March 12, 2025 • 26 mins
Getting help for mental health and substance use issues is not easy. It’s made more difficult when access to the appropriate care is denied. Kandyce Walker discusses her work with people experiencing mental health crises, and her advocacy to get them the help they need. Kandyce was the Chief Operating Officer and Director of Nursing at Trauma Recovery Institute in Cedar Park, Texas. That center, unfortunately, closed due, in part, to lack of reimbursement. Kandyce began working in trauma and recovery in 2006 as an EMT, then worked as a Paramedic, Emergency Medical Dispatcher, and now as a Registered Nurse. Working with patients throughout the process of a physical trauma, Kandyce was witness to its impact on people both physically and emotionally. Kandyce can be contacted at https://www.linkedin.com/in/kandyce-walker-rn-8979a6120
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Mike (00:12):
Welcome, everybody.
This is Avoiding the AddictionAffliction, brought to you by Westwords
Consulting and the Kenosha CountySubstance Use Disorder Coalition.
I'm Mike McGowan.
Given everything we read and hear aboutthe increase in people experiencing mental
health and substance use issues, you wouldthink getting help for those issues would
be increasingly easy, (chuckle) right?
(00:36):
No, wrong.
So many of us rely on insurers whenthey or family members are in need of
higher touch mental health treatment,such as intensive outpatient programs,
round the clock care and residential.
Well, what happens when theaccess to that help is denied?
That's among the topics we're going totalk about with our guest, Kandyce Walker.
(00:56):
Kandyce was, and we'll get intothis, the chief operating officer and
director of nursing at Trauma RecoveryInstitute in Cedar Park, Texas.
Welcome, Kandyce.
Kandyce (01:07):
Hi, Mike.
Thank you for having me.
Mike (01:09):
Well, it's always good to talk to somebody from Texas.
You sound better than I do.
Kandyce (01:13):
(laugh) Well, you know, depending on the weather.
Every day is something different.
We'll see what my mood is like today.
Mike (01:20):
Hey, we're coming out of winter here.
It was minus something last week atthis time and now it's 40 some degrees.
That's spring, right?
Kandyce (01:28):
Yeah, that's spring.
Exactly.
It's coming.
Mike (01:31):
Before we get into the substance of the conversation, I
mentioned in the introduction theTrauma Recovery Institute, you all
had to close your doors, right?
Kandyce (01:39):
We did, actually.
Mike (01:40):
In August of... and what precipitated that?
Because it's germane to our conversation.
Kandyce (01:45):
Yeah, it actually it goes really right in hand with this
conversation that we're having.
So, there were a few differentthings that kind of went into play.
But the Trauma RecoveryInstitute opened in 2001.
Just as a small outpatient, P. H.P. I. O. P. (Partial Hospitalization
and Intensive Outpatient Program)The doctor that we're working with,
Dr. Colin Ross is very well known forhis work with dissociative disorders.
(02:07):
So we were actually a very specializedclinic really specifically working
with dissociative disorders,but really anybody with trauma.
And we realized that there really weren'ta lot of P. H. P. I. O. P.'s around
that were not connected to hospitals.
And so we decided to open up the facility.
I will say that over the four yearsthat we were open or three and a
(02:28):
half, we struggled with insurance.
It was a constant fight all the time.
Every single client.
It was never an easy process.
As the providers, when you're trying tofocus on patient care, which is where your
focus should be, instead, you're puttingendless man hours into just trying to
get paid for your services and don't evenget me started on reimbursement rates.
(02:52):
Reimbursement rates.
So essentially long story shortis in August of 2024, we ended
up having to close our doors.
We were not making enough money toessentially keep the program open
and running at a high quality level.
Mike (03:07):
I'm shaking my head because this is not a new story and it's frustrating.
Part of the reason I'm doing whatI'm doing today is I got tired,
Kandyce, of arguing with insurancecompanies to get an additional 24
hours with somebody that was going toend up in an ER if we discharge them.
Kandyce (03:24):
Absolutely.
Absolutely.
That's why I'm so excited to be heretoday because this is absolutely a
topic that I'm super passionate aboutbecause the reality is that people
do not come to treatment for mentalhealth or substance abuse because
they're doing well in life, right?
They are not doing very good.
And so when you've got somebodywho's already not doing well,
(03:48):
they're not handling emotions.
They've got a lot of stuff that'shappened to them over their lifetime.
Dealing with insurance isan added stressor, right?
So it's like, we're trying to getthem to be able to learn skills
and be able to manage life.
And then you throw in insurancethat says, Oh, Hey, just kidding.
I know you pay a monthly premium,but we're not going to cover this
(04:12):
for X Y Z. And they'll give youwhatever reason they feel like because
every policy is different and everyinsurance company is different and
how they do things are different.
And so then the clients have thislooming over their head of either
A:, how am I going to pay for this?
B (04:28):
you know, am I going to be able to say, am I going to get cut off,
my insurance, then what do I do?
And, you know, and a lot ofAmericans right now can't afford
to self pay mental health.
So then it becomes this epidemicof, well, if you have money.
Then you get treatment.
So it's mental health andsubstance abuse has become a luxury
(04:50):
and it shouldn't be a luxury.
Mike (04:51):
And we'll get into your background in a, in just a little
while, but I, I actually ask you tobe a part of this after reading an
article in ProPublica that chronicledsomebody that you worked with.
And she was getting better.
And then the insurance company said, andI love this, Oh, you're getting better.
(05:11):
Therefore, you no longerneed the treatment.
Kandyce (05:14):
Exactly.
Mike (05:15):
What other disease do we do that with?
Kandyce (05:17):
And I say this all the time where it's like, Okay, here's
the trick is you've got to getbetter, but only get better enough.
Mike (05:25):
(laugh)
Kandyce (05:25):
Because if you get too better, then they don't want to approve you.
So it's really like a double edged sword.
