In this modern age, telehealth is king.  So whether you’re huddled in front of a computer in the corner of your bedroom or have an office suite with bottled water, let’s get real: your only human interaction may be with the Amazon delivery person. And if you actually do talk to other therapists, you probably aren’t comparing bank balances.

So, it’s normal to experience a bit of “imposter syndrome” regarding your business. You wonder, “Am I the only one working so hard and making so little?”

The Heard Surveys

Enter The “Financial State of Private Practice” reports from Heard, a financial management software company for therapists. These reports are the results of extensive annual therapist surveys, and offer a fascinating peek behind the curtain of our profession, revealing the secrets we usually take to our graves (or at least only to our accountants).

The survey covers everything from our average annual income, our fees, how we get clients, how we structure our practices, our average caseloads, how we manage billing, how many of us are secretly wearing pajama bottoms during video sessions (okay, maybe not that one), and much, much more. I highly recommend diving into BOTH their 2025 report and 2026 report summaries, since some different questions are asked in each survey.

Interesting insurance insights

There’s lots of interesting info in the survey results, but since insurance is my jam, let’s look at what the surveys found related to insurance.

From the 2026 survey:

• 75% of clinicians said they accepted insurance
• 21% of clinicians had a waitlist, and these tended to be clinicians that accepted insurance
• 55% of those who billed insurance used billing platforms like Alma, Headway, Grow, and Rula. Of the rest, 16% used a dedicated biller, and 29% did the billing themselves
• Only 25-27% of insurance providers participated in Medicare and Medicaid, perhaps due to complex application requirements and low reimbursement rates in some areas

From the 2025 survey:

• Overall: The average private pay rate for therapists of all license types was $159, yet the average insurance reimbursement rate was 36% lower at $111; In some states, it was 60% to 77% less than their private pay rates.
• Insurance reimbursement varied by state. For example, California, New York, and Colorado therapists reported some of the highest average reimbursement rates, averaging $172- $180, while states like Florida ($137), Texas ($140), Pennsylvania ($146), and North Carolina ($145) came in with significantly lower average rates. Remember that these numbers averaged the fees for providers of different licenses.
• Rates varied by license: The average national reimbursement rate for psychologists was $142, Social Workers $108, MFTs and LMHCs $106, and LPCs $84.
• Rates varied by health plan: Clinicians reported Aetna’s average reimbursement rate was $115; United, Blue Cross, Oxford, and Oscar averaged $106-$108; Medicaid, Kaiser, and Anthem averaged $101-$102; and Cigna, Humana, and Medicare averaged $91-$96.

Again, keep in mind that these rates can vary WIDELY by license, state, and even by city.  Averages for LMFTs in Hollywood, CA would not usually be the same as those in some tiny remote city in the state.

So, how long has it been since YOU asked for a raise?

I suspect one important reason these rates stay lower than they should is simple: many clinicians join a health plan and never ask for an increase. Often, we don’t realize that asking is even an option. But survey results suggest that providers earning more than the entry-level rate are usually the ones who requested a raise at some point along the way. You can read more in my article on asking for raises here. [And in a future newsletter article, I hope to tell you how to use some new comparative reimbursement rate data to more effectively ask for raises — stay tuned…]

Would you make more money if you quit insurance? Not necessarily….

The 2026 report also tackles the big debate: Is it better to take insurance or go cash-pay only? While cash-pay rates might look higher on paper, the survey found it was a bit more nuanced than that.

Because insurance providers reported reimbursement rates 25%–35% lower than average cash-pay prices, it might seem like a cash-pay practice is the clear winner for income. According to the Heard analysis, “the reimbursement gap means that for insurance-accepting practices, volume matters more. You need to see more clients to reach the same revenue as a cash-pay practice, which has implications for your schedule, your energy, and your admin burden.”

However, the fact that insurance-accepting providers more frequently reported having a waitlist suggests that insurance helps keep their practices full.

Furthermore, the survey concluded that the grass isn’t necessarily greener on the cash-pay side. While the average cash-pay-only clinician grossed $94,000, their profit after expenses averaged $58,000. In comparison, the average insurance provider showed a much lower income of $79,000, but ended up with a similar average profit of $55,000 after expenses. Heard’s analysis notes: “The roughly $15,000 revenue advantage for cash-pay practices was largely consumed by higher operating expenses. Going cash-pay-only doesn’t automatically mean taking home more money. The financial picture depends on your caseload, your market, your expenses, and most importantly, how well you manage the money that flows through your practice.”

The Take Away

It’s clear from the Heard data that insurance is a big factor in the lives of most clinicians. While the reports confirmed our biggest grievance—that insurance reimbursements lag far behind cash rates—they also highlighted a major perk: that accepting insurance is often the secret to maintaining a fuller practice and a consistent waitlist. And before you insurance folks envy your cash-pay-only colleagues, remember that their higher gross earnings are often offset by steeper operating and marketing costs. At the end of the day, when the dust (and the expenses) settle, both insurance-based and cash-pay therapists end up with surprisingly similar annual profits.