Private Pay, Insurance, or Both

One of the first big decisions therapists face when starting a private practice is whether to be private pay, accept insurance, or offer a mix of both. This choice can feel weighty, because it impacts not only your business but also your day-to-day experience with clients. I want to start by saying there is no right or wrong answer. Therapists thrive in all three models. What matters most is choosing the approach that best supports your vision, your values, and your circumstances.

A few years into having my private practice, I briefly accepted health insurance. At the time, it seemed like the most straightforward way to have referrals come in more quickly, and to feel financially secure. But I quickly discovered a challenge. As a couples therapist, I found that the reimbursement rates for couples and family sessions were very low. It was discouraging to pour my heart into this work, while realizing that I was not going to earn enough money to cover my expenses and pay myself a reasonable salary.

After some reflection, I made the decision to transition out of insurance panels and move fully into private pay. That path has worked well for me, but I also know many therapists who are thriving while accepting insurance, and some who have found a mix to be the best fit.

So, what are the pros and cons of each option?

Private Pay
The biggest advantage of private pay is autonomy. You set your rates, your schedule, and your policies. You can design your practice around the clients you feel most called to serve and the kind of work you want to do. Many therapists also find that private pay clients tend to be highly invested in the process, because they are choosing to make a significant commitment both emotionally and financially.

The challenge is that building a private pay practice often takes longer. Generally it requires ongoing marketing, networking, and building your reputation so that clients feel confident investing at your rate. This can feel daunting at first, though it becomes easier over time as your practice grows.

Insurance
Accepting insurance makes therapy more accessible for clients who would not otherwise be able to afford it. It can also help you build a caseload quickly, since clients often begin their search through their insurance provider directory. Many therapists appreciate the steady flow of referrals that insurance provides, especially when starting out.

On the other hand, reimbursement rates can be low, especially for couples and family therapy. Insurance companies may also have specific requirements for documentation, treatment planning, and session limits that can feel restrictive. Some therapists find the administrative side of insurance to be draining, while others build systems that make it manageable.

A Mix of Both
Some therapists find balance by accepting one or two insurance plans while primarly offering private pay. This approach can provide a steady foundation of clients while giving you space to grow your private pay practice over time. It also allows you to serve a wider range of clients, which can feel both meaningful and sustainable.

The challenge is that balancing both systems can feel complicated. You will need to track which clients fall into which category and keep clear boundaries around fees and policies. Still, for many, the mix offers the best of both worlds.

Finding Your Fit
As you reflect on your decision, I encourage you to consider not just the financial aspects, but also your long-term vision for your practice. Do you want the simplicity and flexibility of private pay? Do you feel called to make therapy more accessible through insurance? Or does a mix of both align with your goals?

There is room for all of us. What matters most is that you choose a path that allows you to care for your clients while also caring for yourself. I have colleagues who are private pay only, colleagues who accept insurance exclusively, and colleagues who blend both. All of them are doing meaningful work, and all of them are running successful practices in their own way.

If you are struggling with this decision, know that it is not permanent. Many therapists change their approach over time, just as I did. Your practice will evolve with you, and that is part of the process. In the end, private practice is about creating a professional life that feels aligned with who you are.