What Your Therapist Hasn't Told You About Using Insurance

(I have updated this post to reflect the changes to managed care in my area since 2010)

By Unsplash
Once upon a time, I started out as an idealistic new therapist. My work with a non-profit as well as my heart told me that mental health care shouldn't be a privilege for only the wealthy. 

And so I decided to accept insurance, hoping it would help ease the burden of cost for those seeking therapy. And I tried. I really did. Even when I was spending hours on hold (to get payment I had already been promised). Even when I had to write off payment I was owed because it was costing me too much time to pursue it. Even when I was full of private pay clients.

It was a bitter pill to swallow, but I had to admit it: I could no longer afford to be in-network for insurance But I learned a lot of things along the way. Things consumers don't know. Things that I would want to know if I were you. And so I'm here to tell you the

Things I wish all clients knew before/when they are using insurance-approved therapists.

1. Your therapist has to diagnose you to get you reimbursed.

Insurance doesn't reimburse for "marriage therapy" or "I'm having a hard time" or even "grief". It is a medical model, and so this means that payment can only be for a diagnosis. This means that (even in family therapy) a person has to receive a label. And these labels will be part of your official record permanently. This might never matter to you. If you are one of the fortunate ones who has medical, life and disability benefits through your employer... you might never worry about this. But if you're someone who might ever be unemployed, self-employed, or need to purchase your own benefits- a mental health diagnosis can make the difference between preferred coverage or none at all.

2. Your records are not protected.

Your insurer can audit your records at any time they wish. This means any details that your therapist might not have included in the paperwork (perhaps for good reason) is technically open to the eyes of any "claims specialist" the company hires. Again, this might not matter to you. But if you hold high clearance for a job, or have other reasons you want your information to be held confidential- this is important to know.

3. Your care is dictated by the insurer

Most insurance requires some sort of treatment plan to be submitted by in-network providers. This means that (rather than giving you the care that best fits your needs) the therapist is responsible to the (non-mental health professional) claims representative for how you spend your time. To put it simply, an in-network therapist works for the insurance company, not you. It doesn't matter what you and your therapist decide is in your best interest, it needs to fit their matrix of decisions. It also has to fit within the allotted sessions which are determined ahead of time, not based on need.

4. Insurance almost never pays the full fee

This means you are either going to be responsible for the remainder (which you need to clarify ahead of time) or it means your therapist is working for less than a fair market wage. Which leads me to my final, and most unpopoular point.

5. Insurance limits your options

I have said it before, to an angry response. I cringe even as I type. But the truth is: I know very few licensed and experienced therapist on insurance panels.  I have been in this profession over a decade and supervised over 25 interns on their path to licensure. I can count on one hand the number of therapists who I would recommend that are on insurance panels.

That is a dirty secret. I'm not supposed to say that. Therapists don't like that, because it is a sad commentary on the availability of quality mental healthcare. Consumers don't like that because it is obviously unfair. But it is accurate in my area. And so you need to know, that choosing to utilize an insurance-approved therapist means your options will be severely limited.

So what can you do about it? There are options!

1. If possible, pay cash for sessions. 

This ensures that your records and diagnoses are entirely confidential documents. The content of your session stays entirely between you and your therapist. And your care is dictated by what you think you need, not your insurer. Many people have a Health Savings Account (HSA) that will help them pay for sessions and operates just like cash- but they don't realize it.

2. If you cannot afford to do that, consider a non-profit (like the one I co-direct)

Many areas have nonprofits that offer low fee counseling based on income or other eligibility. That takes a little digging, but often you can find it on google by looking for "low fee" or "affordable" or "nonprofit" counseling. You will likely see less experienced clinicians, but you will maintain control and confidentiality.

3. If you need to bill insurance, but have a PPO, attempt to pay for therapy up front and submit for reimbursement.

 This will cost you up front, and your diagnosis will be recorded, but it gives you the freedom to choose any licensed clinician and their records are more protected than if you go with an in-network therapist. Here's an article I wrote about how to do that.

4. If you absolutely must bill insurance and see an in-network therapist, do your due-diligence ahead of time. 

If they are in-network with your insurer, they should have an idea of what level of transparency your insurer expects. They likely know if their notes will be requested, if their treatment plans will be required, and what diagnoses they will need to give you for coverage. Asking ahead of time can help you decide how you want to proceed.

This news does not feel good to report. I don't like the way it is. I hope for a world where quality mental health care is available to everyone that wants it. But if I were you, I would want to know. And I believe in the golden rule. I think consumers deserve to know the nitty gritty details. In fact, I think educated consumers are our best shot at system change. And so... there it is.

