Why Does Opting Out of Insurance Now Require Me to Opt In?

A therapist's rabbit hole through out-of-network benefits, CAQH, DataSpring, provider data—and why I decided to opt all the way out.

It started with what seemed like a fairly mundane administrative request.

I have never participated directly with insurance companies. I built my private practice outside of insurance from the beginning. My clients pay me directly for their care, and some choose to use their out-of-network benefits and submit documentation to their insurance company for possible reimbursement.

Until recently, that meant I didn't need to be credentialed with an insurance company. I didn't need a CAQH account. I wasn't part of an insurance network.

Then Blue Cross Blue Shield asked me to register as an out-of-network provider.

Wait.

What?

If I'm out of your network, why exactly do I need to register to be out of it?

More importantly, this was new for me. I had never needed a CAQH account because I had never participated with insurance.

And now, in order to remain outside the network while my clients used benefits they had paid for, I was being asked to enter the credentialing system I had deliberately never needed to enter.

It felt...icky.

This was one of those moments in private practice when you open a browser tab intending to accomplish a five-minute administrative task and, some indeterminate number of tabs later, find yourself in a rabbit hole learning even more than you ever wanted to know about the structure of American healthcare.

Why would an out-of-network therapist have to register with an insurance company?

There are legitimate administrative reasons insurance companies need information about out-of-network providers. They need to verify that the person who provided a service is actually a licensed clinician, process claims, prevent fraud, and maintain accurate provider information.

I understand the administrative rationale. But I don't entirely accept that it requires the provider to enter the insurer's credentialing infrastructure.

The whole point of an out-of-network benefit, as I understand it, is that the client can seek reimbursement for care from a qualified provider who has no contractual relationship with the insurer. The superbill already identifies me, my licence, my NPI, the services provided, and the information the insurer needs to process the client's claim.

So why, suddenly, do I need to register?

Something about being asked to register with an insurance company specifically so that I could remain outside its network felt...icky.

Not because registering as an out-of-network provider makes me an in-network provider. It doesn't.

But for me, something had changed.

For years, I had been able to remain outside the insurance system while my clients independently chose whether to seek reimbursement from their own insurance plans. Now I was being asked to create a provider-data account and enter the credentialing infrastructure myself.

In other words:

Why does opting out now require opting in?

So I started digging.

And that's how I ended up looking more closely at CAQH.

What is CAQH — and why do therapists know it so well?

If you've never had to become credentialed with an American health insurance company, you may never have heard of CAQH.

Therapists who work with insurance certainly have.

For decades, CAQH — the Council for Affordable Quality Healthcare (sounds almost comforting, right?) — has operated a provider-data system widely used by health plans for credentialing, enrollment, directories, and other administrative functions. Rather than submitting the same enormous pile of professional information separately to multiple insurance companies, clinicians can maintain a centralized provider profile and authorize participating organizations to access it.

Licences. Education. Training. Practice locations. Malpractice coverage. Work history. Credentialing information.

All the glamorous reasons we went to graduate school.

For therapists who participate with many major insurers, maintaining a CAQH profile has effectively become part of the infrastructure of working with insurance.

I wasn't one of them.

And CAQH was a nonprofit.

Except, as I discovered during my little out-of-network-registration rabbit hole, that changed.

CAQH became a for-profit company in 2026

In January 2026, CAQH announced a significant change in its corporate structure.

The organization became a for-profit company owned by twelve shareholder companies affiliated with major U.S. health plans.

Then, in June 2026, CAQH rebranded as DataSpring, powered by CAQH.

I stared at my screen for a while.

Because now the infrastructure clinicians use to provide credentialing information to insurance companies is itself owned by companies affiliated with major health plans.

And meanwhile, here I was—a private-pay therapist who had intentionally stayed outside that system and had never needed a CAQH account—being told I needed to enter it in order to be recognized as out of an insurance network.

I don't know whether those two developments are connected.

I want to be very clear about that.

But the timing certainly made me curious.

And it gave me another one of those:

Huh.

Followed fairly quickly by:

I really don't think I like this.

My concern isn't that I've uncovered a conspiracy. My concern is that I have questions.

There is an important difference.

DataSpring says clinicians continue to control their provider profiles and authorize which organizations can access their information for credentialing and related administrative purposes.

That's important information.

But it doesn't resolve all of my concerns.

Because when I started reading further, I found myself thinking about three things: data, confidentiality, and conflict of interest.

What happens to all that provider data?

Credentialing requires clinicians to submit an extraordinary amount of information about themselves and their practices.

DataSpring's own privacy materials describe uses of information that extend beyond simply putting a digital credentialing application in front of an insurer. They describe research and analytics, combining submitted information with data from other sources, and the use of aggregate or de-identified information for analytics, research, development, and examining healthcare-industry trends.

