Counseling eTherapy Health care How to

How To Pay For Therapy Sessions

by Imei Hsu, RN, MAC, LMHC, RYT

How To Pay For Therapy Sessions

Going to psychological therapy sessions for the first time can be a little unnerving. But if you know you (or a loved one) really need to get a jump on some challenging issues, you’ll need to contact a therapist. Part of setting up your first appointment involves some important decision-making about how to be financially responsible for payment. While paying for services rendered should be a piece of cake, many of you know that paying for medical services isn’t always straight-forward. How many of you have whipped out your insurance card for a medical visit, only to receive a bill with unexpected charges a few weeks later? The more you know about how you will pay for your therapy sessions, the more satisfying your experience.

Using Health Insurance

Get the skinny on paying for counseling BEFORE your first session.

lIf you find using your employer’s health insurance benefits for outpatient medical visits to be confusing, you’re not alone. I have many corporate clients who breathe a sigh of relief when they tell me, “I really don’t know how my insurance works.” These are intelligent people. Often times, understanding their benefits doesn’t get but a few moments of explanation during new employee training. Retrieve your employer’s benefit material, and start looking for medical benefit coverage. Also, have the insurance company’s customer care phone number ready. You might need to make a quick call.

If your employer offers benefits that include outpatient mental health (a.k.a. behavioral health visits), find out how many sessions are covered. While the State of Washington has a parity law requiring health insurance companies to allow participants the same number of medical visits as behavioral health visits,  that doesn’t mean all your visits are fully covered. For example, a company covers your first six visits with a low copay. After the first six visits, the subscriber must meet a high deductible in the calendar year (let’s select $2500 as an example). After the client has paid out-of-pocket the deductible (about 23 sessions on average), the insurance kicks back in at 70% (client pays 20%). For many subscribers, that deductible looms on the horizon. But for therapists who accept insurance payments, it places them in a difficult position. We have to explain to clients that six sessions is not going to solve problems that might have taken years to develop. Yet, we don’t want our clients to terminate too early, only to conclude that therapy didn’t “work”.

In other cases, your employer may offer benefits that are more comprehensive, with no deductible, and a low or non-existant copayment per visit. In this case, the client should consider whether s/he wishes to have behavioral health visits on a legal medical record. While it is against the law for your employer to view the contents of these records (because of HIPPA), you should weigh the costs and benefits of your employer (via Human Resources) knowing you have been in session with a licensed therapist, psychologist, or psychiatrist. If you are unsure about what these costs or benefits could be, I highly encourage you to ask a therapist during the consultation period (i.e when you are selecting a therapist).

Paying Out Of Pocket (OOP)

Paying out of pocket for medical services may not be as hard as you think.

While therapists should not run their practices as a charity, we are a compassionate lot. We see first-hand how the economy has affected individuals and families. But when a caller once shouted, “You therapists should be providing services for free!” I bristle. If that were true, we therapists should have been given a Master Degree education for free, books for free, continuing education units for free, and liability insurance for free. While we’re at it, how about a professional office, donated and maintained, for free?

Our services are valuable, and they need to be honored like the services you receive in any other medical office. Some medical offices do provide financial assistance, but that is usually on a case-by-case basis. If a therapist cannot assist you with lower-cost services, s/he may have local resources, or know of an agency that can provide lower-cost services. If s/he can assist you financially, take a moment to understand what is being offered.

* Low income — a sliding scale may be offered in cases of low income. Low income is considered at or just above poverty level. You may be asked to provide a pay stub as proof of your income level. The exception is for students with catastrophic-only insurance, and no outside support from family. Often, low income sliding scales are provided only at state agencies that receive assistance.

* Hardship —  this includes women and children in situations of domestic violence, those in rehab, and unemployment, and chronic transition that has devastated a person’ s finances, such as death of a spouse, job relocation followed by a layoff, and divorce.

*Scholarship — your state may provide money to single women who qualify. They qualify by income, the type of work they do, or the number of people in their household they support.