It's like, if you are not gettingbetter, Well, then your treatment's not
working and we're not going to cover it.
But if they're getting better,then it's, Oh, well, now they
don't need your treatment.
And I will tell you, I havepersonally done many peer to peers.
(05:46):
So that's kind of the way that it worksin insurance world for those people who
don't understand of like, you get thetreatment, you can get an authorization,
you submit a claim, they can approve ordeny for whatever reason they feel like.
And then at that point, now you haveto appeal and you have to try to
fight to get your money for servicesyou've already provided for someone
and so with insurance companies, theywill essentially come in when you do
(06:11):
utilization review, which is essentiallywhere you discuss the case with them,
(air quotes) "discuss" and they will say,Okay, well, we're not approving anymore.
So they need today's their last day.
Mike (06:23):
Yeah.
Kandyce (06:23):
Well, how kind is that to just take somebody and say, Hey, you
know, this treatment that's reallyhelping you and you're feeling better?
Well, it's gone as of todayand we have no other options.
And so with our facility, one of thereasons that it kind of took a financial
hardship is because the doctor andI, we refused to discharge people on
(06:43):
the day that insurance denied them.
So we would always give them anextra free week to transition.
Now is that the right thing to do?
Yes.
Business wise, is thatthe right thing to do?
It's not for your pocketbook.
You know, so it's likequality care versus money.
Mike (06:59):
Let's use specifics.
We can't obviously use people's names.
But this is somebodytypical typical, right?
She was suicidal, she was depressed,she was cutting up to three times
a week And she was getting better.
Kandyce (07:15):
Right.
Mike (07:17):
And then the review process, as I recall, one of the doctors
took all of seven minutes.
Seven minutes.
Kandyce (07:26):
Seven minutes.
Mike (07:29):
To review a case and say, yeah, I made my determination.
Well, okay.
Who are they working for?
Kandyce (07:36):
I like to think that as Americans, we think that our
medical doctors are the ones thatare deciding what our care is.
Unfortunately, it's theinsurance companies.
Because I've never really understood whyif a doctor says, Hey, I have spent time.
I have evaluated this patient.
I have determined that this iswhat the right thing is for them.
(07:59):
That an insurance company,medical doctors, a psychiatrist,
or whatever doctor he is.
Can get on the phone, ask a handfulof questions and then say, no.
You know, like for instance, forcertain clients that are suicidal
and they're actively suicidal.
I had a client once thatwas absolutely suicidal.
(08:21):
All the documentation toprove it and still got denied.
Guess what?
We won that appeal.
But do you know how many months later?
It was eight months laterthat we finally got paid.
So you know what I mean?
It's like all the documentation,they're just taking it.
And sometimes it depends.
So some insurance companies willuse something called a locus.
It's called a level ofcare utilization system.
(08:43):
And so it's kind of a questionnaire,but it leaves out all the meat to why
a client is there things going on?
So sure objectively that daythey might be doing okay.
But what else is going on?
And so we're not looking at a bigpicture, they're just looking at like
where they're at right in this moment.
Mike (09:04):
And it also assumes a level of care, a continuum of care that may not exist.
Kandyce (09:11):
Correct.
Mike (09:11):
I mean, it's not like you go from floor five to floor four to three to one.
What if you go from five to there isno 4, 3, 2, and now you're just back
in floor one, if that makes sense.
Kandyce (09:21):
Right.
Right.
There's a lot of like continuationof care that just kind of falls off.
When insurance denies.
And the thing is, is that a lotof times, and I'm just going
off my personal experience.
And I'm not going to say everysingle person that we dealt with
with insurance was terrible.
We had some really great ones.
But I can remember very specificallyarguing with a utilization rep because
(09:46):
she initially was like, I'm not goingto approve I. O. P. Level of care.
And then after talking to her, shewas like, well, no, I'm not going to
approve I. O. P., she now needs P.H. P., which P. H. P. Is a level up
when the initial part of the call,she was trying to make me go down.
And it was just this back and forthand the argument of well, they're
(10:08):
getting better so they, they don'tneed treatment and I'm like, okay,
well, or they're getting worse.
A lot of times in treatment andin substance abuse and mental
health they go hand in hand, right?
And you see these things andit's like they're getting better
It's like or they're getting worse.
Sometimes I expect them to getworse before they get better.
(10:29):
If you've been dissociating you'vebeen putting down and you've been doing
drugs and you're doing all the thingsto to keep you from dealing with the
stuff that's causing these symptoms.
When you start bringing it up, youcan get worse before you get better
because you've got to tackle it.
You got to address it.
So having a little bit of setback iskind of really normal when you're going
(10:51):
through the scheme of things, but whenthey take this little snapshot of what's
going on and then make a determinationwithout any external factors of what
is personally going on in their livesand all that, and they'll cut you off.
No, no, no, I have questions.
Just answer the questions.
Okay, but you're missing it.
You're missing it.
(11:12):
And it's just you more,clients are people.
They're not numbers.
Mike (11:16):
And one of the things I don't understand, and I've never really
understood this, is that for instance,when that person we're talking about was
in discharge, it would have cost, I thinkthe article said 10 grand to keep her in
another residential facility for so long.
Well, she ended upsuicidal, redoing stuff.
(11:38):
Ended up in ER and the billto the insurance company
ended up not being 10 grand.
60 grand.
Kandyce (11:45):
Oh, ridiculous.
Mike (11:48):
That's what I don't understand, Kandyce.
It's cost effective to listen tothe people doing the treatment.
And if I can be cynical, it'salmost as though they think
you're scamming them, rather thanproviding accurate information.
Kandyce (12:04):
Absolutely.
And it always felt that way.
I think as a provider in dealing withinsurance companies, it was kind of a
little anxiety inducing for some of myclinicians that had to do peer to peers.
Because you don't feel like you'refighting with somebody to help someone.
You feel like you're fightingan enemy and the insurance
does kind of become an enemy.
