Why I Don’t Take Insurance

Choosing to be private pay instead of insurance-based is not an easy decision. In some ways, it makes my services less accessible (though as a private pay clinician I also can offer a limited number of deeply discounted slots). But it also helps me to be a more resourced therapist and provide the kind of care and support I believe to be most meaningful and healing. 

I opt out of the medical-industrial complex, a system that pathologizes rather than heals, and the insurance system that takes advantage of those who do healing work as well as trying its hardest to cover as little as possible for its customers. I do not support the psychiatric diagnostic system, which is based on colonial and ableist beliefs and structures, that insurance would require me to collude with. (Though I will happily engage in collaborative diagnosis at a client's request to support them receiving the care they need.)

So here’s a breakdown of my decision-making process. 

I can provide sustainable, resourced care

Everything else in this article is about making this statement true. 

Being able to control my own income gives me the freedom to set my own schedule, keep up with training, choose what I believe to be supportive, trauma-informed, and effective treatment modalities, and care for my own mental health (which every therapist needs to do). I take all of that into account when deciding how many clients to see per week. If I needed to somehow see more clients than what is sustainable to make enough money, I would be exhausted a lot and burn out fast.

It is always my goal to show up to sessions rested, grounded, ready to witness, listen deeply, reflect, connect, challenge when necessary… I could write a separate article on all the nuances of what I do in a session. 

The point is that I need to be well-resourced. When I’m not, I’m more likely to miss what’s not being said, to forget that really important detail about what happened when you were 7, to be checked out even if I don’t want to be, and to say something harmful accidentally because I didn’t see all the nuances of my words. While I’m not always at 100%, being able to choose the number of clients I see per week helps me be my best therapist self most of the time. 

Past of providing good care means choosing how I do my work. While most psychological research studies CBT (short-term treatments are, of course, the most appealing to insurance companies and are easier to track for researchers), many of us in the field have come to understand that somatically informed therapy is important for healing and change. We know that many clients have been traumatized and need a kind of deep support that CBT just can’t offer. And we want to be prepared to support clients with any racial or ethnic background, any sexuality or gender, any level of ability or weight, or with any other minoritized or marginalized identity. 

This means getting training outside what our programs had to offer (although I was fortunate enough to go to an existential therapy program, most programs only teach CBT and some psychodynamic or humanistic foundations). I choose training and education that understands that our bodies hold wisdom; that we are whole, complex people with inherent abilities to heal; and that our psychological well-being is bound up in our liberation.  

Your lack of privacy

Insurance companies require a diagnosis to cover treatment, which already reveals some deeply personal information. They also require access to my treatment notes. Imagine that the people responsible for deciding what your healthcare coverage looks like can see the intimate details of what you talk about with your therapist. This kind of documentation on your record can lead to higher premiums for you in the future due to a “pre-existing condition.”

Companies decide to cover treatment based on what’s in those notes and how well I can prove the medical necessity of your therapy to them. If I don’t offer a type of therapy they believe to be “evidence-based,” they may refuse to cover your sessions. This puts pressure on therapists to conform to standards we don’t agree with and on both therapist and client to make things happen fast. Meaningful change takes time. 

Choosing types of therapy

Companies dictate what kinds of therapy are acceptable and covered. Insurance companies prefer therapies that promise change in the short-term, like CBT and DBT. In studies, these therapies do provide quick change for some people—but most studies only look at short-term, not long-term, outcomes.

Many clients are not helped, and might even be harmed, by cognitive and behavioral based therapies. My therapeutic approach is based more on creating a healing relationship, our felt sense of knowing, how we tell our stories, and what our bodies hold. Clients are often in therapy to address lifelong struggles—these cannot be changed in 12 or 16 sessions. 

CBT is more of a band-aid than a root cause treatment. By building expertise based on what’s best for clients, not what insurance wants, I can work with you to dig into those root causes and heal from the bottom up. 

Financial realities

Part of being a private practice therapist is being a small business owner. Most of us prefer to deal with business as little as possible—I got into this work to help people heal. But there are a LOT of costs we have as business owners. This article from another private-pay therapist offers a detailed breakdown of the financial considerations of our business, if you’re curious. In short, we have a high tax burden, ongoing costs for professional training and education, the expense of private healthcare plans, saving for unpaid sick and vacation time, paying off expensive degrees, and more. My session rate takes into account all these expenses; it’s not the same as an hourly wage. 

On top of this, insurance companies dictate what they will pay us, not our own rates. In Minneapolis, insurance companies pay anywhere between $60 and $120 per session—even though my regular session rate is $175. Since my set rate reflects all the financial obligations mentioned above, the income I would bring in from insurance reimbursement falls far short of what I need to cover all my expenses.

Insurance companies are supposed to pay for sessions within 30 days, but bureaucratic nonsense sometimes extends that payment cycle by months. And insurance companies are allowed to take back payments made for previous sessions, sometimes ones that happened years ago–we call this “clawbacks.” Imagine if your boss told you they wanted their money back from your paycheck 9 months ago. Yup, this is actually legal in my field.

Insurance documentation and billing takes time, and I wouldn’t be paid for that time (because I can’t set my own rates). I know colleagues who spend hours every week dealing with paperwork. And on top of that, there are inevitably battles they go through to get paid for sessions insurance would rather not cover, which eat up more hours. 

As a private pay therapist, I get to focus my work hours on seeing clients, thinking through client care between sessions, and educating myself further. This helps me stay grounded in the actual work of healing, rather than getting sucked into institutional procedures.

So this is why I am private pay, and how I set my rate. I know not everyone can afford a private-pay therapist. In a more equitable world, we’d all be compensated fairly from insurance and empowered to do our jobs based on our own expertise. If you’re struggling to find a good fit covered by your insurance and aren’t in a position to pay a full-fee therapist right now, Open Path Collective is a great place to look for therapists who offer significantly reduced rates ($40-70 per session).