* Pro bono — a therapist may choose to offer services pro bono when extreme hardship makes even $10 a session hurt.

Traditionally, therapy offices did not provide the means of paying by credit card. Today, more therapists are joining the 21st century by providing credit card services. The one used at Seattle Direct Counseling is Therapy Partner, which remains HIPPA compliant. Others use Paypal, Square, or bank-supported options over the telephone to assist you in paying. Be aware of any Terms of Use with any of these services.

When You Can’t Use Your Insurance

There are some cases when you can’t use your insurance, and these cases are usually stipulated in your explanation of benefits. These may include treatment for sexual dysfunction, biofeedback, alternative therapies, and couples (conjoint) therapy. Additionally, you may select a therapist you really like, only to find out that s/he does not accept your employer’s third-party payer. Things you should know:

*Ask why your therapist does not take your insurance. In the case of my practice, I “fired” or chose not to renew certain payers because the payouts were some of the lowest in the region. What this means is that the payer determined a low value on psychological services, and then either expects the Provider to suck up the cost, or shafts the patient. Sometimes, it’s a combination of both.

*Your insurance benefit has run out for the calendar year. You must decide if it makes more sense to pay for services OOP, or wait for the next calendar year. If you determine your condition or relationship will worsen without treatment, it’s better not to wait.

In this case, clients cannot ask for a sliding scale, nor can they pay at the level of the Payer (i.e. 70%), and expect to continue using the limited benefit at the start of the next calendar year. This is considered a breach of contract with the Payer, and it could result in loss of paneling with the Payer. Translation: the Payer can fault the therapist by declaring his or her billing as fraudulent.

*Conjoint (couple’s therapy) can be billed under individual insurance only when the identified client has a qualifying diagnosis. When the diagnosis code indicates this, your case can be fully investigated by the third-party payer for validity. A therapist can lose his or her contract with the payer (and be accused of fraud) if s/he bills conjoint therapy as individual therapy simply to save a couple money. [At Seattle Direct Counseling, I do not bill individual therapy for couples. If there is an identified client with a qualifying diagnosis, the partner/spouse can be asked to present in the therapy sessions, but the focus of the therapy must remain on the identified client].

Why Your Insurance Might Not Be Accepted

Over the past couple of years, I have purposely chosen not to renew with specific insurance companies, such as Cigna and Aetna. I am currently making a decision to pursue Group Health for paneling.

While I was about to draft a sample letter to clients explaining why I do not carry certain third-party payers, I was sent one from my dentist that explains this beautifully. I have obtained his permission to reprint the letter,in part or in full, to help educate you as to why many therapists are doing the same [a link will later be provided on the website]. What it often comes down to is a compromise in care. When insurance companies determine a low value on our services, it forces providers to increase their client loads. And in my case, I determine pro bono cases when my client load supports the ability to manage a few clients with no ability to pay. While I have no employees and low overhead costs as compared to a medical office, I still have liability insurance and rent to pay, and both of these costs will increase when: 1) my client load increases above a certain thresh hold, and 2) I move to larger office (which will likely happen very soon).

Be Responsible and Proactive With Payment

Therapy practices are not equipped to be used as a bank if you default on payment. Most therapy practices will not charge you interest if you take more than 90 days to pay. It is advisable that you not attempt to keep a balance in an account of what you owe your therapist by promising to pay at a later date. Instead, discuss your means to pay for visits at the beginning of therapy. This discussion is part of the therapeutic process, and it addresses your ability to communicate, relate, and deal with adult issues of responsibility.

If your financial situation changes in the middle of your therapy process, make sure you discuss that with your therapist. I can’t speak for others, but in my own practice, I fight hard to make it work in your favor to continue therapy while being responsible with cost. Many of my clients can vouch for my willingness to help when the going gets tough.

Do you have a question about how to pay for therapy sessions? Have you had difficulty with your insurance company? You can send an offline email to, and give permission to reprint your comment without identifying information, so that everyone can learn from your experience while remaining anonymous.