Practice Committee Office Hours Update: Do You Have to Sacrifice Your Values to Maintain Financial Stability in Private Practice?

The Practice Committee has been hosting “Office Hours” to debunk some of the most common myths about private practice. Our most recent talk was centered around the dichotomy between the financial piece of private practice and concerns of sacrificing values as practitioners in order to make a living in private practice.

Private practice can be a way of energizing yourself and engaging with the community to do clinical work that you’re most passionate about. If you couldn’t make it, that’s okay, we’re sharing the take home points from our call in this article.

We invite you to join us for our next Office Hour discussions:

• 9/15/26 12pm-1pm EST
  • Myth: Group practices are the way to go to build passive income
  • Reality: There are multiple models of running a group practice but none of them involve passivity.
  • https://nova.zoom.us/j/6986910134
• 11/17/26 12pm-1pm EST:
  • Myth: Insurance or bust to be successful in private practice and private pay is the only surefire way to go in private practice
  • Reality: There are so many ways to set-up payment structure to be successful
  • https://nova.zoom.us/j/6986910134

About the Panelists

Marcy Rowland: I work primarily with adolescents and adults, doing individual, couples, and family counseling. I am in full-time solo private practice. I don’t have any other employees; it’s just me managing everything from scheduling, greeting people at the door, intakes, billing, all that fun stuff. I’m looking forward to sharing some of my experiences with you today about those things and how I’ve been able to bring some of my counseling psychology values in particular, social justice issues into my work. 

Wilson Trusty: I’m also in central Pennsylvania. I do private practice part time. I’m a full-time research psychologist at Penn State and then have a small private practice where I do autism assessment on the side. I’ve been in solo private practice but recently took on an independent contractor who also does assessment. I work completely with adult autism assessment. I do therapy as well, just not in my private practice, but here at Penn State’s Counseling Center. I am also early career and have been in private practice for about a year and a half.

Jake Jackson-Wolf: I’m a licensed clinical professional counselor in Towson, MD. I am the owner of B’well Counseling Services, a group private practice employing a variety of mental health professionals including several professional counselors, a clinical social worker, a clinical psychologist, and a clinical art therapist. We see clients across MD and FL virtually and in person at our office in Towson. We have a variety of specialties including couples therapy, sexual health concerns, eating disorders and body image, trauma, and general mental health issues like anxiety, depression, and life transitions. I have been in practice for nine years.  

Amy Ellis: Like Wilson, I have a full-time job at Nova Southeastern University as an Associate Professor and Director of the Trauma Resolution & Integration Program, but also maintain a part-time private practice. My practice is entirely telehealth, and I treat individuals with histories of complex traumatization. I’m located in South Florida but do have PSYPACT so see clients in other states as well. 

What is it like to run a one-person show?

Marcy: I think I mentioned that I am a bit of a one woman show here. And so, one of the things that comes to my mind when I think about the intersection of social justice and ethics alongside the pressures of generating an income is scheduling. Initially I feared that I would never be able to build a full-time caseload, never be able to have enough clientele on my schedule to cover my overhead, let alone make a living. And I’ve been pleasantly surprised in a lot of ways with regards to how different my real-life experience has been. And certainly, some of that is probably a result of living in a rural community where I think service providers are at a shortage here. But that then puts me in a unique position to be thoughtful about the way that I schedule my time from an ethical or social justice perspective. Being available to my adolescent clients outside of their school day for appointments is very important to me as I recognize their current situation may have already caused them to miss school. So, my office hours might look different than somebody else’s office hours, because I do tend to be here a little bit later in the afternoon and evening and every other Saturday to try to meet the needs of the particular clientele that I’m working with. I also try really hard not to schedule back-to-back clients who might attend the same school to protect their privacy and confidentiality, hopefully minimizing awkward interactions or overlapping social circles that might make people feel uncomfortable or keep them from seeking services. Those are just a couple of the things that I’m keeping in mind as I am considering how my values and the actual function of my practice might work together.

In considering personal (e.g., spending time with family) and professional values (e.g., making an income), how do you decide how to schedule?  

