The Pay As You Go Choice

Paying Out of Your Own Pocket For Your Therapy

Those who have no health insurance or, more commonly, have a health insurance plan that does not include mental health benefits, pay for their therapy themselves.  Occasionally, someone who does have an applicable insurance benefit will choose not to use it.  Why would they do that?

Here are some of the advantages to self-pay therapy:  First and foremost, it is entirely private. The information that you offer in your therapy sessions is between you and your therapist, period.  When a third party is in the picture, the confidentiality is compromised; it's as simple as that.

  Various insurance companies have different reporting requirements.  Some demand clinical treatment reports that the therapist must write on the patient and which can be quite extensive.  They may include a five axis diagnosis, a number designating your level of functioning, some physical information such as weight and height, a delineation of the stressors in your life and more.  The purpose is to prove "medical necessity".  If you have budgeted for a small co-payment, you are in the midst of your therapy process, and the insurance company decides your treatment is not a medical necessity, you may no longer receive the benefit of your sessions being partly subsidized. Some insurance companies require repeated requests for authorizations and may decline a request so, then, unless you can negotiate a fee with your therapist, your treatment will halt.  But then, what happens to all the information the insurance company has collected on you?  I don't know.  But, as long as you remain a subscriber, it seems that there is the chance that you will try again to use their coverage, so it probably makes sense that they would keep your information.  Some say the information is kept in databases accessible to certain entities at the insurance company's choice.
Prior to some sort of report being asked for, because you are a subscriber, the company will already have your basic information, such as, name address, phone number, social security number, and birth date. In addition, a one axis diagnosis will be required for the therapist to be able to bill them for your sessions.

Complete confidentiality is such a cornerstone of therapy, (a therapist is trained to not even reveal that you are their patient, i.e., if someone called your therapist to talk about you, not only would they not enter into a discussion of your personal business, they would not even acknowledge that you were their patient); the code of confidentiality allows a person to come into the therapy office and feel comfortable enough to reveal all; this is why it is so important.

A topic that got a lot of attention when I was in graduate school but which I haven't heard much mention of recently is, labeling.  The concern is that once a person is given a mental health diagnosis, in any context, it may remain associated with their name.   The idea was that they could be labeled and that there might be implications to having a label follow you in life.

In a private pay situation, there is no need for a formal diagnosis.  The therapist may or may not think about this, depending on the case.  But, if it were a part of the therapist's treatment planning, it would be held in confidence.

Even more to the practical perspective, in the U.S., therapy with a credentialed, licensed therapist is an expense you can deduct from your taxes.  You can also claim it as an expense on a medical reimbursement account.  In that case, it is helpful for your finances to pay for your therapy yourself (if you decide to take advantage of these options, of course, you do reveal to the government and the resource who processes your medical account that you are seeing a therapist.  But that it is extent of it).  

So, you control completely who knows what about your therapy.

The fee for therapy may seem high at first blush because most Americans are used to paying a small co-payment for their doctor visits.  ~On the other hand, many do pay out of pocket for the dentist, the chiropractor, the optometrist or the acupuncturist.~  But, if you think just a bit about these services and what the fees are, it will begin to make sense.  If you have any questions about how a fee is set by a therapist, you can ask me in a comment here; also, there is some information on that topic in the post, The Imperfect Therapist.  http://therapiststhoughts.blogspot.com/2011/05/imperfect-therapist.html

On the subject of having control, when a patient uses health insurance (referring to HMO type here) to pay part of the fee for therapy, the insurer decides how frequent the visits will be and how many there will be.  If a subscriber calls and inquires about their benefits, as one of my patients did the other day, they may be told, as she was, that the number of visits is "unlimited".  Technically this may be true; possibly this is what it says in the insurer's contract with her employer-the purveyor of this benefit.  However, that statement,  is actually misleading since the number of visits may be fewer than the patient would like if, again, "medical necessity" is not possible to be proven.   There are some subtle ways  the insurer may use to discourage visits from occurring more frequently than they would like to pay for.  

For example, should a provider be able to make a case for medical necessity in a patient report, the insurer may ask for these reports more often and award fewer visits for the report each time.  When this happens, to be able to continue in a process they find beneficial, some patients will opt to schedule sessions less frequently to make overall therapy last longer.  Of course, they miss out on an optimal experience, in making that adaptation.

Back to the subject of confidentiality:  Every company is different.  Some are more hands off than others.  Some are quite pesky.  One of the things that can happen is something called an audit.  It has nothing to do with money, at least on the face of it.  It is a supposedly random check on the quality of a listed provider's (therapist's) record keeping.  The insurer will randomly select a case and the therapist is required to hand over all clinical notes on the requested cases.  Any and all records found to be not to their liking, the therapist will have to correct or supply required information.  This can be a current case or one from the past.  While this is a very occasional occurrence,  it does happen.  This compromises confidentiality completely.

Another infrequent event is if the insurance has denied any more coverage of future visits, the therapist, on the patient's behalf, may produce an appeal.  Sometimes this leads to the therapist being required to discuss the case with a "clinical case manager" or "care manager".  These are people licensed to be therapists, who are employees of the insurer, and can decide whether or not a case can continue to be covered.  (Yet another person privy to your personal business)

Here is a link to an article on this subject which I found after I wrote mine.  It says  most of the same things but more concisely:
 http://www.americanmentalhealth.com/whyself-pay.trust

Another one I liked, that is an easy read:
http://vswoodpsyd.com/faqs/willmyinsurancepay.html

For description of the Medical Information Bureau, see this site:
 http://www.drsomov.com/paying-for-therapy/

Also see the second half of my post titled, Answering Questions