DataSpring also offers data products and customized reporting involving things like provider networks, access to care, credentialing, practice locations, and insurance offerings.

Some of that may be useful. Better provider data can solve real problems in healthcare.

But once the organization holding an enormous provider-data infrastructure becomes a for-profit company owned by health-plan-affiliated shareholders, I think it is reasonable for clinicians to ask harder questions about how that data ecosystem may evolve.

Could provider information eventually be used in ways that give insurers greater insight into independent practices, markets, provider availability, or negotiating environments?

Could analytics derived from provider information become commercially valuable in ways clinicians didn't anticipate when they originally created their CAQH profiles?

What new products might be developed from this enormous pool of healthcare-provider data?

I don't know.

That's the point.

I want to be able to ask those questions before I hand over my information—not after.

What about confidentiality and commercialization?

Clinicians provide credentialing systems with information we wouldn't ordinarily hand casually to a corporation.

Professional history. Licensure. Practice information. Insurance information. Identifying information. In some circumstances, financial or payment information and other professional details.

DataSpring's privacy policy describes circumstances in which categories of personal and professional information may be disclosed to customers, service recipients, vendors, analytics providers, affiliates, and other third parties, depending upon the service and purpose involved.

That does not mean DataSpring is simply selling clinicians' credentialing files to the highest bidder.

But becoming a for-profit company changes the context in which I evaluate those relationships.

Profit isn't inherently bad. I run a business too.

But I know who my business is accountable to.

When a company responsible for a major piece of healthcare credentialing infrastructure is owned by companies affiliated with the health plans on the other side of the credentialing relationship, I think clinicians are entitled to ask:

Whose interests will shape what this system becomes?

And then there is the conflict-of-interest question

This may be the part that bothers me most.

Insurance companies and clinicians do not always have the same interests.

Sometimes we absolutely do. We all benefit from accurate information, less administrative waste, prompt payment, fewer fraudulent claims, and patients being able to find qualified clinicians.

But sometimes our interests diverge.

Health plans negotiate reimbursement rates. They determine network structures. They create administrative requirements. They make coverage decisions. Clinicians sometimes challenge those decisions, negotiate contracts, leave networks, or choose not to participate at all.

So when companies affiliated with major health plans own the infrastructure through which clinicians maintain credentialing information, it seems entirely fair to ask how future policies and products will balance the interests of providers with those of the organizations that own the company.

I am not claiming to know the answer.

I am saying I care enough about the question that it affects whether I want to participate.

And I'm still stuck on the private-pay therapist problem

This is the piece I keep coming back to.

I understand why an in-network clinician needs to credential.

They are entering into a contractual relationship with an insurer. The insurer needs to know who they are.

But I deliberately chose not to enter that relationship.

I have never been credentialed with an insurance company as a private clinician. I have never needed CAQH.

My clients who have out-of-network benefits have paid me directly and then dealt with their own insurance companies regarding reimbursement.

And now I'm being told that, in order for some of those clients to use the out-of-network benefits they pay for, I need to enter the provider-data infrastructure too.

Again:

I have to opt in so that I can opt out.

Why?

Perhaps there is a perfectly reasonable administrative explanation.

Perhaps this is simply where insurance administration is headed.

Perhaps there is no relationship whatsoever between this change and CAQH's transition to insurer-affiliated ownership.

But I'm curious.

I'm also uncomfortable.

And I don't think clinicians should have to pretend not to be uncomfortable simply because we cannot prove that something nefarious is happening.

Sometimes discomfort is information.

Mine was telling me to look more closely.

Who do I want sitting at the table in my therapy practice?

And eventually I realized this was the bigger question.

I have always chosen to work outside insurance because I wanted more of the therapeutic process to remain between my clients and me.

To pay for therapy, an insurance company generally needs a diagnosis.

It may receive information about services provided and, depending on the plan, may require certain treatment approaches or other conditions to be met for reimbursement. That can limit my freedom to exercise clinical judgment and my client's agency in deciding what works for them therapeutically.

It can also create pressure to make the clinical record fit an insurer's reimbursement requirements rather than allowing the record to simply reflect the work that was actually done.

Neither sits comfortably with me.

Depending on the plan and circumstances, clinicians may have to demonstrate medical necessity, submit treatment information, obtain authorization, comply with documentation requirements, or appeal decisions about coverage.

Insurers can also conduct retrospective audits and demand repayment of previously reimbursed claims when they determine that documentation, diagnosis, medical necessity, or other requirements were not met. Therapists often refer to these repayments as “clawbacks.” I know clinicians who have faced demands to repay thousands of dollars.

