One of the running excuses therapists give for not accepting insurance is the claim that doing so is cost-prohibitive due to low insurance rates and respective paperwork. I called BS so challenged the statements using hard numbers.

I ran numbers comparing cash vs. insurance therapy business models, including hybrid. The results are as I expected: not convincingly supporting private practice models. Creative solutions see a $40/day difference.

First, one aspect mental health (MH) providers will NEVER openly admit on Twitter: some therapists intentionally avoid “difficult clients” including some harder to treat SMI. Reason being: this helps improve perceived efficacy while also reducing stress/cognitive load. Manic episodes & schizo are not easy. But it’s the job.

One convenient way to make this happen is going private practice only, as many SMI populations struggle financially; it weeds out the “trouble”; aka the poor… which is another whole ethical question in itself.

Bottom line is simple: Therapists manage maybe 5-7 clients a day. Let’s call it 5 for easy math, less only supports my point, more offers higher margins. Stacking eliminate loss entirely (which may not be feasible due to burnout).

Numbers Don’t Lie

In WA, it’s $120 cash price vs $100 insurance per 1hr talk therapy, with the *extra 30min paperwork included in estimates below (google). This varies wildly state to state, but core concepts still apply.

Immediately my concern is simple: if your business model is depending on a $$/day difference, you have much bigger problems than low insurance payouts.

But OK, back to numbers:

Let’s call $100/90min = $67/hr without *creative automation.

Mitigate this further through hybrid cash/insurance models (limited to 2 ins. clients per day).


5/day x $120/hr = $600 cash only
5/day x $67/hr = $335 ins. only
*5/day x $100/hr = $500 ins. only
($100-$265/day vs $600 cash)


3/day x $120hr = $360 cash
2/day x $67hr = $134 insurance
*2/day x $100hr = $200 ins.
($40/day less vs $600 cash)

*Paperwork done in same 1hr via creative curriculums.

We are literally talking about hybrid business plans being a *$40/day less payout than cash, double it for $80 to argue. It is true that going insurance only would be hard & is not my recommended solution. Diversified creative hybrid works best.

Not a Convincing Argument for Negating the Poor

I’m sorry, even considering market fluctuations by state, this is not a convincing argument to negate poor (insurance) people from care entirely.

Not saying $200/week less isn’t hard on small business, I’m saying if these are your margins for success, you have bigger problems than just low insurance.

*The claim therapists make is the same 1hr insurance payout requires an additional 30min paperwork unpaid per patient, which I’ve already offered easy solutions around (automating ~30min using pre-prepared resources enabling in-session paperwork).

Myriad of Creative Business Solutions Available

This doesn’t even include the myriad of creative business solutions outside 1:1 service payouts (like renting space & diversifying revenue streams or stacking tech/clinician via automated curriculums).

Ok so still too much? Offer 1 insurance client per day instead of 2, and we are talking $20/day difference, $60 if you triple loss just to argue – chump change for business.

Or instead of tweeting therapy advice all day, go pro bono periodically (yes, I’m annoyed). There’s just no excuse.

The initial response therapists gave me on twitter to my challenging their decisions to go private-only was “you (patients) take the issue up with your legislators, we don’t get paid enough”.

This actually pissed me off. That’s like me asking therapists to call Apple to reduce MacBook costs. Your paycheck. Your problem.

A lack of Accountability Prevalent in MH Providers

It upsets me because I see this lack of accountability/creativity prevalent in MH providers beyond just $$, it also bleeds into treatment approach, failure & mistakes clinicians make. They love talk-only modalities seemingly requiring little overhead/prep. The burden always seems to end back on patient plate unfairly.

I love you all, but have to call out BS when I see it.

Again the conclusion is diversifying business models, capping insurance availability, not overly depending on “mm-hmm” talk therapy, and eliminating excuses. Rent out space during downtime, blah blah blah.

I drop the mic and walk away 🙃

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