Billing Insurance for Couples Counseling
My bottom line for couples counseling and insurance:
I only accept out-of-pocket payments for my full fee.
If you have medical insurance, it’s possible that your insurer has listed me on their website as a provider, whether I’m “preferred” with them or not, and it’s also possible that they have told you they cover couples counseling. This is technically incorrect. Furthermore, to do it, I’d have to breach my own ethical code.
Here’s why:
The insurance industry is built to serve individuals, not couples, which means if we bill your insurance, I have to diagnose one of you with a mental disorder and bill the session as an individual session (with the individual’s spouse/partner present), implying that the session is intended to treat that one individual’s mental disorder. This is why insurance companies don’t really cover couples counseling: they cover individual counseling with the (presumably non-disordered) spouse/partner in the therapy room to help support the diagnosed patient feel better, regardless of what they (non-disordered) need or feel. As far as I’m concerned, that’s not couples counseling.
If I were to bill the session properly and ethically, I would diagnose neither of you with a full-blown disorder, but would code it Z63.0, which is “problems in relationship with spouse or partner.” There are two reasons why that will not work. First, I’m still billing your insurance for one of you, not both of you, and that’s inconsistent with my view of you as my patient. You are both my patient—the relationship unit is my patient. I believe that these details do matter. They have an effect on how we see ourselves and each other, and on he overall treatment. The second problem is that no insurance company I know of pays claims with Z63.0 as the sole diagnosis.
“But,” you say, “I do have a mental disorder! I’m depressed, and my relationship problem contributes to my depression. So I’m fine with you diagnosing me and billing it as an individual with my partner in the room.” I understand that rational. I even share your belief that working on couple issues can alleviate depression and other disorders like anxiety, PTSD, and many more. Maybe it seems like an absurd distinction, but to serve you ethically I still have to hold the line on my belief that what we do in couples counseling treats both of you as a unit, and to do that effectively, I cannot have the paperwork telling me, you, and your partner that your depression is the central problem. It truly might not be. Let’s say your partner also has a disorder in the category that includes depression—bipolar, say, or alcohol dependence. Why should I put your name on the chart and not his? Perhaps his alcoholism is a bigger issue than your depression…but your depression is also a really big deal. It becomes a game of manipulation drawing false distinctions just to get paid. I know many therapists (my past self included) who have blurred this line and said, “Oh, it’s not a big deal, I know the truth,” but I’ve been doing this work long enough to know that blurring a line like that is dangerous.
My holding the line on this can be a source of comfort for anyone who is afraid to begin couples counseling because they (understandably) fear that the therapist is going to side with their partner. I am doing everything I can in and out of my sessions with you to prevent that from happening. Safety and balance in the room is what I am striving to provide in order to allow both partners to feel safe and secure enough to be vulnerable and fairly understood. “Labeling” one of you as the problem does not promote or accurately describe the focus of our sessions together.
And finally, I have learned through experience that out-of-pocket therapy is generally more effective and powerful, both for couples and individuals. You’re investing time and hard-earned money on your relationship. That motivates you, and it makes it a true investment on your part. It can be expensive, though perhaps not as much as you fear; many couples require surprisingly fewer sessions.
If you or your partner have any questions about this topic, please feel free to contact me to discuss it further.