I have had a very small private practice for many years and never processed insurance. I have also practiced within larger institutions who did process insurance. Since I have formalized my private practice into a limited liability company, I have waivered back and forth regarding whether I should become a provider and process insurance, or not. I am in my 6th month of full-time practice, and I still do not process insurance. Despite this, my practice continues to grow.
Occasionally something happens that makes me rethink my stance on processing insurance. A client might ask about insurance or tell me they’d come more often if I took it. They might say to me they have passed my name on to someone who could use my skills, but they won’t come because I don’t take insurance. It may be because they can’t afford it, or merely because they think I should take it because I’m an occupational therapist. I have talked with people that are baffled by this choice, some that are irritated by it, and others that applaud me.
On the topic of not being able to afford “out of pocket” services… I know there are some who think that only the elite can afford to pay out of pocket for the services I offer. I was a little concerned about this too. However, I have found that it is less about income and more about where people place their value. I don’t use a sliding scale or ask about salary when I intake a new client, but I do ask about the type of work they do to get a feel for how they use their body. Their job may or may not tell me about their financial status. 
I don’t know about their spouse, if they have one, or their savings account, or if they have a health savings account. (I do make sure to tell them if they have a health savings account, they can use it since I am an occupational therapist.) With high deductible plans becoming common, more clients are expecting to pay out of pocket. Most of my clients don’t question this arrangement. It is on my website, and I don’t proceed with my evaluation until it is clear that I don’t process insurance. I don’t want any suprises. I also never pressure clients to return. It is up to them if they find value in my services and want to continue. If they do, they decide when and how often. I also volunteer my services to be sure I am helping people who can use my skills but can’t afford them. I do think it is essential to give back to the community and I am working with a local non-profit to do this regularly.
I continually reflect on how I want to grow my practice and how I want to shape my life. When you own a business, it becomes your life. I crave a simple life, and processing insurance is NOT simple. There are many rules to follow and tasks to complete that extend far beyond client care. I want as much of my energy, creativity, time, and problem solving as possible to go into client care. On the flip side, I could charge more and make more if I took insurance. In the state of Nebraska, if I accepted Medicare, I could make about 40% more per visit. If I accepted other commercial insurance products, that number would go up. However, with others, it may go down. Some pay based on the service description (CPT codes) and others pay a flat rate often based on their determination of an average treatment time (usually 30 minutes). I have also compared my hourly rate to other practitioners around the country who have the specialized skills I use in my practice. Some practitioners charge more than triple what I charge. The practitioners are not just on the coasts where the cost of living is higher — many practice in the Midwest. I recently had a client who found an MFR practitioner in Oklahoma for her mother. This practitioner has much less experience and charges double my rate. Ultimately, even though I could make more money, I want do not want any insurance company dictating how I interact with my clients, provide therapy and operate my business.
Recently I had an experience that made me reflect on my decision not to process insurance. Usually, these experiences push me to reconsider processing insurance. Many times, I have reopened my provider application to Medicare, but something always stops me. This recent experience made me dig in my heels and affirmed why I don’t. I don’t want to share too many details about what was going on with my client, but we had a great discussion about insurance, evaluation, and documentation.
The bottom line, not processing insurance allows me to practice how I want to practice. It allows me to spend 100% of my time with a client addressing their needs exactly how I think is best (in collaboration with them of course). The insurance company does not dictate how long each visit lasts and how frequently we meet. It cannot cap how many sessions we can work together. It cannot stop therapy if progress is slow or they deem therapy to be medically unnecessary Many clients begin with several visits, trail off, then come back intermittently as they need help. Each client’s frequency and duration of visits varies widely. Again, the client decides rather than the insurance company.
Insurance companies want objective information. They want proof that a person has pain. They demand objective reproducible, measurable information to prove a person actually has pain, and proof that the therapy being provided is making progress toward an objective, measurable goal. There is not always a clear measurable deficit that accompanies pain. Most of my clients can do all their daily tasks. They go to work every day. They take care of their families. They are happy and interesting people. They have normal range of motion and functional strength. Many have had imaging tests that do not show a problem. …and yet they have pain. Sometimes the pain is mild and intermittent and sometimes it is severe and chronic. But, they are still functional. They must be. Life won’t allow less. It is the quality of their experience that brings them to therapy. My therapist friends might ask, “don’t you use a pain scale?”. I used to. It just doesn’t work for many of my clients.
A pain rating is a snapshot in time. There are times when a client walks in, and they tell me they are doing great right now, but they had pain during the weekend when working in their garden or while at work lifting boxes or it wakes them up at night. The nature of fascial pain is that it does change. It is not always in the same place or the same intensity. It can increase and decrease depending on the overall tension in the body. Tension can change with changes in activities and stress. Both activities and stress change every moment of every day. Pain can get a little better, then worse, then better again. The path to healing is NOT always linear. And, some of my clients say they don’t really have pain. They describe it as tension or tightness in their bodies. So, the pain scale doesn’t really work in my practice, and I no longer use it.
I also don’t typically take measurements or use assessments of any kind. I may do some testing to pin down an issue, or take a measurement if a client has a specific concern about loss of stretgth or motion. I do complete an evaluation with every new client. I get a full history, and I evaluate their body alignment in great depth. We discuss their activities, work and wellness habits. This process helps me determine if there may be a connection between their experience of pain and their life habits. When it comes to them telling me about their pain, where it is, when it hurts and how bad, I simply believe them. I don’t have to have objective evidence (which often doesn’t exist) to prove they need therapy. If they are spending their own money to get help, I don’t need proof. 
I don’t waste any time collecting information I don’t need to help them. I spend 100% of my time collecting data that will help me help them. The information I collect is often subjective, and part of the person’s lived experience and not a standardized assessment. Each follow-up session is 100% problem solving and treatment. I don’t need to spend time repeating assessments to prove change is happening. I simply ask my clients how they are doing, and we go from there.
Note: I am not trying to state that health insurance for therapy services is not a wonderful benefit. It absolutely is. However, it comes with many requirements that shape both the business and the services offered. It is far better suited for diagnoses that come with measurable effects and result in clear funcional deficits. I want to offer something different for my clients who don’t always demonstrate clear measurable impairments or have functional loss. The common thread in both groups is loss of quality of life. That is very difficult to measure.