Hoping for a change,


  1. Hey Krysta--

    Thanks for a well-informed article. I've recently been toying with the idea to withdraw from the insurance panels b/c of the headache and time suck.

    I feel bad doing this, as I've often said that people who have insurance for mental health benefits are not the cause--it's their managed care company.

    Then I had a thought of "well, it's not like they cannot go anywhere else for therapy."

    This day may come sooner than expected:).

    1. i am here to give testimony of how i got back my husband, we got married for more than 9 years and have gotten two kids. thing were going well with us and we are always happy. until one day my husband started to behave in a way i could not understand, i was very confused by the way he treat me and the kids. later that month he did not come home again and he called me that he want a divorce, i asked him what have i done wrong to deserve this from him, all he was saying is that he want a divorce that he hate me and do not want to see me again in his life, i was mad and also frustrated do not know what to do,i was sick for more than 2 weeks because of the divorce. i love him so much he was everything to me without him my life is incomplete. i told my sister and she told me to contact a spell caster, i never believe in all this spell casting of a thing. i just want to try if something will come out of it. i contacted ( ) for the return of my husband to me, they told me that my husband have been taken by another woman, that she cast a spell on him that is why he hate me and also want us to divorce. then they told me that they have to cast a spell on him that will make him return to me and the kids, they casted the spell and after 1 week my husband called me and he told me that i should forgive him, he started to apologize on phone and said that he still live me that he did not know what happen to him that he left me. it was the spell that he traditional spell hospital casted on him that make him comeback to me today,me and my family are now happy again today. thank you Dr Azuka for what you have done for me i would have been nothing today if not for your great spell. i want you my friends who are passing through all this kind of love problem of getting back their husband, wife , or ex boyfriend and girlfriend to contact: Or call +2348132777335 and you will see that your problem will be solved without any delay.

  2. Hi Krysta,
    I am an MFT in Las Vegas who has never accepted insurance and I have been in practice for 9 years. I include info on my website about my reasons for not accepting insurance and how this benefits the client, but I am really impressed w/ how you write about it in this article. I am including a link to your article, credited to you, on my website - for additional reading for my clients.

    Wishing you all the best,
    Lourdes A Viado

  3. Krysta,
    I find that several of your views reflect a failure to grasp how people are struggling in other parts of the country. I am also offended by your accusation that therapists will give appointment slots to full-pay clients over insurance clients, and your insinuation that if a therapist is worth her salt she does not have to accept insurance. I had a full psychotherapy practice in San Francisco for several years and was able to stay off insurance panels. However, when I relocated to the northeast corner of Connecticut, where the economy has not recovered from the 2008 debacle and many people are still losing their homes to foreclosure because they can't pay their bills, I discovered that it is impossible for a clinician to avoid accepting insurance. In order for people to obtain the therapy they need, they must use their insurance. Otherwise, they would have to go without. You may want to reconsider the position that you posit as the "absolute truth."

    1. Thank you for taking the time to comment. I appreciate your perspective. I urge you to re-read what I stated: "Those who are full with clients do not need to go through the headache of managed care. So they don't. The ones who are not full are more motivated to jump the hoops" I believe you illustrated that very clearly in your personal practice.

      Similarly, I am located near San Francisco, CA. I cannot speak for the rest of the country. My intent was never to speak for the "other parts of the country". I am not a national spokesfigure... only a local therapist in practice. ;) Obviously insurance, billing, and licensure issues are very state specific. It might be very informative for you to be able to offer your own blog post, specific to your region of Conn. as it sounds very different from here.

      For instance, what I see more and more often here is that insurance offers very little reimbursement for therapy (if at all) and so the hoop jumping does not garner much help for the client in the end. It's too bad really. Things are changing quickly these days though, so perhaps that will change too.

      Again, thanks for taking the time to comment and share your thoughts. I wish you well!

  4. Wow! I read this and was completely dismayed and surprised by your recommendations and justifications. Speaking from a client perspective here, if I saw something like this on your website, I would RUN to find someone else, not because of the insurance complaints, but because of your utter lack of understanding of a patient's point of view. If you don't want to deal with the payments and hassle of insurance, don't accept it. Plain and simple. But to put this burden on clients or to suggest that they won't get quality care from someone who DOES take insurance is both egotistical and lacking in compassion...two qualities I wouldn't look for in a therapist. I would know this is all about the money, not about care. So why DID you decide to become a counselor in the first place?

