There are several reasons I don't accept insurance
The personal and professional costs of refusing to accept insurance can be significant, however, in my opinion the personal and professional risks, and costs of accepting insurance are far greater - astronomical. Besides the unmanageable legal and regulatory morass entailed in executing and abiding by a contract with an insurance company, there are complex, irreconcilable moral, ethical, legal and philosophical issues. Think of me as a conscientious objector. Not accepting insurance is an affirmation of dissent - dissent from the medical/mechanical/disease model as applied to the mind.
The insurance model is the medical/disease model. I don't apply the medical model to the mind. If I accept insurance I would be complicit in pathologizing/medicalizing human nature, being, and action. In other words, I'd be propagating the disease model.
The disease-model, however, is ultimately not helpful, as well as being unfounded. For all its attempts to incorporate social factors, the [model] renders depression meaningless, because biology effectively trumps other influences. It conveys the message that we are powerless to change ourselves or our situations. When things go wrong, it persuades us we need a pill to put them right. This approach may appeal to some people ... But it is important that everyone knows how little evidence there is to support it (British psychiatrist Dr. Joanna Moncrieff).
Pseudo science Physical diseases are that which can be demonstrated empirically. There is no test or procedure known to medical science that can be used to establish “mental illness.” Decades of scientific research have yielded no physiological pathology.
Diagnosis If you use insurance for psychotherapy, the therapist must give and you must accept a diagnosis from the Diagnostic and Statistical Manual of Mental Disorders - a meaningless, an invalid book published by the American Psychiatric Association in collaboration with the pharmaceutical and insurance industries. Each group has a direct financial interest in focusing on individual pathology (rather than familial or societal), inevitably leading to medication-based solutions and shorter periods of treatment. Diagnoses are based on subjective normative judgments (which are based on personal, social, cultural, and political values not objective criteria) and opinions about a person's behavior and whether it conforms to what is expected or wanted in any given society or situation. Besides being conceptually incoherent and invalid on the basis of science, being diagnosed with a mental disorder has potentially significant adverse affects on opportunities for employment, insurance, licenses, and the right to keep and bear arms, especially given that managed care forces individuals to give up all privacy as a condition for using their insurance benefits. This creates an irreconcilable conflict for me as an agent of an insurance company.
Privacy and Confidentiality are the cornerstones of effective psychotherapy. United States Supreme Court in Jaffe v. Redmond (1996):
"Effective psychotherapy ... depends on an atmosphere of confidence and trust in which the patient is willing to make a frank and complete disclosure of facts, emotions, memories and fears. Because of the sensitive nature of the problems for which individuals consult psychotherapists, disclosure of confidential communications made during counseling sessions may cause embarrassment or disgrace. For this reason, the mere possibility of disclosure may impede development of the confidential relationship necessary for successful treatment."
The fact that there exists not only the possibility but the demand (by insurance companies) to disclose sensitive confidential information renders 'effective psychotherapy' meaningless - a joke, if one takes the wording of the highest court in the land seriously. Individuals have no choice; disclosure of private and sensitive information to hundreds to thousands of unknown people such as gatekeepers and utilization review reviewers is a given when using insurance for psychotherapy. And, well, with the growth of the information broker industry, not to mention hackers, there is no rational basis on which to believe that one's mental health records are safe from inappropriate and unauthorized intrusion. Even worse, few barriers exist to an employer's use of its employees' medical and insurance claim records. While mental health records are supposed to be protected by law to a higher degree than is afforded medical records, if we call psychological and emotional difficulties 'medical problems' and act as if they are, that's a problem that has the potential to erode the higher level of (theoretical) privacy afforded to mental health records by law. I doubt it is reasonable to trust that the privacy and confidentiality law functions as intended. The continual surveillance (managed care) is a harmful intrusion that sabotages the effectiveness of psychotherapy.
Conflicts of Interest Another major ethical conflict in participating in - contracting with - managed care concerns loyalty. I become, in effect, a double agent. I'm an agent of the insurance company, and you, which gives rise to significant conflicts of interest. Insurance companies incentivize professionals to breach their obligations and fidelity, fiduciary obligations, to clients. Insurance companies offer an array of financial incentives and rewards, penalties and sanctions, along with other inducements to alter and limit care to suit their goals, objectives, and business interests, not yours. Decisions may be made that are adverse to you without your knowledge, input, or consent. As a company agent, I may be tempted to (may have to) portray your condition as worse than it is - and justify doing so - to keep reimbursement flowing. If you need more than 6, 12, or 26 sessions, I may be tempted to give you another, more severe, diagnosis to keep the dollars flowing (diagnosis for dollars). At the same time, professionals are bound by other healthcare laws, rules and ethics of psychology licensing boards, and a professional code of conduct. It's immoral and dishonorable to model such dishonest behavior, and unethical and illegal to collude with clients to misrepresent problems in order to gain approval for needed care. Such behavior diminishes the dignity and credibility of the profession, and erodes public confidence in its knowledge.
