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Key Takeaways:

Why I Wrote This Post

A prospective client recently asked me why I had to provide a diagnosis in order for them to use their health insurance for therapy. It’s a good question and one that many people don’t think to ask and even if they do, they may feel awkward asking. Sometimes, people don’t even know that their therapist is diagnosing them with a mental health condition and submitting that diagnosis along with their claim to insurance. If you’ve ever wondered how therapy and insurance work together and what that means for your privacy, this post if for you.

As a therapist, I value transparency and want you to feel fully informed when making decisions about your care. Let’s talk about how insurance affects your therapy experience, especially when it comes to your personal information.

Why People Start Therapy (and Why Privacy Matters)

Regardless of the reason, therapy is a deeply personal process. It’s a space where you’re encouraged to share vulnerable parts of yourself: your thoughts, your fears, your history, your hopes. And for that process to feel safe, privacy matters. Most clients assume everything shared in therapy stays between them and their therapist. And while that’s true for the most part, using insurance introduces a third party.

How Using Insurance Impacts Your Therapy Experience

When you use insurance to pay for therapy, you’re entering into a contract with your health plan that includes rules and documentation. At one time, insurance companies required a pre-authorization process before a client could even start therapy. They wanted to make sure a person was in a state they deemed clinically serious enough to warrant care. Life transitions or moderate distress often didn’t qualify.

What Insurance Companies Require from Therapists

While some of those requirements have loosened over the years, many insurance companies still:

• Require a diagnosis before approving payment
• Set a limit on the number of sessions allowed
• Limit the number of minutes in each session
• Require periodic updates or re-authorization for continued sessions
• Ask for treatment reviews and audits of client records (which can include therapy session notes)

In many cases, these policies exist to control costs. Insurance companies realized that regular outpatient therapy could prevent costly hospitalizations and they adjusted coverage accordingly. But these shifts weren’t necessarily made to improve the therapy experience for clients.

HIPAA stands for the Health Insurance Portability and Accountability Act, a federal law passed in 1996. Its main purpose is to protect sensitive patient health information from being disclosed without the patient’s knowledge or consent. It’s part of the paperwork you sign whenever you visit your doctor for checkups or medical appointments. HIPAA requires health providers, insurance companies and their business associates to maintain strict security and privacy practices when handling your health records.

If you receive a Superbill from your therapist because the therapist does not take your insurance, you are still entering a contract with your health plan that allows them to request client records, including therapy notes in the form of a treatment review or audit. The insurance then decides if your therapy sessions meet their requirements for reimbursement. If not, they may ask you for any reimbursements back, often called a clawback.

Why Mental Health Diagnosis Can Be Complicated

A diagnosis can be incredibly helpful in understanding and naming what someone is experiencing, but it’s not always a perfect fit. For example, someone who is grieving the loss of a loved one may not meet criteria for a depressive disorder, yet they are navigating deep emotional pain. Or someone feeling stuck in their career might be dealing with stress and identity concerns that don’t match a diagnostic label.

Therapists are often placed in a challenging position. To help a client use their insurance benefits, we may need to assign a diagnosis even when we know the person is navigating something deeply human and not necessarily a mental illness. Some therapists feel pressure to choose the “closest match” diagnosis to meet insurance requirements, even if it doesn’t fully reflect the client’s needs. This can lead to records that don’t truly capture the complexity of the situation.

While diagnostic codes are essential for treatment planning in some cases, they don’t always allow for the nuance and flexibility that therapy often requires. Clients deserve to know when and why a diagnosis is being used and what that might mean in the bigger picture.

What Is a Diagnosis and Why Is It Required by Insurance?

To understand how insurance works, we need to look at the DSM (Diagnostic and Statistical Manual of Mental Disorders). It’s the standard classification system used by mental health professionals to diagnose conditions. Originally published in 1952 by the American Psychiatric Association, it has gone through multiple updates (currently DSM-5-TR) and is widely used in both clinical and insurance settings.

In order for therapy to be reimbursed by insurance, a client must receive a formal diagnosis from the DSM. That could be something like:

• Adjustment Disorder (with anxiety, depression, or other features)
• Generalized Anxiety Disorder
• Major Depressive Disorder
• Bipolar 1 or 2 Disorder
• Post Traumatic Stress Disorder

This creates a dilemma. Sometimes people seek therapy for personal growth or support through non-clinical life challenges. But to access insurance coverage, a therapist must assign a diagnosis that demonstrates medical necessity to the insurance company. And once submitted, that diagnosis becomes part of your permanent medical record, potentially visible across various healthcare systems.

Insurance also tends to take a reactive approach to mental health. They often view therapy as a response to a diagnosed condition, not as a tool for prevention or early intervention. Imagine if your primary care doctor could only see you when you had a disease, no routine check-ups or preventative care. The same logic is often applied to mental health: by the time you meet criteria for a diagnosis, you’ve likely already endured significant distress. But what about the months before that, when you haven’t felt like yourself? Paying privately allows people to get support earlier, before things deteriorate.

How HIPAA Protects (and Doesn’t Fully Protect) Your Privacy?