Insurance also makes therapy possible for millions of people who could not otherwise afford it.

That matters enormously.

But insurance is not simply a wallet sitting quietly beside the therapy room.

It is a third party in the relationship.

And after this particular rabbit hole, I found myself asking a very simple question:

How much involvement do I want the insurance industry to have in my clinical practice?

My answer has always been:

Less.

My answer now is:

As little as reasonably possible.

What does being a private-pay therapist change for my clients?

Working outside insurance doesn't remove all constraints. I still have legal obligations. I have professional and ethical standards. I maintain clinical records. I have responsibilities around safety, confidentiality, informed consent, and competent practice.

“Private pay” does not mean “Dylan gets to do whatever Dylan wants.”

Probably reassuring.

What it does mean is that I can keep more of the decision-making about therapy where I believe it belongs: between my client and me.

We can decide what we work on based on what is actually happening in your life.

We can decide whether a diagnosis is useful rather than beginning with the question of which diagnosis will generate a reimbursable claim.

We can decide whether weekly therapy, less frequent therapy, an extended session, or a focused intensive makes sense.

We can decide that grief, identity transition, late recognition of ADHD or autism, relationship patterns, overwhelm, or simply something in my life isn't working anymore is reason enough to come to therapy.

You don't have to become more diagnosable in order for your experience to matter to me.

That is foundational to me.

And then I had to confront the uncomfortable part: cost

There is an obvious problem with everything I've just written.

Private-pay therapy costs money.

Sometimes a lot of money.

It would be disingenuous for me to write an impassioned essay about clinical independence and skip merrily past the fact that insurance makes therapy financially accessible for many people.

I don't believe that people who use insurance are making a lesser choice. I don't believe therapists who accept insurance lack integrity. Many excellent therapists make insurance participation work while fiercely advocating for their clients.

This is about the practice I can operate with integrity—and sustainably.

And this whole experience made me look at my fee structure again, too.

If I am going to opt all the way out—not build a practice dependent on insurance reimbursement, not build my fees around what insurers will pay, and not pack my schedule tightly enough to compensate for lower reimbursement—then I need to structure my practice so that independence is actually sustainable.

For me, that means a smaller practice.

It means having the time and capacity to think deeply about the people I work with, continue learning, prepare for sessions, consult when needed, and remain genuinely present.

It also means thinking seriously about how I can create some financial accessibility within that model rather than pretending that private-pay therapy is accessible to everyone.

So this strange little journey that began with:

Why am I registering to be out-of-network?

eventually became a much larger reconsideration of how I structure my practice—including my fees.

Why I am opting all the way out

There wasn't one dramatic revelation.

There was a series of small moments of discomfort.

The diagnosis required for reimbursement.

The administrative requirements.

The authorizations and claims.

The strange experience of needing to interact with an insurer in order to be outside the insurer.

Then discovering that CAQH—the credentialing system I had deliberately never needed—had become a for-profit company owned by shareholder companies affiliated with major health plans.

Then reading more about the data involved.

Then realizing that I—a clinician who had deliberately never joined an insurance network and therefore never needed CAQH—was now being asked to enter that infrastructure anyway.

I don't know what DataSpring will become.

I don't know whether insurer ownership will materially change how provider data is used over time.

I don't know why this particular out-of-network registration requirement appeared for me when it did, or whether its timing has anything whatsoever to do with the changes at CAQH.

Those are questions, not accusations.

But I don't need proof of misconduct to decide whether participation in a system aligns with how I want to practice.

And for me, it doesn't.

I want my practice to be accountable first to the people who trust me with their stories and to the ethical responsibilities of my profession.

I want as few unnecessary corporate interests in that relationship as I can reasonably manage.

So rather than figuring out how to register myself as sufficiently out-of-network to satisfy an insurance company, I'm choosing something simpler:

I'm opting all the way out.

Which, ironically, I figured out because an insurance company asked me to opt in so I could opt out.

Sometimes administrative paperwork really does lead to personal growth.

I remain annoyed about it.

Why doesn't Elowen Therapy take insurance?

I work outside insurance intentionally because it gives my clients and me greater freedom around privacy, diagnosis, treatment structure, frequency, and the direction of our work.

Insurance can be an important resource, and private-pay therapy is not accessible to everyone. My decision is not a judgment about clients who use insurance or clinicians who participate with insurance plans.

It is a decision about how I can best maintain the independent, relational, clinically thoughtful practice I want to provide.

Can I submit Elowen Therapy sessions to my insurance anyway?

This is changing as I reconsider how much participation with insurance systems I am comfortable maintaining, including out-of-network registration requirements.

Please review my current Fees and Insurance information or ask me directly about what documentation I am currently able to provide for out-of-network reimbursement.