Marcy:  It is important to me to have some consistency in my personal life as well, so I do try to keep one evening to myself and really do protect that time. One of the perks, I suppose, of doing your own scheduling is that I am in charge of that. I can absolutely block off that time on my schedule. But then it is also up to me to respect my own boundaries. And again, sometimes that pressure of wanting to be there for people and meet them where they are puts me in a bit of a bind at times. But I think I’m doing right by me and right by my clients when I am trying to respect those boundaries for myself.

Wilson: Similar thoughts from me too. As somebody who has a full-time job plus private practice, I know that if I work in the evenings after my full-time job, I am not happy and I get burnt out really fast. And so, for me, my private practice is Saturday mornings, 8 a.m. to noon. That’s when I rent out my office space and I do my best to keep everything contained to that. Now that’s not always feasible if I have to do a phone consultation or get a third-party report. But as much as I can, having firm boundaries is something that helps a lot.

What was your decision like to go in-network with insurance versus private pay only and balancing being accessible but also making a living? 

Marcy: I mentioned that I work and live in a fairly rural community and private pay would be a significant financial burden to a lot of folks who live where I do. So, I have made the decision to go in network with insurance, and I find the reimbursement rates highly variable depending on the insurance company. However, some of them can be quite fair. That has really worked for me. But also, being able to make decisions about sliding fee, as I operate under a hybrid model as well. I have the privilege of allowing folks to continue services, even perhaps once they have lost their insurance due to divorce or job loss or might be between insurances for a period of time. I can make those decisions for myself and maintain continuity of care for folks even once they might have had a significant change in their financial status. And that’s really important to me to be able to do that. Also working with adolescents as well, their health insurance is oftentimes tied to their parents. At no fault or decision of their own, sometimes they find themselves in a situation where their insurance has changed or they no longer have the ability to pay. Knowing that I can make those decisions to provide for myself financially, but also maintain some continuity for clients is really something that’s important to me. It’s something I value about being my own employer in these kinds of situations.

Wilson: I think my situation is unique in some ways doing assessment in private practice. I take private pay only. And in general, the reimbursement rates for assessment are a lot lower than for therapy. I did the math once, and if I took the most common insurance in this area, I would net about $25 an hour for assessment, and that’s just not feasible. I can’t afford to take insurance, essentially. That is a struggle and a values question, because there are plenty of people who will reach out to me and say that they can’t afford it. I don’t like that fact, and at the same time from a personal perspective, it’s not feasible to take insurance. Now I do occasionally complete a free autism assessment here in the counseling center where I work, and that’s a way that I try to make that a little bit more accessible, at least to the student body here. I think it depends on your operating expenses, the insurance reimbursement rates for the services that you’re offering, and the reimbursement will be a little bit different depending on the location, the specific insurances that you’re working with, etc. 

Marcy: It’s tricky, and some of this then also reflects on the question or the topic of scheduling as well. I have the luxury of being able to make more money if I’m willing to work more hours. That’s another way to think about balancing those things for yourself, and also then thinking about not just one week at a time, but maybe a whole year at a time as well. Because I don’t have PTO days, I have to sort of build those into my budget for the year along with my expected expenses and costs and income. Wanting to protect that time, means that some weeks have more scheduled clinical hours on them than others. 

Amy: What I’m hearing is that it really depends on what your values are. I think sometimes we get this bad rap that we should never have a value of wanting to have an income and in reality, it’s okay to want to have a very safe, stable income. And it’s also okay to want to have a particular clientele in your practice. For me, I don’t accept insurance, and what that means is I get a particular clientele that can afford private pay and that isn’t always in alignment with the clients that I want to work with. That’s why I offer pro bono and sliding scale/reduced rate services. And so, I’m hearing in this conversation that it’s deeper than just “do you take insurance” or “do you not take insurance”, but who are the clients that you want, what’s your niche, what’s your population, as well as where are you going to feel the most sense of fulfillment while also not burning yourself out? That’s why I always struggle with these types of questions because it’s just so much more nuanced in terms of who you are and what you want to configure your perfect constellation of how you want to structure your finances.