(12:25):
But exactly to your point, what ProPublicawrote about was one wonderful, beautiful
story that actually reflects so manypeople with that exact same story.
That happened more times than I cancount so much so that during UR calls.
I would tell them Okay, well, i'm gonnalet you know you're gonna deny this
(12:47):
and then this client is going to end upsuicidal and they're going to end up at
the ER and you're going to end up withinpatient and now you're going to have
to start back from inpatient down toP. H. P. to I. O. P. So this actually
is going to cost you more money and itcould possibly cost this client's life.
I have sat for hours on the phonecounseling client, like I'm not a
(13:08):
therapist, but talking with clients abouttheir insurance and about the fact that
now the one time that they find a placethat they feel like they fit in, that they
can find similarities in their groups andthey're finding treatment that's helped.
It is now ripped away from them.
So that hope that they had is now gone.
(13:28):
So what is the point in living?
Because I had treatment, I was gonnado it, and now I don't have anything,
and I'm left by myself again.
And so they become suicidal,and then they go to the ER, and
the lucky ones go to the ER.
What happens to the ones who don't andthen we're losing people over insurance
denials when based on the reimbursementrates we got, give me a break.
(13:52):
They're not hurting that bad.
But I use this analogy all the timebecause my previous experience was
I was a paramedic and then becamean RN and then ended up working my
way up at Trauma Recovery Institute.
But I'm like, okay, if somebody gotinto a car accident, just think of this.
Somebody gets into a car accidentand they have broken so many
(14:12):
different bones in their body andthey got to go to rehab, right?
Cause they can't walk, they can't move.
And then insurance company says,okay, well, we're only going to give
you three to four days at a time.
And then I need you to keep callingto let me know, but after 30 days or
40 days, yeah, you're done and no moretreatment that would be cruel and unkind.
(14:36):
So until we can start looking atmental health, just because we visibly
can't see what's going on inside.
And so we start looking at thatthe same way as we look at trauma,
physical body trauma that youcan see, what is the difference?
Mike (14:51):
None.
And you come to thisfrom being an EMT, right?
Kandyce (14:56):
Correct.
Mike (14:56):
You got to see the whole spectrum, and you made the choice
then to work on this end of the field.
Kandyce (15:02):
Yeah, and honestly, it was kind of interesting when I first started
into mental health, I was like, I don'treally have mental health experience.
And then I realized, my timeas a paramedic gave me a lot
of mental health experience.
(laugh)
Mike (15:15):
I would think so.
I would think so.
Kandyce (15:17):
So you get to witness a lot of, you know, some of the most horrific
things that, that you can be a part ofand you see people go through and then
it transitioned pretty well into mentalhealth, but and listen, I'm always been
very, very open about my own story.
Really my passion for mental healthcame from therapy saving my own life.
It's something that I have said for a longtime, I've done a lot of hours of my own
(15:41):
personal therapy, but because I've beenthrough it myself and I've been a client
at some point in my life, I understandhow they feel because I've been there.
And where my life was at versus whereit is now, I would have never guessed
that this is what would happen.
And that's just with treatment,it can really change your life.
Mike (16:00):
Yeah, I think that story is so typical of a lot of, not all, but
a lot of practitioners got into theline of work because they were helped.
Kandyce (16:10):
Yeah, it will.
And especially when you think aboutlike in your lowest times, you're
like, I'm never getting out of this.
There's no help for me.
There really is.
It's the right help, but you gotto be able to get to it if you
need to use insurance and how manypeople need to use insurance, a lot.
(laugh)
Mike (16:28):
Is that how you access the help for yourself?
How did you end upaccessing the help system?
Kandyce (16:35):
So I actually was able to just save up enough money to where
I was able to do therapy enough.
And luckily I just got lucky and I luckedout with the most rockstar therapist ever.
And so she was able to get a lot donewith what I could do, but I mean, we're
running into this pretty much everywherewhere individual clinicians and therapists
(16:58):
are not getting paneled with insurancesbecause A: it's not worth it, B: the
reimbursement rates are trash, C (17:04):
they're going to have to fight to get their money.
And so they're going to a cashpay option, which I understand.
They got to make a living.
They've got to earn it.
But then you've got somebody who'sstruggling to, they, they're having
a hard time even keeping a job.
And now I got to look for $100to $200 a week for self pay.
(17:25):
I mean, it gets pricey.
So a lot of people have to usetheir insurance, but if nobody's
taking insurance anymore, then what?
Mike (17:33):
Well, okay.
Let me break that down.
Cause this is a conversation,Kandyce, I have a lot with my
friends who are therapists.
If you go to a cash pay system.
Well, what's your clientele looklike and what do the underserved do?
And now we see the Medicaid system.
We don't know, but as we sit here, theMedicaid system is being threatened.
(17:58):
So what do people do whodon't have access to cash?
We can't just serve people who can pay.
Kandyce (18:06):
Yeah.
And you know, and I think that that tome is what the sad thing about this is.
Which is kind of reverts back to the wholeif you have money, you get care, right?
So you it's a privilege.
You know what people who don't have fundsare doing is they're going to you know
local community centers and we try to youknow stay in contact with all like any
(18:28):
kind of programs that offer discountedtherapy services and things like that.
Now you're going to get what comeswith that, which is going to be
probably early level clinicians,and there's nothing wrong with it.
Hey, I used to hire early levelclinicians all the time and I love them.
So no shame on that.
But, you know, you're going to havehigher turnover because if they're
(18:49):
not hardly charging anything, thenpeople are not hardly making anything.
And so when you're a newtherapist, and you're trying to
build yourself up, that works.
But once you get out on your own,you're like, I can make more money.
Everybody needs to beable to afford to live.
And with cost of living goingup as it is, it's making it hard
for clinicians and clients, both.
Mike (19:12):
Well, the case that we're talking about that was in the article, you
managed to guide that person backinto the appropriate level of care.
