Why Don't More Specialized Therapists Take Insurance?
Updated: Apr 21, 2022
I get it, I really do. As someone who has been a client and is now a therapist, I know how hard it is to find a therapist- especially a specialized one, that takes insurance. It's already hard to find a therapist with current openings, let alone one that will bill your insurance directly. Unfortunately, because of this, a lot less people are able to access mental health care. It seems like an easy fix on the outside: if all therapists took insurance, more people could get help. However, I am about to explain to you why it's not that simple- and why the responsibility lies with health insurance companies- not therapists.
1- Most insurance companies do not reimburse therapists on the same level as other healthcare providers; and depending on your geographic location, the reimbursement rate may not even be livable for the therapist. For therapists in high cost of living areas such as California or New York this is exactly the case. As therapists we go to school full-time for 6-10 years, then we have a few years of unpaid or low paying internships while we gain hours for licensing. Most of us are around 100k in debt (at least- I have colleagues that are closer to 300k). On top of that, we have daily living expenses and future financial goals to prioritize for our families, just like you. If you live in Southern California like me, you know that managing debt, future planning, daily family expenses and rent upwards of 3k a month is going to require being paid much more than $50 an hour-and keep in mind insurance only reimburses that for face-to-face client time, not the consultation groups, extra training, documentation, treatment team collaboration and between session emailing that most specialized therapists like myself provide. For providers, this is a recipe for burnout and subpar client care.
2- If you DO take insurance as a therapist- then there is the issue of actually getting paid. It is common for insurance to refuse claims, to not pay therapists for months (while you are still seeing the client), and to later take back their claims for services already rendered. Therapists often have to jump through hoops, taking up MORE unpaid time, just to get paid for an hour they already worked. This is not sustainable for most therapists who don't have savings or a partner to cover monthly expenses while waiting for insurance claims to be paid.
3- Even if it were easier to get paid on time by insurance, there is the issue of capacity. If you need to make $1500 a week to cover expenses (which is right at the poverty line in major California cities like San Francisco, San Diego and Los Angeles), at a rate of $50 an hour, you would need to see at least 30 clients per week. Most therapists do not have the mental and emotional capacity for this. I hear from most therapists that 18-25 clients a week is all they can manage, and personally I like to keep my caseload under that. As a therapist who gives my clients 150% when I am present with them, and who is constantly doing behind the scenes work to offer specialized eating disorder care, I simply do not have the time, energy or mental capacity to provide top notch care and see more than 18 clients per week. Unfortunately, our field has such a high burnout rate, and more people are leaving the field now then ever due to these issues. If we don't have time to take care of ourselves and our families, we just cannot do good work with clients.
4- Another issue is confidentiality and the pressure to diagnose when you take insurance. When you bill insurance, your client must agree for their private health information to be shared with insurance. This includes treatment plans, case notes, diagnosis and services rendered. You often have to defend your client's need for therapy and MUST give clients a psychiatric diagnosis in order to get reimbursed. This leads to over medicalization of social and emotional struggles. This can also haunt clients lives later on when applying for life insurance or a security clearance for a government job. Yes, your diagnosis can prevent you from getting certain jobs or cause you to pay higher life insurance premiums. This is cruel, unfair and I refuse to participate in this as a therapist. I also believe many of our personal struggles with food and body are related to societal issues and systems of oppression, giving someone a diagnosis just to get reimbursed feels like being complicit in a system unwilling to be held accountable for harm.
5- Finally, the other issue is related to treatment planning and which treatment approaches are reimbursed by insurance companies. Insurance companies have strict guidelines on 'what is therapy' and what is not. This is based on which practices are considered 'evidence based' which is both good and bad. While there are many wonderful evidence based practices that I do use with clients, they do not work for everyone, and it's often not so black and white. Meaning, we may use a blend of different therapeutic styles to best fit your individual needs. Clients are not a one size fits all. Clients are complex and layered, requiring skilled therapists to individualize treatment. Insurance companies dictate which practices therapists can use, and therefore, determine the course of YOUR treatment without ever even knowing you as a person. The practices that become 'evidence based' are also often not culturally sensitive, and are not normed and validated across various racial, ethnic, gender and sexual minority groups. This means what is 'evidence based' is not actually evidence based for everyone.
Most therapists- like myself- want to help as many people as we can and we dream of a day when therapy is more accessible too. Please know we want this and wish there was an easier way that was sustainable for providers and clients, and could simultaneously protect your privacy and treatment. Instead of blaming therapists, join me in taking action against our broken healthcare system by writing advocacy letters to state policy makers and healthcare companies. We need your help to make this more accessible.
If you are struggling to afford therapy, you can always ask your therapist about their sliding scale or pro-bono policy. To offset the financial burden, most therapists like myself do offer a certain number of reduced fee sessions per year that still allows us to protect your confidentiality and sustain our livelihood.
I am sending you so much compassion if you are struggling to find a therapist right now, let's change the system together. You deserve care, and we do too.