Center Institute

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What I learned about therapy by being out-of-network

If you’re not going to be in-network with insurance companies, you are actually going to have to do things differently than the hundreds of other in-network therapists in your area. I know from my own experience that this extra thought and effort is well worth the pay off, but it does take some intention and strategy. For me, here’s what the payoff has been:

  • I see only clients with whom I love working.
  • I get to do the quality of clinical work I believe in, and offer extra services that I know help the process.
  • I limit my caseload to something that is manageable enough for me to also run a second business (Center Institute) and to take every Friday off to be with my daughter.
  • I can take time off when I want to and still bring in enough money to pay my salary (and yes, I have a salary from my business, that is totally consistent and predictable).

But there’s more than that. I’ve actually learned a lot about myself and about what it means to me to be a therapist. In leaving the insurance networks, I’ve learned that…

  • I have to OWN what I do. I have to be able to stand up and say what I do… and mean it–not feel shy about it or be tentative.
  • I have to constantly be focusing on doing a great job clinically. This means making sure I am consistently reading to further my knowledge about the best clinical care for my ideal clients. It means engaging in trainings that interest me and are relevant to my ideal clients.
  • I have to run an excellent business … which means being prompt and professional in the running of my practice. It means returning phone calls as quickly as possible. It means having a professional system for billing and receipts. It means providing extras in the services I offer.
  • People do want to have a choice in the providers they visit. They are willing to work with someone out-of-network if they are getting the services they want with a person that feels like a good fit. With so many high-deductible plans these days, people don’t seem to assume or even worry about insurance covering services as much as they might have if they had better insurance. And even my clients with great plans, seem to feel that working with the provider of their choice is worth the investment.
  • Clients want extra help. They are willing to pay for services that go beyond the once-a-week therapy visit. And this is not just for clients who are seeing therapists using a DBT model. This seems to be true for a broad spectrum of clients.
  • Insurance companies don’t know about therapy; I do. Once I stopped giving up my clinical decision-making power over to insurance companies, I was free to begin thinking about what made the most clinical sense for the population I work with. And not surprisingly, clients seem happy to look to a therapist to help with the treatment plan, rather than their insurance company.
  • Therapy is at least as valuable as other things that people pay for – massage, acupuncture, naturopathic doctors, vitamins, seeing a specialist… Well, hey there: therapists are mental health specialists.
  • Clients act differently when they are paying for your services; I began to see this when I worked at an agency where some of my clients paid nothing to see me and some paid something and others paid a lot. That is not to say I never had a hard-working, focused, no-fee client, but the trends became clear over time; when a client was investing financially in the process, they more consistently invested emotionally and energetically as well. I’ve found the same to be true in my private practice.
  • Charging a fee for service gets easier over time. I remember when I first started my practice, I had never had to deal with the money end of the therapy relationship before. And it felt weird and awkward to ask for money at the end of sessions. Aside from the fact that I’ve done away with the antiquated check writing ritual that ends most therapy sessions (I teach an alternative in the Group Intensive program), I have found that my own comfort with the exchange of money for the service I provide has gotten much easier with practice.
  • It doesn’t matter what other people in your community are doing if you do your thing really well and get the word out. When I first started charging real money for my services, I was constantly worrying about what other therapists were charging and if I was charging too much or too little in comparison. I worried that if I charged more than the “senior” therapists in my community, it would be bad somehow. It turns out, it doesn’t really matter what other therapists are doing. If you are providing a useful service that potential clients find valuable, they will invest in it. I needed to let the clients decide if it was worth it and stop judging and worrying so much.

What scares or excites you most about the thought of working either in- or out-of-network in your practice? I’d love to hear.

8 Responses

  1. I may be moving to that model; thank you for sharing your experience.

    • Evan Center says:

      I hope you’ll find the info on this site helpful in making the choice to take the leap. If you get the right systems in place you won’t regret it! Let me know if I can help!

  2. I agree with everything in this article. My practice has been insurance free from the get go, and I wouldn’t have it any other way. I feel like it also holds me more accountable as a psychologist- meaning, when people are paying out of pocket for a service like this, you have to be consistently on top of your game. There is no laziness here, and I am very thankful for that level of accountability on behalf of my clients!

    • Evan Center says:

      Thanks for sharing your experience, Blair. I think that is SO true – as much as we should all be on top of our game all the time, there is an added layer of accountability when we are part of a free market system. I also find that my clients are more accountable as well – they have some skin in the game as it were and really work hard toward their goals in our collaborative process. -Evan

  3. I’d love to move to this model but find it hard to “get going”–where do you start? How do you advertise? How do these clients end up finding you? I’d love more information about that. This seems very much in line with what I do anyway. Thanks for making me think perhaps it might be a possibility for me!

    • Evan Center says:

      Have you checked out my free resource, The Referral System Template? If not, you can get it here. The system I share in the template is how I get most of my clients, but I also get some through my website or other web searches. What I actually guide therapists through in my Six Month Intensive is exactly how to “get going” with this sort of practice so you don’t have to spend years fumbling around (like I did) before you figure out the pieces to make it work. I am glad you found this blog inspiring!

  4. I agree and appreciate the rationale behind going out of network. As a clinical social worker who is also a Geriatric Care Manager in private practice I give my clients the option to file for reimbursement with their health insurance.

    Recently I read something that said I have to formally “opt-out” of Mecicare as a clinical social work provider. Would love to hear more about this part if anyone has experience with reimbursement.

    • Evan Center says:

      Thanks so much for asking that question — I had not heard about that, but after doing a little research, I found this (note section 40.9). It does look like as a LCSW you do need to actually opt-out in order to not be “in-network” with Medicare. It does not look difficult to do, but unless you opt-out (or opt-in) you are apparently in a sort of limbo which assumes you are in-network.