State of Mind

I’m a Therapist. Here’s Why I Don’t Take Insurance.

The solution to the mental health crisis is not simply more practitioners.

A hand holding up an insurance card. The card has a red X through it.
Photo illustration by Slate. Photos by Getty Images Plus.

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Recently, I read that many parents of depressed teens and young adults are having difficulty finding a therapist for their children. One mom said she contacted over sixty therapists, and all said they were full. The article, published on Good Morning America’s website, described the increased rate of suicide among teen girls and women in their twenties, and how they wouldn’t—or couldn’t—seek therapy for depression, anxiety, and other serious conditions. The article offered an explanation that you’ve probably heard many times: there are not enough mental health professionals to meet the demand.

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Of course we need more mental health providers in our country. But this is not the complete story by any means. The truth is that providers often have space in their calendars—just not for patients paying with insurance. I know because I’ve turned patients away, claiming my calendar was full, when really, it was only full for patients who couldn’t pay my fee out of pocket.

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That was back when I took insurance at all. Today, I’m one of the many providers who doesn’t accept insurance, thereby making my services inaccessible to many. This is a tough calculus for therapists, so let me explain why it’s so hard to provide affordable therapy and what can be done about it.

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When I started my psychotherapy practice twenty-five years ago, I wanted to earn a good income—but I also wanted to help people who couldn’t easily afford therapy. Eventually, I joined all possible insurance panels so that many of my patients could just pay a low co-pay, typically $15 to $40 per session. The insurance companies reimbursed me at a rate of $60 per session. That was considerably less than my going rate of $120 to $150 during that time, but by accepting insurance I was able to treat those who would have had difficulty affording my usual fee. Still, I kept some appointment slots open for private-pay patients who didn’t have insurance and were willing and able to pay more for therapy. (Under the terms of the insurance agreements, we weren’t allowed to accept patients with insurance who might choose to supplement insurance payments or pay more privately. Either we treated them under their insurance plans or we couldn’t see them at all.)

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All went well for the first three or four years. Then I started to notice something a little troubling. Whereas most employed people receive raises from time to time, years went by with no change in my compensation from insurance companies. I checked with other therapists and everyone else experienced this as well. It got to the point after a few years where we were paid less per session than the price of a mani-pedi or salon haircut. Not to denigrate salon workers, but they typically don’t need to invest years of post-graduate education, training, and expense to qualify for their jobs. Meanwhile, I was able to raise my private pay rate over the years to match the going rate in our profession.

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When I worked with insurance companies, I needed to submit paperwork for each patient, and occasionally spend twenty to thirty minutes being questioned by an insurance representative about the necessity for continuing a patient’s therapy. These extra requirements were often time-consuming and were unpaid. That the insurance companies questioned my treatment protocol especially bothered me. It was in their best interest to keep treatment as brief as possible. And while my reimbursement rate was stagnant, my patients would complain about hefty increases in their insurance premiums. Of course, at this point I realized that insurance companies were the ones profiting from this arrangement.

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My office expenses including rent, utilities, and malpractice insurance, rose almost every year. Vacation time or other time off was self-funded. The low insurance compensation I received from insurance companies was worth less and less. I already did some volunteer counseling for an organization, and I didn’t want to practically volunteer for insurance companies as well. I finally stopped working with insurance companies after a decade of practicing.

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More and more therapists only see patients who pay us directly. None of my close colleagues who have been in practice for a long time accept insurance. A quick perusal of the Psychology Today website in my general community shows that less than twenty percent of the therapists listed accept insurance. Typically, these therapists are relatively new to the profession and are building their practices. Many therapists find it much more gratifying to be in charge of our own therapy practices instead of relying on insurance companies to treat us fairly. We set our own fees. Many of us offer sliding scale payments to try to accommodate those who can’t easily afford therapy.

Some therapists will take insurance, but only for a limited number of clients, and often when potential clients with insurance contact them, they will simply say they are unavailable instead of trying to explain the situation.

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If you can’t use your insurance because all the therapists on your panel claim they are full, it is important to contact your insurance company and put the problem into their hands. You (and your employer) are paying premiums and you are entitled to service. Have the insurance company contact therapists and find some options for you. If you need therapy more urgently, you can try asking therapists if they have appointment slots available for clients who can pay out of pocket.

If out of pocket fees are too steep for you, here are a few suggestions for finding the most affordable treatment: ask about sliding scale fees (the listings on Psychology Today note which therapists offer a sliding scale). Contact family service agencies and other social service organizations that offer therapy at lower fees. You might also try searching for a therapy at a university training center for psychologists; often they provide lower-fee sessions with graduate students who are accruing hours toward their licenses and are well-supervised. Group therapy can be a possible alternative to one on one therapy, and fees are much lower.

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One last suggestion for finding affordable treatment is to ask for shorter or less frequent sessions. Some therapists may be willing to accommodate you this way if they think treatment can still be effective.

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My hope is that insurance companies will raise their therapist reimbursement rates to increase the number of available appointments for their members. No one wants to pay monthly premiums and not be able to receive mental health care, and it is essential that everyone who seeks mental health assistance be able to obtain it. But even if more mental health providers join the field, they will still need to be able to make a living at their jobs.

​​If you need to talk, or if you or someone you know is experiencing suicidal thoughts, text the Crisis Text Line at 741-741 or call or text 988 to reach the Suicide & Crisis Lifeline.

State of Mind is a partnership of Slate and Arizona State University that offers a practical look at our mental health system—and how to make it better.

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