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Many therapists are told going in-network with insurance is the only way to be "accessible." We’re told it’s the quickest way to fill a caseload and the "right" way to help the community.
While that can be true, I want to lean into the word “and.” You can build a sustainable practice and be accessible, all while your clients still utilize the insurance benefits they already pay for every month.
If you’re curious how, keep reading.
Before I stepped into private practice, I was deep in the world of non-profit trauma work in shelters, residential crisis centers, foster care, and trauma recovery centers. Like so many of us in community mental health (CMH), I pushed myself until I hit an abyss. I was working 40+ hour weeks and could barely make ends meet, let alone care for my own emotional well-being.
I realized that if I was going to keep being a therapist, my life had to be built around my work—not the other way around. I heard horror stories of insurance from other clinicians: clawbacks for clients, denied treatment, and reimbursement rates so low that therapists are forced to see 30 or 40 clients a week just to survive.
Burnout taught me I cannot be an effective therapist if I am seeing 40+ people a week. I am not a robot. I am a human providing deep, relational care. My clients deserve 100% of my energy, not me showing up at 5% capacity. I don’t want to model burnout for my clients. I want to model a life built on boundaries and self-care.
When I’m rested, I can hear the things clients aren't saying out loud. I can hold the space for their deepest trauma without feeling the "clock" ticking in the back of my mind because I’m worried about my next 10 sessions that are back to back.Â
I can remember the names of the important people in their lives and details they forgot they even mentioned because my focus isn’t on figuring out when I’m going to use the bathroom or eat. I can form meaningful rapport and connection because my nervous system is regulated enough to meet theirs.
Being out-of-network (OON) is the boundary that allows me to be the therapist my clients deserve, not the therapist they get.
In-Network‍
You’re contracted with an insurance company to accept a set rate. Sometimes clients still pay a co-pay, other times insurance covers the full session. This is a vital resource for many, and that choice should always be respected and supported.
Out-of-Network‍
You set your own fee and are not contracted with an insurance company, but clients can still get money back from their insurance if they have out-of-network benefits. They pay you upfront, a claim is submitted, and their insurance can reimburse them a significant portion.
By staying out-of-network, I protect my capacity to offer high-level, specialized care without a third party dictating the "how" or the "how long" of our healing journey.
If a client has a preferred provider organization (PPO) plan, they likely have out-of-network benefits.
If you are weighing the decision to move out-of-network, here is the reality of how it changes your clinical work.
Specialization vs. Standardization‍
Insurance often prefers short-term, symptom-focused treatments. By staying out-of-network, you have the freedom to use specialized or integrative modalities (like EMDR or somatic work) without justifying why you aren't using a "one-size-fits-all" CBT manual.
‍The Ethics of Presence‍
In-network rates often force a volume-based model. Managing a smaller out-of-network caseload allows you to dedicate the time and emotional energy each human actually requires.
‍Privacy and Documentation‍
While we still provide a diagnosis, the clinical oversight is night and day. You aren't constantly defending your client's "medical necessity" to an auditor who has never met them.
Plan Limitations
Not everyone has out-of-network benefits. Clients with HMO plans rarely have this option. As ethical practitioners, we have to be upfront about this so the client can make an informed choice.
‍The Deductible Barrier‍
This is the biggest hurdle. Clients generally pay more at the beginning of the year. Once that deductible is hit, costs drop significantly. Using a tool like Thrizer helps bridge this gap so the "upfront cost" isn't as much of a barrier.Â
‍The Diagnosis Dilemma‍
Since insurance is involved for reimbursement, a diagnosis is still required. I always handle this with transparency—explaining to the client that a diagnosis is a guide for the system, not a label for who they are as a human.
‍The Reset‍
Deductibles typically reset every 6–12 months. This is something we have to navigate with our long-term clients to ensure therapy remains sustainable for them throughout the year.
Once you decide to practice out-of-network, you have to decide how you’ll help your clients get reimbursed.
‍The Superbill (Manual)‍
You provide the client with a superbill at the end of the month and they have to upload it themselves. It’s a heavy administrative burden for a client who is already struggling.
‍Integrated EHR Filing‍
Some EHRs allow you to file for the client. The client still has to pay your full fee upfront and wait weeks or months for a reimbursement check from their insurance to arrive in the mail.
I chose to partner with Thrizer because it addresses the actual barriers that keep clients from specialized care: the paperwork and the upfront cost.
Transparency First‍
Before we even start, we check the client's benefits. No one is left guessing.
‍Automated Claims‍
Every time a session is charged, a claim is filed. This ensures every dollar counts toward the client’s deductible immediately.
‍The "Co-pay" Model (Thrizer Pay)‍
This is the game-changer. Once a client meets their deductible, they can choose to pay only their "co-pay" responsibility. Thrizer covers the rest of my fee and handles the wait for the insurance reimbursement. It reduces out-of-pocket costs for the client so they can focus on therapy, not waiting for a reimbursement.
‍Direct Deposit (OON Pay)‍
Thrizer additionally has a lower fee option for clients to receive a direct deposit in their bank account after a few weeks if they prefer to wait to get reimbursed.
‍Hands-Off (Superbill)‍
If you prefer a more hands-off approach, Thrizer has a simple option for your clients to upload a Superbill and get reimbursed with ease.
To my fellow therapists: I want you to know it’s more than possible to build an out-of-network practice and still be an accessible therapist. Thrizer helps your clients successfully navigate their out-of-network benefits and just pay a co-pay for your sessions. This allows you to receive your full private pay rate upfront, while your clients get the care they deserve.
–Â
Sabrina Cruz is a Licensed Clinical Social Worker (LCSW) in Florida and Tennessee, as well as Telehealth Provider for South Carolina and Vermont residents. She’s been in the field for nearly a decade working with adults and youth who’ve experienced sexual, emotional, and physical abuse in a variety of settings from foster care, advocacy centers, and shelters to individual therapy. She’s a Trained EMDR Therapist (Eye Movement Desensitization Reprocessing) and uses Parts Work and somatic techniques in session. She became a registered Yoga Teacher in 2020 and a Reiki Master in 2024. These tools have supported her personal trauma recovery journey and she is grateful to use them with clients today. ‍
‍Visit her website and connect with her on Instagram at @holistictherapywithsabrina for more content from a therapist who helps people-pleasers stop being everything to everyone and start letting their needs matter, and voices be heard.
