The actual benefits, costs, and operational consequences of accepting insurance
On accepting insurance, staying private pay, and why making mental healthcare more accessible shouldn't require providers to sacrifice their own financial stability.
There's a moment that happens when a therapist starts thinking about opening a private practice, or when an established practice begins trying to grow, and someone inevitably asks a perfectly reasonable question.
Should we start accepting insurance?
It sounds like a relatively straightforward decision. More people can afford treatment, the practice becomes accessible to a larger patient population, and insurance directories may provide a consistent source of referrals. For providers who entered behavioral health because they genuinely want to help people, accepting insurance can feel like an obvious way to make their services available to those who need them.
And then someone opens a credentialing application.
Suddenly, that licensed, highly educated professional is trying to reconstruct their employment history from eleven years ago, locate a malpractice certificate that apparently exists only in a former employer's inbox, and explain to an insurance portal why their address doesn't match a record nobody can identify.
And that's before contracting, enrollment, payer-specific requirements, fee schedules, claims, denials, and the inevitable conversation with an insurance representative who assures you that everything looks correct on their end.
Wonderful. Perhaps someone could explain why nothing is getting paid on our end.
I've spent a considerable amount of time working with insurance companies, credentialing providers, negotiating and navigating payer relationships, and managing the operational systems responsible for turning clinical services into actual revenue. And if there's one thing I've learned, it's that accepting insurance is much more complicated than simply deciding you want to be accessible to more patients.
I've also seen the other side.
Providers who remain private pay because they want greater control over their schedules, fewer administrative responsibilities, and the ability to establish fees that reflect the actual cost of providing treatment.
And honestly, I understand both perspectives.
I also find it interesting how quickly this conversation can become unnecessarily judgmental.
There's sometimes an assumption that providers who accept insurance are more committed to accessibility, while those who remain out-of-network are prioritizing income over patient care.
I don't think it's nearly that simple.
A therapist who accepts reimbursement rates that don't support the cost of operating their practice, spends evenings completing unpaid administrative work, and eventually burns out isn't necessarily improving access to care in any sustainable way.
And a therapist who remains private pay, develops a manageable caseload, maintains financial stability, and offers limited reduced-fee appointments isn't automatically disregarding the needs of people who can't afford treatment.
There are legitimate benefits and drawbacks to both approaches.
And considering I named this particular corner of the internet Tina Out of Network, I suppose it was only a matter of time before we had this conversation.
First, Can We Acknowledge That Getting Paneled Is Not One Simple Process?
One of the things that drives me slightly crazy about insurance credentialing is how casually people use the phrase "getting paneled."
Someone will tell me they're working on getting paneled with an insurance company, and my first question is usually where they are in the process.
Because there are several different steps involved, and they don't all mean the same thing.
A clinician needs to have the appropriate professional license and identifying information. Their credentials may need to be reviewed and verified by the payer. A contract may need to be negotiated or accepted, and the provider then needs to be properly enrolled and loaded into the insurance company's systems.
Depending on the practice structure, there may also be organizational enrollment requirements, multiple practice locations, additional provider identifiers, and different insurance products operating under what appears to be the same company.
And these processes don't always happen in the same order.
One of the more frustrating things about insurance is that a provider can be fully credentialed without being properly contracted, or contracted without being correctly enrolled for claims payment.
I've seen situations where a clinician appears in the payer directory but claims still deny because something wasn't loaded correctly on the insurance company's end.
Other times, a provider is approved for one insurance product but not another, even though both plans carry the same recognizable company name.
And then there are the joys of mismatched tax IDs, provider taxonomies, service locations, and effective dates.
All of which can prevent payment for services that were appropriately delivered.
This is why I get a little nervous when someone tells me that a provider has been approved and is ready to begin seeing forty insured patients next week.
Approved for what, exactly?
Because there's a fairly significant difference between having a credentialing approval letter and confirming that the provider is correctly enrolled, effective, and able to submit payable claims for the intended services and plans.
And those differences can become very expensive when nobody catches them until several weeks of claims have already been submitted.