    1. Thank you for taking the time to give feedback. I realize that my candor is not everyone's taste. Like I said, "I would want to know! I think you deserve to know!" But that doesn't mean I'm right for you.

      The good news is: I'm nobody! Just a therapist working in a private practice in a state that has a terrible managed care problem. I don't speak for the whole of therapist-dom. And that's good because maybe that means there are therapists who don't share my disillusionment. (I want to be them!)

      In any case, hopefully my tone in this article conveyed the great depth of my thought and care towards my clients and the managed-care-conundrum. It is heartbreaking!

    2. I don't see why people would get upset at her for stating reality. That's all it is, really. Not her fault.

  5. Hi Darcy,

    I read your article because I'm curious about how reimbursement is going for MFTs. (I will be deciding between an MSW and an MFT.) I appreciate your perspective. Thank you for taking the time to write the article and for leaving it up.


    1. Good for you for taking the time to research before deciding between the MSW and MFT. And now, we have the LPCC added to the mix!

      As far as insurance reimbursement goes, I believe it's all the same for the moment. Of course, politics can always change that. In fact, if they had made the grandfathering easier I would have double licensed myself as an LPCC and MFT just to cover my bases. But alas, they decided on a large amount of education units that made it not feasible.

      Starting from scratch, you have a lot of interesting options ahead! Best of luck to you!

  6. Hi Krysta,

    Thank you for taking the time to write about your perspective and share it. At one time, MFTs had a hard time with being covered for services; MSWs had it easier. I was just taking a look at that, as I will be deciding on my master's studies down the road.

    I'm glad you shared how the decision to accept & process insurance affected the quality of your life. Making a living, having time to be healthy, and having time to live a balanced life are very important. I, for one, would highly respect a therapist who is a model of self-care and doesn't try to be a martyr.

    BTW, you practice in my old stomping grounds - Roseville, CA. I've moved to colder climes in British Columbia, Canada. Roseville sunshine sure does sound inviting right now!

    Thanks again!

    1. Oh I hope you're staying warm! We have had plenty of sunshine to go around lately. I'm told it is too much- now we have a drought. But I sure do enjoy it.

      Good luck in your future studies! Thanks for the encouragement. :)

  7. I love your candor. All therapists who are somewhat business savvy-think like this-you are just open to sharing it. I think you ARE compassionate to inform people how it all works so they can make the best decision. If someone doesn't like the truth about how the system really works and think that the better you get at your profession you should still make the same as someone starting out then-then probably don't have a true understanding of giving and taking AND business in general. Your perspective is refreshing. Love it.

    1. Thanks for your feedback LD. I appreciate the encouragement :)

    2. Hi Krysta,

      I am a cash-only therapist in NC. Surely there are differences between my local area and yours, given my very different part of the country, but despite that there is so much you've said here that resonates with me! I have been called foolish, stupid, willfully blind, and many other things by others who have criticized my decision to not contract with insurance. I have been feeling very lonely and isolated in the local therapy community as a result. Most of my colleagues say of insurance, "it isn't hard, it just takes a few minutes" and yet these same colleagues continually complain of paperwork woes. Your viewpoint is immensely validating for me and I wanted to thank you for putting this article out there. It has helped me to feel much better about my slowly growing practice. I'm 25 and fresh out of school (graduated just one year ago), and being new I am of course making plenty of mistakes. That said, I have been adamantly against signing any contracts with managed care companies. It just feels bad to me and seems like a tactic that many other therapists do to ensure financial security. The problem is the huge and many costs associated with taking insurance. Like you, I only bill out of network insurance at this time. I just give my clients a receipt and instructions on how to send in their receipts.

      Thank you for encouraging me! This is just what I needed at this time.

    3. Josh- I am so glad it was encouraging to you. I love hearing from those who are newer in the profession. I feel it is so important to encourage one another. :)

      Something that has worked exceptionally well for me- I pay for myclientsplus (online website) where I am able to submit insurance receipts electronically for free (the website is a flat monthly fee). All I do is make sure to note that my client paid me in full, and the insurer will reimburse the client any money that is owed them. This has been a good compromise for my clients who wish to receive insurance money. It makes it easier on them than submitting a paper insurance bill. And it works for me, because any discrepancies in payment become their responsibility to follow up.

      Plus, all my client info is available from any internet connection for me... so I can get phone numbers and addresses even from my home should I need them. Something to think about! Most of my clients don't bother billing insurance, but for the few who do still need to- this helps them not get overwhelmed by the process- and it's instant for me. I don't have to do any additional work really (other than initially putting in their insurance card info).

