Couples therapy can be a lifeline for many relationships, providing the necessary tools and guidance to navigate the turbulent waters of partnership. However, despite its proven benefits, insurance coverage for couples therapy remains a complicated issue. In this blog post, we will explore in detail why insurance companies don’t cover couples therapy, even though they may tell inquiring clients that they in fact do cover that treatment.
Couples therapy, also known as marriage or couples counseling, including discernment, premarital, sex therapy, and separation counseling, is a specialized form of psychotherapy designed to help couples resolve conflicts, improve communication, and build healthier relationships. It is widely recognized for its effectiveness in addressing issues such as communication breakdown, trust issues, intimacy concerns, and more. In fact, various research studies have found that premarital counseling can actually reduce the risk of divorce (we found figures to range between a 17% and 50% reduction in divorce rates). In spite of this, insurance companies don’t cover this relational treatment, for reasons described below.
Insurance Coverage for Therapy:
Insurance companies generally offer coverage for mental health services, including therapy. However, the extent and specifics of this coverage can vary significantly from one plan to another. Here are some key reasons why insurance companies often don’t cover couples therapy:
CPT Codes:
While therapists can bill insurance for sessions with a non-client family member or spouse/partner present in therapy with a current individual client using CPT code 90847, it’s crucial to understand the nuances of this approach. Despite insurance companies labeling this as “family therapy” or “couples therapy,” the treatment is defined as individual therapy with a non-client present. The code stipulates that only one person is considered the therapist’s client, while additional attendees are designated as “non-clients.” This method does not accurately capture the essence of couples therapy, where both members of the couple are considered clients in their own right.
For precise documentation of couples therapy or family therapy, it is imperative for therapists to create billing documents that accurately identify the relationship itself as the client. Unfortunately, there is no insurance covered CPT code for couples therapy, as all codes inherently assume one individual client and non-client(s). Essentially, because the relationship itself is the “client”, insurance companies do not consider CPT code 90847 to be the appropriate coding for couples therapy.
If only one person attending couples/family therapy is the client, and additional attendees are non-clients, the CPT code would be billable and accurate. An example would be an individual client bringing in a spouse/partner into therapy for a few sessions to support their individual mental health diagnosis and treatment. If treatment continued such that the relationship, rather than one individual, became the focus of treatment, the CPT code 90847 would no longer be accurate, and a new code would be assigned.
TLDR: there is no CPT (Current Procedural Terminology) codes that cover treatment when the relationship is the client, as all billable codes require an identified patient and a “non-client”. Because we are subject to insurance audits from Premera, we cannot simply choose a covered code, because an audit would reveal that we have inaccurately billed, and we could be charged with insurance fraud.
Diagnostic Criteria:
Insurance companies require a diagnosis to justify the medical necessity of any treatment, and will approve or deny treatment based on whether or not they deem the diagnosis to be a covered mental health issue. For individual therapy, this can involve diagnosing conditions like depression, anxiety, or PTSD. However, couples therapy doesn’t fit neatly into this diagnostic framework because it focuses on the dynamics of the relationship rather than an individual’s mental health condition. Typically, the most accurate diagnosis associated with couples therapy, “Z63.0: relationship issues with spouse or partner”, is not covered by insurance companies, as they do not consider relationship issues to be a covered mental health issue. Essentially, if a relationship is the focus of treatment, rather than a specific mental health diagnosis, treatment is not covered by insurance.
We have seen a trend in companies adding couples therapy to their employee benefits package. If your company added “couples therapy” it may mean that they are now covering the Z63.0 code. This doesn’t solve the issue of there being no billable CPT code to accurately describe the client as the couple (2 people).
TLDR: companies may now see that the diagnosis “Z63.0: relationship issues with spouse or partner” is coveted, but the issue of the CPT code remains, making billing for this treatment inaccurate, in the eyes of insurance companies.
Medical Model vs. Relational Model:
Insurance companies tend to operate within a medical model, which prioritizes the diagnosis and treatment of individual medical conditions. Couples therapy, on the other hand, is rooted in a relational model that focuses on improving the dynamics between two people. This fundamental difference in perspective can make it challenging for insurance companies to see the therapeutic value in couples counseling, in spite of long term, research backed, proven benefits in a variety of areas, from individual mental health, to an improvement in physical health.
In the medical model, an identified patient needs to be assigned a covered diagnosis, which can include the spouse or partner in therapy sessions. For example, if a patient is diagnosed with OCD, and the focus of treatment is on the patient’s mental health issue, their partner can attend sessions as part of the patient’s support system. If the focus of treatment shifts to focus on the impact on the relationship, and relationship issues associated with the diagnosis, coverage quickly gets into a grey area. When billing insurance, therapists are required to continually assess for the most accurate diagnosis, and adjust insurance claims accordingly. If at any time the focus of treatment shifts to the relationship, rather than the individual patient’s mental health diagnosis, insurance coverage ends there, as the most accurate diagnosis to describe the treatment being received becomes the (typically) non-covered Z63.0, and the CPT code 90847 becomes inaccurate, and the clinician needs to update the client chart accordingly .
TLDR: In traditional couples therapy both patients are considered to equally be the therapist’s client: they start therapy together, and attend sessions together and/or separately for equal amounts of time. The therapist is aligned with the treatment goals of both parties, and is invested in the health and well-being of both parties. In this case, there is no “non-patient”, and the couple’s therapy chart would legally be the property of both parties equally. The relationship itself is the client, rather than an individual client, which means that the CPT code 90947 is not applicable.
Legal Ramifications of Inaccurate Billing:
As an in-network provider with Premera insurance plans, we are required by our contract to assign an accurate diagnosis and CPT code to our clients who would like to bill insurance for treatment. While some therapists will simply assign an individual patient, choose a covered diagnosis, and bill insurance for therapy, Premera reserves the risk to audit client charts at any time, to see if we are accurately billing. If they determine that the most accurate diagnosis is Z63.0, that the relationship is the focus of treatment, and/or that the CPT code 90847 is not accurate because all attendees are clients, we are subject to insurance payments being “clawed-back”, and can even be charged with insurance fraud. For these reasons, we cannot bill Premera for couples and/or family therapy, but we are proud to offer low cost services, as we believe in the efficacy of couples therapy, and believe that mental health care should be affordable and accessible.
Alternatives and Solutions:
While insurance coverage for couples therapy may be limited, there are several alternatives and solutions to consider:
- Self-Pay: many couples opt to pay for therapy out of pocket. While this can be a financial commitment, it ensures privacy and autonomy in choosing the therapist. SCS offers couples therapy between $60-$175/session, based on experience level and training, and our self-pay options can be found on our website.
- Employee Assistance Programs (EAPs): some employers offer EAPs that provide a limited number of counseling sessions for employees and their partners. These programs may cover couples therapy in certain cases. For example, Lyra EAP will cover up to 25 sessions per year, and our owner and resident sex therapist, Brittany Steffen, is in-network with Lyra.
- Sliding Scale or Reduced-Fee Services: most therapists offer sliding scale fees or reduced-fee services based on income, making therapy more accessible. At Steffen Counseling Services, we offer this option in the form of our clinical internship program. Our interns offer relationship therapy at our sliding scale rate of $60-$75 per session, which can be less than a copay, depending on your insurance plan.
- Health Savings Accounts (HSAs) or Flexible Spending Accounts (FSAs): these accounts can be used to pay for couples therapy with pre-tax dollars, providing a financial advantage. SCS accepts these forms of payments, and can provide invoices to meet any proof of treatment requirements associated with HSA/FSAs.