Why I Don’t Take Insurance
Reasons Why I, and Many Other Therapists, Pass on Insurance
I’ve had this topic on my list of Things To Write About for a while. I’m writing it now because I’m smack in the middle of an insurance situation, the type which I’ve been trying to avoid by not taking insurance.
Many therapists don’t take insurance, which we understand may be a barrier to getting the mental health treatment clients need. Some clients don’t have insurance. Others who do often find themselves on waiting lists because the therapists who do take insurance typically reserve just a few available slots for insurance clients. Additionally, some insurers only cover a limited number of sessions, sometimes as few as eight, which is really stingy. It’s been estimated that in my state of California, about 42% of us don’t take insurance.
I understand the frustrations felt by clients who hear, phone call after phone call, “Sorry, I don’t accept insurance.” Therapists are therapists because they want to help people, and we also want to be able to help people who can’t afford full fees out of pocket.
But what it comes down to for me — and many others — is that I can’t help you if I can’t afford to stay in business.
In 2008, a mental health parity act was passed that stated that mental health services should be as easy to access as physical health services. But applying the same standards to practices that are structured very differently continues to hamper affordable access to mental health services. For instance, physicians can see four patients in the hour that we see one. Additionally, doctors can bill for multiple services for each patient, whereas we typically bill for one service.
Because of this, and just generally, reimbursement rates from insurers to therapists is pretty low. Primary care physicians earned nearly 24% more than mental health providers in 2017. If being a therapist in private practice is your only gig, it’s nearly impossible to have a full or majority caseload of insurance clients and eke out a living. We have have to cover expenses such as rent, liability insurance, slip-and-fall insurance, required continuing education courses, business and professional licensing fees, marketing, getting listed on sites where clients can find us, software that helps us with scheduling and billing, credit card processing, website domain and hosting, plus any other number of one-offs that help us evolve and grow in our profession.
Keep in mind, too, that most mental health clinicians in private practice see between 16–20 clients per week. This is considered full time for us. For me, 18 clients are as many as I can see in week and remain present with all of them without feeling stressed. For each of those 18 clients, in addition to the hour we’re together, I take notes, I make and update treatment plans and goals, I handle billing, I may consult with peers, I may do some research on their specific struggle, I develop intersession work for couples and a few clients who I see sporadically. It is not difficult for those 18 hours a week to double when all is said and done.
When insurance is added, well… Much of the work of accepting insurance is done up-front: filling out an application form (and attaching whatever documentation is required) and submitting an initial treatment plan. Most of the time, the subsequent work of filing claims and getting paid goes smoothly. But when it doesn’t, it really doesn’t. Huge insurance problems can cause a therapist to lose thousands of dollars in revenue, both by not getting paid and by having to spend a great deal of time trying to get paid. In a lot of cases, just giving up is the sanest — if not the most financially sound — way to go.
I mentioned above that I am currently dealing with an insurance situation. I have a somewhat new client that submitted an invoice from me to their insurance company to get partially reimbursed for my out-of-network services. Providing this invoice, which is referred to as a superbill, is a fairly common practice for therapists. Even if we don’t accept insurance, at least some insurers will partially reimburse their members for therapy services. My client’s insurer is a huge well-known entity and I have had a good number of clients who have provided superbills to this same company. Except this time, my client’s claim was denied.
After some back and forth between myself and my client, and between my client and the insurer, they received an email copy of letter snail-mailed to me (that I have yet to get) from the insurer stating that they were missing some information from me and could not therefor fill their claim. As the letter did not say what information was missing, I called the suggested “help” number. I spent the first hour trying to navigate a vague and confusing phone tree, and another 45 minutes on hold waiting for a person to talk to. The person-to-person interaction was fine, although their insistence that the paperwork I needed to fill out and submit was “standard operating procedure” is blatantly false, since I’ve never had to submit said paperwork to this company before. Never. Ever. Not once.
I don’t mind doing this for my clients. I want them to get reimbursed. But the runaround on the phone tree and the wait-time for a live representative makes me shudder when I imagine having to go-to-bat for even a handful of clients and for myself whenever there is a glitch in the insurance machinery.
So… I offer clients superbills. I offer a sliding scale to those who can’t afford my full fee. I offer services to a couple of clients who can’t even afford the low-end of my slide.
It’s not enough. But until “parity” actually adds up to insurance companies making the process smoother for both clients and therapists, and pays us enough to make it worthwhile, I won’t be taking insurance.
Statistics used in this article came from the 2020 California Health Report.