Should you accept insurance?Find out with real 2025 numbers.
Most providers underestimate insurance reimbursement by 2-4×. We've seen therapists skip insurance because they heard “90834 only pays $30” — when commercial actually pays $90-160 in most metros.
This calculator uses actual 2025 Medicare Physician Fee Schedule rates, geographic adjustments by state, and commercial payer multipliers from Urban Institute and HCCI research. Pick your specialty, your CPT codes, and see what you'd actually earn.
Tell us about your practice
Geographic adjustment: 100% of national rate
Typical for your specialty: $130-$250
How many patients you currently see per week at your cash rate
CPT codes you bill
The procedure codes you'd submit for insurance reimbursement. Pre-filled with the most common codes for your specialty. Volume below is relative weighting across codes.
Reimbursement reality
What each code actually pays in Pennsylvania for a therapist (masters-level), 2025 rates.
| Code | Medicare | Commercial (typical) | Commercial range | Medicaid |
|---|---|---|---|---|
90834 Psychotherapy, 45 minutes | $78.75 | $126.00 | $89.25 – $162.75 | $43.31 |
Note: Medicare reimburses therapist (masters-level)s at 75% of the physician fee schedule (statutory reduction). Commercial payers do not apply this reduction.
The “insurance only pays $30” myth
In Pennsylvania, commercial insurance pays about $126 for 90834 (Psychotherapy, 45 minutes) — 4.2× more than the $30 figure providers often cite.
Even Medicaid pays $43 here. The $30 number usually traces back to an outdated state Medicaid encounter rate or a deeply discounted Optum carve-out — not what most commercial payers actually pay.
If you accepted insurance
The volume lift from being in-network is the real story. Most providers see 2-4× more weekly visits within 6 months of joining 2-3 panels.
Currently 12 cash visits/week. Typical lift: 24-48 visits/week with insurance.
75% commercial / 15% Medicare / 10% Medicaid
Annual revenue comparison
Cash-only
- •No billing overhead
- •No claim denials
- •Patients pay at time of service
- •Patient pool limited to those who can pay out-of-pocket
Hybrid
- •Insurance: ~$111/session (blended)
- •Net collection: 94%
- •Billing overhead: 7%
- •Best of both — premium cash + insurance volume
Insurance-only
- •Gross billed: $148,705
- •After collection: $139,783
- •After billing overhead: $129,998
- •Highest patient volume / referral access
Your bottom line
Adding insurance to your existing cash practice would add roughly $74,285/year (74% increase) — net of billing overhead and realistic denials.
Insurance pays roughly 28% less per session than your cash rate for 90834 ($126 vs $175), but you'd need to fill 3× more sessions to make up the gap — which is exactly what being in-network typically delivers.
Specialty context: For a new or under-filled caseload, joining 2-3 commercial panels (BCBS, Aetna, Optum) typically lifts weekly visits 2-4x within 6 months. Headway, Alma, and Grow Therapy exist because that volume effect is real.
The billing overhead is the reason most providers stay cash-only.
We run medical billing end-to-end for independent practices — eligibility verification, claim submission, denial workflows, and patient billing — on a no-risk basis, with deep specialization in behavioral health and surgical. You only pay a percentage of what we actually collect. If the math above looks good but the billing operation feels like too much, that's exactly what we take off your plate.
Where insurance pays off
The right answer depends on your specialty's payer dynamics, your current caseload utilization, and whether your patient population can sustain cash rates.
Patient populations are insurance-dependent. Cash-only caps your addressable market at <10%. Insurance volume lift typically exceeds the per-session rate gap by 3-5×.
Pediatric and rehab markets run on insurance. Cash niches exist but are limited. Insurance gives you access to referral networks (PCPs, schools, hospitals).
Insurance for volume + caseload-building. Cash for premium services and established clients. The 60/40 or 70/30 mix is often the sweet spot.
Limited insurance coverage (chiro), strong cash markets, or service offerings outside what insurance typically reimburses.
What providers get wrong about insurance
The cash-vs-insurance debate is dominated by anecdote. Here's what the data actually says.
"Insurance only pays $30 a session."
For a 45-minute therapy session (90834), commercial insurance pays $90-160 in most metros — 3-5× the $30 figure. The $30 number usually traces to an old Medicaid encounter rate or a deeply discounted carve-out.
"Billing overhead eats all the profit."
Well-run outsourced billing costs 5-8% of collected revenue. In-house staff runs 8-12%. Even at the high end, the volume lift from being in-network more than makes up for it.
"Insurance always pays less than cash."
Per session, often yes — by 20-40%. But insurance practices typically run at 80-90% capacity vs 40-60% for cash. The math is about volume × rate, not rate alone.
"Credentialing takes forever and isn't worth it."
Initial credentialing takes 60-120 days for most panels. Pick 2-3 strategic panels (largest local commercial + Medicare if Tier-1 specialty) — you don't need to join everyone.
"Insurance reimbursements have been crushed."
Medicare rates dropped 2.83% in 2025 (and recovers 3.3% in 2026). Commercial rates have held or grown in most markets, especially for behavioral health where shortages are pushing rates up.
"You can't make a living taking Medicaid."
State-dependent. Montana Medicaid pays 111% of Medicare. Rhode Island pays 37%. Most behavioral health Medicaid rates rose in 2023-2025. Check your specific state before assuming.
How the numbers were calculated
Medicare rates: 2025 Physician Fee Schedule national non-facility (office) rates, derived from the CMS Final Rule published Dec 2024. Conversion factor: $32.3465 per RVU.
Geographic adjustment: Composite GAF derived from CMS 2025 GPCI components (work, practice expense, malpractice) blended at typical office-based weights. HCOL metro overrides available for major cities.
Commercial multipliers: Specialty- specific commercial-to-Medicare ratios from Urban Institute and HCCI professional- services analyses (most recent: 2019-2023 data). Mental health, PT, and primary care typically cluster at 105-130% of Medicare for professional services.
Medicaid multipliers: State-level Medicaid-to-Medicare fee indices from KFF and Urban Institute (Zuckerman et al.). Range: 37% (Rhode Island) to 111% (Montana).
Statutory reductions: Master's- level mental health providers (LCSW/LMFT/LPC) are paid at 75% of the physician fee schedule by Medicare. Registered dietitians: 85%.
Net collection / denials: MGMA benchmarks. Average practice collects 94% of contracted allowed amounts; world-class operations reach 98%.
Numbers are estimates for planning purposes. Actual reimbursement depends on your specific contracts, locality (HCPCS Locality vs state), modifiers, payer policies, and patient cost-sharing. Verify with your specific payer contracts before making business decisions.
Numbers look promising? The hard part is operations.
The economics of accepting insurance often work. What usually stops providers is the operational burden — eligibility checks, claim submission, denials, and patient billing. DGC runs that workflow end-to-end for independent practices of any specialty, on a no-risk basis: you only pay a percentage of what we actually collect.