Couples Therapy And Insurance: What You Need To Know
By Mary Attridge, ATR-BC, ATCS, LCMHC, EMDRIA-CIT
Have you been considering getting some couples therapy recently and wondering what the difference is between individual and couples therapy? Have you called in and been more expressly warned that your insurance may not cover this type of service? Or maybe you’re already engaged in couples therapy and either your claims have been denied or they’ve been “clawed back” by your insurance from your provider at a later (sometimes much later) date and now you have a bill you weren’t expecting? I’m going to explain some of the underlying reasons and structures that set this up to be a much greater grey area than individual therapy, especially when it comes to if and when you wish to use your insurance and access your benefit.
But first, a disclaimer: In no way, shape, or form am I about to give advice about your specific situation, your insurance, or any kind of billing strategy. My intention is to give you information, in the spirit of transparency and you really have a right to know, so that you can make a better decision for yourself and feel more empowered in this process. So here we go…
I am going to break this information into some subsections so that it will hopefully be easier to follow because it is complex and there are several main themes that are at play and together with your therapist, you’ll all be working to balance towards the greatest benefit and success in your circumstance. The 3 main themes I will be speaking to are:
1. Case conceptualization and clinical implications,
2. How insurance policies are legally set up for the member and the provider, and
3. Billing coding and diagnoses.
Couples Therapy Case Conceptualization and Clinical Implications
Couples and relationship therapy can be conceptualized into two main ways of thinking about them and it will depend on the therapist and how they work as to how they will then treat you, your partner(s), and your relationship.
In a case where you are being seen as an individual, this is simple because there are only one set of organs that is the client. When it comes to more than one set of organs coming in for treatment, we have to determine who is the client. For some clinicians, the client is the relationship, no matter how many sets of organs are in the room for the session.
For others, couples/relationship therapy is an intervention not unlike EMDR or DBT and intended to support one individual. In these cases where the clinician conceives of couples/relationship therapy as an intervention, they can “identify” a “patient,” treat them for their unique set of symptoms, and if that identified patient is covered by an insurance policy, they can try and use their insurance to cover the treatment.
In either conceptualization, there are implications for the treatment. When a clinician sees the relationship as their client, they are saying that all parties are equal contributors to the distress and discord in some fashion or another. They are saying that all members are empowered to do something about their contribution and collaborate with the other(s) in the relationship. It puts the members on more equal footing with one another and does not engage with putting some kind of implied fault with one of the partners in the relationship, potentially reinforcing unhelpful paradigms in the relationship.
If the clinician sees that couples therapy is an intervention intended to address specific effects of the dynamics of the relationship on the individual’s well-being, they are focusing compassionately on this person’s condition first and foremost. They may be seeing that bringing a partner into the treatment might help to clear up perceptions and alleviate distress for the individual, moving them towards improving their symptoms.
How Insurance Policies are Legally Set Up for the Member and for the Provider
A health insurance policy provides for coverage of each individual set of organs listed on the policy. This means that you and anyone you have listed in your household typically, have a policy with your chosen insurance company and while they are under the same policy number, they are seen legally as individual sets of organs; Your household all together as a whole is not what is covered. A relationship is not a member of an insurance policy nor is there any option for this to my knowledge.
If I am contracted with an insurance company to be an in-network provider, this will mean several things:
1. I am accepting a negotiated rate for my services that usually affords you, the member, a discount. In exchange, my name and information become readily available for referral and for me and The Healing Group, it allows us to live out more fully our value of having our services and expertise being accessible to more folks in our community.
2. I agree that I am not going to bill for “unnecessary services” or hold you accountable for these. I will give a generous benefit of the doubt here and I imagine that they have this clause to protect you from bad actor providers who would recommend things you maybe don’t need and do not have actual evidence basis to support. That said, for the record, there is excellent evidence to support the efficacy of working with relationships to improve the overall quality of life and functioning of the members of the relationship. Additionally, this is why, if you work with us at THG, we will have you sign something called an Advanced Notice of Non-Payment to give you the opportunity to understand that there may be things we might recommend and that your insurance has already said explicitly or implicitly (i.e., we experience a high degree of denial for the service or diagnosis) that will not be covered.
