Author: Taana Abbitt

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Why Do So Many Therapists Not Take Insurance?

If you’ve been looking to start therapy, you’ve probably noticed that it’s hard to find a therapist who takes insurance nowadays. You might leave messages for 20 therapists on your insurance company’s list of “in-network” therapists, half of whom don’t call you back, and of the rest, at least half no longer take that insurance. The remaining few might have long wait lists to get in and actually start having therapy.

Many people saw the recent news where the CEO of United Healthcare was shot and killed by a disgruntled insured person, who had experienced a serious injury to his back. The chilling words he had written in his journal were, “these parasites simply had it coming.”

While gun violence is never justified in my opinion, many people can unfortunately relate to the now common struggle of fighting to get insurance to cover their medical expenses. Insurance companies seem to use every trick in the book to avoid paying claims. Here is a #1 bestselling book about it by Jay M. Feinman.

The Top 3 Health Insurance Companies Made a Combined $44 BILLION Dollars in Profit, Just in 2023.

Insurance companies make outrageous profits by charging consumers a ton of money for insurance premiums (The average cost per family is up to $26,000 per year) and then creating practices designed to keep as much of that money as possible.

Those practices are: denying claims, underpaying or refusing to pay providers for services already provided, and trying to pass as much of the cost of their healthcare on to their customers as they can (co-insurance/co-pays and impossible deductibles, I’m looking at you). Now insurance companies are even using AI to generate denials for 90% of claims made.

No Insurance Company Pays a Sustainable Wage

Each insurance company sets their own rate that they will pay for a therapy session. The #1 reason so many therapists don’t take insurance, is that even the best rates insurance companies offer is equivalent to the Phoenix market rate for an intern (a student who is still in graduate school). Interns don’t have the financial burden of paying the cost of operating a business.

Even new graduates, who are beginning to translate their academic learning into real world skill in working with clients, typically charge $20+ per session more than the highest insurance company rate. The current Phoenix market rate for an experienced, independently licensed therapist is closer to double what insurance offers. However, the rate the therapist actually charges is irrelevant. If a therapist agrees to be “in-network” with an insurance company, they agree to accept whatever rate that insurance company decides to pay.

The lowest insurance company rates don’t allow therapists to stay in business

If the insurance you have is one of the lower paying ones, it will be even harder to find a therapist that accepts it. Therapists might start out thinking they can accept the lower rates if they offset them with higher paying insurance and cash-pay clients. However, insurance company contracts require that the therapist doesn’t discriminate in accepting their clients. If an in-network therapist has an opening, the therapist is not allowed to turn a client away due to the insurance they have.

This leads to therapists having all their appointments filled by the lowest-paying insurance clients (because so few therapists will take that insurance), which will cause their business to go under. The only way a therapist can prevent this, is to not work with that insurance anymore.

To make matters worse, a bunch of insurance companies recently dropped the rate they were paying therapists even lower, and therapists have no control or ability to negotiate this, except to discontinue working with that insurance.

This explains why lists of “in-network” therapists are often called “ghost lists.” It looks like a list with lots of options, but the list is not accurate- it’s full of practices that are closed, or lists therapists that no longer take that insurance.

Therapists often have high business expenses

Most therapists have a heart to help others and want therapy to be accessible, but financial demands are a reality that can’t be ignored for long. There are therapists that actually go into debt running their practices when they accept insurance. That’s obviously an unsustainable business model. The financial burden of making therapy accessible to more people shouldn’t fall on individual therapists, it should fall on insurance companies who are flush with all those profits.

Many therapists can’t afford to accept even the best insurance company rates. Between huge student loan payments for 6+ years of higher education, required business expenses such as liability insurance, licensure renewals and ongoing training, office rent and utilities, electronic medical record software, and debit/credit card fees, some therapists who accept insurance can’t afford to have in-person offices anymore. This is one reason so many therapists now only offer virtual therapy. Not to mention, whatever is left over after taxes is the therapist’s income to pay their own costs of living.

Due to the emotional labor of the work therapists do, and the critical need to maintain their own mental health, full time employment for a therapist is 20 therapy sessions per week. Given the low pay insurance offers, therapists often need to do closer to double the amount of therapy sessions in a week to make ends meet. This creates conditions for therapists to be burned out or have “compassion fatigue,” be disconnected from their work, have trouble keeping all their client’s info organized in their heads, and just in general being overwhelmed.

Insurance Companies Know their Process Makes it Difficult and Confusing for Therapists to Get Paid, and That is Intentional

Insurance companies routinely give themselves 60-90 days to pay for that session you just had. Considering all the different insurance companies, a therapist has to pay a bookkeeper to track what’s been paid for and what hasn’t. I’ve recently heard that some insurance companies have postponed payments for 6 months or longer. Therapists have no control when this happens. The bills the therapist has to pay won’t wait.

