Why We’re Therapists That Don’t Accept Insurance
Are you curious why, even as we push for mental health to be as accessible and normalized as physical health, some therapists (including us) still opt out of accepting insurance?
On the blog today, we want to talk about our decision at Crescent Counseling to not accept insurance.
We get asked about this a lot, and we’re used to potential clients that sound like a wonderful fit for the therapy work we do opting to not work with us as soon as they find out we don’t accept insurance. We put a lot of thought into our decision to not accept insurance and did a lot of research along the way. We’ve both worked in a private practice setting that did accept insurance in the past, so we’ve experienced both accepting and not accepting insurance. While we do believe that mental health IS health, we feel strongly about not accepting insurance unless something systematically changes about insurance.
In doing our research and having countless conversations, we’ve found that most people are unaware of the downsides that go along with using insurance to pay for therapy.
We know the feeling of searching for a “therapist near me” and trying to find someone who aligns with everything you need - someone who specializes in what you’re struggling with, who you vibe with, and who fits your price range. And we do believe that mental health treatment should be accessible to all. We’ve found there are more ways to make that happen than just through accepting insurance.
We want to share some of the reasons why we don’t accept insurance as therapists, covering reasons that tap into both our own well-being as well as the well-being of our clients.
Confidentiality & Privacy Issues (and Treatment Dictatorship)
It's concerning to think that the confidentiality we uphold in therapy could be compromised by insurance requirements. Legally, as your therapists, we must maintain client confidentiality, except in very specific scenarios (like if we have reason to believe you’re a danger to yourself or someone else) OR when insurance is involved.
So, what does that mean?
When insurance companies fund your mental health treatment, they reserve the right to review (or audit) the session notes and treatment plans we’ve written to monitor for potential fraud or unnecessary insurance use to ensure the insurance company isn’t losing money. What this means for you is that in order to save the company money, a non-therapist at your insurance company could end up making decisions about the number of counseling sessions covered for you, based on their assessment of your progress.
The idea that your sensitive counseling information could be handled by someone outside the therapeutic relationship is unsettling to us and feels at odds with the core values of therapy. We can’t support non-therapist employees of insurance companies having access to your file with the ability to decide what your progress does and doesn’t look like. This is probably one of our top reasons for making the decision as therapists to not accept insurance.
We don’t want to see you in therapy longer than you need. We’re actively trying to work ourselves out of a job by truly helping you! And we don’t need someone from insurance companies to define your progress for us. That’s for us to do, collaboratively, over the course of our therapeutic relationship to make sure you’re getting what you need out of your therapy.
We’d Have to Give You a Diagnosis (Assumption of Illness)
Another key reason we opt out of accepting insurance is the necessity for a diagnosis for coverage. Insurance models demand each therapy session be classified as "medically necessary," which requires assigning a diagnosis from the DSM-5.
Many seeking therapy might not meet the criteria for a specific diagnosis, creating a challenging situation for both client and therapist. This requirement for a diagnosis, which must align with what insurance considers "medically necessary," illustrates part of the complexity behind our decision to not accept insurance.
Imagine if you're seeking therapy but don't meet the criteria for one of the diagnoses required by insurance. You find a therapist through your insurance, and there's a strong therapeutic connection. However, without a qualifying diagnosis, you face paying the full session fee out-of-pocket or inaccurately claiming a diagnosis for insurance coverage. This places both therapist and client in an ethical dilemma, as fabricating a diagnosis constitutes insurance fraud and can have long-term consequences. This ethical concern is a significant reason why some therapists, including us here at Crescent Counseling, decide against accepting insurance.
While receiving a diagnosis can sometimes have a positive impact (like being validating or helping various professionals working with you quickly communicate with one another), we don’t believe that only specific diagnoses make therapy “medically necessary.” You are more than a diagnosis. We want to work with you as a whole person, not just as a checklist of criteria for a diagnosis. And we don’t like the pressure of our diagnosis or lack thereof being the reason you can’t get coverage through your insurance because we don’t feel comfortable making one of the few diagnoses insurance deems worthy of therapy.
All diagnoses should be 100% accurate and ethical. The requirement by insurance companies that individuals meet a certain diagnosis threatens this. Issues like your history of abuse in childhood or problems in your relationship with your partner deserve attention through therapy, whether or not you meet a specific DSM diagnosis.
Having a Diagnosis Can Impact Insurance Premiums & Have Other Negative Consequences
When insurance does require us as your therapist to turn over your file (including your session notes, diagnosis, and treatment plan), that file then becomes a part of your medical record. If your therapy diagnosis becomes part of your medical record, it might influence future life insurance applications or job screenings that review medical histories. There's a risk that these entities might view a diagnosis unfavorably, potentially raising premiums or affecting job opportunities. While we believe in mental health awareness, we know the reality is stigma does still exist.
