of these platforms and stuff. What is happening to the client data? What's happening to the session notes? What's happening, you know, to the information, where is it going? Is it getting de-identified and re-identified and all of that. We have to be protective of what we are. If we're gonna operate within that system it's still you have to protect the client. MIranda Palmer, LMFT she/her (22:50) Yeah. And there's that you were talking about that issue of of like tracking tracking what's happening with the the billing and with the denials. there's a a study in twenty twenty four that said nineteen percent of in network claims and thirty seven percent of out out of network claims submitted to healthcare dot gov plans were denied. one in five sorry. Kelly Higdon, LMFT (22:57) Mm-hmm. Okay. MIranda Palmer, LMFT she/her (23:19) For 36% of all denials, over 28 million claims, their least the listed reason was simply other reason not listed. So they're just like, meh, we don't know. And this is crazy. Less than 1% of denied claims are ever formally appealed. Of the appeals that do get filed, 40 to 75% are overturned. Right? So this place of like Like sometimes you're like, there must be what's happening? Well, why why are denials going up? Why is this getting more complex? Well, because maybe it's working as designed. If you can if you can deny as many things as you can deny without it becoming an issue. And 99% of those denials mean that like nobody bothers you again. Can you imagine like at Scale at 28 million claims, what that does to your bottom line and to your stock price, like it's wild. Kelly Higdon, LMFT (24:27) I really appreciate some of these doctors who like record themselves calling insurance companies. And this one recently he was calling for an a peer-to-peer review of like, why are you not covering this procedure? And she's like, Well, I don't show a history of XYZ. He's like, it's in the second paragraph. I detailed it out. And she's like, the AI gets overwhelmed if you give too much information. So just deny it. She's like, I'll I'll aprove it. Sorry about that. And so It was interesting of like this concept of th they're banking on us being quiet, they're banking on us being complicit, they're banking on us being worn down. And what does that sound like, y'all? An abusive relationship. Counting on that that dependency, you need me, you know, like I'm the one in control here, and you need me more than I need you. And go ahead. MIranda Palmer, LMFT she/her (25:29) Well, and that like what a great example of AI has the technology to not get overwhelmed. He's talking about it's in the second paragraph. It's not that but it costs them less to use the AI if they don't have as much bandwidth, if they're not giving AI the amount of bandwidth. It costs them less to have that peer person just read over it when the AI denies it. In theory, right? Kelly Higdon, LMFT (25:44) Mm-hmm. Mm-hmm. MIranda Palmer, LMFT she/her (25:59) than to get that person to get on the phone with a peer to peer. But they don't do any of that. Why? Because it costs them even less if we don't have the time and energy to get on the phone and navigate it. Like they're banking on. Like it doesn't have to be this way. And like right now, there's no there's no liability insurance for them. Nothing happens to them. They don't get malpractice insurance for denying healthcare, but are they practicing healthcare? Absolutely. They are practicing healthcare right now. They're determining whether this is medically necessary or not. How wild is that? And I mean, we're talking about this earlier, the like frustration of like I can see that the system is completely broken. At this point, all I want is like catastrophic care because I understand that like if something huge happened, like what needs what needs to happen. that like a three million dollar medical bill, right? Most bankruptcy in the United States is because of medical medical debt. So like I just want catastrophic care. But now somehow in the midst of trying to fix this broken system, you can't get catastrophic care either. So it's this like very at every place it feels It feels broken and again it's systemic, right? It's not something where we can easily change the system. It's sort of like when like when I had clients that were in relationships with people that were in law enforcement, so different level of complexity. It was a different level