Should I take insurance in my private practice?
There are many ways to explore this question. At the surface the question is often posed as a query about financial viability, “can I make a living if I only work fee for service? Do I have to take insurance in order to have a sustainable income?” But a deeper exploration reveals more nuanced factors for consideration. Payment for services involves conflicting values regarding self- care, the insurance industry and access to service for clients. From my perspective at the most basic level the question regarding whether or not to take insurance is a social justice issue. Thinking only in terms of what makes the most money in the easiest way possible is not congruent with my social justice background.
Self- care is a legitimate concern, and in fact an ethical issue. (ACA, 2014). The time it takes to navigate insurance billing and the inability to receive fair market value for services takes a toll on therapists, depleting energy that could otherwise be used in the service of our clients and ourselves. Research shows that administrative responsibilities, especially those associated with insurance and managed care, and reduced reimbursements contribute significantly to burnout (Barrett, 2014). Thus a decision to provide only fee for services does positively contribute to therapist well- being, which ought to have a positive outcome for clients as well. The concern here is the ability of a wide range of clients to be seen under a strictly fee for service practice. Therapists are likely to be successful in making a reduced stress living but are they adequately serving the population in need?
Working with insurance can provide access to services that clients that might not otherwise be able to afford. And yet, there are again ethical considerations with utilizing insurance. Many therapists opt out of utilizing insurance not because of the additional paperwork and reduced reimbursements but because they cannot abide by the risks to their clients associated with utilizing insurance. Insurance companies are profit driven. They are not directly aware of the treatment process, the unique aspects of the client-therapist relationship or even best practices, especially as it relates to children’s services!
When utilizing insurance, client care can be determined by what the insurance company deems to be medically necessary. Treatment can be mandated with regard to the number of sessions, the length of sessions, who is present in a session, and other factors. A diagnosis must be given and that diagnosis stays with the client for the duration of their existence – with implications for future employment and access to insurance coverage. Confidentiality of sensitive material cannot be guaranteed. Additionally, insurance coverage can change mid-treatment resulting in abrupt treatment disruptions, financial burdens or the need to transfer care to another provider. All of which are destructive to the client. Sadly, this is not uncommon. Too often I have been faced with the dilemma of how to continue care for an established client that no longer has insurance coverage. A further frustration is that the insurance companies even influence fee practices for non-insurance using clients, mandating that all fees and fee policies be consistent across client populations.
Given the risks and ethical dilemmas posed by utilizing insurance for mental health (or really any health care services) many therapists and medical providers refuse to work with insurance companies. Some provide services at a reduced rate or on a sliding scale, others provide a certain number of pro-bono hours or do random write offs in order to serve more vulnerable populations.
Community mental health clinics are often unable to provide adequate mental health care. Therapist caseloads are excessively high with limited support, which leads to burnout. Recently I was contacted by a judge requesting that I see a client he wanted transferred from our local center because the client could only be seen every few weeks due to overscheduling. Wait lists are long; appointments are not guaranteed to be available on a consistent schedule.
In researching perspectives regarding fees and services, I encountered many conflicting opinions. I was particularly interested in a comment in which a therapist that had recently moved to a different part of the country stated a complete shift in perspective. He had formerly been absolutely pro “fee for service” until he moved to a new community resulting in a radical change of heart; he realized that no one in his community could afford to access services out of pocket (Barnett, 2014). A private practitioner in an affluent community has different factors to consider than one in a more rural or economically depressed community. What works for any one therapist will be unique to them and the communities in which they practice.
Therapists in private practice have the privilege of being able to determine their own billing practices and caseloads. In determining fee policies and client capacity we should take considerable time to reflect on the the myriad implications of our decisions. Using a strictly financial basis for decision making is not best practice. Access to quality mental health services is a complicated ethical and social justice issue.
American Counseling Association (2014). ACA Code of Ethics. Alexandria, VA: Author.
Barnett, J. (2014, December). Distress, burnout, self-care, and the promotion of wellness for psychotherapists and trainees: Issues, implications, and recommendations. [Web article]. Retrieved from: http://www.societyforpsychotherapy.org/distress-therapist-burnout-self-care-promotion-wellness-psychotherapists-trainees-issues-implications-recommendations
Dancy, Krysta. (2016) What Your Therapist Hasn’t Told You About Using Insurance. [Web article]. Retrieved from: http://www.confessionsofatherapist.com/2010/12/what-your-therapist-hasnt-told-you.html)
Mersen, Molly. (2016) Using Insurance to Pay for Mental Health Counseling: A Therapists Perspective. [Web Article]. Retrieved from: http://www.huffingtonpost.com/psyched-in-san-francisco/using-insurance-to-pay-fo_b_11996758.html