Insurance is Unnecessarily Hard

A common question I get when I’m out networking or from prospective clients is “Do you accept insurance?” The answer as of this writing in February of 2025 is “No, unfortunately.” There are a few reasons for this. Firstly, I am currently credentialed as a licensed professional counselor candidate (LPCC). Counseling and psychotherapy are regulated professions in most jurisdictions, with some offering credentials to unlicensed psychotherapists as just that – unlicensed. There are several reasons why someone may practice without a license, one being that they are credentialed in one jurisdiction, but there’s very minimal reciprocity between states when it comes to transferring a license from one state to another. For licensed professional counselors (LPCs), most jurisdictions – at least to my knowledge – have a candidacy period during which LPCCs are required to work under the supervision of a more seasoned, appropriately credentialed counselor. This leads us to the first issue with insurance: paneling and credentialing.

              Let’s peel back the curtain a bit on how providers come to accept insurance. The first thing to do is to get credentialed with National Provider and Plan Enumeration System (NPPES) and be issued a National Provider Identifier (NPI) number. From what I’ve investigated so far, this part is simple enough. The next part is going to the insurance companies and applying to be paneled as an in-network provider to bill their clients’ insurance for services rendered. There are a few sizable problems for the LPCC when it comes to insurance paneling. Firstly, most insurance companies will not panel licensure candidates without a lot of extra red tape. In certain organizational settings, LPCCs are absolutely covered by insurance. This is because those large organizations are already paneled. They cut through the red tape for the candidates they employ, in part through providing supervision to employees. They also have billing and insurance departments to handle the logistics of submitting claims and superbills to the insurance companies. For the LPCC in private practice, this sort of company infrastructure is entirely absent. So why not cut my teeth in a larger organization, fulfill my candidacy requirements, and iron out the details of private practice later? In a nutshell, it comes down to a combination of personal preference and quality of care. While we may be inclined to imagine therapists and the field of counseling and psychotherapy as paragons of wellness and work-life balance, that is not always the case. Large clinical settings can come with heavy caseloads and paltry compensation – a recipe for burnout and declining quality of care for clients. These are challenges with which I would rather not concern myself. My clients come before all of that, always.

              The second challenge is another can of worms. Paneling is time consuming. According to a helpful blog post from Simple Practice, an electronic health records service for therapists, paneling can take months. Where does that put the private practitioner in terms of getting paneled with multiple insurance companies and on their different and uncertain timelines? It would likely be a financially precarious situation if we were to put our practice on hold and wait to start seeing clients until we are paneled with insurance companies, and we may even receive a polite rejection letter from them. For my own part, it would most definitely be ruinous to my financial wellness. Another noteworthy logistical challenge is the process of billing in private practice. Navigating the insurance system and the administrative workload related to submitting claims and the potential need to fight for clients’ claims to be processed in the event of denial means fewer client sessions, consequent decline in revenue, disruption of work-life balance, and - almost inevitably - reduced quality of care and service for the client. While I would like to think of myself as not at all susceptible to this problem, there is also a very real risk of developing a sense of resentment toward an individual client because their insurance sucks.

              So far, we’ve touched briefly on the potential financial challenges that can come with getting paneled and accepting insurance, but we’ll take a quick look at a possible solution that raises a more indirect challenge to maintaining financial well-being. One could, with sufficient revenue, hire a clerical worker, which could free up time and space to accept more clients and hold more sessions. However, paying a clerical worker can be costly. If it’s not costly, then it would very likely be doing clerical staff an injustice by undercompensating them for their time and effort. If there’s one thing I am all about, it’s justice, especially when it comes to matters of labor and compensation. This brings us at last to the ethical considerations that come with accepting insurance.

              Let’s quickly revisit the example of hiring a clerical worker. This person would have to be highly trustworthy and competent, as they are handling clients’ private protected health information (PHI). Any mishandling of PHI – intentional or otherwise – comes back on the business, and it’s the counselor’s license that is at risk in the event of a breach of HIPPA or related laws and regulations. It would be clinically unethical to take on a clerical worker with a questionable set of skills and attitudes regarding the handling of PHI. As I mentioned previously, it would be exploitative to not appropriately compensate a clerical worker who possesses those skills. Finally, there is the matter of ethics in diagnosis.

              We professional counselors abide not only by the regulations of the jurisdictions where we work, but by the American Counseling Association’s (ACA) Code of Ethics. Among the standards set forth in the Code, are ethical standards of practice related to diagnosing clients and remaining within our scope of practice. The former is fairly straightforward. It is important to be judicious, honest, and accurate when rendering diagnoses. The latter is more roundabout. So what do these ethical standards have to do with insurance? Insurance companies require medical coding of a diagnosis in order to file a claim. This necessarily involves affixing a label to a client’s goals and concerns even in the absence of a clearly defined mental disorder. Some conditions are especially challenging to correctly identify, and many tests and assessments to render diagnosis fall strictly in the purview of doctoral-level psychological assessment specialists, i.e., outside of my scope of practice. A full assessment would then require a referral and lead to additional costs of time and likely money to the client to ensure accurate and ethical medical coding related to treatment. Many insurance companies will also cover only a set number of sessions. One workaround is to render a new or different diagnosis to reset the clock on the number of sessions covered, but there are only so many conditions for which a client would meet the diagnostic criteria that any further changes fall outside of ethical practice.

In all, many of the challenges counselors in private practice face when navigating the healthcare system boil down to the fundamental brokenness of that system. Large organizations are favored over smaller practices, the trade-off being gaps in consistency and quality of care. This isn’t to say that there are not phenomenal therapists working in large clinical settings and mid-sized group practices, but they’re more likely to get lost in the shuffle of heavy caseloads and medical coding. They are also much more likely to face burnout and are largely undercompensated to offset the costs of outsourcing the logistics of billing to another department.  I think it raises a question of loyalty. Insurance companies are loyal to their shareholders. Employees are expected to be loyal to the organizations that employ them. For my part, my loyalty is to my clients. I hope we see substantive changes to our healthcare system that lower the barriers to accessibility that are all too common for clients/patients and providers alike. I fully intend to further explore my options for paneling as soon as I can, but if it stands between me and extending the best possible care and service to my clients, then it simply is not an option.