3. I will bill accurately with the billing code and diagnosis that I assess is most appropriate to describe our session and your overall symptoms. As a point of order, this is the clinician’s prerogative and scope and not the insurance’s though many times their reasons for denial would seem to assert that this is theirs.
Billing Coding and Diagnoses for Individuals and Couples
You probably get an EOB after any visit with a provider. On it, you will see that there is usually a 5-digit code and description of the code. Typically, from us, you will see the billing code of “90837” if you are being seen individually. This code is an easy way for the insurance company to identify that, ah, 1, this session was at least 53 minutes (and your provider will enumerate the time you begin your session and the time you end your session) and 2, it was for the treatment of one set of organs.
There are other billing codes as well that describe other time allotments, who/what is being treated, and the quality of the session (we have something called add-on codes that will describe if there are extra measures that were needed in order to progress with treatment or if there was a crisis, etc.). When treating a relationship, the correct code to use is a 90847 when all members of the partnership are present. There are some important things to note about this code: 1. It covers 26-74 minutes of treatment. Unfortunately, most insurances pay this as if we were seeing you for only 30-40 minutes. Their reimbursement rate for the code is equivalent to a 90834 for individuals (which is already discounted) and that code covers 38-52 minutes of treatment. I do not know any clinician that feels that this time constraint is effective for treating a relationship. Most of us like at least the 53 minute hour. It is also not what is demonstrated in the literature as best practices yet here we are…
When it comes to diagnosing a client, we use something called the Diagnostic and Statistical Manual, commonly known as the DSM 5-TR. This manual is put together and reviewed regularly by top experts in the field who have experience specific to the diagnosis they are contributing information; mainly psychiatrists and clinicians. Diagnoses describe unique sets of symptoms and are intended to help both guide our treatment planning and hopefully afford you, the client access to care. The caveat is once again, these are described for one set of organs only and none are intended or allowed for describing a relationship. Here is how these 2 factors play out in your treatment:
If I am a clinician who conceptualizes that couples/relationship therapy is an intervention, I can justify having an “identified patient” to bill the work and give a diagnosis from the DSM 5-TR* and can more likely bill using the 90837* billing code.
If I am a clinician who conceptualizes that couples/relationship therapy is about treating a relationship, then I am unable to give a diagnosis beyond “No Diagnosis” and I am likely billing using the 90847 billing code. Because typically insurance requires a diagnosis and because there is no identified patient really, there is no member under which to bill the claims. Yes, due to the way most EHR software is set up, it appears that there is an identified patient, a member, in reality, there is not and absolutely sets up the potential for the provider to be accused of insurance fraud.
Isn’t this so much fun, not stressful at all, and encouraging? ;)
Conclusion
All of this said, couples therapy is proven as one of the most “bang for your buck” kinds of therapy as is proven in the research (see the sampling of “Receipts”). Even when it’s the relationship that is being treated, all members benefit, emotionally, mentally, and physically, from the process, especially when you have someone highly skilled and trained who knows what they are doing and sincerely cares about everyone in the room.
*The diagnosis and billing code given does not automatically guarantee that insurance will cover the claim(s). It does however check the boxes that are needed to be checked to possibly be covered.
Receipts
https://pmc.ncbi.nlm.nih.gov/articles/PMC10087549/#famp12824-sec-0005
“In addition to reducing either general or specific relationship difficulties, evidence from several clinical trials supports the beneficial impact of couple therapies for coexisting emotional, behavioral, and physical health concerns,” (Babinski & Sibley, 2022; Fischer et al., 2016; Goger & Weersing, 2022; Hogue et al., 2022; Lamson et al., 2022; Stith et al., 2022).
https://www.tandfonline.com/doi/full/10.1080/23761407.2018.1563013
“The results strongly suggest that the intervention of EFCT not only improved marital satisfaction (Hedge’s g coefficient = 2.09) but also, the improvement in marital satisfaction was sustained at follow up. This sustained improvement was evident through the results of both the Friedman’s repeated-measures and the post hoc Wilcox (χ2 = 6.500, p = 0.039).”
https://psycnet.apa.org/buy/2023-02978-001
