Insurance Injustice and Rage Tears

Photo by Tim Mossholder: Pexels.com

I think it’s the first time I’ve experienced rage tears with a client. I’ve been angry. I’ve been sad. And I’ve cried with clients. Oh yes, I’ve cried. 

My client can’t see me, but they hear the tears in my choked speech on our call. I name the tears for them so they doesn’t misunderstand. I don’t need my client to caregive me, I want to show them how much this upsets me too.

It’s been two months since we’ve had a call. 

Six months of fighting with their insurance.

One year of unpaid claims.

And weekly phone calls of the insurance panel stating claims aren’t being paid because they only pay for one diagnosis. Suddenly. In 2025. No other diagnoses will do.

I can’t make sense of it. As a Type-A, detailed therapist, I jump all the hoops they want me to jump through. 

File a certification request. Fax it.

File an appeal. Fax it.

The appeal was lost in their department. Start over.

An appeal that they will approve when they want to, no timeline is guaranteed.

Thousands of dollars unpaid, a ticking timeline of when claims will be “out of timely filing.”

Of course I have rage. 

I have rage for a broken system. A system that I’ve worked with for 16 years. I proudly took Medicaid until I didn’t. Then I told other insurance panels I was done. And yet with this client, I’d told myself I would see them until the end. Only I thought the end would be the illness that shortens their life. 

So now here I sit, the tears just below the surface as I tell my client their options. Options they can’t afford. And yet they say they don’t want to start over. They don’t want another therapist. Weeks away from our ten year anniversary of working together, I remind them of their hard work up to this point, reflecting on how much they’ve accomplished. How much they’ve grown.

Just in case we can’t work together. 

In case their insurance decides their mental health doesn’t matter.

So I write this to process the rage. And I wait. And they wait. And we wait.

A Caution When Setting Different Rates in Private Practice

Disclaimer: I am not a lawyer. This content does not replace a professional consultation with a legal representative.

What do I need to consider when setting my rates?

It’s a common question I’m asked as a Financial Therapist to therapists. Although there are multiple factors to explore when raising your rates (join us in our upcoming workshop!), there is another piece to the puzzle that’s been on my mind lately.

For therapists in private practice who take insurance, there are parameters they agree to as part of signing a contract and being in-network. One of which is that Balance Billing is illegal in Colorado. Balance Billing describes billing your full rate to insurance, being paid your contracted rate by insurance, and billing the client the difference. This is a no-no in Colorado.

An example:

Your private pay rate is $150

Insurance pays you $121

You invoice your client for the difference, which is $29

Seems pretty straight forward that this won’t fly. But what about in private-pay practices? Are you allowed to charge different clients different rates?

Yes and no.

For different services, it is common and accepted to have different rates. For example, your individual therapy rate may look different than your couples or family therapy rate, EMDR intensive rate, or 60 versus 90 minute session rates. Some folks are charging a higher rate for “premium times” like evenings, which feels a little sticky unless it’s in writing and known to all clients when scheduling for them to make an informed decision regarding their therapy.

What about charging a client a “supply fee” for being in-person? This feels like a gray area in private pay practices.

What feels even more sticky to me is setting different rates for in-person versus telehealth sessions, which has come up more often as professionals explore hybrid practices where they offer both.

For example:

A therapist charges $150 for a 50 minute telehealth individual session.

They charge $175 for a 50 minute in-person individual session.

The cost difference is that they want to charge more for in-person to offset costs like office space or rent, or gas and supplies like coffee and tea that are utilized for in-person services. As a business owner, I understand that thinking. And yet, the bottom line is that those expenses are tax deductions and part of doing business.

Here are two reasons I would caution a therapist against having different rates for telehealth and in-person sessions.

1.     It feels discriminatory

That’s right, this could put you at risk of being accused of discrimination. What if your client has a disability that requires or prevents them from in-person sessions? Does in-person at a higher rate convey a message to an able-bodied person? There are aspects here to think about as a private practice therapist.

2.     It encourages insurance companies to follow suit with wanting to pay providers less

I can tell you how upset the therapist community was when certain insurance companies suggested a lower reimbursement to therapists for telehealth after the pandemic. The argument against this? We are still doing quality work via telehealth and continue to support meaningful client outcomes towards their goals via video. So if we support a different fee structure for in-person vs. telehealth in private practice with private-pay clients, are we not encouraging insurance to reignite this initiative too? As you can imagine, this would have a negative ripple effect on therapists who want to be paid fairly by insurance, and in response, might limit their number of telehealth sessions which reduces access to care for clients.

So what can you do? Rather than charging different rates for telehealth vs. in person, consider raising your rates overall to address the added expenses of in-person services. Not sure what this needs to look like? Join us August 15th from 12pm-130pm MT to engage in a live webinar workshop on raising your rates.

Raising Your Rates Workshop Objectives

1)    Remove money blocks to raising your rates

2)    Identify factors for raising your rates

3)    Explore strategies for implementing new rates

I hope I can convey that my goal in writing this is to support you as a business owner AND therapist. To hold space for multiple views while also owning that I’m risk-adverse. Raising rates is one aspect to consider in response to added expenses in practice, while knowing that things are constantly changing, which means revisiting ideas often to support your business growth.