Jake: And to make it even more complicated, the question has historically been, “do I operate in or out-of-network with insurance or private pay only”? When I think today that conversation is even more complicated by, “do I operate in-network with insurance by signing up with one of these platforms that’s going to do this for me, and I’m essentially working under their group practice?” Something I’ve talked about before is how I’ve explored other third-party payers more recently. For example, I’ve signed contracts with EAPs and partnered with nonprofits that want to offer therapy services and might get grant funding. And so, thinking a little bit broader about the choice. It isn’t just “do my clients pay me or does a private insurance company pay me?” but thinking about the different sources and ways of diversifying your income streams. For example, I’m outside of DC in Baltimore and a year ago there was a huge federal workforce that was deeply impacted a year ago as all these federal employees lost their jobs and insurance. So, thinking through it more broadly than just in or out-of-network, or private pay or insurance-based, just adds to the complication. 

How do you get information about reimbursement rates to adequately financially plan?

Wilson: They’re not available and people are not allowed to disclose the exact amounts. People who take insurance would probably have more knowledge of this but as somebody who is out of network, I can’t actually get the exact reimbursement rate. My understanding is that you have to work with the insurance companies to get that right now. That’s different with Medicaid and Medicare as all of that is public. Private insurances tend to use that as a benchmark to some extent. 

Jake: People who are not in-network anymore know what they used to get paid, and they are no longer contractually obligated to withhold the information. So, that’s one avenue to explore, if you know anyone who was previously in-network and has access to those rates. Or, if you’ve been a patient somewhere in-network or you know someone who has been treated, EOBs (Explanation of Benefits) list what the contracted rate is with the provider. 

Amy: However, the reimbursement rates depend on where you’re located so that adds another factor. 

Should I ever end my relationship with an insurance company if the rates are too low?

Marcy: Don’t be afraid to end your relationship with an insurance company that is not doing right by you, whatever that might be. You can dump them. Though, you may not be able to get back on if your needs were to change, but you’re not stuck with them forever.

Jake: And it can be hard to end a relationship with insurance companies. They ignored three letters saying I would like to be off the panel. In one instance, I sent a letter in October saying I plan to be no longer credentialed as of December 31st of this year and they made it retroactive to the date that the letter was sent. So, then I had to re-credential for three months. If there’s a game to be played, they will play it. And with persistence you can usually get your way.

How do you determine what insurance panels to apply for?

Amy: You can look at insurance as either it’s a marketing strategy where people who have XYZ go onto the website, and then they get funneled to you because they want to use their insurance, or you can look at it like “ah, yes, my clientele keeps coming to me, and they really want me, and I’d be able to retain them if I were on XYZ insurance”. It might not make as much sense to go for XYZ insurance because they offer a $200 reimbursement rate if nobody has that insurance and nobody’s coming to you for your particular expertise. Wilson mentioned Medicare, and I think that’s a legitimate one to consider, that there’s a lot of people who have Medicare, and it’s a very public amount of money that you know, and you can anticipate, and it doesn’t seem to carry the same issues. And don’t forget, there’s also the middle path of doing single case agreements.

Do you think there should be a reduced rate for seeing a patient more than once a week? And what would you do if a patient demanded that?

Amy: I have done this and learned a lot of lessons along that path. Let’s say I have a client who is paying $10 for a weekly session, which is aligned with my social justice lens. And then unfortunately, the client starts struggling and it becomes clinically recommended that I start seeing them twice a week. So now they’re paying $20 per week. When the time comes for the client to start being seen once a week, the question looms of whether you should go back to $10/week or keep the $20/week because you know they can afford it. The way to protect against this is to have a specific reduced rate contract that I have my client’s sign. One of the factors is that it’s time limited. It’s 12-15 weeks and then we will reevaluate so that I’m not locked into anything. And that if we determine that we want a higher frequency than what we’re already meeting at, that that will be a collaborative decision as to whether I’m the right fit. I do think it’s a useful reminder to clients as they re-sign every couple of months to not take things for granted. In short, morally, my answer is yes, you should offer more sessions if somebody needs it, and at reduced rate as we want to increase access. As a businessperson, I think that there’s more nuance involved in it.

