It’s understandably frustrating when insurance says that marital therapy is covered, but the claim comes back as denied. Here’s what you need to know.
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The Confusing (but Short) Answer
Most insurances cover the cost of couples counseling. However, counseling for relationship issues is not a covered benefit. This slight-of-hand happens on a regular basis to insurance subscribers everywhere.
Every. Single. Time.
Confused? Annoyed? You’re not alone. This all boils down to how and what. Let’s dig into this a bit.
Insurance companies always deny coverage for the same three reasons:
- The provider is out of network
- The treatment is experimental
- The treatment is not Medically Necessary
It’s this third part that matters in this scenario. It used to be shrouded in hidden, rarely spoke language kept a closely guarded secret by the insurers. These days, it’s common knowledge that for something to be “Medically Necessary”, the service must be:
- For the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms
- Not primarily for the convenience of the patient, health care provider, or other physicians or health care providers
And therein lies the rub:
- Relationship and marital issues are not considered an illness, injury or disease
- The main (primary) focus of couples counseling/marital therapy is to repair or assist the relationship
- Treatment for relationship and marital issues are considered by the insurers to be a “convenience”
Procedure Codes (“How”)
It’s important to understand what type of service you are receiving. When your therapist sees you, a specific code is used to let your insurance what type of service was provided. This is called a Current Procedural Terminology (CPT) code. For individual therapy sessions lasting 38-52 minutes, the code is 90834. When psychotherapy is provided for both the patient and a family member, the code is 90847. There are dozens more, but these two will be enough for this example.
When you call up your insurance company to ask if they cover couples counseling, from their point of view you are essentially asking, “Do you cover CPT code 90847?” And yes, most insurance plans do indeed cover this code. But that’s only half of the question. Unfortunately your insurance reps leave off the other half of the question.
Diagnosis Codes (“What”)
The confusing part comes from the second half of the question: “Do you cover couples counseling… for relationship issues?” It seems ironic, doesn’t it? When you ask your insurance this question, they often don’t hear that second part (even if you emphasize it). Ultimately, the issue lies in the answer to the question, “Why am I seeking therapy?”
For billing purposes, your insurance company will want to know why you are receiving therapy by using a diagnosis code. For example, Major Depressive Disorder has (among the options) a code of, “F33.1”. For Generalized Anxiety Disorder, the code is “F41.1”. It’s a great way to cure insomnia by reading up on all the possible codes out there.
In this case, the codes are mental health diagnosis codes, and they describe why someone is receiving treatment and what the focus of therapy is. Unfortunately for us, the code for “Relationship Distress with Spouse or Intimate Partner” is “Z63.0”. This code belongs to a group of codes that are not considered mental disorders.
Here’s how a scenario when calling up your insurance tends to go:
Insurance Rep: “Hello, welcome to Insurance XYZ. How may I help you?”
You: “I’d like to know if couples counseling is covered by my insurance.”
Insurance Rep: “Yes, of course; couples counseling is a covered benefit under your plan.”
You end up receiving this false hope, until the bill from your therapist arrives with an insurance denial.
The scenario actually plays out significantly different when you speak the true language of insurance companies:
Insurance Rep: “Hello, welcome to Insurance XYZ. How may I help you?”
You: “I’d like to know if CPT code 90847 for a diagnosis of Z63.0 is covered by my insurance.”
Insurance Rep: “Yes, CPT code 90847 is covered.”
You: “But what about for a diagnosis code of Z63.0?”
Insurance Rep: “Hmm… Well, I’ll have to transfer you to a care representative to answer that second part. Hold on…”
Care Representative: “Yes, how may I help you?”
You: “Will my insurance cover the cost of treatment for a diagnosis code of Z63.0?”
Care Representative: “No, I’m sorry. That is not a behavioral health code.”
In the end, you find out that this is essentially a type of “bait-and-switch” played out by the insurance company. Knowing the right language will save you a ton of headache.
What if I have a Mental Health Issue, Too?
This is a valid question. Technically, yes, if you have a mental health disorder, your therapist could list this as your diagnosis. But this is misleading if the clinician does not treat you primarily for this disorder.
Say you have Major Depressive Disorder that is listed on your billing to your insurance but you receive couples counseling as the primary focus of your sessions. The insurance company would require all of that money to be paid back if the clinician were audited, and can border on insurance fraud depending on the circumstances (arguments vary, but as always, the insurance wins).
It’s not different from visiting a medical doctor for cosmetic surgery and saying, “but I also have a broken leg.” If the focus of treatment is the cosmetic surgery, your doctor cannot claim to have been treating you for a broken leg. It’s a great way to lose one’s license.
What about Adjustment Disorder?
Many insurance reps, in an attempt to be helpful, may suggest that your therapist could list your diagnosis as “Adjustment Disorder”. This is a fancy way of saying that you are not handling your situation well and that it is drastically affecting you and your life. And to be fair, some situations requiring marital therapy involve someone being significantly impacted by the stress of a relationship problem.
However, treatment would need to focus primarily on the person with the Adjustment Disorder, not the relationship. Fine, we can adapt couples counseling for this easily. However, the symptoms you are experiencing need to be clinically significant in order to meet the definition of Adjustment Disorder by having:
- Marked distress that is out of proportion to the severity or intensity of the stressor, taking into account the external context and the cultural factors that might influence symptom severity and presentation; or
- Significant impairment in social, occupational or other important areas of functioning.
This can be very subjective and open to interpretation. And often, if the insurance company considers something to not be “out of proportion” or of “significant impairment”, it doesn’t matter what the clinician says; the insurance company always wins.
It’s also debatable as to whether or not using a mental health disorder as a way to qualify treatment for couples counseling is ethical. And once you start discussing ethics, mental health therapists start to get real squirrelly. No one wants to deal with the the potential risk to reputation and/or license to practice, especially with ethics and licensing.
Can my HSA/FSA Card be used for Couples Counseling?
This all depends on your Health Savings Account or Flexible Spending Account rules. Many HSA/FSA cards are liberal regarding this, as long as it is a health-related expense. And seeing a therapist certainly should qualify and audits in this area are generally rare. However, they do happen, so you will want to review this with your HSA/FSA plan restrictions and requirements first.
Marital therapy and couples counseling isn’t covered by insurance, unless your situation fits all the stringent criteria needed by your insurance, or if your therapist is practicing in a risky and potentially unethical manner. I don’t recommend it and strongly advise against it. Unfortunately, in our society couples counseling just isn’t given the same priority as depression or anxiety. And that’s a shame.
Don’t let that stop you, though. If your relationship is at risk, the bottom line is that it’s at risk. Whether it’s covered by insurance or not is like debating if you should get treated for a broken leg or not; it’s pointless when compared to the issue at hand, and often leads to a worse situation if not treated. Get help if you need it.
Image by Karen Warfel/Pixabay