And then how long does it take toacquire the support system and the
skills necessary to be in a safe zone?
Kandyce (19:29):
That's a really great question.
And I really think it kind ofdepends on the client, right.
And it kind of dependson where they come in at.
How much treatment have they already had?
Where are they at?
What are they trying to focus on?
I had clients that sometimes they'dcome and they would say, I have two
weeks and I'm like, all right, geton in here and we're going to do the
best we can with the two weeks we got.
(19:50):
I had one client with an insurance policythat there was no authorization needed.
And so she was able to staywith us for almost a year.
And based on trauma history, sheneeded it, she needed all of that
because we're not talking, I mean,like, of course, we've got anxiety,
depression, some of the basic stuff.
(20:10):
I always say that, like all of usAmericans live with every single day now.
But no, as a joke, but no, a lotof our clients are coming because
they have horrific, horrific pasts.
Things that we read about with theJeffrey Epstein stuff and the physical
and the sexual and the psychologicalabuse and these kind of things, they don't
(20:32):
get better after 30 days of treatment.
This is a lifetime of abuseand of hurt and of harm.
And that doesn't just magically go awaybecause you attend 30 group sessions and a
couple individuals, you know what I mean?
Mike (20:48):
Yeah, and we've had so many people on this podcast and I've worked
with so many people over the yearswho in recovery will drop on you.
Oh, yeah, and did I talk to you about thesexual abuse that I suffered which is...
If they're using substances or they'redisassociated, we'll never deal with it.
It's only from a safe place thatthey can deal with some of that
(21:11):
really hard stuff to turn that cornerand not carry the shame with them.
Kandyce (21:16):
You literally just hit the exact thing that I learned.
The one thing that I learned in runningTrauma Recovery Institute was the
number one thing for clients is safety.
Safety.
They need to feel safe in theenvironment that they're in.
They need to feel safe with the peoplethat they're in the group with, and
they need to feel safe with thoseclinicians that are leading groups,
(21:39):
or the clinician that's with them.
So, that's in a facility setting,but in an individual therapy setting.
Like that safety and that trust haveto be there before they'll open up.
And so, that was another thing we wouldgo into with insurance companies, is,
you know what, it might take two tothree weeks for us to build safety.
For us to even build thatcore, like we are here for you.
(22:03):
We are here to help you.
These people have been abused,abandoned, taken advantage of.
They come to us with other treatmentcenter trauma, other clinician trauma.
They don't trust people.
And what I would say.
Every time you don'ttrust me and guess what?
If you did, I'd be a littlemore concerned, right?
Because your entire life hastaught you don't trust anybody.
(22:25):
So that trust building needs to bebuilt into treatment center times
of how much time they're giving butthese insurance companies are not
looking at our clients as people.
It's all about money.
Mike (22:39):
Yeah.
So what are you doing now?
Kandyce (22:42):
So I'm actually in the process of moving into actually
working for a billing company.
It's a, just a smallbusiness billing company.
Believe it or not, it's actually the onethat I hired and they worked with me.
And so we essentially wentthrough the ringer together.
And so now my goal is to advocatefor clients, facilities, doing
(23:03):
appeals like I will fight theseinsurance companies because I'm now
seeing it with other facilities.
So that tells me we weren'tthe only one dealing with this.
Mike (23:13):
Oh, no, I think it's endemic.
Don't you?
Kandyce (23:16):
Absolutely.
And until we really start openly talkingabout it... I do love this new age and
era where now we're starting to talk aboutmental health and substance abuse and how
really, truly important this stuff is,but until we can get the word out there
of like, hey, these insurance companiesgot to quit deciding and well, insurance
(23:37):
companies deciding what our client care isgoing to be, our doctors need to do that.
Mike (23:42):
Yeah.
Did you ever, this is going tosound like a weird question.
Kandyce (23:45):
Go ahead.
Mike (23:46):
Do you ever see the Incredibles?
Kandyce (23:48):
Yes.
Mike (23:49):
Okay.
All right.
The, the scene we're talking about, ifthose of you who've seen it know what I'm
going to say is where he sits there andhe whispers to the woman, I can't tell
you what to do, but if I were you, I'd goto this floor and fill out this form and
do this as a way to just get more care.
People need advocates, Kandyce.
Kandyce (24:08):
Absolutely and that has been my goal since Trauma
Recovery Institute closing.
I mean, it broke my heart.
It broke my heart that we were providingreally good care and like top of the
level, the clients kept coming back.
Our referrals were based onclients telling other clients,
like they were our babies.
We loved them.
(24:28):
We had an amazing facility.
So to see it shut down becauseof something like this.
Now I just use that anger and I fuelit towards advocating for other people
because you'll learn a lot and a lotof people really just don't know.
And so you go off of like, I don't know,my insurance sent me a bill and then it
says I owe this much and I pay it andI just, or they said I can't, you know,
(24:51):
they're not going to cover it and now Iowe $20,000 like, okay, let's fight this.
And I think insurance companiesalmost kind of they, I don't
know, I'm looking for the words.
So it's almost like they arehoping that you don't fight them.
Mike (25:07):
Right.
Kandyce (25:08):
Because guess what, then you don't have to pay and sometimes
fighting them is exhausting.
Mike (25:12):
It is.
Maybe I should call you Mrs. Incredible.
Kandyce (25:15):
Yeah, hey, there you go.
I'll take it!
Mike (25:17):
Yeah, it has to, I'll let you go with this.
It has to feel good.
It has to feel good when you helpsomebody navigate that system.
Kandyce (25:26):
Absolutely.
Mike (25:27):
Because who would know how?
You and I know the system andwe struggle navigating it.
Kandyce (25:32):
Mm hmm.
Even knowing the system,you struggle with it.
So people who don't know anythingabout the system, those are my people.
That's who I want tohelp because it's unfair.
Mike (25:47):
I hope you're continue to do it.
We can hear the passion in your voice.