This reality of how a diagnosis can be used against you is distressing, and it can even deter individuals from seeking necessary mental health support. Everyone deserves access to mental health care without fearing negative repercussions on their future opportunities.
Retroactive Claim Denials
Insurance companies sometimes demand therapists refund payments for services rendered, even years after the fact, due to discrepancies in documentation or billing. These discrepancies can even be as small as errors in punctuation or the margins in their documentation.
This practice, known as clawbacks, can financially strain therapists, with some cases involving substantial sums to be repaid in a short timeframe. This highlights a significant financial risk for therapists working within the insurance framework. We’ve heard of this common practice literally bankrupting therapists and just feels like icky business on the part of insurance companies.
Low Rates, Delayed Payments, and Sometimes Even No Payment at All
Under ideal conditions, therapists might wait 3-6 months to receive payments from insurance companies, sometimes even longer. The process involves significant administrative work, requiring about 90 minutes of additional, uncompensated time per session, leading to a disproportionate effort-to-compensation ratio. Given the high costs of education and living expenses, such delays and low compensation rates contribute significantly to therapist burnout, underscoring a major drawback of relying on insurance reimbursements for mental health services.
At Crescent Counseling, we value our ability to specialize in the areas where we thrive as clinicians. We both choose to invest our time and money into pursuing advanced clinical training so we can truly help our clients. For Allison most recently, this meant completing her Level 1 Gottman training for couples counseling, and for Amanda this has meant her dedication to training related to both Brainspotting and the Safe and Sound Protocol. Low rates, delayed payments, and the occurrences of no payment at all take away therapists’ resources to provide their best clinical selves to clients.
Burnout
We’ll admit it. We’ve been there. We’ve had our own experiences with burnout. Our dedication to our clients was always there, yet the demands of settings that accept insurance became detrimental to both our well-being and our ability to be excited about accepting new clients. This led in part to our transition away from insurance-based practice, a move that has significantly improved the quality of care for our clients.
This scenario is a common narrative among therapists, highlighting the challenging balance between providing care and managing the burdens associated with insurance.
Not to mention the change we’ve seen in our clients who moved from using insurance to cover therapy to private pay. There really seems to be a difference in how some individuals show up for themselves in therapy when they’re taking the hard step of prioritizing their mental health, and budgeting both the time and money for consistent therapy.
If the full fee for therapy seems out of reach and you wish to find quality care without relying on insurance, there are viable alternatives to consider. These options provide a middle ground for those seeking affordable therapy solutions.
Out-of-Network Benefits / Reimbursement
Certain insurance plans offer reimbursement for sessions with out-of-network therapists, covering a percentage of the cost. For instance, if a session costs $150 and your insurance reimburses 50%, you'd initially pay the full amount but later receive $75 back. This feature is more common in PPO plans than HMOs.
Always confirm your plan's specific reimbursement policies to avoid surprises. If eligible, your therapist can give you a superbill to facilitate this process, though some insurers might still require a diagnosis for out-of-network claims.
At Crescent Counseling, we offer a service called Reimbursify that helps with this process. We can use Reimbursify to help determine your eligibility of benefits and to easily file out-of-network claims through an app. Ask us for a link to check your out-of-network benefits!
Sliding Scale
Many therapists offer a number of sliding-scale spots to make therapy more accessible. This approach caters to various needs—whether it's for specific groups, individuals with limited income, or upon request. For instance, a therapist charging a regular rate might have slots at reduced rates, making therapy affordable for those who otherwise couldn't bear the full cost. This practice broadens access to mental health care.
This practice also aligns with our commitment to support the community while not accepting insurance. We both reserve a certain number of slots on our client roster for seeing clients through Open Path Collective.
FSA/HSA
Numerous employers offer Flexible Spending Accounts (FSAs) or Health Savings Accounts (HSAs), which many therapists accept for payment. Using these accounts for out-of-pocket payments means you're utilizing pre-tax dollars, ultimately leading to cost savings on therapy sessions.
The decision to use insurance for therapy ultimately rests with you. If you're already benefiting from therapy under your insurance plan and have a good relationship with your therapist, there's no need to change your approach. Our aim is not to sway your choice but to ensure you're informed about potential drawbacks of using insurance for mental health services. Many are unaware of these cons, so we hope this information aids in making a choice that aligns with your needs. Feel free to reach out with any questions!
