When San Francisco resident Natalie Dunnege needed a therapist, she couldn’t find one who took her insurance.

“When I would call them they wouldn’t return my phone calls or they wouldn’t be accepting patients,” she says.

Insurance companies say there’s a shortage of therapists.

But it’s not that simple. Especially in urban areas, there are lots of therapists. They just don’t want to work with the insurance companies.

Take Michael Klein, a psychologist practicing in San Francisco for more than 20 years. He considers it his spiritual calling to help people calm their social anxiety and to help couples stop fighting and build trust.

“With the right kind of support, they blossom,” he says.

Klein doesn’t accept insurance -- and he’s far from alone. Nearly half of therapists in California don’t take insurance, according to a recent survey from the California Association of Marriage and Family Therapists. The same is true of psychiatrists. There are two reasons why, Klein says.

“One, because the reimbursement rates don’t provide a living wage,” Klein says. “You can’t own a home and drive a car and survive on what in-network providers pay you.”

Most insurance companies pay therapists in their networks between $60 and $80 per session. In the Bay Area and Los Angeles, therapists say the market rate for therapy is more like $150 or $200 a session.

“The second thing is the paperwork. For an hour of psychotherapy you spend a half hour of paperwork. So, I got into this field because I don’t like paper work,” Klein says with a laugh.

On that first point -- money -- insurance companies acknowledge that they may have to raise their rates to attract more therapists, particularly in rural areas. But they also say it’s on therapists to compromise.

“I think it’s unrealistic to expect either the state of California taxpayers or for health plans to just pay providers whatever they ask to be paid,” says Charles Bacchi, CEO of the California Association of Health Plans, a trade group for the insurance industry.

“That's not sustainable,” he continues. “So you're either in the system, and you want to be part of our health care system. Or you want to do concierge service outside of it and just pretend our health care system doesn't exist. That's your choice as a provider. Our job is to find providers that are willing to be part of the solution and willing to provide coverage to those of low and moderate income."

That’s exactly how San Francisco psychologist Jonathan Horowitz feels. He wants to take insurance. But he’s hit roadblock after roadblock. He sent out 10 applications to insurance companies and got nowhere.

“I might knock on Cigna’s door and say, 'Hey are you guys accepting any new therapists in 94105?'” he says. “And they might say, 'No we’re not doing that. We’re totally full.'”

Six different companies told Horowitz their networks were full.

So even though a patient like Natalie Dunnege might call seven therapists in her insurance network and not be able to get an appointment, insurance companies are telling new and willing therapists that there’s no demand for them.

“I definitely think it’s to control costs,” Horowitz says. “That’s very clear.”

He tried for a year, and one company finally said yes. Sort of. Horowitz never got a formal notice saying his clinic was admitted to the network.

“It was just like, 'Oh wait, it looks like we’re suddenly getting a couple referrals from them. I wonder if we’re in their directory,'” he explains.

They were. Sort of. The clinic was listed in the directory. But the therapists who work at the clinic weren’t approved yet, meaning there was no one who was allowed to see the clients calling the clinic.

So Horowitz tried to call the insurance company to clear things up. He tried many, many times. Here’s what happened during his latest attempt to navigate the automated phone system:

Insurance company automated attendant: First I’ll need your provider identification number. If you need a moment, say, hold on.

Horowitz: Hold on.

Sound familiar? Turns out therapists get the automated run around as much as patients do. Horowitz persevered.

Insurance company: Okay, please say or enter your pin.

Horowitz: My pin? Is this my pin? (He enters a few numbers).

Insurance company: I’m sorry I couldn’t find an account using the info you gave me. Do you already belong to the network?

Horowitz: I think so?

Insurance company: Sorry, yes or no.

Horowitz: Um, I don’t know ... yes?

Insurance company: Alright. And have you already requested a credentialing application?

Horowitz: Yes.

Insurance company: Sorry could you repeat that.

These experiences did not bode well from Horowitz' perspective.

“Honestly, I got a really bad feeling about it,” he says.

He figured, if this is what it’s like just finding out if he’s in the network, how’s it going to be when he has a problem with a claim and can’t get paid?

“I could just see that getting out of hand really quickly,” he says. “So at that point we just said, do we really even want to do this?”

Not just that. The reimbursement rate was even lower than he expected, and the billing was so complicated that he was going to have to hire someone to do it. He says he couldn’t afford that.

“We made the decision that we’re just going to cancel the contract and continue to go with cash,” he says.

Easier said than done. Horowitz hasn’t been able to get through to anyone on the phone to cancel the contract. In the meantime, prospective patients are finding his name on the directory and are calling for appointments. Horowitz says he just has to say no.