I'm going to attach.
Kandyce's LinkedIn information in caseyou want to get a hold of her and just
continue this dialogue somewhere else.
Thanks for your passion, your hope,your expertise, Kandyce, this is great.
For those of you listening, we hopeyou join us anytime you're able.
And until then, we hopethat you stay safe.
(26:09):
Speak up when you can.
And if you're able to, speak up forpeople who can't speak up for themselves.
Welcome, everybody.
This is Avoiding the AddictionAffliction, brought to you by Westwords
Consulting and the Kenosha CountySubstance Use Disorder Coalition.
I'm Mike McGowan.
Given everything we read and hear aboutthe increase in people experiencing mental
health and substance use issues, you wouldthink getting help for those issues would
be increasingly easy, (chuckle) right?
(00:36):
No, wrong.
So many of us rely on insurers whenthey or family members are in need of
higher touch mental health treatment,such as intensive outpatient programs,
round the clock care and residential.
Well, what happens when theaccess to that help is denied?
That's among the topics we're going totalk about with our guest, Kandyce Walker.
(00:56):
Kandyce was, and we'll get intothis, the chief operating officer and
director of nursing at Trauma RecoveryInstitute in Cedar Park, Texas.
Welcome, Kandyce.
Kandyce (01:07):
Hi, Mike.
Thank you for having me.
Mike (01:09):
Well, it's always good to talk to somebody from Texas.
You sound better than I do.
Kandyce (01:13):
(laugh) Well, you know, depending on the weather.
Every day is something different.
We'll see what my mood is like today.
Mike (01:20):
Hey, we're coming out of winter here.
It was minus something last week atthis time and now it's 40 some degrees.
That's spring, right?
Kandyce (01:28):
Yeah, that's spring.
Exactly.
It's coming.
Mike (01:31):
Before we get into the substance of the conversation, I
mentioned in the introduction theTrauma Recovery Institute, you all
had to close your doors, right?
Kandyce (01:39):
We did, actually.
Mike (01:40):
In August of... and what precipitated that?
Because it's germane to our conversation.
Kandyce (01:45):
Yeah, it actually it goes really right in hand with this
conversation that we're having.
So, there were a few differentthings that kind of went into play.
But the Trauma RecoveryInstitute opened in 2001.
Just as a small outpatient, P. H.P. I. O. P. (Partial Hospitalization
and Intensive Outpatient Program)The doctor that we're working with,
Dr. Colin Ross is very well known forhis work with dissociative disorders.
(02:07):
So we were actually a very specializedclinic really specifically working
with dissociative disorders,but really anybody with trauma.
And we realized that there really weren'ta lot of P. H. P. I. O. P.'s around
that were not connected to hospitals.
And so we decided to open up the facility.
I will say that over the four yearsthat we were open or three and a
(02:28):
half, we struggled with insurance.
It was a constant fight all the time.
Every single client.
It was never an easy process.
As the providers, when you're trying tofocus on patient care, which is where your
focus should be, instead, you're puttingendless man hours into just trying to
get paid for your services and don't evenget me started on reimbursement rates.
(02:52):
Reimbursement rates.
So essentially long story shortis in August of 2024, we ended
up having to close our doors.
We were not making enough money toessentially keep the program open
and running at a high quality level.
Mike (03:07):
I'm shaking my head because this is not a new story and it's frustrating.
Part of the reason I'm doing whatI'm doing today is I got tired,
Kandyce, of arguing with insurancecompanies to get an additional 24
hours with somebody that was going toend up in an ER if we discharge them.
Kandyce (03:24):
Absolutely.
Absolutely.
That's why I'm so excited to be heretoday because this is absolutely a
topic that I'm super passionate aboutbecause the reality is that people
do not come to treatment for mentalhealth or substance abuse because
they're doing well in life, right?
They are not doing very good.
And so when you've got somebodywho's already not doing well,
(03:48):
they're not handling emotions.
They've got a lot of stuff that'shappened to them over their lifetime.
Dealing with insurance isan added stressor, right?
So it's like, we're trying to getthem to be able to learn skills
and be able to manage life.
And then you throw in insurancethat says, Oh, Hey, just kidding.
I know you pay a monthly premium,but we're not going to cover this
(04:12):
for X Y Z. And they'll give youwhatever reason they feel like because
every policy is different and everyinsurance company is different and
how they do things are different.
And so then the clients have thislooming over their head of either
A:, how am I going to pay for this?
B (04:28):
you know, am I going to be able to say, am I going to get cut off,
my insurance, then what do I do?
And, you know, and a lot ofAmericans right now can't afford
to self pay mental health.
So then it becomes this epidemicof, well, if you have money.
Then you get treatment.
So it's mental health andsubstance abuse has become a luxury
(04:50):
and it shouldn't be a luxury.
Mike (04:51):
And we'll get into your background in a, in just a little
while, but I, I actually ask you tobe a part of this after reading an
article in ProPublica that chronicledsomebody that you worked with.
And she was getting better.
And then the insurance company said, andI love this, Oh, you're getting better.
(05:11):
Therefore, you no longerneed the treatment.
Kandyce (05:14):
Exactly.
Mike (05:15):
What other disease do we do that with?
Kandyce (05:17):
And I say this all the time where it's like, Okay, here's
the trick is you've got to getbetter, but only get better enough.
Mike (05:25):
(laugh)
Kandyce (05:25):
Because if you get too better, then they don't want to approve you.
So it's really like a double edged sword.
It's like, if you are not gettingbetter, Well, then your treatment's not
working and we're not going to cover it.
But if they're getting better,then it's, Oh, well, now they
don't need your treatment.
And I will tell you, I havepersonally done many peer to peers.
(05:46):
So that's kind of the way that it worksin insurance world for those people who
don't understand of like, you get thetreatment, you can get an authorization,
you submit a claim, they can approve ordeny for whatever reason they feel like.
