For various reasons, I do not take insurance. If you need to see someone and use your insurance coverage to pay for your sessions, I recommend that you consult your insurance company’s directory of providers and choose someone there who may meet the characteristics of experience, training, education, and geographical location that you may be looking for. If you wish to explore using your insurance with me as an out-of-network provider, please review the following information.
Dr. Z is an out-of-network provider, i.e. he is not listed as an in-network provider by any health insurance company.
Therefore, Dr. Z is not able to accept partial payment (copay) or submit a claim to an insurance company on your behalf.
As an out-of-network provider, Dr. Z can provide you with a detailed receipt (also known as a “superbill”) with all the information needed to submit the expense to your insurance company and receive reimbursement according to your insurance coverage.
Submitting the claim is therefore your responsibility and payment in full is required at the time of your visit with Dr. Z.
DOES MY HEALTHCARE INSURANCE COVER COUPLES COUNSELING?
If you’re seeking help for a troubled relationship (marriage, engagement, committed dating) be aware that this will be considered your “diagnosis.” The diagnosis code “Z63.0 Partner Relational Problem” will appear on the receipt that you will submit to your insurance company for reimbursement.
Insurance companies do not pay for a "Z code". They only pay for treatments that are “medically necessary.” You must receive a specific diagnosis of a mental health disorder (e.g., depression, anxiety, OCD, etc.) that is negatively affecting your health on a day-to-day basis. Most relationship problems are not mental health disorders.
Be savvy as you research this matter. You are expected to understand what your health insurance policy covers and what it does not cover. Many policies state that they will pay only for treatment considered to be “medically necessary.” They have the right to withhold payment if a treatment is considered outside the scope of coverage. It’s like trying to get your dental insurance to cover cosmetic whitening or veneers. It is not going to happen. Insurance companies view the treatment of relationship problems much in the same way that they view cosmetic procedures: it may be greatly beneficial, but it isn’t “medically necessary.”
Will your insurance cover this out-of-network expense?
Ahead of your first appointment with Dr. Z, we suggest that you call your insurance company and ask questions such as:
Is pre-certification or pre-authorization required to see an out-of-network provider? If so, obtain and write down the authorization number or code.
How many sessions will the insurance company authorize with an out-of-network provider? What are the “reasonable and customary” amounts covered for the initial intake session (CPT code 90791) and for subsequent sessions (CPT code 90834 or 90837 for individual therapy and 90847 for family therapy) provided by an out-of-network, licensed mental health clinician?
If you are seeking couples or marriage therapy, does the insurance company cover this as a benefit? Many health insurance companies do not cover couples therapy because it is not considered “medically necessary.”
Do you have a deductible you need to meet before your insurance starts to reimburse this out-of-network expense? If so, how much of the deductible do you still have to meet for this calendar year?
Is there a maximum number of sessions per calendar year, and is there a lifetime maximum number of sessions? If so, how many of these sessions have already been used?Depending on the answers you receive, you will be able to make an informed decision on whether to see Dr. Z as an out-of-network provider and still be able to be reimbursed for this expense by your health insurance company – OR – seek an in-network psychotherapist through your insurance company’s directory of providers.
What If I Get a Diagnosis?
If you have symptoms consistent with a mental health diagnosis, the treatment will focus on the mental health disorder and not on the relationship. The other person (your partner) will attend the sessions solely in support of you, for counseling that is focused on your mental health disorder. Obviously, no marriage counseling is possible under this scenario, and it is unethical to call it anything else just to make it medically necessary. To do so would be committing insurance fraud.
What Are the Drawbacks of a Diagnosis?
Anything that is part of your treatment becomes a permanent part of your healthcare record. When you apply for new health insurance, life insurance, and many types of jobs, you may be asked to provide an authorization to release information to view your entire medical record. With health care reform, being denied coverage due to a preexisting condition is less of an issue; however, insurance companies can charge much higher premiums if you have ever been treated for a mental health disorder. The mental health diagnosis is not the only thing that becomes part of your file. Insurance companies require treatment plans, progress reports, and all of your personal information to determine medical necessity and what, if anything, they will cover. These details about your treatment should be private, but instead they will be open and available to anyone with access. This could include potential employers. It is reported that the average insurance claim passes through and is viewed by 14 people while it is being processed.
What Else Can I Do?
Check if your insurance will reimburse you for out-of-network providers (see the information about out-of-network on this page.)Use pre-tax dollars in your Health Savings Account (HSA) or Flexible Spending Accounts (FSA) to pay for therapy. Dr. Z accepts all HSA and FSA cards with major credit card logos on them. Please note that the same rules for coverage may apply to HSA and FSA account: check with your insurance company before you begin using them for treatment other than “medically necessary,” i.e. for relationship counseling.