Money, Pay, & Reimbursement Nonwithstanding the fact that money in our culture is a highly potent issue, and, correspondingly, that the matter of fees in therapy is a highly charged emotional issue, money is one of the most important parameters that defines psychotherapy. Money is a boundary in the sense of defining the business and professional nature of the psychotherapist-client relationship. The fee and fee arrangement are important determinants of the nature of the therapeutic process and set a boundary for the therapeutic relationship; money is one of the parameters that define and differentiate psychotherapy from friendship and other intimate relationships. It may be helpful when considering the issue of money to be mindful of the reality that the way we treat and relate to money is influenced less by logic and more by deep-seated beliefs that we are often unaware that we hold.
There are valid practical realities for psychologists as well. The rates of reimbursement are inadequate to sustain the operation of a private practice. Reimbursement rates have declined year after year in spite of the rising administrative costs of running a private practice. As a matter of fact, over the past decade, up to the time I quit accepting insurance January 1, 2016, reimbursement rates were 20% less than they were in 2005, and still falling. In contrast, the cost of living over the same period of time has grown exponentially - basic necessities like food cost 33 - 64% more. To add insult to injury, government insurers sometimes stiff providers for hundreds of dollars of services provided.
Besides being unsustainable, unjust, and demoralizing to accept less pay year after year in exchange for personally demanding work - the requirements for detailed documentation of psychotherapy sessions conflicts with a psychologist's duty to protect the privacy and confidentiality of individuals in one's care, and is contrary to the advise of risk management experts.
Professional Judgment Employees of the insurance company become the de facto judges of what you need and how much you need, effectively usurping a professional's judgment and autonomy. Some insurance companies routinely trump psychologists' judgment by requiring the psychologist to send an individual, say suffering from depression, to a psychiatrist with the expectation that chemical therapy - the use of so-called "anti-depressants" - will be the first line of treatment. This absurd ethic continues in spite of the 50 years+ of documented lack of evidence of efficacy, and, more importantly, the documented evidence of harmful adverse effects on cognitive, emotional, and behavioral functioning. The continual intrusion of managed care procedures, rules, and requirements is coercive, detrimental to the development of an effective psychotherapist-client relationship, and contrary to the rational, ethical, and humane practice of psychology.
Required Acceptance of Nonsense There's no way around it, an agent-therapist must medicalize the human condition and associated problems in living. Agree to diagnose disorders/diseases that are invalid, and justify your reasoning. Contend with the temptation to over diagnose and over treat in order to be compensated. Call insight-oriented psychotherapy a "medical treatment" when doing so is illogical and untrue. Label grief a depressive disorder. Accept the notion of medical necessity when, in reality, it's a social and political requirement that derives from an underlying pseudo-scientific base. Treat human beings as problems to be fixed as quickly as possible. Focus on superficialities without addressing underlying problems. Use interventions that are erroneously thought of as techniques, and are ineffective. Contend with company directives that result in a gross misunderstanding of what therapy is and how it works. The best therapists would not accept such conditions.
Dehumanization The crux of the matter is this: construing the psyche as physical or mechanical results in the loss of human agency, moral agency in particular, and with that identity, choice, and responsibility. Human beings are moral agents who, as such, have the capacity to think, make meaningful choices, and act in accordance with their values. If a person is depressed, there is a reason to be depressed. To medicalize human thought, feeling, and action is to objectify and dehumanize humanity.
All unwanted behavior is not sick; to say all unwanted behavior represents illness is to pathologize human existence, and, more importantly, to confer authority on the medical establishment to “treat” and control people. Not surprisingly, given a misunderstanding of human suffering, the efficacy of medical treatments are not borne out by the evidence, and, contrarily, in some cases, cause irreparable harm.
An open invitation
The way managed care clinicians are paid often distort professional and clinical judgment. With a primary emphasis on cost containment, your needs are invariably compromised. Caveat emptor
The medical model as applied to the mind is a woefully misguided approach to the human struggles and agonies that people bring into counseling.
Therapy is an open-ended, collaborative, human encounter.
According to one of the most successful investors in the world, and the second wealthiest person in the United States, the best return comes from investing in yourself.
I invite you to consider the choice of consulting with one of the few remaining independent practitioners who has chosen to cease to be involved in the immoral, unethical, absurd policies and practices of managed care.