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A Case For Private-Pay Therapy

As an introduction, I’d like to make clear that it I do truly understand it is a privilege to have the ability to pay out of pocket for mental health care. There are some insurance companies that truly make mental health care accessible to their users, and if you have this opportunity, I (as a clinician who is not in network with any insurance companies) fully support you utilizing it. However, after many conversations with peers and loved ones, I wanted to address the elephant in the room: why does it makes sense for therapists to not accept insurance?

Almost a third of therapists in practice do not accept insurance. They will describe their services as “out-of-pocket” because the fee for the session comes straight from the client. This can feel limiting and strange to clients—if I am paying 300-600 per month for insurance benefits, why would I pay separately to receive mental health care?

Whether or not a therapist takes insurance is a decision that is not made lightly, or purely through greed. There is a lot of nuance to the discussion, and as a therapist I wanted to present one side of the story.

Why it benefits the therapists and the clients they serve:

Quality, expert therapists want to be compensated fairly.

Your therapist that takes your insurance may be seeing 30 clients a week, on top of billing, running a business, and documentation to make a living wage. On the other hand, OOP (out-of-pocket or private pay) therapists can choose the number of clients that works best for their practice. They can focus on client resources, continuing education, their own self-care and on *you*. They aren’t chasing after insurance companies hoping to get their denied claim resubmitted, which means they are much more likely to have the capacity to give you the very best care they can.

Insurance (probably) doesn’t help as much as you think it does.

First, does your insurance cover mental health services? Unfortunately, this isn’t always standard practice, and you should always check your policy when you are shopping to make sure mental (or behavioral) health services can be utilized. Second, do you have to meet your deductible before they will cover the services? A deductible means you will be paying out-of-pocket anyway without receiving the benefits of OOP care. The standard deductible for a healthcare marketplace plan in Pennsylvania is $2500. Third, once you reach your deductible, at what percentage does your insurance cover your services? Mine, for example, only covers 80% and that is after I pay a $35 copay.

What does it mean for privacy?

When insurance is paying for your sessions, it means that their employees are looking over notes and treatments plans from your sessions in order to decipher whether it is clinically appropriate for you to be in therapy. In other words, insurance companies have entire departments dedicated to double checking our work. The insurance company has full power to see your personal and private notes and have the ability to stop payment at any time if they don’t see a medical necessity. This gives a lot of power to strangers who are not in session with us.

Insurance requires a diagnosis to be given to the client no matter what it is they come in for. Even then, there are some diagnoses that insurance companies do not believe require therapy. This means that if a therapist wants to continue seeing a client, they have a moral quandary: do I tell the truth, that this person might just need some therapeutic work on attachment and grief, or do I say that they have Major Depression? Or Post-Traumatic Stress disorder? Worse yet, that diagnosis can stay in your medical records for years. If you are given a diagnosis that isn’t true, it could be used to steer treatment from future doctors or shown to jobs that require a background check.

Of course there are reasons why it benefits the client and the therapist to use insurance. Especially for the client, it can make care accessible in a difficult situation. But, let’s face it—the health insurance industry in the U.S. has many broken parts, and it may be worthwhile to shift focus on helping provide access in other ways.

How can we do that? There are several ways that Mending Space is working to make out-of-network care more accessible.

VCAP – The Victim’s Compensation Assistance Program is a fund provided by the government of Pennsylvania for victims healing or recovering from trauma related to crime. VCAP pays an average of $13 million per year on behalf of crime victims and can reimburse for out-of-network expenses. If you are looking for counseling based on trauma from a crime, please look into this program:

Sliding Scale – Many out-of-network providers provide sliding scale spots on their schedule to clients who are in need. Sliding Scale means that the out-of-network cost can vary and decrease greatly based on a client’s income and needs. The Mending Space currently has sliding scale spots open for any clinician.

Pay-it-forward funds – As a project in the near future, The Mending Space would like to be able to make it possible for clients to receive free or extremely low cost services from dedicated counseling professionals by establishing grant funds for therapy. If you are interested in helping to provide therapy to other people by funding sessions, please reach out to me at to learn how.

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