And then at that point, now you haveto appeal and you have to try to
fight to get your money for servicesyou've already provided for someone
and so with insurance companies, theywill essentially come in when you do
(06:11):
utilization review, which is essentiallywhere you discuss the case with them,
(air quotes) "discuss" and they will say,Okay, well, we're not approving anymore.
So they need today's their last day.
Mike (06:23):
Yeah.
Kandyce (06:23):
Well, how kind is that to just take somebody and say, Hey, you
know, this treatment that's reallyhelping you and you're feeling better?
Well, it's gone as of todayand we have no other options.
And so with our facility, one of thereasons that it kind of took a financial
hardship is because the doctor andI, we refused to discharge people on
(06:43):
the day that insurance denied them.
So we would always give them anextra free week to transition.
Now is that the right thing to do?
Yes.
Business wise, is thatthe right thing to do?
It's not for your pocketbook.
You know, so it's likequality care versus money.
Mike (06:59):
Let's use specifics.
We can't obviously use people's names.
But this is somebodytypical typical, right?
She was suicidal, she was depressed,she was cutting up to three times
a week And she was getting better.
Kandyce (07:15):
Right.
Mike (07:17):
And then the review process, as I recall, one of the doctors
took all of seven minutes.
Seven minutes.
Kandyce (07:26):
Seven minutes.
Mike (07:29):
To review a case and say, yeah, I made my determination.
Well, okay.
Who are they working for?
Kandyce (07:36):
I like to think that as Americans, we think that our
medical doctors are the ones thatare deciding what our care is.
Unfortunately, it's theinsurance companies.
Because I've never really understood whyif a doctor says, Hey, I have spent time.
I have evaluated this patient.
I have determined that this iswhat the right thing is for them.
(07:59):
That an insurance company,medical doctors, a psychiatrist,
or whatever doctor he is.
Can get on the phone, ask a handfulof questions and then say, no.
You know, like for instance, forcertain clients that are suicidal
and they're actively suicidal.
I had a client once thatwas absolutely suicidal.
(08:21):
All the documentation toprove it and still got denied.
Guess what?
We won that appeal.
But do you know how many months later?
It was eight months laterthat we finally got paid.
So you know what I mean?
It's like all the documentation,they're just taking it.
And sometimes it depends.
So some insurance companies willuse something called a locus.
It's called a level ofcare utilization system.
(08:43):
And so it's kind of a questionnaire,but it leaves out all the meat to why
a client is there things going on?
So sure objectively that daythey might be doing okay.
But what else is going on?
And so we're not looking at a bigpicture, they're just looking at like
where they're at right in this moment.
Mike (09:04):
And it also assumes a level of care, a continuum of care that may not exist.
Kandyce (09:11):
Correct.
Mike (09:11):
I mean, it's not like you go from floor five to floor four to three to one.
What if you go from five to there isno 4, 3, 2, and now you're just back
in floor one, if that makes sense.
Kandyce (09:21):
Right.
Right.
There's a lot of like continuationof care that just kind of falls off.
When insurance denies.
And the thing is, is that a lotof times, and I'm just going
off my personal experience.
And I'm not going to say everysingle person that we dealt with
with insurance was terrible.
We had some really great ones.
But I can remember very specificallyarguing with a utilization rep because
(09:46):
she initially was like, I'm not goingto approve I. O. P. Level of care.
And then after talking to her, shewas like, well, no, I'm not going to
approve I. O. P., she now needs P.H. P., which P. H. P. Is a level up
when the initial part of the call,she was trying to make me go down.
And it was just this back and forthand the argument of well, they're
(10:08):
getting better so they, they don'tneed treatment and I'm like, okay,
well, or they're getting worse.
A lot of times in treatment andin substance abuse and mental
health they go hand in hand, right?
And you see these things andit's like they're getting better
It's like or they're getting worse.
Sometimes I expect them to getworse before they get better.
(10:29):
If you've been dissociating you'vebeen putting down and you've been doing
drugs and you're doing all the thingsto to keep you from dealing with the
stuff that's causing these symptoms.
When you start bringing it up, youcan get worse before you get better
because you've got to tackle it.
You got to address it.
So having a little bit of setback iskind of really normal when you're going
(10:51):
through the scheme of things, but whenthey take this little snapshot of what's
going on and then make a determinationwithout any external factors of what
is personally going on in their livesand all that, and they'll cut you off.
No, no, no, I have questions.
Just answer the questions.
Okay, but you're missing it.
You're missing it.
(11:12):
And it's just you more,clients are people.
They're not numbers.
Mike (11:16):
And one of the things I don't understand, and I've never really
understood this, is that for instance,when that person we're talking about was
in discharge, it would have cost, I thinkthe article said 10 grand to keep her in
another residential facility for so long.
Well, she ended upsuicidal, redoing stuff.
(11:38):
Ended up in ER and the billto the insurance company
ended up not being 10 grand.
60 grand.
Kandyce (11:45):
Oh, ridiculous.
Mike (11:48):
That's what I don't understand, Kandyce.
It's cost effective to listen tothe people doing the treatment.
And if I can be cynical, it'salmost as though they think
you're scamming them, rather thanproviding accurate information.
Kandyce (12:04):
Absolutely.
And it always felt that way.
I think as a provider in dealing withinsurance companies, it was kind of a
little anxiety inducing for some of myclinicians that had to do peer to peers.
Because you don't feel like you'refighting with somebody to help someone.
You feel like you're fightingan enemy and the insurance
does kind of become an enemy.
(12:25):
But exactly to your point, what ProPublicawrote about was one wonderful, beautiful
story that actually reflects so manypeople with that exact same story.
That happened more times than I cancount so much so that during UR calls.
I would tell them Okay, well, i'm gonnalet you know you're gonna deny this
(12:47):
and then this client is going to end upsuicidal and they're going to end up at
the ER and you're going to end up withinpatient and now you're going to have
to start back from inpatient down toP. H. P. to I. O. P. So this actually
is going to cost you more money and itcould possibly cost this client's life.