      Best wishes in your new practice! It is really amazing work!

      There must be some differences between states in this case- we can't bill insurance until licensed (usually takes 2-5 years post graduate education)... so I'm interested in your process and what that entails? It sounds different!

  8. Krysta,

    Thanks for the wonderful recommendation on the myclientsplus. I will admit, the site looks very barebones and not the most "polished" or "attractive", but I am considering a 30-day free trial. I would love to list you as a referral person so that you get some credit for referring me.

    With regard to your question about insurance, let me clarify! I cannot bill insurance. However, I am an accepted Out of Network (OON) provider. I tell this to clients. I also explain that even if I had the choice, I would NOT bill insurance but will always, regardless, be happy to give a receipt for OON billing. The myclientsplus website seems like a nice tool I may have for doing this, but $19.95 is a steep fee for a simple service like this. I am still not sure!

    North Carolina does expedite the process for MFTs, though. We have a provisional license we can attain immediately upon graduation. I sat for (and passed with flying colors!) my national MFT exam 4 months before I graduated. Talk about things moving quickly :) I started in private practice right out of school and 9-10 months later I am seeing a decent sized caseload. That said, I could be far busier! I know it will come with time. I am already seeing generous amounts of word of mouth referrals, plus my efforts with Psychology Today and Google Ad Words Express.

    I would love to keep chatting - and I am DEFINITELY going to follow your blog, since we appear to think alike!

    1. Josh- Is it $19.95 for you? I'm fairly certain its $29.95 for me!

      Just to be clear- it's "bare bones" because only you see it- no clients. ;) So it's not attractive really. It does have some integrated calendar function and credit card billing etc... but I don't use those features. I tell you, the automated CMS-1500 forms are worth it to me. No printing or filling out. But maybe I'm paperwork averse.

      Interesting the process No. Carolina goes through. In CA, we must practice as interns (post graduation) for 3000 supervised hours and a minimum of 2 years before sitting for 2 different exams (which usually also take an additional year because of state board processing time). I'm a little jealous that you were able to be in your own practice so quickly! Wow- big difference!

  9. I have some really mixed feelings about your posting and perhaps it's because I'm soon to graduate with my Psy.D not a masters and I know that they programs train clinicians differently but I doubt that would account for all of my dismay. Frankly, it's alarming to me because I have never (nor do I plan to) share my billing struggles with my clients. Although my work as a psychologist will be a "job", I chose this profession to help and support the positive growth of those I'm entrusted to support. I feel that by alerting them to billing challenges sends a message that I'm not there for them, I'm there for the money and this is not foundation I want to build rapport on.

    So while I think it's helpful to let clients know about the possibilities of how their information may be accessed, I have concerns that this post airs on the side of scaring people into paying quick and easy cash (which only benefits the clinician) and inaccurately states that a person can "pay for therapy up front, and submit your receipts for reimbursement. In the end you come out of pocket the same amount". I say this is inaccurate because anytime a person uses an out of network provider the reimbursement rate is ALWAYS lower than in network providers meaning that the client holds more of the burden.

    As, I said, I can see the benefit of "some" of the info you present here but I do not agree with the majority (or the tone)... And yes, I am also in the San Francisco bay area.

    1. Thanks for taking the time to comment. I certainly understand that there are many students (and clinicians) who do not chose to self-disclose with clients. And plenty who do not like the "business" of private practice, and would rather not discuss it. I know you are in good company. Perhaps a majority!

      Again, I know my candor is not to everyone's taste. And that's okay! I understand the concern. I gave this a lot of thought over the years as I have received plenty of feedback on it. Ultimately- I continue to keep it up because:

      It's something *I* would want as a consumer. So in essence (as many therapists) I seek to talk to the type of client I typically attract: a business- minded, independent, highly-educated consumer who doesn't want a hierarchical relationship with their therapist. Believe it or not, I have been thanked by clients for writing this post. And maybe even more to my pleasant surprise- I have been selected as a therapist by this post! That's always a cool experience.

      Like teachers, and mentors, and any service professional, therapists come in all stripes and colors. I really honor that your thoughts on this topic might not mirror my own.

      I also know this is a topic I changed my mind on... as I was in the business longer. I got tired of watching clients (who I cared deeply about) get screwed over by terrible billing practices and their insurer. I got tired of them (unknowingly) being labeled and having their confidentiality breached. I thought they deserved to know what was happening to them! This took time and experience for me to feel the way I do. Initially I started out feeling hell-bent on offering insurance-approved therapy. It wasn't until I saw what was happening to the clients that I got upset about it.

