RN psychotherapists push back on insurance providers not recognizing their practices

·10 min read

Tara Tourloukis is a registered nurse, a psychotherapist, and the owner of the Wellness Nurse, a Kincardine-based practise she started last year to “inspire and empower individuals to increase their mental health and wellness literacy.”

While the Wellness Nurse has been operating only for the last year, she says that she’s been working in mental health for a lot longer:

“I’ve been a nurse for 19 years, and most of that’s been in mental health. Last year, I decided that I needed something that allowed me to have a bit of a more flexible schedule. So (I’ve been practising) just in the last year, although I’ve been working in mental health and outpatient therapy for the last decade.”

Aside from her career, she also holds a master’s degree in psychiatric nursing as well. Though she is qualified to practise psychotherapy, according to the provincial government, if you were to go see her, you might not be covered by your insurance. In fact, if you go see any RN psychotherapist (there are over 65 in Ontario, according to Tourloukis) you may be in for a rude awakening when the bill comes.

Tourloukis is a member of an informal group of RN psychotherapists who take issue with their practices not being recognized by some insurance providers, even though they are recognized by the provincial government, under the Regulated Health Professions Act, 1991, as qualified and permitted to practise. As Tourloukis explains, in 2017 psychotherapy became a controlled act and only permitted to be practised by six colleges: the College of Nurses of Ontario, the College of Registered Psychotherapists of Ontario, the College of Psychologists of Ontario, the Ontario College of Social Workers and Social Service Workers, the College of Occupational Therapists of Ontario, and the College of Physicians and Surgeons of Ontario.

It’s important to note that, under their clients’ plans, psychotherapy is covered. Just not psychotherapy practised by an RN.

“What we do on our invoices is put ‘psychotherapy’,” Tourloukis explains. “And we will put our College of Nurses of Ontario registration number. So it would have been identified that the service was for therapy. That service was denied.”

She and her group claim that insurance providers give the following reasons as to why they are denied coverage:

Nurses are not qualified to perform psychotherapy;

Nurses, under their policy of coverage, are not “identified” as psychotherapists;

Nurses must be registered with the College of Psychotherapists of Ontario (CRPO);

The only providers permitted to perform the controlled act of psychotherapy in Ontario are Registered Psychotherapists; and

Nurses are identified as only being qualified to perform home care and foot care under their policy.

Tourloukis explains that while she could get registered under the CRPO, it’s an arbitrary rubber-stamp that would cost her time and money. The province already recognizes her as being able to practise psychotherapy, she says. “Part of it is, ‘why would we become duly registered if we strongly identify as being nurses?’ Quite often clients seek us out because we’re nurses, right? Because nurses have some unique skills that we bring to the table that maybe other professions don’t.”

Why Nurses?

The reasons why seeing an RN psychotherapist are summed up by Tourloukis:

“First of all, we practise from a holistic, person-centered lens. Nurses are taught to look at the whole picture, not just the diagnosis, not just the symptoms, but look at the whole picture and the whole system. So, the socio- economic, the environmental, the housing and the social determinants of health. All of those things, nurses look at. Most of us are really familiar with how the health-care system works and can play a bit of a navigator role. Imagine you’re somebody who comes for therapy, and you also have some health issues. You might need some support in navigating the mental health-care system or the health-care system. Nurses, typically, are really good at being navigators because we know the health-care system. When we talk about things like anxiety, or depression, there’s a real physical piece that goes along with that. We’re skilled and we’re educated in terms of the body systems and how that kind of connects to mental health. Most of us have a mental health background. So along with psychotherapy, we’re incredibly knowledgeable about diagnosis and illness as it relates to mental health. And the medication piece – although RNs cannot prescribe medication, we’re certainly knowledgeable in medication.”

Taylor Davy of London, Ont. sees a colleague of Tourloukis—Sheena Howard of Peterborough. She says that she was drawn to Sheena’s practise after a lifetime of searching for a “competent psychotherapist.” She says that there was a connection with Howard that she hadn’t experienced in the 30 years she’s been looking.

“I came across Sheena’s profile and something about it just kind of spoke to me. I had reached out to three people that day asking if they had any openings and the two other people said they didn’t, but [Howard] wrote back and said she actually did. And it was quite serendipitous because she is everything I’ve been looking for in a therapist.”

She says that even finding a psychotherapist that’s open for new clients is difficult enough but finding a compatible one makes it almost impossible. Adding insurance into the mix provides another hurdle.

“I wish I had the money or the resources to be able to see her weekly. I truly can’t afford it. She’s doing her best on her end to keep it as affordable as possible, but it’s still a lot of money for me out of pocket… it’s a real struggle just to be able to do the therapy.”