I have sat for hours on the phonecounseling client, like I'm not a
(13:08):
therapist, but talking with clients abouttheir insurance and about the fact that
now the one time that they find a placethat they feel like they fit in, that they
can find similarities in their groups andthey're finding treatment that's helped.
It is now ripped away from them.
So that hope that they had is now gone.
(13:28):
So what is the point in living?
Because I had treatment, I was gonnado it, and now I don't have anything,
and I'm left by myself again.
And so they become suicidal,and then they go to the ER, and
the lucky ones go to the ER.
What happens to the ones who don't andthen we're losing people over insurance
denials when based on the reimbursementrates we got, give me a break.
(13:52):
They're not hurting that bad.
But I use this analogy all the timebecause my previous experience was
I was a paramedic and then becamean RN and then ended up working my
way up at Trauma Recovery Institute.
But I'm like, okay, if somebody gotinto a car accident, just think of this.
Somebody gets into a car accidentand they have broken so many
(14:12):
different bones in their body andthey got to go to rehab, right?
Cause they can't walk, they can't move.
And then insurance company says,okay, well, we're only going to give
you three to four days at a time.
And then I need you to keep callingto let me know, but after 30 days or
40 days, yeah, you're done and no moretreatment that would be cruel and unkind.
(14:36):
So until we can start looking atmental health, just because we visibly
can't see what's going on inside.
And so we start looking at thatthe same way as we look at trauma,
physical body trauma that youcan see, what is the difference?
Mike (14:51):
None.
And you come to thisfrom being an EMT, right?
Kandyce (14:56):
Correct.
Mike (14:56):
You got to see the whole spectrum, and you made the choice
then to work on this end of the field.
Kandyce (15:02):
Yeah, and honestly, it was kind of interesting when I first started
into mental health, I was like, I don'treally have mental health experience.
And then I realized, my timeas a paramedic gave me a lot
of mental health experience.
(laugh)
Mike (15:15):
I would think so.
I would think so.
Kandyce (15:17):
So you get to witness a lot of, you know, some of the most horrific
things that, that you can be a part ofand you see people go through and then
it transitioned pretty well into mentalhealth, but and listen, I'm always been
very, very open about my own story.
Really my passion for mental healthcame from therapy saving my own life.
It's something that I have said for a longtime, I've done a lot of hours of my own
(15:41):
personal therapy, but because I've beenthrough it myself and I've been a client
at some point in my life, I understandhow they feel because I've been there.
And where my life was at versus whereit is now, I would have never guessed
that this is what would happen.
And that's just with treatment,it can really change your life.
Mike (16:00):
Yeah, I think that story is so typical of a lot of, not all, but
a lot of practitioners got into theline of work because they were helped.
Kandyce (16:10):
Yeah, it will.
And especially when you think aboutlike in your lowest times, you're
like, I'm never getting out of this.
There's no help for me.
There really is.
It's the right help, but you gotto be able to get to it if you
need to use insurance and how manypeople need to use insurance, a lot.
(laugh)
Mike (16:28):
Is that how you access the help for yourself?
How did you end upaccessing the help system?
Kandyce (16:35):
So I actually was able to just save up enough money to where
I was able to do therapy enough.
And luckily I just got lucky and I luckedout with the most rockstar therapist ever.
And so she was able to get a lot donewith what I could do, but I mean, we're
running into this pretty much everywherewhere individual clinicians and therapists
(16:58):
are not getting paneled with insurancesbecause A: it's not worth it, B: the
reimbursement rates are trash, C (17:04):
they're going to have to fight to get their money.
And so they're going to a cashpay option, which I understand.
They got to make a living.
They've got to earn it.
But then you've got somebody who'sstruggling to, they, they're having
a hard time even keeping a job.
And now I got to look for $100to $200 a week for self pay.
(17:25):
I mean, it gets pricey.
So a lot of people have to usetheir insurance, but if nobody's
taking insurance anymore, then what?
Mike (17:33):
Well, okay.
Let me break that down.
Cause this is a conversation,Kandyce, I have a lot with my
friends who are therapists.
If you go to a cash pay system.
Well, what's your clientele looklike and what do the underserved do?
And now we see the Medicaid system.
We don't know, but as we sit here, theMedicaid system is being threatened.
(17:58):
So what do people do whodon't have access to cash?
We can't just serve people who can pay.
Kandyce (18:06):
Yeah.
And you know, and I think that that tome is what the sad thing about this is.
Which is kind of reverts back to the wholeif you have money, you get care, right?
So you it's a privilege.
You know what people who don't have fundsare doing is they're going to you know
local community centers and we try to youknow stay in contact with all like any
(18:28):
kind of programs that offer discountedtherapy services and things like that.
Now you're going to get what comeswith that, which is going to be
probably early level clinicians,and there's nothing wrong with it.
Hey, I used to hire early levelclinicians all the time and I love them.
So no shame on that.
But, you know, you're going to havehigher turnover because if they're
(18:49):
not hardly charging anything, thenpeople are not hardly making anything.
And so when you're a newtherapist, and you're trying to
build yourself up, that works.
But once you get out on your own,you're like, I can make more money.
Everybody needs to beable to afford to live.
And with cost of living goingup as it is, it's making it hard
for clinicians and clients, both.
Mike (19:12):
Well, the case that we're talking about that was in the article, you
managed to guide that person backinto the appropriate level of care.
And then how long does it take toacquire the support system and the
skills necessary to be in a safe zone?
Kandyce (19:29):
That's a really great question.
And I really think it kind ofdepends on the client, right.
And it kind of dependson where they come in at.
How much treatment have they already had?
Where are they at?
What are they trying to focus on?
I had clients that sometimes they'dcome and they would say, I have two
weeks and I'm like, all right, geton in here and we're going to do the
best we can with the two weeks we got.
