I tried to work as an in network therapy provider. I really tried.

When I pivoted back to offering therapy two years ago, I vowed to give it a solid effort. I committed to going all in on a two-year experiment to see if I could make it work. I wouldn’t go so far as to say I had an open mind, as insurance companies are evil and the system is exploitative and broken (a well-informed and evidence-based opinion), but I did believe it could be possible for me to stretch and bend my values around the system to hold it imperfectly in a way that was workable.

I found a creative way to become an in-network therapy provider with one major insurance company under the contract of another therapist, allowing me to avoid signing a direct contract with the devil, and for the last two years I have directly billed insurance for therapy services.

I very much appreciate the accessibility and long-term consistency that subsidized therapy can help to foster. If we had a community care model of health care, or even the non-profit health care system this country used to have in place, clients could access the therapeutic support they need for a modest fee while therapists are compensated with a living wage.

Alas, that is not the system in which we are living.

I love my insurance clients. I love the work we do together. I want to continue those clinical relationships and welcome in all the other insurance clients that could benefit from the special brand of healing and growth that I foster. But the cost and the risk are too great.

Rate

Insurance companies do not pay therapists a living wage and the rate of reimburse is no where near compensatory for the time and expense required to become a licensed therapist.

Insurance contracts forbid therapists from sharing or stating publicly the session rates they are being paid. As a believer in the benefits of transparency, I would share all of those numbers with you if I could.

The only way to make accepting insurance financially sustainable is quantity (group practices and therapists with high client loads are more often paneled with insurance companies), but quantity has a direct and inverse relationship to quality.

While clients are expecting the co-pays and deductibles, they are also potentially on the hook for any fees their insurance refuses to pay (which can be surprising and significant).

Documentation

The documentation required to justify medical necessity to insurance companies is excessive and often counter to client well-being. Therapists must impose a diagnosis from a limited set of medically-approved options, create a theory-based treatment plan, write pages of case notes after every session documenting personal details that track the perfect balance of progress and impairment, in addition to the copious administrative work of submitting and processing (and sometimes fighting for) claims and payments. The insurance company gets a seat in the therapy room, undermining confidentiality with access to client records and de-centering clinical best interest with their own separate interests.

It’s fracturing my soul trying to serve two competing masters. The increased work for the reduced pay is untenable. The privacy concerns, especially under the current administration who is rampantly outlawing menstruating and trans bodies, feels too grave to bypass.

Clawbacks

I spent this two-year experiment living with a persistent and justified anxiety around audits, where insurance companies demand and review every piece of documentation in your client files in an investigation with the goal of finding any excuse to deny coverage, and clawbacks, where insurance companies force therapists to pay back the money they’ve been paid for potentially years of services rendered.

Being hit with my first clawback was the catalyst for my decision to end my relationship with insurance.

Private Pay

Exorcising the insurance goblins from the therapeutic relationship, we are left with the private pay model, wherein clients pay therapists directly for services. One third of all therapists in the US are private pay (not in network with insurance companies).

My entire coaching practice is currently and has always been private pay. Half of my therapy caseload has consistently been private pay. The supervision I provide associate therapists will also be private pay.

Fifty minute sessions are provided for a fee of $200.

Superbills

Within the private pay model, clients may receive reimbursement from their insurance company for therapy services through their out-of-network (OON) benefits. This is a nice compromise in that insurance is still paying for some of the services, but without access to and influence over treatment.

Here’s the process:

1. Your card on file will be charged the fee after our session on the date of service.
2. I will provide you with a receipt known as a “superbill.” Clients receiving weekly therapy typically choose to receive a monthly superbill.
3. You will upload that superbill to your insurance company’s website, often through a button inviting you to “Submit a Claim.”
4. Your insurance company will reimburse you a percentage of what you paid, in accordance with your specific plan. This is usually mailed to clients as a paper check.

If the executive functioning of this process feels daunting, there are services like Reimbursify that can handle the process for you for a small fee.

Questions for your insurance company:

If you want to know more about your policy’s specific procedures and benefits, I recommend calling your insurance company and asking any questions you may have.

• Does my plan cover outpatient individual therapy with a Licensed Marriage and Family Therapist (LMFT)?
• What are my out-of-network benefits for those services?
• Do I have a deductible or co-pay? How much?
• What is the process for submitting a claim? Where do I upload superbills?
• How much will I be reimbursed for each session?
• What is the timeline for receiving reimbursement?

Information you may need:

At any point along the process, your insurance company may ask you for any of the following information (all of which is also included in your superbill).

• CPT code for first session: 90791
• CPT code for psychotherapy: 90837
• NPI: 1245098904
• EIN: 86-1242246
• Therapist name: Rachel Rainbolt
• License number: MFT.LF.70057868
• Therapy location: Telehealth

*Note: Clients are responsible for any and all communication with their insurance company.

While I continue to advocate for a community care model of social governance in which health care is easily accessible, services are client-centered, and therapists are compensated with a living wage, this private pay model with superbills for out-of-network insurance reimbursement is the most values aligned way of honoring needs in the therapeutic space that I can offer.