None of this means insurance participation is a bad idea.
It means the decision comes with operational responsibilities that need to be understood before a practice builds its financial expectations around them.
Accepting Insurance Can Make an Enormous Difference in Access to Care
I don't want the administrative frustrations to overshadow one of the most important arguments in favor of insurance participation.
For many people, it's the difference between being able to receive ongoing mental health treatment and not receiving it at all.
Weekly therapy can become financially difficult very quickly when someone is paying the full fee out of pocket.
For a person who needs psychiatric medication management, ongoing psychotherapy, or a more intensive level of behavioral health treatment, those costs can become a significant barrier.
Even people who have the financial resources to pay privately may reasonably expect to use the health insurance benefits they're already paying for.
And I think that's a fair expectation.
When a provider joins an insurance network, patients may be able to access services through copayments, coinsurance, or other plan benefits rather than paying the entire private-pay fee.
Of course, having insurance doesn't automatically mean treatment is affordable. High deductibles, limitations on benefits, authorization requirements, and other cost-sharing obligations can still create considerable financial strain.
But network participation can remove or reduce an important barrier.
It can also help providers become easier to find.
Many people begin searching for mental health services through their insurance company's directory because they want to identify someone who's covered under their plan.
An accurate in-network listing can create a source of referrals that doesn't require a therapist to become a social media personality, master search engine optimization, or spend half their discretionary income convincing Google that their practice exists.
For smaller practices, that visibility can be valuable.
Insurance participation can also support referrals from hospitals, physicians, treatment programs, and other providers who are trying to help patients access appropriate follow-up care.
And for organizations offering multiple levels of treatment, being in-network may make it easier for patients to transition between services without having to start their search over again.
That continuity can be particularly important in behavioral health, where interruptions in care can have meaningful consequences.
But while accepting insurance can improve access, I think we have to acknowledge that simply having providers listed as in-network doesn't necessarily mean patients can actually obtain appointments with them.
A provider directory filled with clinicians who aren't accepting new patients, have incorrect contact information, or aren't properly enrolled doesn't accomplish much.
And the research suggests that these access problems are far from isolated.
A 2024 analysis from RTI International found that commercially insured patients used out-of-network behavioral health clinicians approximately 3.5 times as often as they used out-of-network medical or surgical clinicians. For psychiatrists, the difference was approximately 8.9 times, and for psychologists, 10.6 times.
That's a substantial disparity.
It suggests that having behavioral health benefits on an insurance card doesn't necessarily translate into being able to find appropriate treatment within the network.
And I think that's where the conversation becomes more interesting.
Because if we want more behavioral health providers to accept insurance, we probably need to spend some time understanding why so many are reluctant to do so.
Rather than simply criticizing them for making that choice.
And Then There's the Part Where Insurance Has to Pay Enough to Keep the Practice Open
I think one of the most significant misunderstandings about insurance participation is the assumption that a contracted reimbursement rate tells you how financially viable the arrangement will be.
It doesn't.
A payer might offer a therapist a particular amount for a psychotherapy session, and on the surface, that rate may appear perfectly reasonable.
But the therapist isn't simply getting paid for the fifty or sixty minutes they spend with a patient.
They also have documentation requirements, scheduling responsibilities, administrative work, continuing education, malpractice coverage, technology expenses, and the time involved in coordinating care.
Depending on the practice, there may be rent, billing services, support staff, credentialing costs, supervision, and other operating expenses.
And when insurance is involved, there can be additional time spent verifying benefits, obtaining authorizations, correcting claims, resolving denials, managing reimbursement delays, and responding to documentation requests.
Not all of that work is billable.
In fact, an impressive amount of it isn't.
Which means a reimbursement rate that initially looks acceptable may become considerably less attractive once the practice calculates what it actually costs to earn and collect that payment.
And this isn't simply a complaint from frustrated providers.
A 2024 report from the National Academies of Sciences, Engineering, and Medicine examined the barriers affecting behavioral health providers' participation in Medicare, Medicaid, and Marketplace insurance plans.