of danger. There are guns in the house, and there's a lot of stuff that happens inside of the profession to protect one another and because it can also impact that person's ability to do their career, there's a lot of reasons for that to try to keep it quiet. and so it always was a lot more complex. Like this feels like that level of complexity is like we're in this icky, funky, systemic Kelly Higdon, LMFT (28:21) Mm. MIranda Palmer, LMFT she/her (28:27) Now it's not just them, but it's maybe their sergeant who is also protecting them. And then there's this other person that's coming in and there's like a whole association and there's millions of dollars lobbying to say, No, no, no, this is exactly how it's supposed to be. And you're like going, Wait, what? do you not see what is happening here? This is wild. Kelly Higdon, LMFT (28:50) No wonder we're not laughing. MIranda Palmer, LMFT she/her (28:55) Well, I mean we are laughing, but like in the like, is this are you like when I got the thing that said that they were that the the AI that they were trying to push forward licensing for AI physicians, specifically that language. And you're like, wait, what? Like no, wait, okay, don't panic. It's just a subject line of an email. Maybe it's clickbait. No. Kelly Higdon, LMFT (29:15) Mm-hmm. Ha ha MIranda Palmer, LMFT she/her (29:23) I mean it it's baiting me all right. Like what is happening right now? And then diving into those into those pieces. And they're they're comparing, like one of the the insurance executives was comparing it to, well, this is just like when we were trying to go from like autonomous vehicles, like where we tested them for a while before they could be self-driving, you know, and there's like a lot of safety issues with that. So obviously we're gonna take our time. Kelly Higdon, LMFT (29:28) Yeah. MIranda Palmer, LMFT she/her (29:53) No, that's not what's happening right now. Kelly Higdon, LMFT (29:56) Have you been to San Francisco and watched the Waymo's all get confused? It's not fun. MIranda Palmer, LMFT she/her (30:00) No, it's not good. okay. Kelly Higdon, LMFT (30:04) Yeah, coming like coming back a little bit to like what Don had said to us. I mean thinking about working with people in relationships that are abusive, of like it does take a lot more effort and intention to take care of yourself through that to find some joy, you know? And I'm curious. About the people listening, like, are you finding joy? Are you still playing? Are you taking care of yourself? Cause I think one of the things that also came up in the sprint was this conversation of you can't sit at your computer all day long and just hope that you know, just work, work, work, work. There has to be you have to have a life as well. And how we do that may look different as everything that's happening in the world is happening. But I do find I I do find laughter just it hasn't been around this stuff lately. MIranda Palmer, LMFT she/her (31:13) No. If y'all can give us a a topic that is super funny, that would be great. I mean, maybe it is. Maybe, maybe that's part of we'll we'll open up comments on this blog where it's like share your favorite meme. Like maybe we'll do a little meme challenge. I'm not sure. Tag us, tag us on TikTok or Instagram in like your favorite silly meme, and we can just do a meme react. I don't know. Kelly Higdon, LMFT (31:30) Ha ha. Ha ha. MIranda Palmer, LMFT she/her (31:41) Well also, this blog is gonna be out by the time that this this gets released. And to be clear, like we go into more detail of like, hey, this is the the history and the whatever and resources and what have you. but there's also like an invitation to give us feedback, to share your stories, to to know that this is you know, a work in progress. This is one iteration of it. This is one way of of conceptualizing it in an imperfect way. so like we we want to be clear. We know this is an imperfect thing. but we would love to hear from you whether the seeing it in this way is helpful. if it gives you Does it shut you down or does it inspire you? Does it help you to have more compassion for your colleagues? Maybe. does it help you to feel more clarity about what to ask for from politicians or more clarity about where you want to put your vote or what I don't know. Like, what does this do for you? If anything, maybe you're just like, it's overwhelming. It it shuts me down. I know there was one