For therapy clients, this means your diagnosis, treatment notes and session details are safeguarded under HIPAA rules. Therapists must store records securely, only share information when necessary and give you the right to access your own records. However, HIPAA doesn’t prevent your information from being shared with your insurance company when you use your benefits and it doesn’t eliminate the risk of data breaches, especially when third-party services are involved. In addition, using an AI chatbot or tool doesn’t protect your data either. Understanding HIPAA helps you make informed choices about your privacy and how your health data is used and stored.

What Happens to Your Diagnosis After It’s Filed?

Here’s where privacy concerns come in.

When your therapist submits a claim to your insurance provider or if you submit one yourself using a Superbill, they must include your diagnosis. (usually starts with the letter F). That information is then stored in insurance databases and may be accessed by various entities: claims departments, auditors, data analysts and in some cases, third-party business associates. With increased outsourcing of data processing and customer service operations, your information could be shared beyond your insurer, sometimes with companies located overseas.

I’ve personally called the provider phone line on the back of the insurance card and spoken with representatives based in other countries, raising valid questions about who truly has access to sensitive health data. While these call centers may be trained and compliant, your records may travel through several systems before your claim is processed.

And while HIPAA provides some protections, it doesn’t prevent data breaches. In recent years, millions of health records have been exposed through cyberattacks. For example:

• Episource had a data breach in 2025 that exposed the health information of 5.4 million people.
• UnitedHealth Group suffered a massive breach in 2024 that compromised personal data across its subsidiaries, including Optum and Change Healthcare. It impacted 190 million individual’s personal data like names, social security number, medical records and claims information.

No one can fully predict how diagnosis data might be used or accessed in the future. That uncertainty can feel unsettling, especially when you’re seeking care during a vulnerable time.

How a Mental Health Diagnosis Can Affect Your Future

While insurance claims are often seen as a temporary transaction, the diagnosis used in those claims may follow you far beyond your time in therapy. Health records can be accessed when applying for life insurance, long-term disability insurance and certain types of government jobs or security clearances. While it’s not guaranteed that a mental health diagnosis will be used against you, the possibility is there and it’s something to be aware of.

The health tech industry is also evolving rapidly, with data-sharing becoming more common between platforms. While these tools can improve care coordination, they also increase the number of entities that may access or store your data. Choosing to pay privately gives you more control over how much of your personal story is shared across systems.

Why Many People Choose Private Pay for Therapy

Benefits of Paying for Therapy Privately

How Private Pay Therapy Offers Flexibility and Depth

Without the constraints of insurance, your therapist can also tailor sessions more flexibly to your needs. You’re not limited by a pre-approved treatment plan, a set number of minutes per session or a maximum number of sessions. Some clients find that this allows for deeper, more holistic work. This is especially true for those seeking EMDR therapy for trauma or ERP therapy for OCD.

Why Therapy Feels Expensive but It’s One of the Best Investments

We don’t question spending hundreds of thousands of dollars on a house, because we see it as a long-term investment in security, comfort and future value. And yet, when it comes to our mental health, the very thing that shapes how we experience life, relationships and even our ability to enjoy that home, we hesitate to spend a fraction of that amount.

Therapy is like purchasing real estate in your internal world. You’re building emotional equity, things like confidence and self-worth. You’re making upgrades that increase your ability to handle stress, communicate clearly and advocate for yourself and your future. Just like a house, the more care and attention you put into it, the more it gives back over time.

Therapy is one of the most powerful investments you can make in your long-term well-being, relationships and personal growth. You can choose to see therapy as an expense or as an investment.

I’ve seen my clients improve in so many ways through therapy. They’ve landed better paying jobs with improved work-life balance, pay raises beyond the annual salary increase, improved relationships with partners and sometimes healthier relationships with new partners. Whatever the case, they made an investment in their therapy and now they’re reaping the benefits of it.

Private pay isn’t always feasible for everyone which is the reason I offer a sliding scale to make sessions more accessible for those who are budget-conscious. Many therapists do the same. Accessibility is often equated with low fee. But that’s not completely true. There are many insurance based practices who are inaccessible because they have their therapists seeing 30+ clients a week (hello burnout) and no one else can get in or are put on a waitlist. Rather than waiting on a waitlist, you might want to consider a private pay practice.

How to Protect Your Privacy as a Therapy Client

Here are some steps you can take:

• Ask your therapist how your records are handled
• Consider paying privately if you don’t want a diagnosis on record
• Request a Good Faith Estimate if you’re paying out of pocket
• Read your health insurance policy’s privacy practices

Know that even with HIPAA protections, your data may still be vulnerable

You Deserve Therapy That Feels Safe and Empowering

At its core, therapy is about connection, healing and transformation. For many people, insurance makes therapy more accessible and that’s a wonderful thing. But it also comes with tradeoffs, like needing a diagnosis and possibly sharing your sensitive health information more widely than you expect.

If you have concerns about your privacy, let’s talk. Whether you decide to use insurance or pay out of pocket, you deserve to feel safe and empowered in your therapy journey.

Book a free consultation to explore your options and learn more about how I can support you.

Frequently Asked Questions