The report identified inadequate reimbursement, administrative complexity, credentialing requirements, delayed payments, and claims-related burdens as important factors influencing whether providers participate in those networks.
It also recognized that smaller and independent practices can be particularly affected because they often lack the administrative infrastructure available to larger healthcare organizations.
Which seems like a fairly important detail.
A large behavioral health organization may have dedicated employees managing credentialing, billing, authorizations, and revenue-cycle follow-up.
A therapist operating a solo practice may be doing all of those things personally.
And I think we sometimes forget how different those two situations are when discussing whether accepting insurance is financially reasonable.
The reimbursement disparities are also worth examining.
RTI's 2024 research found that in-network reimbursement for medical and surgical office visits was, on average, 22% higher than reimbursement for behavioral health office visits in the commercial claims studied.
That doesn't mean every payer reimburses every behavioral health service inadequately, and actual rates vary by location, provider type, procedure, and contract.
But it does raise an important question about whether reimbursement structures adequately support the services we're asking behavioral health providers to deliver.
If insurance companies want sufficient numbers of qualified clinicians in their networks, the financial arrangements need to make participation reasonably sustainable.
Because a provider can't continue accepting reimbursement that doesn't support the actual cost of their services simply because doing so would make access easier for patients.
At least not indefinitely.
And I don't think we should expect them to.
The Administrative Work Doesn't Magically Disappear After Credentialing
I think this is one of the more unpleasant surprises for providers who are new to insurance participation.
Once the credentialing is complete and the contract is active, the ongoing administrative responsibilities are just beginning.
CAQH information needs to remain current. Licenses and malpractice policies need to be maintained. Practice locations, addresses, provider rosters, and other information need to be updated when something changes.
And then there's the actual business of getting paid.
Claims need to be submitted accurately, payment information needs to be reconciled, denials have to be addressed, and unresolved balances require follow-up.
Some services need prior authorization. Others may require continued-stay reviews or additional clinical documentation to support medical necessity.
And when an insurance company determines that something doesn't meet its requirements, the provider or practice may find itself spending additional time appealing a decision involving care that's already been delivered.
It's a fascinating arrangement.
The clinician remains responsible for the patient's treatment, but the financial viability of that treatment may depend on navigating a complicated administrative process established by an organization that wasn't present for the clinical encounter.
Prior authorization is particularly frustrating because the work required to obtain approval can consume significant time and occasionally delay clinically appropriate care.
A 2025 survey from the American Medical Association illustrated the broader problem, reporting substantial physician and staff time devoted to prior authorizations each week, along with widespread reports of treatment delays and increased burnout.
That survey wasn't limited to behavioral health providers, so I wouldn't use its findings as an exact representation of every therapy practice.
But the larger issue is familiar to anyone who's spent time dealing with payer requirements.
Administrative work has a cost.
And when that work becomes excessive, the cost is often absorbed by clinicians and staff who would otherwise be spending that time providing or supporting care.
I think that's one reason some providers become disillusioned with insurance participation.
It's not necessarily that they object to accepting lower reimbursement in exchange for serving a larger patient population.
It's that the lower reimbursement sometimes comes with substantially more work, greater uncertainty about payment, and less control over how they structure their practices.
And the financial consequences can be significant.
With private pay, the practice may collect payment at or before the appointment.
Insurance reimbursement generally involves a much longer process between delivering care and receiving payment.
Even when a claim is submitted correctly, payment may take time. If the claim denies or requires additional information, the delay can become considerably longer.
That's why I think providers need to understand the difference between the amount they're charging, the reimbursement they're contractually entitled to receive, and the money that's actually being collected.
A $200 charge isn't necessarily $200 in revenue.
And an insurance contract promising a particular allowed amount isn't a guarantee that the money will appear in the bank account next Tuesday.
If only.
Cash flow matters, particularly for smaller practices that still need to pay their expenses while waiting for claims to resolve.
A contract can look profitable on paper while creating significant financial strain if reimbursement is unpredictable or administrative costs are too high.
