Insurance Reimbursements, Fraud, and Marriage Counseling
Many couples who come for counseling want their insurance to pay their costs. And some plans to cover marriage (or couples) counseling. But the reality isn’t as clean or straightforward as some might want.
Health insurance is built on a “break/fix” model. You get sick and need medical care. The insurance will help pay for the costs of your care. Health insurance companies generally pay for medical care that enables you to heal and return to normal.
When the “break/fix” model is applied to counseling, health insurance companies want to pay for the treatment of a mental illness. They don’t want to pay for marriage counseling. They rely on the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition) to define a “mental illness.” If a medical professional is treating a mental illness (using the medical model), then insurance companies will cover the costs of that treatment in alignment with the terms of their contract with you or your employer.
I find the manual to be terribly inconsistent, to the point of not making sense at times. For example, alcohol addictions are considered a mental illness, but porn addictions are not. Those who have controlling and angry personalities may be diagnosed with a personality disorder, but no disorder exists for those with overly energetic, happy, or pleasure-seeking personalities (for my colleagues, I’m thinking of Millon’s Turbulent personality construct).
Because there is no mental illness diagnosis for marriage problems, mental health professionals usually diagnose an individual with a mental illness and then see the couple for couples or marriage counseling.
Some insurance companies won’t cover couples counseling, while others may offer reduced benefits. It is not uncommon for the reimbursement rates to the health care providers to be lower for couples counseling than for individual counseling because couples counseling doesn’t fit the medical “break/fix” model.
Hence, when I speak with prospective clients about couples or marriage counseling, I tell them to A) check with their insurance company about their coverage for marriage counseling (CPT code 90847) and B) consider going a private pay route and plan to turn in the costs of their sessions to their insurance companies as out-of-network benefits.
It is a serious thing for a mental health professional to commit fraud. One of the most common ways to commit fraud is to give an individual a mental health diagnosis (such as an Adjustment Disorder) so that insurance will cover the costs of the sessions. The sessions are billed as individual counseling (CPT codes 90834 or 90837), and the charting is done as individual counseling with a spouse present. Still, in reality, couples or marriage counseling is provided. This type of fraud happens every day across America. The entire system, IMHO, is just kidding itself.
When couples work with me, most (but not all) find they have substantial improvement in 15-20 sessions. At my rate of $150/hr, couples will usually spend between $2000 - $3000 to heal what is broken. The costs are typically spread over 4-6 months, making a private pay option financially viable for many. Plus, they can use their HSA (Health Savings Account) dollars by turning in receipts for their counseling costs. I find it is cleaner and more honest to have couples pay for marriage counseling than to bill insurance for an individual session while performing marriage counseling.
If you are seeking marriage counseling, be sure to check with your insurance company about their benefit coverage for sessions billed under a 90847 code, not just a 90834 or 90837 code. And check with your Psychologist or therapist about how they decide which codes to use for insurance reimbursement. Fraud is a serious crime, and none of us wants to be on the wrong side of that equation.
Bill English, PhD, MDiv, MA, LP
(PhD is in Business Management)