Jake: It’s also worth evaluating whether or not that’s the right level of care or place for the person to be treated. One of the therapists that works in my practice shared that their client needed to see them more often but couldn’t afford it. And my approach is, then this might not be the right place right now. Let’s figure out a plan for getting you to a place that’s more sustainable. I think it opens the door to that conversation. As for the word “demand”, there’s something more to investigate. If I’m the client presenting with “here’s how this is gonna work…” versus collaboration and an egalitarian negotiation. At the end of the day, it’s the therapist’s call about what fees they’re willing to accept or not.

Marcy: There can often be some challenges too around how much time a client might be accessing you outside of session as well. It’s important to have a conversation about whether time spent addressing their issues over the phone should be another scheduled session, or whether we have a 20-minute phone call that is not billable to insurance. Those conversations aren’t always easy to have. Thinking through having a policy about that, even if it’s just a policy for yourself, so that you’re not always making those decisions time and time again, but rather having a rubric that you use for yourself to think about whether it’s a higher level of care that’s needed here, or whether we are going to need to schedule a second session, because there’s so much time being spent outside of sessions still dedicated to the same client or the same issue.

Wilson: I can share another experience with that too and the importance of being really clear about expectations from the outset. In my practice, I always do 15-minute consultations to see if somebody’s appropriate for services. And one of the questions I ask is if they’re having any difficulty paying for basic needs like food, transportation, medical care. And if somebody answers “yes” to that, I have a really frank conversation with them about whether this is a good idea for them to get an assessment since they’re having this financial concern. Because if they’re saying they’re having this problem with finances and basic needs, I don’t feel like that is ethical to put that additional financial burden on clients, unless there’s some sort of clear plan in place. I had one client who said that they were fine financially but during the intake it became clear that they didn’t understand how much they were going to pay or how their income compared to fees. And so, I did some consultation with another assessment psychologist and ultimately had a phone call with the client, met with them once for free to explain the situation and make a referral to somewhere that they could potentially have their insurance covered. I made that decision because I wouldn’t have taken them on if I had known about the financial difficulties that they have because it wouldn’t be fair to them. 

How do you handle chronic late cancellations and/or rescheduling? 

Wilson: Part of this feels tongue in cheek because with autism assessment, there are almost no cancellations or no-shows because people have usually been waiting for a long time, so consistency is really excellent. I will say in therapy I have a clear attendance policy that’s laid out in the consent document, where if they don’t give me advance notice, it’s a $100 no-show fee. And, that if they have 3 absences within a 5-week period, unless we’ve agreed on that in advance, that’s an automatic termination. And the reason for that is that they’re not going to be able to benefit if they’re not coming consistently and it’s taking slots that other people could have used. For me, I view that as an ethical issue. Thinking about the ethics code, if it’s reasonably clear that somebody is not benefiting from therapy, you have an ethical obligation to terminate. And so, you’re actually doing more harm than good if you keep somebody who’s not consistently attending. In that case, you need to get them to something else that they can actually benefit from. I’d say that it’s not ethically justifiable to keep somebody on if they’re having that much of a problem. Now, of course, there are always individual circumstances, and you also need to provide termination counseling to make sure that they’re set up well. But for me, I’m very boundaried about that.

Marcy: I would say I follow a similar guideline, although I think my situation is complicated a bit by working with adolescents who are often dependent on other people to get them to their appointments.  But thinking about accessibility, it’s also why I chose the office location that I did. I’m walkable from the high school and the junior high. Again, that doesn’t fit everybody’s needs; pivoting to telehealth at a moment’s notice is another way I’ve been able to help kind of reduce the barriers to access, but also maintain some more consistency on my schedule, on my end as well.

Jake: I have a group practice and when people in the group come to me and say, “I feel so terrible, I’m gonna have to charge them, should I give them a freebie?” I always say, “tell me more about why you feel bad about doing exactly what you agreed to do?” There’s something interesting to explore there, usually for ourselves, about why do I feel this guilt, or why do I feel like I should give someone a freebie? So many folks have it written one way and then the first no-show or late cancel go, “oh, well, I usually give people the first one.” And if you want to give people the first one, write that into your agreement. Because there’s actually some potential liability in that. If you lay something out and make an agreement, and then you don’t abide by it, what are we demonstrating to clients? Or, if you do choose to not give someone a freebie and it comes up in another setting, they’re like, “hey, I see Jake too. Yeah, he’s always so chill about the late cancel. And they’re like, what? He’s charged me every time.” 