      Best wishes on your own process!


  11. I Promise to Share This Loan Testimony Because of God Favor in My Life, i have being in search of loan over the internet and still was not able to get a loan because i'm blacklisted due to my bad credit score i lost my job and i lost my home i was living in the street frustrated without shelter or food , till one day i came across a testimony on the internet of how this company have been helping people with loans so i tried unfortunately my loan was granted without no collateral i applied for $100,000 i am so happy thanks be to shelter finances please in case you need a legit lender and a God fearing lender contact now here is their email :(

  12. Hello we offer International loan to both individuals and companies worldwide. Our interest rate is 3% per year.

    We give loan from any amount of $2000 to $30,000,000.00 for any legal purpose.

    We also give loan from a long term of 1-25 years . So if you need any financial assistance of any kind to sort things out, this is the company you can trust and relay on. Applications is available for applicants who are 18 years and older.

    Contact us today for all your financial needs.

    Best Regards,
    Mr. Richy Scott


    Here comes an Affordable and Legit Loan that will change your life for ever, I am Dr. Bentley Grants a certified loan lender, I offer loan to individual and public sector that are in need of financial Assistance in a low interest rate of 2%. Bad credit acceptable,The Terms and Conditions are very simple and considerate.You will never regret anything in this loan transaction because i will make you smile. Email: ( have you been looking for a quick and legit loan online why don't you try Dr. Bentley Grants loan company and be free from debts note getting
    a loan from this company is 100% assured and guaranteed

    We have provided over $50 Billion in business loans to over 25,000 business owners just like you. We use our own designated risk technology to provide you with the right business loan so you can grow your business. Our services are fast and reliable, loans are approved within 24 hours of successful application. We offer loans from a minimum range of $10,000 to a maximum of $800 million.

    Do you find yourself in a bit of trouble with unpaid bills and don't know which way to go or where to turn? What about finding a reputable Debt Consolidation firm that can assist you in reducing monthly installment so that you will have affordable repayment options as well as room to breathe when it comes to the end of the month and bills need to get paid? Dr. Bentley Grants Loan Home is the answer. Reduce your payments to ease the strain on your monthly expenses. Emai(

    Our services include the following:

    *Truck Loans
    * Personal Loans
    * Debt consolidation loans
    * Car Loans
    * Business Loans
    * Education Loans
    * Mortgage
    *Refinancing Loans
    * Home Loans

    NOTE:Bear in mind that it will only take less than 24 Hours to process your file is 100% Guaranteed no matter your Credit Score.

    Yours Sincerely,
    Dr. Bentley Grants
    Phone: +1 (940)226-3822

    We are certified and your privacy is 100% safe with us. Worry no more about
    your loans or finances.

    Get your instant loan approvals an Affordable and Legit Loan that will change your life forever

  14. I am Amanda a widow at the moment with three kids and i was stuck in a financial situation in January and i needed to
    refinance and pay my bills. I tried seeking loans from various loan firms both private and corporate but never with success,
    and most banks declined my credit. But as God would have it successfully, I was introduced to a legit loan lender who gave
    me a loan of 80,000USD and today am a business owner and my kids are doing well at the moment, if you must contact any

    firm with reference to securing a loan without collateral , no credit check, no co signer with just 2% interest rate and better

    repayment plans and schedule, please contact Fidelity loan. Here is their email you can contact them now if you are in need

    of a loan as well via: They doesn’t know that am doing this now but am so happy now and i

    decided to let people know more about their firm and also i want God to bless them more for their good works. You can

    contact them through this email or telephone number or call or text them on +13137774025

  15. This is anger from USA, am sharing this article to give thanks to Dr,UZOYA who helped me to bring back my EX lover that broke up with me for 5 months. I was searching for advise on what to do to get back my EX lover and i came across a post of a woman in USA called LAURA giving thanks to Dr.UZOYA for helping her to get back her lost HUSBAND who left her for years with her kids. I contacted the spell caster for help due to the fact that i needed my EX lover desperately because he is the love and my life. To God be the glory, my EX lover came back to me within 2 days after Dr,UZOYA finished preparing the spell and i want the world to join me to give thanks to Dr,UZOYA for helping me. Viewers reading this article that also need his help should contact Dr,UZOYA with his email; his telephone number +1(301) 909 8775.


Thank you for taking the time to comment. Please note that this (being the internet) is not a confidential or secure way to contact me. If you wish to speak with me privately, please call me at 916-270-7413 or visit my site