Self-Pay vs. Insurance
There are a number of counseling issues that insurances generally won't pay for because they deem them to be a "non-medical
necessity" and label them as" V-Codes" (meaning, "issues we won't pay for"). HMOs tend to be more rigid with this, with PPOs and
EAPs being more flexible and lenient. Therefore, if you're not sure, call your company and ask them up front if they will pay for the
main issue you'd like to work on in counseling.
Many times, you will need to pay my regular self-pay fee when primarily coming in for any of the following "non-medical necessity"
Couples or Family Therapy (some insurances will pay for this, some won't)
Habits/Addictions (other than chemical dependency)
*If you call your insurance company, explain your situation, and they give you an authorization number to have sessions with me,
there shouldn't be a problem with being covered--whatever your presenting issues may be. I assume that if they give you an
authorization number, they're willing to pay for you.
For most other counseling issues besides those listed above, you should have the choice of either: 1) using your health insurance to
help pay for our sessions together, or 2) keeping your personal issues private from your insurance company and choosing the "self-
pay" (non-insurance) option .
Note: if you want to use your insurance and you have an HMO, call your company first to see if I am contracted with them on their
panel of providers. I've offered a partial list of the insurance companies I'm with on the "Insurances" web page that you can go to by
clicking the "Insurances" link to the left or by clicking here.
If I am not listed with your HMO, they usually won't pay. PPOs will always pay, but if I'm not on their "preferred provider" list, I am
considered an "out of network provider". If this is the case, you can still work with me, but you will probably have to pay a slightly
Typical issues usually reimbursed by health insurances for a limited number of sessions (+ examples) include the following:
Mood Disorders (Depression, Bi-Polar)
Anxiety Disorders (Panic, Phobias)
Adjustment Disorders (Life Transition Difficulties such as Divorce)
Chemical Dependency (Drinking, Drugs, Smoking)
Psychotic Disorders (Schizophrenia)
Childhood Disorders (ADHD, Defiance)
There are benefits and drawbacks to either using your insurance for payment or by choosing the "self-pay" option (no insurance
involvement at all). I will briefly review the main "pros and cons" of both, along with my own personal opinions. Hopefully, this
information will help you choose the best option for yourself. I want you to be knowledgeable about your payment options and satisfied
with your choice.
OPTION #1: INSURANCE REIMBURSEMENT
*Lower fees: insurance co-pays generally average about $10-25 a session for HMOs and $25-65 for PPOs, with the insurance
company paying the remaining balance.
*Limited coverage: Nearly all insurance companies put a limit on the number of sessions they will pay for—often before you feel ready
to end your sessions. Most companies give an initial authorization of between 3-12 sessions only, with additional sessions approved
or denied depending on if the insurance deems that further work is "of a medical necessity” (a judgement they make after I plead your
case to them in a phone call just before you reach your session limit).
*Choice of therapy focus: Most insurances will only pay for sessions they deem as being a “medical necessity”--which may conflict
with what you want to work on (as described previously)
How it Works:
If I am a formal “provider” on your insurance’s panel/network:
*You (the client) call your insurance company before our sessions begin to get an “authorization for counseling services number”. You
write this number down on your “client information” form and I bill your insurance. All you pay me each session is your co-pay as
determined by your insurance plan (usually $10-25 for HMOs, $25-65 for PPOs).
If I am not a formal “provider” on your insurance’s panel/network:
It depends. If you have an HMO, they will generally not pay for you to see me (although you can call them and ask). Otherwise, if you
have a PPO, you can still meet with me and pay a little higher proportion of the fees for myself being an "out-of-network provider.
In these cases, You pay in full at the beginning of our sessions at the standard rate. Then you take the information from my billing
statement after our counseling session(s) and submit it to your insurance, asking to be reimbursed for mental health services with
an “out of network provider”. They are obligated to reimburse you for whatever number of sessions and at whatever % rate of the
fees that was agreed upon in your contract with them. After submitting the form and details I provide you, your PPO insurance
company will mail a reimbursement check to you, not me.
Why is it set up that way (with you paying all of the money up front and having to bill and receive reimbursement % yourself--instead of
me doing this all for you)? I don't know. PPOs are just designed that way with "out-of-network" providers. Perhaps they're trying to
discourage you from taking advantage of your benefits. However, the ability to select whichever qualified person you want to work
with is a great advantage. II try to make dealing with this easier for you by giving you all of the information you'll need on your billing
statement (upon request).
If your insurance company will authorize your sessions with me and the main focus of our work together is with one of the typically
reimbursable conditions (mentioned previously), then using your insurance may be the way to go for you. If you want to go this route,
call your insurance company and see if they will authorize sessions to work with me. If not, and/or if your main reason for coming in
falls under the issues insurances generally won't pay for, then you should consider the "self-pay" option below.
OPTION #2: SELF-PAY
Confidentiality Preservation: No insurance company knows of our meetings together or what they are for.
Absolute Choice in Treatment Length: You choose how long and how often you come in for sessions without limitation (in
collaboration with myself).
Choice of Therapist: If you like me and my credentials, you may freely choose to work with me as your therapist without worrying
about if I am on your insurance’s “approved provider list”.
Choice of Therapy Focus: You choose whatever goals and issues you would like to address to promote your emotional and
psychological well-being. In short, you decide what’s important for you to work on, and that is all that is required. You act as the top
expert of yourself and the issues you want addressed.
Independence/Ownership of your Therapy: When you pay for something completely yourself with your hard earned money, you are
more likely to appreciate it, value it, and take it more seriously. I have found that people who completely pay for their own therapy tend
also to be more committed to the process and make greater changes. Since the changes you want from counseling are seriously
important issues for your happiness and satisfaction in life, you may consider choosing the self-pay option whether your insurance
would cover you or not.
Cost: You’ll pay the full price yourself ($130/session), which may or may be an issue to you, depending on your availability of
How it Works:
Process: You pay at the beginning of the session with cash or check (and soon, credit card or debit/ATM card) and receive a receipt. If
finances become a problem, I sometimes will negotiate a lower fee on a case-by-case basis, based upon demonstrated need.
Another option is spacing out the sessions from once a week to every 2, 3, or 4+ weeks. In short, I will do my best to make self-pay a
workable option for your situation.
Honestly, I think "self-pay" is the best choice of the therapy payment options for the previously stated reasons, providing you can
work it into your budget. However, I realize that real world finances don’t always allow clients to choose the self-pay option. Therefore,
I will do my best to work with my client's insurance when this is the chosen payment option.
Think seriously about your choice of payment. I will respect and work with whichever of these payment options you choose as my
client. Questions, concerns, or opinions about payment options? Let’s discuss them together.
Randy A. Gilchrist, Psy.D.
*If interested, you may also go to www.sandiegotherapists.com/comparison.html for a further description of the pros and cons of self-
pay vs. insurance.
**For more information regarding my self-pay fees, click my "Self-Pay Fees" page link at the far left or click here.
***To view the insurances I am currently accepting new clients with, as well as the process of dealing with insurances, click my
"Insurances" page on the left or click here.
Randy Gilchrist, Psy.D.
1899 East Roseville Parkway Suite 100
Roseville, CA 95661
(916) 899-4990 email@example.com
Counseling and Psychotherapy Services
Licensed Clinical Psychologist #PSY19726
Licensed Marriage and Family Therapist #MFC39159