Which is why I don't think joining an insurance network should ever be evaluated solely by looking at the fee schedule.
Staying Out-of-Network Isn't Automatically the Easier Choice, Either
At this point, private pay might sound like the obvious solution.
Set your fees, collect payment directly, avoid much of the insurance administration, and spend more of your time focusing on patient care.
There are certainly appealing aspects to that model.
Out-of-network providers may have greater flexibility in establishing fees that reflect their expertise, operating costs, and the type of services they provide.
They may also have more flexibility in scheduling, appointment length, and offering services that don't fit neatly into standard insurance reimbursement structures.
A practice operating entirely on a self-pay basis can often avoid much of the routine work involving payer authorizations, claims, denials, and appeals.
And because payment may be collected at the time of service, revenue can be more predictable.
For a therapist who wants to operate a smaller practice, maintain a manageable caseload, and spend less time dealing with insurance companies, those are meaningful advantages.
But there are limitations.
The most obvious is affordability.
Many people simply cannot sustain ongoing private-pay treatment, particularly when sessions occur weekly or when treatment involves multiple providers.
And even patients with out-of-network insurance benefits may face higher deductibles, significant coinsurance, or reimbursement based on amounts that are considerably lower than the therapist's actual fee.
Depending on the arrangement, they may also have to pay the provider up front and wait for reimbursement.
That can create a substantial barrier.
I also think it's important to recognize that out-of-network doesn't always mean the same thing as private pay.
Some providers give patients superbills that can be submitted for potential reimbursement. Others may submit out-of-network claims themselves or work through arrangements such as single-case agreements when appropriate.
Those options can be helpful, but they don't eliminate uncertainty.
A patient having out-of-network benefits doesn't automatically guarantee that a particular service will be covered or reimbursed.
And providers need to be careful about how they explain those benefits.
Patients should understand their financial responsibility, what the practice charges, whether reimbursement is anticipated, and what the limitations may be.
Because telling someone that they can probably submit the charges to insurance isn't particularly helpful if they later discover that their out-of-network deductible is several thousand dollars.
There's also the matter of attracting patients.
An in-network provider may receive inquiries through insurance directories and payer-related referral relationships.
A private-pay practice may need to invest more intentionally in its reputation, professional relationships, website, community presence, and other referral sources.
That can work exceptionally well, particularly for providers with specialized training or a clearly defined patient population.
But it may take time to build.
And while private pay can reduce insurance-related administrative responsibilities, it doesn't eliminate the obligations associated with operating a healthcare practice.
Licensing, privacy, documentation, informed consent, appropriate financial disclosures, and other professional and legal requirements still apply.
For example, federal good-faith-estimate requirements under the No Surprises Act generally apply to uninsured or self-pay individuals in covered circumstances, subject to applicable rules and exceptions.
Out-of-network status isn't some magical exemption from healthcare regulation.
Although I can certainly understand why someone might wish it were.
Maybe We Should Stop Treating This Like an All-or-Nothing Decision
One of the things that frustrates me about discussions around insurance participation is how often they're framed as though providers must make one permanent choice.
Either they accept insurance or they don't.
But there are plenty of situations where a more selective approach makes sense.
A practice might participate with certain commercial insurance plans because the reimbursement rates are reasonable, the administrative processes are manageable, and the contracts provide access to a patient population the clinicians want to serve.
At the same time, it might decline participation with another payer whose rates don't support the practice's operating costs or whose administrative requirements create disproportionate challenges.
Some organizations may choose different payer strategies for different services.
Psychiatric medication management, individual psychotherapy, psychological testing, intensive outpatient treatment, and other behavioral health offerings don't necessarily share the same reimbursement structures or operational demands.
And some services may be covered by insurance while others are legitimately offered on a self-pay basis, subject to contractual and legal requirements.
The point is that network participation can be an intentional business decision rather than a philosophical declaration.
I think the conversation should begin with understanding which patients the practice intends to serve, what services it provides, what those services actually cost, and how different reimbursement arrangements affect both access and sustainability.
Then look at the individual payer relationships.
