Why I Don't Accept Insurance

Many clients are confused by my not taking insurance. Some have even asked if they can give me the paperwork from their insurance so I can join their network. I can certainly understand any client wanting to make the most of their insurance. However, there are several reasons that I choose not to directly accept or bill insurance. Some of those may also be reason for you to reconsider attempting to use your insurance for counseling.

Who Is The Client?

When it comes to insurance, there can only be one client. For an individual client, this may not be much of an issue but for couples or families, this can be a problem. It means that I have to identify someone as “the client,” the one with the problem. The other person can be there as a support according to the insurance records (coded as “family therapy”). However, only the one person is listed on the insurance claim. 

Couples or family issues are best seen as something that the pair or group of you are addressing together, and even subtle notions that someone’s diagnosis can be blamed for all of the issues can create difficulties in therapy. Therapy is about everyone coming in and owning their own parts in the problems within the bigger system. Having an one person as the “identified patient” can get in the way of that.

How Bad Is It?

Insurance companies only pay for what they see as “medically necessary.” In other words, they want to make sure that your mental health issue is so severe that it impacts your everyday functioning at work, school, social situations, or daily living such as bathing, eating, etc. When billing your insurance, your therapist needs to make a strong justification for what your diagnosis is and how it impairs you from being a functional individual.

This can be a big problem. First, many clients come in to work on issues that aren't mental health disorders. They seek treatment before their issue would meet the criteria for diagnosis as a mental health disorder (and that is a good thing). Rather than being supported in taking a proactive approach to dealing with their mental health, clients are penalized and by their carriers because what they are seeking help with is not “medically necessary.”

This becomes even more complicated with couples. Most insurance policies don’t cover marriage or couples counseling. It is diagnosed as a Z-Code, a code that indicates an issue that may come up in therapy that does not qualify as a mental health diagnosis. It is this code that most insurers will simply reject. Some therapists will bill insurance for couples counseling by diagnosing the “identified patient” with a mental health diagnosis. The problem is that if they then do marriage therapy, they are not actually treating the diagnosis that is being billed for. This does not fit with my ethical standards.

The Impact of a Diagnosis

The other issue with insurance requiring a diagnosis is simply that you now have a diagnosis. I have had more than a few clients get caught up in their diagnosis and see it as part of their identity. Rather than dealing with an issue they are facing, they become their issue. I don’t see my clients as disorders and symptoms and I don’t find that they benefit from seeing themselves that way either. I see them as whole and complete people who, like everyone, struggle at times to adapt to what life brings them. I believe that they benefit the most when they are able to take this perspective also.

Your Diagnosis, Your Privacy, and Your Choice

Once that diagnosis is reported to the insurance company, it will remain on your medical records for the rest of your life. Many people don’t realize how that can impact them and how they lose control of access to that information when that file is shared with those who need access to it. A diagnosis says nothing about who you are now, how you have adapted and grown, your strengths, and what actual symptoms you experience. And yet, a diagnosis will say a lot for those who read it and may negatively impact you in the future. Your diagnosis can follow you around in school or college and be a barrier to doing certain things such as working with the military, being hired for federal jobs, obtaining security clearances, working in aviation, and any other jobs requiring health-care related checks. In fact, many schools and healthcare institutions are now employing policies to screen out employees who may be unstable or cost too much money in mental health care and lost work days. Your choice in who knows your diagnosis disappears once that diagnosis is provided to your insurance.

Further, insurance companies require clinicians to reveal diagnoses, symptoms, behaviors, and treatment plans that itemize the issues we are working on and the goals we have set. I’m unwilling to reveal confidential, potentially damaging information if hacked, to the insurance company to justify my clients’ needs for emotional support. Avoiding interactions with insurance companies protects the confidentiality of my clients. 

Insurance companies also limit the number of sessions they will pay for a client. Your treatment method, approach, and length is decision is between you and I. I do not think it is appropriate for healthcare decisions to be determined by insurance screeners and treatment to be determined based on production pressures from a corporation whose operating philosophy is based on attempting to increase profits and minimize payouts.

Insurance and the Therapist

It would be disingenuous to not acknowledge that there are reasons I have for personally not wanting to take insurance. Accepting insurance demands a significant amount of time and patience to fulfill paperwork demands, pursue reimbursements, re-authorizations for treatment, etc. Additionally, insurance companies pay what they believe a provider should be paid, sometimes as little has half of a provider’s fees, and are increasingly making it difficult to get paid. This means I spend more time working in order to get paid less. This time spent trying to get paid a portion of my fee would detract from my time spent on better things such as broadening my expertise in order to provide higher quality services, seeing clients, and taking the time I need to take care of myself so that I can be focused, energized, and refreshed when I sit with my clients.

Is There Any Way to See You and Use Insurance?

Some insurance carriers will reimburse for out-of-network mental health services. In those cases, I am able to provide clients with a “super bill,” itemized statement of the services rendered, how much you paid for your services, and a diagnosis. Whether such reimbursement is an option, what diagnoses are covered, and the percent that is reimburse will all vary from plan to plan and carrier to carrier. You’ll want to check with your insurance company for specific details. Please be aware that all of the concerns listed above about privacy, diagnoses, and your medical records still apply when a super bill is submitted.


You recognize that you are wanting to better yourself. Don’t let the cost of counseling or therapy services scare you away. This is an investment in your and/or your relationships overall wellbeing and health. Working with a therapist with whom you connect and have confidence is a big part of building that wellbeing. After all, it is more important to invest in your health early on rather than experiencing greater struggles later on in life.