And 60-90 days later, the insurance companies don’t always pay, even though the service has already been provided. Each insurance company has their own requirements in order for the therapist to be paid. They often will deny payment for therapy sessions unless there is evidence of medical necessity documented in every session, along with whatever else their individual requirements are. This means a therapist often needs to hire and pay an insurance billing specialist, too.

In order to meet insurance compay requirements, therapists often have to give inaccurate diagnoses

This can lead to therapists sometimes intentionally giving inaccurate diagnoses that are more severe problems, because the client’s real diagnosis might not indicate enough “medical necessity” and be denied by the insurance company. One example is that a person with childhood trauma might get diagnosed as having Bipolar Disorder, becuase that is always reimburseable. Insurance companies have decided that some mental health problems deserve therapy and others do not. Now that more severe and debilitating diagnosis is added to the client’s medical history with the insurance company. It’s why therapists who take insurance are required to give you a diagnosis in the first session.

Insurance companies often arbitrarily limit sessions

Insurance companies also are known to arbitrarily determine a pre-set amount of sessions depending on the diagnosis that is given – such as generalized anxiety disorder – You get six sessions, then your coverage is denied and you have to pay out of pocket. They may or may not communicate this to the therapist and client ahead of time.

Insurance companies violate client’s confidentiality just to look for petty technicalities

Many insurance companies require a copy of each completed therapy note, completed treatment plan, completed biopsychosocial assessment. They look for specific info that they require (such as medical necessity) that might be missing to use as a basis to deny payment. Not only are they are violating the client’s confidentiality in having their staff read the client’s very personal info, they add it to the client’s medical records in their system. And let’s be honest, they hold it against the client in determining future premiums and deductibles. I’ve experienced this personally.

Jumping through insurance companies’ hoops equals unpaid time for the therapist

This is all unpaid time for the therapist – making sure they know and document the individual requirements of each insurance company they work with, then the time to review and collect the records and securely fax or email the confidential info to the insurance company.

So if the insurance company can find any petty technicality to use to deny the claim (from 60-90 days ago, remember), then the therapist has to get on the phone and try to argue with level one support about why they should be paid for the work they already did. This is all hours of unpaid time, when the therapist could be seeing other clients and generating income to pay their bills.

When you factor in the very low pay in the first place, the need to also pay a bookkeeper and an insurance billing specialist, and the extra time to jump through their hoops and argue to get paid when they could be generating income, there isn’t much to motivate a therapist to work with any insurance companies.

If all that wasn’t enough, have you ever heard of “Clawbacks”?

There is one more potentially disastrous element to working with insurance. There is something called “clawbacks,” that insurance companies are known to do. Clawbacks mean the insurance company has up to 2 years to decide they don’t want to cover those sessions they already paid for.

The insurance company can “review” the case and decide to send the therapist a letter demanding back the money for all the client’s therapy sessions. The therapist has no choice but to pay it back. This can amount to thousands of dollars. I have even heard of insurance companies clawing back ALL the funds they paid for EVERY client that therapist worked with, all because one piece of info they require was missing from one therapy note or there was not sufficient “medical necessity” documented in one case.

No therapist has those huge sums in reserve to pay back the insurance company, especially when they are making such low pay in the first place. When this happens, the therapist then has to try and collect the full cost for all these past therapy sessions directly from the client, who may not even be working with them anymore. And the client certainly doesn’t expect to be hit with that bill.

So, If it’s So Terrible, Why Would any Therapists Take Insurance??

It’s mainly due to the prospect of a steady flow of new clients.

Group practices sometimes take insurance, because they might be large enough to absorb the extra cost and unpaid time. Group practices usually hire newly graduated therapists, who will typically work there for 2-3 years under supervision, until they get their independent licenses. The fully licensed owner of a group practice can be approved by insurance panels, and then the rotating cast of associate therapists actually do the therapy. Group practices need a steady flow of new clients for all their associate therapists, and insurance provides that.

In addition to new therapists who need experience, sometimes even more experienced therapists have a hard time attracting and retaining clients for various reasons, and if they accept insurance, they get a steady flow of new clients. It allows them to stay in business.

Is It Any Wonder So Many Therapists Don’t Take Insurance?

There is no doubt that our current insurance system in the US is badly broken. Insurance companies exploit their customers with huge premiums and passing as much of the actual cost of their healthcare on to them as they can. Insurance companies also exploit providers with unsustainably low pay, denials of payment, and making providers put in hours of unpaid time, just to fight to get paid. Even after the insurance company has paid, they have up to 2 years to demand all the money back.

Therapists Who Don’t Accept Insurance
The Real Reasons (That Nobody Tells You) Therapists Don’t Accept Insurance
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Social media WANTS you to feel broken!

