Why I Don’t Accept Insurance for Couples Therapy

I often have couples tell me that they want to use their insurance for couples therapy or have been to a couples therapist before and that therapist billed their insurance.  So why don’t I?
Insurance companies require 3 things to pay or reimburse for counseling: 
  1. an identified client
  2. a mental health diagnosis
  3. evidence of treatment that directly serves the identified client AND the mental health diagnosis

MOST of the time, individual therapy is covered by insurers because it is simple for the therapist to identify who the client is, assign a diagnosis (assuming there is one that fits the presenting issues), and provide a treatment that is likely to help the diagnosis (for example, Joe attends therapy for his generalized anxiety disorder, and the therapist uses cognitive behavioral therapy to treat his generalized anxiety disorder).  This would be an ethical use of insurance, and the therapist would be able to provide documentation that fits with the treatment being provided.  If the insurance company audited the client’s file, the therapist could show that he/she provided therapy to the client (Joe) and used established treatment methods (cognitive behavioral therapy) to treat the diagnosis (generalized anxiety disorder).

In couples therapy, this is totally different.  Who is the client?  The relationship – both people.  Insurance companies don’t yet have a clear way to cope with this.  They want to know there is 1 client.  They will sometimes reimburse for “family sessions” but they still want to know who the primary client is.  That leads to the second problem: What is the diagnosis?  When I work with couples, the only diagnostic issue I am treating is “problems in the relationship”.  There is a code for this, Z63.0, but most insurers do not cover it.  Further, let’s say you meet the diagnostic criteria for generalized anxiety disorder.  If you are seeing me for couples therapy, then I am not treating you for generalized anxiety disorder.  I am treating the problems in your relationship and we will assume that you either see another therapist for your generalized anxiety OR that your anxiety might lessen over time as your relationship improves.  Either way, the treatment I am providing is Emotionally Focused Couples Therapy.  It’s a wonderful, evidence-supported treatment method for helping couples; it is not a treatment for individual mental health diagnoses.  
So given all that, my documentation of our work together will show that both partners are the clients, we are working on problems in the relationship, and I am using Emotionally Focused Therapy to achieve this.  Sadly, I have yet to find an insurer who will pay for that.
So why did your other therapist bill insurance?  Some therapists are billing insurance because they’re not truly doing couples therapy – they are treating you for a diagnosis and your partner happens to be in the sessions with you learning how to help you with your diagnosis.  Other therapists have a different understanding of insurance laws and regulations and genuinely believe they are operating within those bounds.  And other therapists believe the ends justify the means.  They know that couples therapy is necessary and helpful so they choose a client to diagnose, code sessions as though they are treating that one client, and they assume the insurance company won’t audit their records.  After speaking with insurers and other respected colleagues and trainers in my field, I have come to the conclusion that I cannot ethically bill insurance for the couples therapy I provide.  Other counselors might come to different conclusions.