The Rising Appeal of Private Pay: The Benefits of Going Out-of-Network for Mental Health Therapy
An increasing number of therapists are choosing not to panel with health insurance companies in the US. There are a lot of factors that go into the search for mental health care and finding the best fit for you. You can view the Pros & Cons table below for a quick overview of considerations when deciding between seeing an In-Network or Out-of-Network therapist:
A few quick notes on terminology:
In-network provider/therapist: This is a healthcare provider that is paneled with your insurance company. That means you can use your health insurance benefits to pay for their services, as the insurance company has already pre-approved them as an in-network provider.
Out-of-network provider/therapist: This is a healthcare provider that is not paneled with your insurance company. They may be paneled with other insurance companies, or not paneled with any insurance companies at all. Some insurance plans offer reimbursement for out-of-network services that you receive. If you are eligible for this reimbursement, you will pay your therapist their full fee upfront, and your therapist will provide you with a superbill (a specialized receipt) to submit to your insurance company for reimbursement.
Private pay or out of pocket pay: This means instead of utilizing insurance benefits to pay for treatment, you will pay for the healthcare service like you would for any other product (cash, credit card, etc.). Even if a therapist is in-network with your insurance, you are allowed to opt for paying out of pocket if that is something you choose to do.
Let’s dive deeper into some of the benefits of seeing an out-of-network therapist and paying privately for your mental health care.
You have a wider selection of therapists to choose from.
If you are on the search for a mental health provider, you have probably experienced the arduous process of having to filter through layers and layers of therapy search engines. You may have had to apply filters including location, setting preference (in-person vs online), therapist demographics (gender, sexuality, ethnicity, etc. in hopes of increasing your odds of finding a therapist that clicks with you or “gets it”), and therapeutic modality (CBT, DBT, person-centered, psychodynamic, narrative, internal family systems, EMDR… why are there so many choices?!). By the time you’ve also added the insurance filter and then tried to see which therapists in your search results have immediate availability, you might not be left with many options. For many therapy seekers, insurance becomes a barrier in your search for a therapist who is a good fit for your needs, preferences, and identities. Forgoing insurance can help open up your search to a wider variety of therapists.
TLDR: You have more choices when picking a therapist if you aren’t limited by your insurance network.
You may receive a higher quality of care.
Running a business - even a healthcare business - is expensive. In comparison to the costs of running a private practice, health insurance companies offer an unsustainably low reimbursement rate to therapists paneled on their insurance. Therapists that are paneled with insurance have no say over how much they are compensated per session by insurance companies. In order to make ends meet and still make a liveable wage, in-network therapists often have to carry substantially larger caseloads (sometimes 30-35, or even 40 clients a week!). Then factor in all the other between-session responsibilities that they have to take care of (notes, admin, emails, marketing, professional development, prep time…) - that is a lot to do in just one week!
In comparison, out-of-network therapists can decide how much they charge per session. By charging a higher fee, they are able to hold a more sustainable caseload and thus have more physical and mental capacity to focus on your care. Plus, they may be less susceptible to burnout, which translates to a lower likelihood of them having to do last minute health related cancellations on you, or stepping away from the field altogether.
TLDR: Out-of-network therapists can have smaller caseloads, and therefore more time and energy to spend focusing on your care.
You will have greater freedom and control over your care.
If you opt to see an out-of-network therapist and your insurance were to ever change, it wouldn’t affect your therapy care. This means more consistency in your mental health care, and less time, energy, and worry wasted on re-establishing services with a new provider, just because your insurance changed.
Additionally, insurance companies often dictate how long your sessions are or how frequently your sessions can be. By going out-of-network, you have more flexibility with your therapist to tailor the length and frequency of each session to your needs and treatment plan. For example, there are many situations where you might want or benefit from 90 minute therapy appointments. Seeing an out-of-network therapist gives you the freedom to opt in for longer appointments. You and your therapist can also decide on the length of your overall treatment, instead of being constrained by insurance determinations of “medical necessity”.
By seeing an out-of-network therapist, your therapist may also be able to have more freedom and creativity in the therapeutic approaches they use to support you. For example, group therapy and couples counseling are often not covered by insurance, and would require you to see an out-of-network provider or pay out of pocket for these services. Some people can also benefit from real world support to help them generalize their skills learning from therapy into the real world. This might look like doing therapy out in the real world with your therapist, whether it is part of an exposure therapy protocol, walk and talk therapy, nature-based therapy, or something else! You might not get offered these out of the box approaches if you were seeing an in-network therapist due to the constraints of insurance.
TLDR: Going out-of-network for therapy can open up more options around how long your sessions are, how frequently you see your therapist, how long your overall treatment lasts, and what creative strategies your therapist may be able to tie into your care.
You will have more privacy for your mental health care.
People are often surprised to learn that there are not a lot of regulations from a federal or state legal level around what your therapist is required to document about you in their notes. Do you know who does have a lot of rules and regulations around this though? You guessed it - insurance companies. Insurance companies have a heavy hand in controlling what your therapist must document about you in their treatment notes and records. Notes must be written in a specific way that justifies to insurance companies that there is “medical necessity” for why they should cover your care. In fact, under Washington state code WAC 246-809-035, you have the right to ask your therapist not to keep a clinical record of you at all. However, if you are using your insurance benefits to see a therapist, insurance companies will still require your therapist to keep a clinical record of you, even when the state does not.
Another example of this control being exerted is in the issue around diagnosis. Insurance companies require your therapist to provide a diagnosis for every session that they are paying for. Many mental health diagnoses require at least a few sessions for the therapist to thoroughly and accurately evaluate your symptoms. However, due to the insurance company’s diagnosis requirement, this process often gets curtailed or rushed for the sake of meeting insurance rules.
You might consider paying out of pocket or seeing an out-of-network therapist if these privacy issues are of concern to you. Additionally, if you are on a partner or family member’s insurance plan and don’t want them to know about your therapy treatment, paying out of pocket can be a way to protect your privacy.
Note: In-network is not always cheaper
A quick note - while seeing an in-network therapist is often the cheaper option, there are circumstances in which it is not necessarily the case. For example:
If you have good out-of-network benefits, it is possible your insurance will reimburse you enough for an out-of-network therapist’s session fee that your out-of-network session cost might be lower than your standard in-network copay.
If you have a high in-network deductible that you haven’t met yet, you need to meet that deductible before your insurance benefits kick in. In this situation, in-network and out-of-network therapists can cost the same amount for you.
Clearly the American health insurance system is complex, hard to navigate, and often counterintuitive. There can be a lot of barriers to accessing mental health support, and there are a lot of factors to consider as you search for care that is most aligned with your needs and preferences. If you are considering seeing an out-of-network therapist, in the next blog post we will go over what information you should gather from your insurance company to understand your out-of-network benefits.
About the Author
Adora (she/her) is a licensed clinical mental health counselor associate and owner of Spring Day Therapy PLLC. In the past she has worked in various mental health settings with different age groups, populations, and levels of care. In the therapy room, Adora operates from a DBT-informed and culturally-responsive lens to support clients in working through challenges and create real-life changes. Her work is further enhanced by her passion and training in supporting autistic individuals and providing culturally responsive care for Asian populations.
Outside the therapy room, Adora has experience working in mental health research, and is also the founder and president of FAUNA Mental Health Foundation, an Asian mental health advocacy nonprofit. She currently leads an international team of volunteers and interns to provide accessible mental health resources through their website and workshops with community partners.
Interested in receiving therapy with Spring Day Therapy? Fill out an interest form below to schedule a free 15-minute phone consultation with Adora!
