Billing insurance isn't as simple as just sending off a bill. There are benefit verifications, pre-authorization requests, claim forms... and that's just the beginning. Every insurer the provider contracts with has different rules, different points of contact, and different processes to follow. The more forms of insurance a provider accepts, the more difficult it becomes to manage them all. With so many moving parts, billing insurance is rarely a simple affair. It demands more of the therapist's time, which means we have to charge more to make it worthwhile.
2) Client Accountability
I strive to make myself and my business accountable to the people that matter: my clients. Their well-being is, after all, the mission. I feel the relationship between the client and the provider needs to be the entire focus of a business. At Warrior Massage, my clients pay for my services and support my business. I am invested in and accountable only to the client. In an insurance-based practice, the client is not the one paying for the services, which shifts the focus away from the client and onto the insurer. Instead of thinking "what can I do to make this client's visit as awesome as possible so they'll keep coming back?" the provider is thinking "what can I do to make sure the insurance company keeps paying for this claim?"
While the insurance company creates rules to ensure medical necessity, improve client outcomes, and prevent fraud, these rules can get in the way of what a client actually wants or needs. This can be as simple as the inconvenience of delaying treatment while waiting to find out if it will be paid for. It can also mean modifying one's treatment to suit an insurer's protocol for how a patient should be treated.
3) Loss of Flexibility & Control
With every insurer comes a contract of some kind which proscribes the manner in which a provider can manage patient interaction. For instance, some contracts may prevent a provider from charging missed appointment fees; others require that the provider give their members a favored rate, effectively eliminating the provider's ability to provide discounts and special offers to their other clients.
In most provider-insurer relationships, the insurer holds all the cards. An insurer often doesn't pay for up to 90 days (there is a lot of processing on their end), with no penalty, and can deny payment for a number of reasons. Providers sometimes find out a claim is being denied only after they have been treating the patient for some time. And with the high number of claims being processed, not every one is fully vetted before it is approved. Claims can be audited years after payment is made, and a provider can then be told to return the money if the insurer decides to retroactively deny the claim.
4) Legal & Ethical Issues
Besides the specific contracts that come with each insurer, there is a whole minefield of legal and ethical pitfalls that a provider billing insurance must navigate. Simple things that are common practice in everyday business become unethical or even illegal when a third party (insurer) is paying the bill. A keen example is referral rewards: it is a common, accepted, and even lauded practice to give some kind of reward as an incentive to those who refer new patients. However, when those patients are insurance claimants, it is called a "kickback" and it is illegal.
While the above does not include every reason not to accept payment by insurance (I could go on, but who really wants that?), it should shed light on why I (and other providers) might "turn down money."
I also hope that it does not come off as condemnation of insurance entirely. As a therapist I have worked (and continue to work) as an insurance provider, but not at Warrior Massage. It can be a great thing, allowing patients who may not otherwise be able to afford the cost get treatment that can vastly improve their health and quality of life. Most clinics and insurance providers hire professionals with specialized training whose job it is to navigate the process of insurance billing, making it a much more viable business choice. If Warrior Massage ever grows enough to make such a thing a possibility, insurance may be integrated into the practice. But until then, keeping the practice "cash only" keeps business simple, honest, and affordable.