Last week, I called an insurance company. This call triggered why I switched to Private Pay Therapy.
I was on hold for just over an hour. When someone finally answered, I was transferred — twice — to different departments, each time explaining from the beginning why I was calling. After the second transfer, I was told that the issue I was calling about couldn’t actually be handled over the phone. For anything that could be resolved through the portal, they don’t speak with practitioners directly. I would need to submit a message online. Response time: five to ten business days.
I hung up. And then I went to see my next client, because my caseload was full and people were waiting.
That hour — plus the transfers, the explanation, the being told to go away and wait — produced nothing. No resolution. No payment. No answer. Just time I didn’t have, spent on a system that was not designed with me, or my clients, in mind.
That is not an unusual week. That is a Tuesday. With multiple clients scheduled in a day, there is no time to call back. No time to send a message.
And it is one of the reasons I made the decision to leave insurance-based practice entirely.
When I first became a therapist, I accepted insurance because I wanted to help as many people as possible. That felt like the right thing to do. And for a long time, I believed the system would support the kind of care I was trained to provide.
It doesn’t.
Not because the people working within it don’t care — they do. But the structure of insurance-based therapy was never built around how healing actually works. It was built around billing codes, session limits, and diagnoses that have to fit a box before anyone can get help. It is built around profit for a billion dollar company. Insurance companies are profiting billions yet clawing back money from clients and providers. This is not a system I want to be a part of.
For the people I work with — adults facing a life-altering diagnosis, watching someone they love decline, grieving a future they had counted on — that box doesn’t fit. Anticipatory grief isn’t a disorder. Caregiver exhaustion isn’t a pathology. And the kind of work it takes to find solid ground in the middle of unimaginable loss doesn’t happen on an insurance company’s timeline.
What Insurance-Based Therapy Actually Looks Like
Here’s what most people don’t know until they’re already in the system — and what most therapists are too burned out to say out loud.
Before a single client ever sits down with me, insurance participation requires credentialing. This is the process by which an insurance company verifies that I am, in fact, a licensed therapist. It sounds reasonable. In practice, it means submitting the same documents to multiple panels, waiting anywhere from 90 to 180 days for approval, following up repeatedly with people who may or may not call back, and sometimes — after months of paperwork — being told the panel is closed. No clients. No reimbursement. Just time.
Once credentialed, the work of actually getting paid begins. And I use the word “work” deliberately.
Insurance companies require a diagnosis to authorize treatment. Before your first session is complete, a mental health label has to be assigned to your file — one that will follow you in ways you may never fully see. For some people, that diagnosis is accurate and appropriate. For many of the people I work with, it isn’t. Grief is not a disorder. Anticipatory loss is not a disease. But without a billable diagnosis, there is no authorization, and without authorization, there is no payment.
Beyond diagnosis, insurance dictates how often you can be seen, for how long, and sometimes even what approaches your therapist can use. Sessions get cut off not because the work is done, but because the authorization ran out. Clinicians spend hours on documentation and prior authorizations — hours that used to go toward client care. Insurance reimbursement rates are low enough that therapists who accept them are often managing caseloads of 30, 40, or more clients just to keep the lights on. That is not a judgment of those clinicians. It is a structural reality. And it means something for the quality of attention any one person receives.
Then there are the notes. Insurance companies dictate not just that you document sessions, but how — specific language, specific formats, specific proof that the session was “medically necessary.” I have spent significant time rewriting notes not because the clinical content was wrong, but because the phrasing didn’t satisfy a reviewer who never met my client, doesn’t know their story, and is working from a checklist. Notes that don’t meet the standard — whatever that standard happens to be that quarter — can be denied. That means no payment for a session that already happened.
And then it gets worse.
Clawbacks are when an insurance company pays a claim, then sometimes months later decides it shouldn’t have, and takes the money back. Not because fraud occurred. Not because the session was undocumented. But because an internal audit flagged something, a policy changed, or a coding technicality emerged that no one mentioned at the time of service. I have had sessions I conducted, documented thoroughly, and was paid for — reclaimed, sometimes a year later, with little recourse.
Payment timelines in general are unpredictable. Weeks of waiting is standard. Denials that require appeals are common. Each appeal is more time — time spent on hold, time spent resubmitting, time spent writing letters to justify care that was clearly appropriate. It is not unusual for a single denied claim to require multiple rounds of follow-up before it resolves. Some never do.
Meanwhile, the client sitting across from me — or on the other side of the screen — deserves a therapist whose mental energy isn’t split between clinical care and an ongoing administrative battle with their payer.
For the people I work with, who are often already stretched thin by a diagnosis, a caregiving role, or a grief that doesn’t pause — they deserve more than a therapist who is quietly exhausted by a system designed to delay, deny, and reclaim.
Why I Made a Different Choice
Recently, I started being honest with myself about what my clients actually needed — and what insurance was actually allowing me to give them.
Grief moves slowly. It doesn’t follow a treatment plan. It resurfaces when a scan comes back, when a medication stops working, when a holiday arrives and the absence is louder than everything else in the room. The people I work with don’t need eight sessions and a coping skills handout. They need a therapist who knows their story, who has time to sit with them in the hard parts, and who isn’t watching the clock because four other clients are waiting.
Moving to a fully private pay practice wasn’t a financial decision. It was a clinical one.
It means I carry a smaller caseload — intentionally. It means I have time to prepare for your session, to think about what came up last week, to bring my full attention to the work we’re doing together. It means I’m not spending the last ten minutes of our hour writing a prior auth request. I’m present with you.
It also means I can work with you for as long as the work requires. Not as long as your plan allows.
What About Cost?
I want to be straightforward here, because I know cost is real.
I know my rate is not a small number. I know that can be a barrier for some clients.
What I’d invite you to consider is this: many insurance plans include out-of-network benefits that can reimburse a meaningful portion of that cost. As a private pay client, I can provide you with a superbill — a detailed receipt — that you can submit directly to your insurance company for reimbursement. Depending on your plan, you may recover 50–80% of session fees once your out-of-network deductible is met. I’m happy to help you understand how to check your benefits before we ever schedule a first session.
If private pay isn’t workable for you right now, I will never want you to go without support. I’m glad to help connect you with trusted colleagues who may be a better fit for your current situation.
What This Means If You’re Considering Working Together
If you’ve been searching for a therapist who specializes in anticipatory grief, chronic illness grief, or caregiver grief — and you’ve been frustrated by long waitlists, rushed sessions, or clinicians who feel stretched thin — I want you to know that the experience here is intentionally different.
The work we do together belongs to you. It isn’t filtered through an insurance portal or capped at a number someone decided in an actuarial table. It’s built around what you’re actually carrying and where you actually want to go.
If that sounds like what you’ve been looking for, I’d be glad to connect.
Please reach out if you have more questions. Consultations are always free.
Sherri Webster, LCSW, C-SWHC is a licensed clinical social worker and founder of Rising Sails, a private telehealth practice serving adults navigating anticipatory grief, chronic illness grief, and caregiver grief. She practices across Delaware, New Jersey, Maryland, Virginia, Florida, and South Carolina, with in-person sessions available in Dover, Delaware.