Not just whether the insurance company has a recognizable name or a large membership base, but whether participating in that particular network makes sense.
What reimbursement is available for the services being delivered? How frequently are claims denied? How much staff time is required to manage authorizations? How long does payment typically take? Are there recurring credentialing or enrollment problems?
And does the practice have the operational capacity to support the administrative requirements?
Sometimes a lower reimbursement rate can be more financially viable than a higher one if claims are paid consistently and require minimal additional work.
For example, a plan paying $150 per session with relatively straightforward billing and reliable reimbursement may be more attractive than one paying $190 while requiring repeated authorizations, extensive follow-up, and lengthy payment delays.
The higher number looks wonderful until someone calculates the actual cost of collecting it.
And those costs matter.
I also think providers should consider how the decision affects their own capacity and professional well-being.
If accepting an additional insurance plan significantly increases patient demand but requires the clinician to spend evenings managing claims and authorizations, is that arrangement actually sustainable?
Or would it make more sense to invest in administrative support, limit participation to selected plans, or reconsider the practice's payer mix?
There's no universal answer.
But there should be an informed one.
And I think that's where providers can get into trouble when they make insurance decisions based primarily on what other practices are doing.
The fact that another therapist accepts a particular insurance plan doesn't necessarily mean the contract will make financial sense for you.
Your overhead, patient population, specialty, available hours, administrative support, and operating model may be entirely different.
The decision deserves more consideration than simply identifying which company is most frequently mentioned when prospective clients call.
Credentialing Is Also a Really Good Way to Discover How Organized Your Practice Actually Is
There's another reason I find credentialing so interesting, beyond the fact that I apparently enjoy spending an unreasonable amount of time dealing with payer systems.
Credentialing has a remarkable ability to reveal operational problems that may not have been particularly obvious before the process began.
Something as straightforward as submitting an application can turn into an adventure when basic provider information isn't consistent across systems.
The clinician's name appears one way in CAQH, the practice address is slightly different on the NPI record, the tax information doesn't match what the payer has on file, and the malpractice policy lists an outdated location.
Then someone realizes the payer application was submitted three months ago, but nobody can find confirmation of what happened afterward.
Which is usually when everyone begins forwarding emails containing phrases like "I thought this was already handled."
I've seen how easily these problems develop when credentialing responsibilities are divided among employees without clearly defining who owns the overall process.
The clinician assumes the practice is managing everything. The administrative team believes the payer representative is handling enrollment. Billing expects claims to process because the contract was signed.
And the insurance company may have an entirely different understanding of the situation.
The result can be a provider who's actively seeing patients while the practice struggles to determine why reimbursement isn't happening.
I think this is particularly important for smaller practices, where the person managing credentialing may also be responsible for scheduling, billing, patient communication, and several other administrative functions.
The problem isn't necessarily that credentialing is intellectually difficult.
It's that it involves a substantial number of details, multiple systems, long processing periods, and very little tolerance for inconsistencies.
Something as minor as an incorrect effective date or service location can create problems that take considerable time to resolve.
And unlike some administrative tasks, a mistake may not become obvious until after the clinician has already provided care.
That's why I believe credentialing should be treated as an ongoing operational responsibility rather than a one-time application project.
Provider information needs to be maintained. Payer participation should be verified. Recredentialing deadlines need to be monitored, and changes to locations, ownership, or practice structure should be communicated appropriately.
There's also value in having a reliable process for confirming that everything is active before the practice begins billing under a new arrangement.
I realize none of this sounds particularly exciting.
But neither does explaining to a therapist that several weeks of claims have denied because the payer loaded the wrong taxonomy code.
And between the two, I'd much rather spend time getting the details right at the beginning.
The Part of This Conversation That Bothers Me Most
I think what frustrates me about the insurance debate is that we often place the responsibility for making behavioral healthcare accessible almost entirely on the providers delivering it.
We criticize therapists for remaining private pay because their services are too expensive for many patients.
But then we ask those same therapists to accept reimbursement rates that may not reflect the actual cost of providing care, navigate increasingly complicated administrative requirements, and absorb the financial consequences when claims are delayed or denied.
