Is Insurance Your Best Option for Therapy?
My Struggles with Insurance and Mental Health Care
Before starting my practice, I completed months of consistent research, plus all the years of thought prior to setting my timeline to launch a practice. Two of the largest stuck points that I had were setting a session rate, and whether or not I was going to accept insurance. Every therapist that I spoke with about whether or not to take insurance encouraged me to try and stick with private pay if I could, and shared about the nightmare of working with insurance. So, I began my practice private pay. After the difficulty deciding on my rate, and ultimately deciding to go with the national average for therapy, I kept getting stuck on the thought of, “Even if this is a reasonable rate for the value I am hoping to provide, what about the people who can’t afford it?” This brought the dilemma up in my mind again… and again… and a few more times.
Here are some of the things that I weighed through when making my decision, ways that I make care accessible, and hopes for the future. I will start out with the benefits of insurance, and I promise that I am not being cynical in making the list shorter than the deficits. I value honesty in my practice and want to provide an honest view.
Benefits of Using Insurance
Increasing Accessibility
The primary benefit of insurance is that it lowers the cost of entry to getting services, which ultimately allows more people to get the support that they need. I am all about this, and no therapist that I know came into the field with a driving goal of making money. We came into this field to serve others, and to try to help as many people as we can. For the last five years, I have been able to support clients that run multi-million dollar businesses, as well as those who did not have a dime to their name. I have found my work with every client deeply rewarding, and it was never impacted by the compensation I received.
Consistency in Attendance (In Some Cases)
With the lower cost for clients who have low or no co-pay, this often means that they are more regularly able to attend their sessions. This unfortunately is not always the case though. I would like to preface by sharing that this is not the majority, but I have regularly seen this turn into clients “no-showing” their session without notice, since there was no perceived loss to them monetarily. This is often why clinicians may institute a no-show fee, not only to increase buy-in, but also because this could lead to a large risk to the clinician if repeated by multiple clients in a given week.
Deficits of Using Insurance
As you will read below, these are some of the items that I struggled with when deciding whether or not I would be accepting insurance for services. This was not a financial decision, it was a quality of care decision. and consideration of how I do right by the people we serve.
Requiring a Diagnosis
If you decide to use your insurance, it is a requirement that there be a diagnosis on file for you, which I belief is not always appropriate. The Diagnostic Statistical Manual (DSM) was never intended to be used as a reimbursement tool, but unfortunately has become just that. If you are seeing a therapist and using your insurance, you have a DSM diagnosis on file. Every time I meet with a new client, I review with them that there needs to be some type of diagnosis on file to use insurance, and work collaboratively with them. Although there are some cases that collaborative diagnosis is not always feasible, such as with a psychotic disorder, in most cases, the client has either previously received a diagnosis that is in line with their experience, or have an understanding of the connection. There are however cases where someone does not meet criteria for a diagnosis, which often leads to clinicians having to use one of the following “catch-all” diagnoses with a “Not Otherwise Specified” specifier: Adjustment Disorder, Mood Disorder (NOS), or Anxiety Disorder (NOS). This is one of the many ways that therapists have to “play the game” with insurance, and I believe the only ethical way to do this is to work collaboratively with the client.
“Pre-Existing Condition”
With the requirement for a diagnosis to receive treatment, you have a pre-existing condition on file. Insurance companies are allowed to classify diagnoses such as depression or anxiety as a pre-existing condition. Luckily, due to the affordable care act, an insurance company can’t refuse to cover you due to a pre-existing condition, but this could still affect your premiums. This is another reason why it is very important that clinicians are clear about what they are diagnosing and why. I have seen mental health diagnoses be used to impact custody hearings, scholarship approval, and federal clearance. This again, was never what the DSM was intended to bring about. It was intended to be a manual that supported treatment efficacy and increase understanding of diagnosis.
Surprise Billing
Insurers have the ability to review your therapist’s progress summaries (one is required with each insurance claim), and can decide based on the treatment goal, modalities, and other factors, whether or not to reimburse the claim. This is not always clearly communicated, and as claims can take up to or exceeding 60 days to be reimbursed, there may have been several sessions where the client was being seen that insurance is no longer going to cover. This can result in the client getting a surprise bill of hundreds or more than a thousand without warning. Understandably, this can cause a major therapeutic rupture, and often either ends in the therapist writing off the loss and losing their compensation, or the client terminating therapy due to the unexpected expense.