Social media use has a negative impact on self-esteem

Lately, I’ve heard lots of comments from people I work with on feeling bad about themselves from doom-scrolling on social media. The negative effects on self-esteem from social media use are well documented. Everyone carefully crafts their “brand” in order to make themselves look like they’re living their best life.

It’s hard to feel good about your real life, when you are comparing yourself to carefully crafted and curated brands, that are not a real or complete representation of that person or their lives. You have to assume it’s not actually real or true. In fact, the way I see it – the harder someone is working to make their lives/themselves look great, the worse they actually feel or the worse their reality really is.

I may have a unique perspective cause I’m a therapist. I’ve had people come to me because they feel guilt and distress over the fact that they are cultivating an online image and reputation that’s not based on reality. Think workout influencer, who looks that way because they have an eating disorder, not because they follow their own advice.

When you treat it like it’s real or true, you give it power.

Anyone can claim to be an expert

Nowadays, anyone can call themselves an expert in anything. But when they didn’t do the work to have any legit expertise in that area, what do they do? They fake it. They say things that sounds good. They make it up as they go along. They steal it from other people. But do they know what they’re talking about? Hard no.

Social media is even officially backing away from fact checking… https://www.npr.org/2025/01/12/nx-s1-5252739/meta-backs-away-from-fact-checking-in-the-u-s

AND something else is going on, too.

Advertising! Everyone is selling themselves, their “brand,” and their perspective. They’ve figured it all out. Follow them. Give them your money.

Advertising has to create problems to sell you

What’s the first rule of advertising?

Make people realize they need your product or services by pointing out there’s a problem.

Since there is such an explosion of “entrepreneurs” in the “wellness” industry, completely unregulated, and all competing with each other for your money, they are finding NEW and CREATIVE ways to make you feel broken. They have to make you feel like there’s something wrong with you, so they can sell you their expensive fake solution.

I have recently heard examples like:

(From a successful businesswoman) “I read today online that my success is driven by my childhood trauma – now I feel bad about the success I’ve worked so hard for, cause it was just a symptom of my trauma.”

(From a young adult) “I was reading online today that people with childhood trauma don’t set goals for themselves and meet them. I feel bad about myself cause I don’t do that, I’m not sure what I want to do yet. It feels like I’m trapped in my trauma.”

(I looked that last one up, and sure enough, it was an ad selling coaching – coaching by people who don’t even have a high school diploma. Think about the irony of that for a second).

It’s just marketing

They are trying to make you feel bad about your success, or your normal phase of life, in order to sell you their “brand” or services. They’ve figured it all out, so don’t you go feeling good or even ok about anything, cause then you might not need to give them your money!

I’m gonna go out on a limb and say these are probably not licensed therapists who are making people feel broken and inventing reasons for everyone to feel bad on social media. They are people who are not actually educated, trained, or licensed to work with people with trauma or mental health issues. Therefore, they are desperate to attract business and legitimacy.

If you’re the one finding fault with the most things, you win all the money!

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On the receiving end of abuse from a Borderline

Or, The Toxic Dance of Borderline Personality Disorder and Codependence

I have been on the receiving end of abusive behavior from adults with Borderline Personality Disorder (BPD), or Borderline traits (BT), both personally and professionally. By abusive behavior, I mean the offloading of personal responsibility that often comes with an explosion of criticism, blame, and anger.

No one is immune to being affected by abusive behavior. If you are a caring person, it is upsetting, confusing, and painful to experience.

Being a therapist, I’ve noticed patterns with this type of toxic behavior, and I am going to share them as well as the distorted thoughts that fuel them, in this post. I hope this will validate your experience and help to bring some insight into what’s going on.

It starts with an adult who refuses to take responsibility for their problems

It’s not listed in the diagnostic criteria for Borderline Personality Disorder, but having worked in this field for decades, I can tell you that people with BPD/BT often defend against accepting responsibility for their problems. It is a priority to see themselves as a victim, and to deny their own agency, or their role in problems that happen.

Potential areas where people may avoid taking responsibility can be: managing their finances, dealing with problems with their children, their relationships, their own mental health, emotions, or trauma, substance abuse, workplace problems, or their work or life purpose. In general though, people with BPD/BP often want other people to take care of their needs and problems for them.

As adults, we all must take responsibility for our own problems and for having what we want in our lives. No one else has the power to do this, not even a therapist. As a therapist, I can only try to lead people towards healthy behavior, I can’t control their choices.

They latch on to a caring and responsible person

When a person with BPD/BT finds a caring and responsible person, who is willing to have some type of relationship with them (personal or professional), they are drawn to them. Over time, they latch onto this person in a dependent way, that is inappropriate for an adult.