Kelly Higdon, LMFT (32:47) Mm-hmm. MIranda Palmer, LMFT she/her (33:06) because we kind of previewed this with our the people in our business school. And one of the people was like, my gosh, like I could feel this viscerally. Like this reminded me of all the experiences that I've had with insurance. And they said, I could go over all the ways that this has happened to me, but I'm I'm not gonna re-traumatize myself. And I'm like, absolutely not. Like, please don't feel that way. So, but I I do think there's a lot that you know we are. Kelly Higdon, LMFT (33:28) Yeah. MIranda Palmer, LMFT she/her (33:36) holding sometimes in our individual situations. So if you need a place to feel held, to feel heard, to not be gaslit, to be like validated, like let us be that spot. Kelly Higdon, LMFT (33:49) Mm-hmm. Read the blog and then watch some comedy or something. It's called balance. MIranda Palmer, LMFT she/her (33:54) Yeah, please do. Tag us in a meme. Go dance, go ro go roll down a hill in the dirt or something. Did you ever roll down hills, Kelly? Like a big grassy hill. Kelly Higdon, LMFT (34:03) Not dance. Okay, well first of all I grew up in the desert, so we slid down sand dunes on cardboard. There was no I didn't MIranda Palmer, LMFT she/her (34:19) Yes. So okay, but so what we would do, and by we I mean cooler people than me, because I wasn't as cool, is they would sneak onto the golf courses in the area, right? For like the rich people that like the rest of us were not allowed into. You'd sneak in at night and they have nice big hills and so you could roll down the hills or in the they would take dry ice and like sit on it and slide down the hill and stuff. Yeah. Kelly Higdon, LMFT (34:26) Okay. Nice. Ooh. Wow. I'm very allergic to grass, so that is not appealing if I want to get covered in welts, but but MIranda Palmer, LMFT she/her (34:56) You look so rosy. Look at you, you're so pretty. Look at all those pretty big bumps. Kelly Higdon, LMFT (35:02) Yeah. Yeah, go roll down the hill for fun. MIranda Palmer, LMFT she/her (35:08) but look, now I'm picturing, okay, like what this is gonna be a fun art project. Not for not for you, for me. for you, it's horrible. But like you roll down the hill, right? Then you have all of these welts, and then I just sit with a paintbrush and I just make a design based on the welts Kelly Higdon, LMFT (35:16) Ha Yeah, lucky we Gosh, see y'all, we do laugh. You have to be ridiculous at some points. Cause it you have to match your humor to the ridiculousness that's out in the world. MIranda Palmer, LMFT she/her (35:32) Yeah. Yes. Sometimes you just gotta one up it. Also, for any of you, okay, this we're gonna wrap this up because this one has to be short because it's two, whatever. But if any of you are millennial or younger and you're like looking around the world going, this is feeling a little a little different. And if you haven't watched the movie Idiocracy, 10 out of 10 recommend. Give it a watch. Kelly Higdon, LMFT (36:09) All right. Well, on that note, we shall bid you adieu. Until next time. Keep laughing. Keep finding some of the joy in all this wild life hurdling through space on a rock. Just trying to love on people and care for them. All right. Until next time. MIranda Palmer, LMFT she/her (36:28) Rock out

Resources:

The Power and Control Wheel, developed by the Domestic Abuse Intervention Programs (Duluth Model): https://www.theduluthmodel.org/wheels/

KFF analysis of claims denials on healthcare.gov marketplace plans, 2024: https://www.kff.org/patient-consumer-protections/claims-denials-and-appeals-in-aca-marketplace-plans-in-2024/

No Surprises Act enforcement status: https://www.jdsupra.com/legalnews/no-surprises-act-implementation-in-2026-4720339/

Recorded peer-to-peer review call ("the AI gets overwhelmed"): https://www.instagram.com/p/DZOQUb2uPMe/

Starting a Counseling Practice Success Stories podcast: find it wherever you listen to podcasts

Questions? Reach us at help@zynnyme.com

About the Authors: Kelly Higdon and Miranda Palmer are the co-founders of ZynnyMe and creators of Business School for Therapists. Since 2010, they've helped tens of thousands of therapists build sustainable practices through organic digital marketing strategies that actually work—without wasting money on ads or time on tactics that don't convert. Because your practice deserves to be found by the people who need you most. Learn more here.