Her insurance provider is Sun Life, and figuring out the coverage has been difficult:

“We spent literally hours on the phone with them,” said Davy. “We have been denied so many times. My husband has spent a collective nine hours. I’m up to about 14 hours. [Howard] spent about four hours herself. We couldn’t get a straight answer for the longest time and then finally found out the issue was that she wasn’t technically a psychotherapist. She was an RN. But I kept saying to them, ‘Well, if the Ontario government recognizes RNs as allowed to practise psychotherapy, why aren’t you recognizing that as well? It doesn’t make any sense.’”

Amanda and Brad’s Story

Amanda McArthur and Brad Carman of Kingston also see Howard for psychotherapy. They also have Sun Life as their insurance provider. They also reported a similar story as Davy’s, in that their search for a psychotherapist was strained and difficult in an already difficult time.

On Sept. 29 of last year, the couple welcomed their son, Declyn Carman, into the world.

He was diagnosed with Down Syndrome and AVSD complete. As Amanda said, “His health was always a concern for us. We’ve been in and out of the hospital and just kind of making sure that he was healthy enough to go for surgery.

“On New Year’s Day, at about one in the morning, he was just super upset. We couldn’t calm him. He was just not himself. So we took him to emerg the next day, and we were in there for quite a bit before they took Declyn up to the pediatric unit. He had a fever. They couldn’t get the fever down.”

On Jan. 3, at three months old, Declyn passed away. Advised that they should seek counselling for their loss, Amanda and Brad found that easier said than done.

“When we were looking for a therapist, we did some research,” Amanda said. “Here in Kingston, we were looking for a few things. One of them was someone that could do grief counselling, someone for family counselling. In Kingston, we couldn’t find anybody that would take us. They were all full. But in saying that we had seen [Howard]’s profile online. Her website really stuck out to me in the fact that she was a registered nurse. I just felt a little bit comfortable with that title. She just seemed very personable, friendly, and that she would be the best fit for our family.

“I think understanding Declyn’s condition as well… she’s aware of the terms and what has happened to him. She has more of the insight that a nurse would. She was very aware of everything that we went through at the hospital – which wasn’t easy. Declyn definitely did not have an easy go the last day of his life. (Howard), being aware of the terms and what a hospital setting is like, also feels a little bit comforting.”

She describes her feelings when she found out, after already seeing Howard, that her services wouldn’t be covered by insurance as disappointed, frustrated, and devastated.

“We’ve been through a lot. The last thing that we wanted to worry about was a financial burden for therapy, which is something that we were strongly suggested to get. It was so hard to, first of all, find someone that would speak with us… And then to pay this up front, it was hard. It was very frustrating. I think Brad and I can both say we really wanted the help for us but also for our children.”

After some back and forth with their insurance, Brad said that “they basically wrote us a letter back and said there wasn’t going to be any coverages for her services. Our kids have talked to her a couple times. Now Amanda has talked to her a couple of times. All of it has been out of pocket with no coverage.

“It’s kind of a big burden when you have the insurance benefits, and certain things are not covered, because there’s loopholes, basically. It’s money that we don’t necessarily have and want to spend right now. But we know that the services that are provided from [Howard] are going to benefit everyone within our house. That’s our main objective right now, to make sure that everyone mentally is dealing with this as best as we can.”

They say that Declyn had an enormous impact on their lives – and their children’s lives. After his passing they have been looking for a way to make sense of his death.

“One of our main goals was to kind of figure out what the purpose was of his life and his passing. When someone passes away, that’s an important thing to do,” Amanda said. She said that shedding light on this issue, on this discrepancy, can be that purpose. “So like Brad said, if it’s going to help other families, then we’re doing our job.”

In a letter from Sun Life to Sheena Howard—about RNs being covered as psychotherapists in general—the insurance provider wrote:

“Today (April 6, 2022), our standard contracts don’t support this coverage. Our contracts weren’t designed, nor priced, to allow psychotherapy services for RN’s… We’re looking at revising our contracts and processes. Our approach to mental health coverage has evolved as well. Unfortunately, we don’t have a definitive timeline of when changes may be made… this letter does represent our current final position.”

The Sun Life representative who provided the letter was contacted but didn’t respond in time for press.

Tourloukis indicated that aside from Sun Life, Manulife and Canada Life have also rejected their claims. She noted that Greenshield was one of the only insurance companies which recognized RNs as psychotherapists.

Connor Luczka, Local Journalism Initiative Reporter, Listowel Banner

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