(19:50):
I had one client with an insurance policythat there was no authorization needed.
And so she was able to staywith us for almost a year.
And based on trauma history, sheneeded it, she needed all of that
because we're not talking, I mean,like, of course, we've got anxiety,
depression, some of the basic stuff.
(20:10):
I always say that, like all of usAmericans live with every single day now.
But no, as a joke, but no, a lotof our clients are coming because
they have horrific, horrific pasts.
Things that we read about with theJeffrey Epstein stuff and the physical
and the sexual and the psychologicalabuse and these kind of things, they don't
(20:32):
get better after 30 days of treatment.
This is a lifetime of abuseand of hurt and of harm.
And that doesn't just magically go awaybecause you attend 30 group sessions and a
couple individuals, you know what I mean?
Mike (20:48):
Yeah, and we've had so many people on this podcast and I've worked
with so many people over the yearswho in recovery will drop on you.
Oh, yeah, and did I talk to you about thesexual abuse that I suffered which is...
If they're using substances or they'redisassociated, we'll never deal with it.
It's only from a safe place thatthey can deal with some of that
(21:11):
really hard stuff to turn that cornerand not carry the shame with them.
Kandyce (21:16):
You literally just hit the exact thing that I learned.
The one thing that I learned in runningTrauma Recovery Institute was the
number one thing for clients is safety.
Safety.
They need to feel safe in theenvironment that they're in.
They need to feel safe with the peoplethat they're in the group with, and
they need to feel safe with thoseclinicians that are leading groups,
(21:39):
or the clinician that's with them.
So, that's in a facility setting,but in an individual therapy setting.
Like that safety and that trust haveto be there before they'll open up.
And so, that was another thing we wouldgo into with insurance companies, is,
you know what, it might take two tothree weeks for us to build safety.
For us to even build thatcore, like we are here for you.
(22:03):
We are here to help you.
These people have been abused,abandoned, taken advantage of.
They come to us with other treatmentcenter trauma, other clinician trauma.
They don't trust people.
And what I would say.
Every time you don'ttrust me and guess what?
If you did, I'd be a littlemore concerned, right?
Because your entire life hastaught you don't trust anybody.
(22:25):
So that trust building needs to bebuilt into treatment center times
of how much time they're giving butthese insurance companies are not
looking at our clients as people.
It's all about money.
Mike (22:39):
Yeah.
So what are you doing now?
Kandyce (22:42):
So I'm actually in the process of moving into actually
working for a billing company.
It's a, just a smallbusiness billing company.
Believe it or not, it's actually the onethat I hired and they worked with me.
And so we essentially wentthrough the ringer together.
And so now my goal is to advocatefor clients, facilities, doing
(23:03):
appeals like I will fight theseinsurance companies because I'm now
seeing it with other facilities.
So that tells me we weren'tthe only one dealing with this.
Mike (23:13):
Oh, no, I think it's endemic.
Don't you?
Kandyce (23:16):
Absolutely.
And until we really start openly talkingabout it... I do love this new age and
era where now we're starting to talk aboutmental health and substance abuse and how
really, truly important this stuff is,but until we can get the word out there
of like, hey, these insurance companiesgot to quit deciding and well, insurance
(23:37):
companies deciding what our client care isgoing to be, our doctors need to do that.
Mike (23:42):
Yeah.
Did you ever, this is going tosound like a weird question.
Kandyce (23:45):
Go ahead.
Mike (23:46):
Do you ever see the Incredibles?
Kandyce (23:48):
Yes.
Mike (23:49):
Okay.
All right.
The, the scene we're talking about, ifthose of you who've seen it know what I'm
going to say is where he sits there andhe whispers to the woman, I can't tell
you what to do, but if I were you, I'd goto this floor and fill out this form and
do this as a way to just get more care.
People need advocates, Kandyce.
Kandyce (24:08):
Absolutely and that has been my goal since Trauma
Recovery Institute closing.
I mean, it broke my heart.
It broke my heart that we were providingreally good care and like top of the
level, the clients kept coming back.
Our referrals were based onclients telling other clients,
like they were our babies.
We loved them.
(24:28):
We had an amazing facility.
So to see it shut down becauseof something like this.
Now I just use that anger and I fuelit towards advocating for other people
because you'll learn a lot and a lotof people really just don't know.
And so you go off of like, I don't know,my insurance sent me a bill and then it
says I owe this much and I pay it andI just, or they said I can't, you know,
(24:51):
they're not going to cover it and now Iowe $20,000 like, okay, let's fight this.
And I think insurance companiesalmost kind of they, I don't
know, I'm looking for the words.
So it's almost like they arehoping that you don't fight them.
Mike (25:07):
Right.
Kandyce (25:08):
Because guess what, then you don't have to pay and sometimes
fighting them is exhausting.
Mike (25:12):
It is.
Maybe I should call you Mrs. Incredible.
Kandyce (25:15):
Yeah, hey, there you go.
I'll take it!
Mike (25:17):
Yeah, it has to, I'll let you go with this.
It has to feel good.
It has to feel good when you helpsomebody navigate that system.
Kandyce (25:26):
Absolutely.
Mike (25:27):
Because who would know how?
You and I know the system andwe struggle navigating it.
Kandyce (25:32):
Mm hmm.
Even knowing the system,you struggle with it.
So people who don't know anythingabout the system, those are my people.
That's who I want tohelp because it's unfair.
Mike (25:47):
I hope you're continue to do it.
We can hear the passion in your voice.
I'm going to attach.
Kandyce's LinkedIn information in caseyou want to get a hold of her and just
continue this dialogue somewhere else.
Thanks for your passion, your hope,your expertise, Kandyce, this is great.
For those of you listening, we hopeyou join us anytime you're able.
And until then, we hopethat you stay safe.
(26:09):
Speak up when you can.
And if you're able to, speak up forpeople who can't speak up for themselves.
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