Here is why couples counseling isn't covered by insurance.

Couples counseling isn’t covered by insurance? No, couples counseling is not covered by commercial health insurance carriers. But if you assumed it was, you are not alone. Confusion about whether couples work is covered by health insurance is widely misunderstood by clients and therapists alike.

 

Health insurance is only intended to pay for the treatment of illnesses and injuries. When a patient accesses psychological counseling the therapist must diagnose that patient with a mental health illness in order to have the treatment covered by the patient’s health insurance. In couples counseling, there is no illness being treated. Instead the challenges within the relationship are being resolved. This process isn’t covered by insurance. 

 

But another person told me couples counseling was covered by insurance? There may be therapists who use the billing codes for Individual Counseling, Individual Counseling with family member present and Family Counseling in order to receive reimbursement for couples counseling. In this case, the counselor is providing a non reimbursable service to the clients and billing the insurance company for a reimbursable service. This practice is illegal, unethical and can result in serious legal consequences for therapist. The only allowed service under all of the billing codes listed above is to implement a treatment plan that is designed to alleviate mental illness. If the assigned client's family would like to participate in sessions they may do so in order to support the identified client's treatment goals of alleviating mental health illness. 

 

If a therapist is found to be misusing billing codes listed above, the insurance company can and may:

• rescind payment for all claims submitted under that client’s policy; 

• withhold payment of all other submitted claims from that therapist for any other clients within the therapist's practice; 

• end the contract with that therapist;

• submit a complaint to the state licensing board;

• which may result in the suspension or revocation of the therapist’s license;

• and/or refer the case to local law enforcement.

 

But when my relationship is good, I’m less depressed and/or anxious. Shouldn’t that be covered? In order to receive insurance reimbursement for counseling from any health insurance carrier, the therapist must first diagnose one client with a mental health illness and then write and implement a treatment plan for the exclusive purpose of resolving the identified client’s mental health illness(es).

When health insurance companies audit a client’s chart, they review treatment plans specifically for how it alleviates the identified client’s diagnosed symptoms. If mental health counseling benefits the client by improving the client's relationships, that's a positive outcome and something all therapists want for their clients, however, it is not the primary goal of individual mental health treatment per the provider contract agreement. 

 

Bottomline: Therapists can provide couples counseling which focuses on learning to resolve conflict and improve communication within a relationship OR they can provide individual counseling which focuses on alleviating symptoms resulting from a mental health disorder. Therapists cannot provide the first and bill for the latter. 

Here is why providing couples counseling and billing insurance for individual or family counseling is unethical:

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Once a therapist bills insurance for individual counseling only one individual becomes the client and the therapist is required to follow the HIPAA federal law. This law requires the therapist to not share any information about the client with any party unless it meets specific criteria set forth in the law. If the identified client (the client's whose insurance is being billed) tells a therapist to withhold information from his or her partner (the family member), the therapist cannot share that information. The partner, whose insurance wasn't billed is only considered a family member under the law. The family member isn't considered a client because the family member's insurance isn't being billed. This means the therapist is also under no legal obligation to provide service records to that family member without the client's consent. Moreover, the therapist has a legally binding obligation to prioritize the identified client over the family member in all therapeutic matters. Afterall, it's the identified client's therapy not the family member's. 

 

Imagine a circumstance where clients proceed with a separation and legal proceedings after attempting reconciliation through counseling. What if the family member (not covered by HIPAA) requests the service record and the identified client refuses to share the record? The therapist can't provide the record or they can be held liable for providing HIPAA compliant information to an unauthorized party. On the other hand, the family member has participated in multiple sessions with the understanding that they are an equal person in the relationship. Is it only then that the family member discovers that they aren't entitled to records for therapy sessions he or she attended? But it was supposed to be couples counseling? 

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In my service agreement with couples clients, both clients are entitled to the service records and I will never withhold any information from either client under any circumstances. All of our communication is communicated in session or transmitted through a secure online messaging platform and both clients are copied on each message. This is clearly documented in my service agreement. 

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Bottomline: Couples counseling is substantively different from individual counseling. Implementing effective, ethical and legal couples counseling requires research, training, legal counseling and experience. When you become my client you benefit from the time and dedication I have invested in my work. Clients of mine who have worked with other couples counselors in the past and come to me after, consistently report experiencing greater efficacy in their treatment. 

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