Limited Number of Sessions
Depending on the diagnosis, insurance can decide whether or not to reimburse the claim or may also decide a limit for how many sessions the client can receive within a year for that diagnosis. This often leads to either surprise billing or an abrupt end to treatment or forces the clinician to “play the game” again and tweak the diagnosis. Again, I believe that this can only ethically be done with the client’s consent and understanding, but is still not something that I feel is appropriate.
Limitation on Self-Actualization Work or Maintenance Level Care
I personally believe that therapy can be not only a means to help someone reach their baseline state of well-being, but also to help someone live the best version of their life possible. With insurance, doing self-actualization work does not meet criteria for treating a disorder. I do not view the people we serve as “disordered”, or view the work that I do as simply treating ailments. I want to help the people we serve thrive in life.
Reduced Buy-In to the Process
For a simple but effective analogy, picture how you consume a fast food burger. Now, picture how you value a meal at a steakhouse for a special event. You experience the two completely differently. The same can be true for buy-in to therapy. There are clearly always exceptions, and I have done work that was truly meaningful with clients who were not paying for their sessions, but I have also worked with several who would either show up to session and express that they did not have anything to work on/speak about, or simply did not show at all. Therapy is an investment, and I do believe that so long as you are investing yourself then you will see a return, but with that in mind, studies have regularly shown that we more highly value things which we have a financial stake in.
Waitlists for Treatment
There is a heightened demand for therapy, and a clinician shortage. Unfortunately, for many reasons, that would take another post to cover. With this heightened demand, many find it difficult to connect with a therapist and will call several before finding one that accepts their insurance and has an upcoming opening. With the narrowed scope of only looking at clinicians who accept a specific insurance type, the client might be pressed if they have an insurer that is difficult for therapists to work with.
Therapists and Agencies Having a Higher Caseload than is Reasonable in Order to Make a Living
Due to many insurance agencies offering, in some cases, half (or less) of a clinician’s full session rate, this leads to agencies and individual practices taking on more clients than is reasonable to get by. A therapist is not truly compensated by the hour since a good deal of their work takes place outside of the session (training, researching, charting, etc.) and you would not want a therapist who is working 40 hours seeing 40 clients back-to-back. This is a surefire way to burn out and not provide quality care. The majority of clinicians I have encountered feel that it is best practice to see six clients a day at the most so that the clinician can be fully present to each session. This means that a clinician will only have 24-30 hours of seeing clients a week (assuming that each client shows, as discussed in the section above on no-shows). If a client does not attend, the insurance agency denies a claim, or they are receiving half of their rate, this could lead to serious hardships of the therapist and their family.
How Clinicians Provide Equitable Care without Insurance
To help combat some of these challenges, therapists often implement some of the same practices that I offer in my own practice. For starters, I offer a set number of pro-bono slots that clients with low or no income can use that do not have insurance, or do but can not afford a co-pay. Another practice that I offer is a discount for clients who are veterans, active-duty service members, first responders, front-line healthcare providers, mental-health clinicians, and/or educators. I also offer to private-pay clients a sliding scale fee, meaning that depending on their ability to pay, I adjust their session rate. So long as I have my practice, I will continue to maintain these steps to help increase accessibility to treatment.
How to Ethically Accept Insurance if You Decide To
Ultimately, despite the deficits involved in taking insurance, the primary driver in accepting insurance is the benefit of accessibility to services. For the last five years I have worked with clients, some of which, did not have a dime to their name. I was profoundly changed by this work and the people I came to know, who were so incredibly deserving of care. The best way to justify making this change, if you decide to take insurance, is to inform every client that you work with of the pros and cons of using insurance, work collaboratively with the client when changes are necessary, and show up for them the same way regardless of how they are accessing services. I currently accept insurance through the clinic I work with on the days I am not running my practice, and I do tell every client at that clinic the factors involved in using their insurance. These have been productive conversations and most clients have been grateful to get this information that previous clinicians had not shared.
I am hopeful that, with the growing change in viewpoints around mental health care, insurance companies will restructure their systems and move in the right direction for the people we serve. I am a member of several associations which fight to change these systems and look forward to seeing some of these deficits hopefully disappear soon. If you have more questions about accessibility to treatment or about using insurance, feel free to reach out and I would be happy to help!
