The MANY Reasons I Don’t Accept Insurance

As a therapist in private practice, one of the most common questions I’m asked is, “Do you take insurance?”

"I'm in it for Miles" Mixed Media Collage by Jackie Schuld

I don’t.

I believe insurance is necessary and good in many circumstances, such as mental health organizations, hospitals, etc.

However, insurance does not work well for me in my solo private practice.

Why?

Well, there are multiple reasons.

It’s a lengthy and complicated process to get paneled with insurance.

When I started my practice, I wanted to start seeing clients right away. Some therapists have such a difficult time getting paneled with insurance companies that they pay people to help them navigate the process.

Insurance sets the fees.

I got into private practice so that I could have control over my own business, including what I charge for the services I provide. Insurance decides how much they will pay for my services.

Insurance fees are insufficient.

The fees set by insurance companies represent systemic injustice. They are not enough for therapists to live sustainably. For therapists in private practice, our businesses need to financially provide for all of our needs: business expenses, health insurance, retirement, student loans, sick days, safety net, vacation time, and more.

Insurance typically pays in the range of $50-120 per therapy hour. While these amounts might feel like high numbers, they do not go far unless we overload ourselves with clients. This is not healthy for us and decreases the quality of our work.

I’m calling out the systemic injustice component of insurance fees because therapists are significantly less than other medical/health professions (a fact I attribute to the profession being founded by “helpers” and primarily composed of women, which I write about in my essay on Martyrdom Mentality).

I want to see a sustainable amount of clients.

As mentioned previously, the only way to meet the financial needs of my life with insurance fees is to see a high caseload of clients. Therapeutic work is emotionally and mentally demanding work. A high caseload is exhausting and compromises our wellbeing and the quality of therapy we provide.

I want to see a caseload of 8-12 clients and provide exceptional therapy to them. I want to have room in my schedule in case a client needs to schedule an emergency appointment or a second weekly meeting to process difficult things. I want to take time to thoughtfully research and prepare for each client. I want to slowly process my thoughts after a therapy session and write my insights for our next meetings. I want to take breaks between clients to discharge all energy from the previous client and center myself for the next. All of these things are not possible with a caseload of 20+ clients.

Insurance sets limits on the length of treatment.

Insurance companies determine how long an individual can be in therapy. For example, they may determine that an insurance client can only have 7 sessions. Everyone is a unique individual and requires different lengths of therapy. I want this decision to be determined by my client and myself.

Insurance sets limits on therapy session length.

Insurance companies set limits on how long therapy sessions can be. The typical therapy session is 1 hr, which is 50 minutes of client time and 10 minutes of note taking. As an art therapist, I have found that 80 minutes of client time is far more effective for the way I provide therapy. We do so much art and processing in a session that 50 minutes does not allow a client to adequately express their feelings, digest their thoughts, ground, see new insights, and integrate those insights.

Insurance requires a diagnosis.

For an individual to qualify for therapy covered by insurance, they must have a mental health diagnosis. Many individuals seeking therapy may not qualify for a diagnosis - such as individuals who want to improve their relationships and grow in positive ways. Furthermore, a diagnosis stays on a person’s permanent health record.

Diagnoses are pathologically based.

Diagnoses are determined by negative symptoms present and how long they have been present. They do not take into account the systemic impacts on a person (i.e. the mental health impacts of poverty, difficult family environment, systemic racism, etc.). These symptoms are also frequently based on studies centered around white cis-gendered people.

Billing insurance requires extra paperwork and time.

Billing insurance companies can be incredibly time consuming because they require specific codes, notes, and more. So many therapists find it difficult that they pay a biller to do the work for them.

Insurance has access to therapy notes.

Insurance companies frequently request access to a client's therapy notes to ensure treatment was necessary and that quality services were provided. I prefer that clients’ notes remain confidential and that they control who sees them.

Insurance companies do clawbacks.

Months after treatment is over, insurance companies can determine that an individual was actually not qualified for therapy and demand the money back from the therapist. They do this by not deducting it from any future payments for current clients. I’ve heard this happen over and over again, and the amount is usually in the thousands. Some therapists even set aside a portion of each paycheck in case they get hit with a clawback.

It is difficult to leave insurance companies.

The process to leave insurance companies is difficult and frequently unclear. Many insurance companies require multiple steps (letter, contacting the company, etc.) and require 6-12 months notice.

Insurance is confusing for clients.

Many clients are confused about the actual benefits provided by their insurance companies. Some are frustrated to learn that they have to first meet their deductible before their insurance will even cover mental health. Others still have to pay a co-pay. Some are dismayed to find they personally have to pay for cancellation fees or special service requests (such as documentation letters needed for school, housing, etc.). I want to leave this level of confusion and frustration outside of therapy - the inner work of therapy is hard enough. It is far more clean to have a straightforward self-pay fee that the client can expect and rely on.

Insurance makes it difficult to find an available therapist.

Insurance companies provide directories of therapists who are in-network with them. These directories are often referred to as "ghost networks" because individuals can't actually find available providers. Frequently the therapists are already full, the contact information is incorrect, the providers do not respond to contact, or the therapists are no longer in-network with that provider. It is a time-consuming and frustrating task for individuals to reach out to therapist after therapist after therapist.

I created a private practice so that I could tailor everything about my business to my values and standards.

Insurance does not meet them.

Do I think insurance still has value? Absolutely, it works for mental health group providers and other large mental health organizations that can navigate the challenges of insurance and have access to larger resources (such as grants, funds from the government, employees to interact with insurance, and more). These organizations also assist individuals that have no other choice than to use insurance.

Do I wish we all had high quality universal health care? Yes. But we don’t. So I make business choices for my private practice based on what currently exists. Insurance as it currently exists does not align with my business practices and values. So I opt out.

I understand that this means I will not be able to help everyone and be accessible to everyone. And yet, whether I take insurance or not, I am never able to help everyone and be accessible to everyone. The minute I charge $1, there is someone that cannot afford my fee (a beautiful point made by Kelly Diels in her excellent blog post about economic justice).

I am an individual in private practice and can only help a limited number of people. I can do far more for the people I do see if I am taking good care of myself.

I cannot solve systemic problems (our healthcare system) with individual sacrifices (making less money in my business, overworking myself, etc.) and compromising my values. I structure my business so that I thrive and can show up rested, ready, and happy to work with my clients.

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