A new therapist's caseload fills only as fast as new clients reach them, and only as high as those clients stay. The caseload settles near the number of new clients they get each week times the number of weeks an average client stays, and it takes longer than that many weeks to get close. For clients who use insurance, add the wait until the clinician can bill each payer.
A hire is paid for from the first week, and the caseload is what pays it back. An owner who knows the two numbers below can tell, before the offer goes out, whether the practice can fill the caseload at all.
What decides how full a caseload gets?
Two numbers do. One is how many new clients start with the clinician each week. The other is how many weeks a client keeps coming. Queueing theory has a name for the product of the two, Little's law: the average number in a system equals the arrival rate times the average time each one spends in it (Little, Operations Research, 1961).
For a clinician who sees each client weekly, that means the following.
Read the first row slowly. A clinician who gets two new clients a week and keeps each for ten weeks will never carry 25, however long the practice waits. More intake raises where the caseload settles, and so do longer stays.
How fast does it get there? Little's law says where the caseload settles, not when. If every client stayed exactly the average, it would settle in that many weeks. Real stays vary: some clients leave after one or two sessions and a few stay for a year. In a simple model where stays vary that much, reaching five-sixths of the settling level takes about 1.8 times the average stay. For the second row, that means about 18 weeks to reach 25 clients, not 9.
The table assumes weekly sessions and steady intake. Clients who never come back after the first session pull the real number below it. A client seen every other week fills half a weekly slot, so count two of them as one when you set the target.
How long do therapy clients stay?
Often not long. A meta-analysis of 669 studies of adult psychotherapy, covering 83,834 clients, found that "the weighted dropout rate was 19.7%" (Swift and Greenberg, Journal of Consulting and Clinical Psychology, 2012). In routine care, a review of 20 samples found the mean number of sessions ranged from 2.86 to 45.1 between samples, with a median of 8.21 across the samples' means (Flückiger and colleagues, Psychotherapy and Psychosomatics, 2020).
That spread is the reason to measure your own. A practice whose clients stay eight sessions needs twice the intake of one whose clients stay sixteen to fill the same caseload. And the first session is where many clients are lost. The post on missed first sessions covers what a practice can do about the wait before it.
How long does credentialing take in Texas?
No public source gives a time for each Texas payer, and the guide to what a hire costs found none either. Three rules still set the shape of the wait.
- Commercial HMOs. The Texas Department of Insurance says an HMO must tell an applicant in writing whether it is accepted "no later than 90 days from receipt of an application for participation" (TDI, HMO provider credentialing requirements, updated July 3, 2023). Three months is a long time to hold a caseload open, and we found no stated deadline for PPOs.
- Texas Medicaid managed care. A Medicaid plan has to offer expedited credentialing to licensed clinical social workers, licensed professional counselors, licensed marriage and family therapists and psychologists who join a group that already has a contract with it. Once the clinician is Medicaid-enrolled and has sent everything the plan asks for, "the MCO must treat the provider as if the provider were in the MCO's provider network" (1 TAC §353.423). If the clinician then fails credentialing, the plan may take back the difference between in-network and out-of-network pay.
- Medicare. Medicare began paying marriage and family therapists and mental health counselors on January 1, 2024, and each one bills under their own enrollment (CMS).
The practical step is the same for all three. Start the day the offer is accepted, not on the first day of work. Many payers will not take an application until the clinician has an NPI, a current CAQH profile, a start date and a practice address, so get those ready first. Then send each application as soon as that payer will accept it. For an associate about to be licensed, the day to send is the day the license issues. The post on billing before credentialing is done covers what each payer pays for in the meantime.
How should the first clients be booked?
Fill from the payers the clinician can already bill. Self-pay clients and clients whose plan has finished credentialing go to the new clinician first. A client whose plan is still pending goes to an established clinician or waits, with their consent, rather than being seen and billed out of network by accident. The post on claim denials explains the denial code that a pending enrollment produces.
What to do this week
- For each clinician hired in the last two years, count the weeks from their first session to a full caseload.
- Count the new clients your newest clinician got in each of the last eight weeks, and take the average.
- For clients who ended treatment in the last 12 months, work out the average number of sessions they came to.
- Multiply the new clients a week by the average weeks a client stays. If the result is below the caseload you promised, the clinician will not fill at today's intake, and the next hire will not either.
- List every payer each new clinician needs, send each application as soon as that payer will take it, and write down what each one waits on.
Sources
- A proof for the queuing formula L = λW, John D. C. Little, Operations Research, 1961.
- Premature discontinuation in adult psychotherapy: a meta-analysis, Swift and Greenberg, Journal of Consulting and Clinical Psychology, 2012.
- Is there an evidence-based number of sessions in outpatient psychotherapy?, Flückiger and colleagues, Psychotherapy and Psychosomatics, 2020.
- HMO provider credentialing requirements, Texas Department of Insurance, updated July 3, 2023.
- 1 Texas Administrative Code §353.423, expedited credentialing process.
- Marriage and family therapists and mental health counselors, Centers for Medicare and Medicaid Services.
Pass it on