Amy: I think it all boils down to what you have in your informed consent document, and the way I was trained is that your informed consent is a living, breathing document. I do have that spelled out that you always get one freebie, for whatever reason I also have it specifically noted that within 90 days, if you have three or more cancellations or reschedules, we will talk about it and potentially change the time of your appointment. I will no longer be able to hold that existing appointment. And to be explicit, I charge my full fee for cancellations which you can do in private pay but may not be able to do with insurance-based fees. 

Wilson: I’ve learned generally that I have to spell things out more clearly and be more consistent and more explicit about things than when I’m working in an organizational setting. 

Marcy: And for those of you who might be working with adolescents or children or families, making sure that it’s clear to every member invested in the arrangement. Because again, my 14-year-old kids aren’t paying their late cancel or no-show fees. 

Jake: And I see a lot of couples, and I’ve had a similar issue, where if one member of the couple shows up–especially if they’re coming to my office separately–if one shows up and the other one will be 10-15 minutes late, my operating on a “no secrets policy” with couples, I’ll say, “you can sit here, but I’m also not going to bring you in until we’re ready to start.” And this is the time that we scheduled, this is the time that we have. And so, it’s certainly something to talk about when it’s a pattern. 

How do you prevent burnout when it comes to balancing ethics/aligning your values and wanting to earn well? 

Wilson: You know, one concern that we’ve talked about here is does this policy distract from the client care piece? So, being very clear with people and explaining your no-show policy, does that in some way, interfere with relationship building? And I think that’s a relevant concern because we spend a lot of time talking with colleagues about the logistical pieces, but how do we still stay grounded in what we’re wanting to do clinically with our clients here?

Marcy: I think all of these conversations are relational and it is an opportunity to build trust and safety even by outlining what one can expect from treatment. I think alliance can be built even in talking about boring paperwork and consent with a client. But then in terms of preventing burnout, I think a lot of that is on me to be sure that I’m scheduling myself appropriately. One of the signs of burnout for me is if I am grateful when somebody doesn’t show up for their appointment that I’m probably over scheduling myself. And so that’s one indicator that I might need to change how I’m operating.

Jake: That makes me think of the old expression about business ownership: I didn’t want to work 40 hours for somebody else, so I work 100 for myself. We need to try to notice what that balance is of the upside that you get to chart your own destiny and then the other emotional labor that comes with that. I also think it’s self-reflective, just trying to find enough space to sit and think, how’s this going for me? What do the next three years look like? What’s the next five years look like? What’s the next week look like?

Wilson:  I like the relational part of this, too, and that, even in setting these clear boundaries this is part of forming a safe therapeutic space. I’m actually moving out of state to a different job. I’m going to be keeping my private practice but will be switching from assessment to telehealth therapy and having an independent contractor who’s staying here and doing assessment. In making that transition I was emailing all of my contacts in the community letting them know that I was leaving and introducing this independent contractor who’s going to be taking over for me. It was an interesting experience reaching out to all of these agencies in the community, individual therapists and people, and seeing all at once “here are the connections that I’ve made in the community, the people that I know.” It hit home to me that regardless of your practice model, you can have in mind this business piece and at the same time form these really strong relationships with your community, making partners, becoming a trusted resource. I think I’ve experienced that more in private practice than working at an organization because I can go out as the individual practitioner and form these personal relationships on behalf of my practice and not necessarily just under the umbrella of a group.

Marcy: And thinking about how that aligns with values as well. Having the opportunity to respond to something in the community as it might occur, whether that’s a tragic loss in the school, or a need for training, being able to step into some of those roles and having relationships with community partners that might tap you as somebody who could provide that service. It’s sometimes as gratifying to be working outside the four walls of this office as it is to be sitting on the couch here.