In the beginning, they may put the other person on a pedestal, creating a sort of parent/child dynamic or a powerful/helpless dynamic. The person with BPD/BT begins to act out their pattern of helplessness and playing the victim (complaining a lot about others or talking about how they have been wronged by others or by situations), which elicits sympathy from a caring person at first.

If you are a person with codependence, you may also feel drawn to this person in return, because it gives you the opportunity to prove yourself and play the role of a rescuer or fixer (Spoiler alert – this is your childhood trauma getting triggered. Did you grow up with a parent or other adult who didn’t take responsibility for their problems?).

A person who is not codependent may feel compassion, but would also see that the habit of playing the victim and acting helpless is a big red flag.

An expectation that the other person will take over responsibility

The person with BPD/BT has an expectation that the caring and responsible person will “fix” or “rescue” them by taking over responsibility for whatever their problems are. Sometimes this expectation is voiced, sometimes it’s not. But it’s there, and it gets stronger over time.

Therapists are especially vulnerable to this, because people are coming to us for help with their problems. But when a person continues to refuse to help themselves, refuses to take responsibility for their problems, and continues to self-sabotage, they will not get better, even in therapy. This is also very difficult for therapists to address directly, because a person with BPD/BT often experiences any challenge to their behavior or choices as rejection or invalidation, and will double down on their helplessness, self-pity, and play the victim role with the therapist. For example, they may claim the therapist has now wounded them by suggesting they do something different, how could they say that if they truly understand them? They must be a terrible therapist.

Their jealousy, self-pity, and shame begins to show up in the relationship

Over time, invariably the person with BPD/BT begins to feel jealous or envious. Why does the other person have what I want? That’s not fair. All the while, they avoid acknowledging that the responsibility for things to be different falls squarely on them, and it’s impossible for another person to give them what they want, or to do it for them.

As they engage in a relationship with a person who takes responsibility for their lives and their happiness, the person with BPD/BT becomes filled with jealousy, self-pity and shame over their unaddressed problems. They continue to self-sabotage. They run to the other person expecting to be rescued.

Impossible expectations lead to blame and anger

Eventually, the person with BPD/BT begins to blame and become angry at the other person for failing to rescue or fix them. They begin to think, How dare the other person not give me what I need! Can’t the other person see I’m suffering? The answer must be, they don’t really care about me. They want me to be stuck in this misery. They are mean. They are uncaring. They are selfish.

At some point, the person with BPD/BT blows up all their anger and blame at the other person. It can erupt seemingly out of nowhere. The person with BPD/BT reaches a peak of jealousy and shame and their anger takes over. They see themselves as being wronged. They’ve been expecting the other person to fix or rescue them, it’s not happening, and now they are gonna let that other person know just how uncaring, stupid, and selfish they are and how much they’ve hurt them.

When you are on the receiving end of this anger and blame, it is confusing and hurtful. If you have self-worth and good interpersonal boundaries, you might feel angry at the attack. If you defend yourself, it won’t do any good. They will double down. Seeing themselves as the helpless victim of any situation is how people with BPD/BT function. You are not going to be able to change that, either. They will refute any logic, because they need to maintain their view of themselves as the victim.

If you don’t recognize that you don’t have the power to control another person’s choices and problems, it can be extremely hurtful and painful. You’ve been trying your best, but ultimately, you cannot control them. In either case, when you are a caring and compassionate person, you may take the blame and the anger that’s being directed at you, and question yourself. It’s hard not to be affected by this distorted perspective.

They play the victim role, even when they are being abusive

The purpose of all this anger and blame being directed at you is to pressure you to take responsibility for them all the harder. If you don’t take it up, you may be discarded by this person. Because in their minds, you have hurt them.

This anger and blame is the person with BPD offloading all the shame they feel for their problems onto you. It’s not your shame, you are not the one in the wrong. You can’t stop another person from sabotaging themselves. You cannot control their choices, no matter how much you care about them.

To make things more confusing, often the person with BPD/BT intends to continue the relationship, even after this abusive explosion. They may try to avoid talking about it or addressing it, and want to just act as though it never happened. If you show that you are affected or upset by it, they’ll ask “what’s wrong with you?” They will not acknowledge that you are human, that you have feelings of your own, or that their behavior could impact you.

In worst case scenarios, you’ll be gaslighted into it being YOUR problem if you got upset, because they were just telling you like it is. If you stay in the relationship, you are now participating in a cycle of abuse. If the person with BPD/BT doesn’t take responsibility for their behavior, the anger and resentment will build, and the explosion and blame will happen again.

They are stuck in an abusive cycle

The only answer to their problems is for the person with BPD to recognize that only they have the power to take action or make different choices to help themselves. As long as they are shopping around for someone else to fix it, they will stay stuck in this abusive cycle with other people.

If you have been on the receiving end of this type of abuse from a Borderline, I can help you understand and process this confusing experience, and to release the toxic shame and anger that has been offloaded onto you.