And somehow, we're surprised when some of them decide they would rather operate outside those networks.
I don't think providers should be exempt from considering affordability or the broader access needs of their communities.
Those responsibilities matter, particularly in a profession centered around helping people.
But I also don't think we should expect individual clinicians to solve the financial and structural problems of the healthcare system by continually accepting arrangements that make their own practices less sustainable.
That's not a particularly effective long-term access strategy.
Especially when behavioral health is already struggling with workforce shortages and significant unmet need.
At the same time, I don't want to romanticize private pay as though it's automatically the more ethical or professionally fulfilling option.
A provider can be financially successful while serving a relatively narrow segment of the population, and that does raise important questions about who has access to quality care.
Not everyone can afford to pay privately for ongoing treatment.
And patients shouldn't have to choose between using insurance benefits they've paid for and receiving clinically appropriate care from someone qualified to provide it.
Both realities deserve attention.
Which is why I think the larger conversation needs to involve more than whether individual therapists should accept insurance.
We should also be asking whether payer reimbursement is adequate, whether credentialing processes are unnecessarily burdensome, whether provider directories accurately reflect available care, and whether administrative requirements are creating barriers that ultimately affect patients.
Because the consequences of those systems don't stay neatly contained within a practice's billing department.
They influence which providers participate in networks, how many patients those providers can realistically serve, how much time clinicians spend on administrative work, and whether organizations can remain financially stable.
And eventually, those decisions affect the person who's simply trying to find a therapist who accepts their insurance.
The Actual Point
I think the decision to accept insurance deserves a lot more nuance than it typically receives.
Being in-network isn't automatically evidence that a provider is more committed to patient access, just as remaining private pay isn't proof that someone values income more than clinical care.
There are legitimate financial, operational, and ethical considerations on both sides.
I've spent enough time working with insurance contracts, credentialing processes, reimbursement structures, and revenue-cycle problems to understand how quickly a seemingly reasonable payer relationship can become an expensive administrative burden.
I've also seen how difficult it can be for patients and families to find appropriate treatment when their insurance benefits don't connect them with providers who are actually available.
And I don't think either issue should be minimized.
For some practices, accepting insurance can significantly improve access, support a more consistent referral base, and create a financially sustainable model.
For others, remaining out-of-network may allow providers to maintain manageable caseloads, offer specialized services, reduce administrative burdens, and preserve the financial stability necessary to continue practicing.
And for many, a selective approach may offer a reasonable balance.
What matters is understanding the decision before committing to it.
That means examining actual reimbursement, administrative responsibilities, patient demand, clinical capacity, operating expenses, and the broader goals of the practice.
It also means recognizing that participating in a network requires more than completing an application, and that remaining out-of-network comes with its own responsibilities and limitations.
I don't believe every therapist needs to become an expert in payer contracting or revenue-cycle management.
But I do believe providers benefit from understanding enough about those systems to recognize what they're agreeing to and whether the arrangement supports the practice they're trying to build.
Because the goal shouldn't simply be to accept as many insurance plans as possible.
Nor should it be to eliminate every administrative inconvenience at the expense of patient accessibility.
The goal should be to create a practice that provides quality care, remains financially sustainable, and serves its intended patient population responsibly.
And sometimes that means accepting insurance.
Sometimes it means declining a contract that doesn't make sense.
And sometimes it means recognizing that the answer isn't the same for every provider, payer, or service.
The question isn't whether going in-network makes you a better therapist. It's whether the arrangement allows you to remain an effective, accessible, and financially sustainable one.
I think that's a much more useful conversation than assigning moral superiority based on whether someone's name appears in an insurance directory.
And if you're currently navigating credentialing, contracting, or insurance enrollment, I genuinely hope your experience is relatively painless.
May your CAQH attestations remain current, your effective dates match across every system, and your claims process correctly on the first submission.
And may you never have to explain to another insurance representative that yes, the clinician really does work at the address that's been on every application for the past four years.
Although that last one may be asking a little too much.
