Couple Therapy and Medical Insurance

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“Hi, My name is XXXX. My significant other and I are looking for couple’s therapy to resolve our conflict. We have xxxxx insurance. If you take this insurance, can you give me a callback?”

I received inquiries similar to this daily. As a result, I often clarified with the clients: what are you looking for, mental health service or couple’s communication service?

What is medical insurance?

Let’s take a step back first. Medical insurance covers medical expenses like car insurance covers car accident expenses. Therefore, to file for the medical insurance claim, your request must fulfill what medical insurance calls “medical necessity.”

Does your conflict between you and your partner a medical necessity? No, it’s not. Your conflict is an interpersonal problem, not a medical problem.

“Wait, but my insurance covers couple’s therapy!” 

The answer is yes but not confirmed. The correct filing code is “family psychotherapy with the patient present.” It means that one of you has mental health issues that fit with the medical diagnosis, and the significant other is in the session to assist the recovery of the identified patient to recover.

So, now, what does that mean?

It means that the treatment is primarily for the person with the diagnosis of mental illness, and the treatment plan and content it is working towards allowing this person to recover or acquire better function.

Research shows that many couple conflicts involve one or both partners with a mental health diagnosis. Therefore, technically, it’s doable to file an insurance claim for a couple’s therapy as long as there is a medical necessity for one of the partners.

At the same time, the implication is: that the couple is in therapy for the identified patient to recover from the mental health issues.

Therefore, if you are looking for the couple’s therapy to resolve the conflict or communication difficulties in the relationship, meaning the treatment goal is for a better relationship and both partners participated in their shared responsibilities, that’s not a medical necessity.

“My husband/wife/partner does have depression/anxiety (etc.). Can you use him/her/they to file for insurance?”

The answer is yes, and I can probably do that based on medical necessity. However, what are you intend to get out of counseling? The medical documentation must reflect the medical diagnosis, including the diagnosis, treatment goals, and notes. If the diagnosis is the identified patient’s mental illness, the treatment goals and process will have to reflect on the treatment of this person’s mental illness.

So, what’s the implication?

It means that if I either have to fabricate the medical documentation, which I am not willing to, or you have to focus on treating the mental illness, not the couple’s communication or conflict resolution.

So, the bottom line is, what are you looking for in your couple’s therapy? Are you looking to help one of your partners recover from a mental illness, or are you looking to better your relationship? Individual? Relationship?

From a relationship perspective, there is no right or wrong person in the relationship because the relationship is the result of everyone’s actions. When emphasizing one of the partners as an identified patient unintentionally also put the responsibility of communication unattended. There seemed to be an unspoken message between the partners to blame each other for the conflict. Still, neither one was taking the responsibility to address their contribution to the issue. For example:

“You need to get your irritation under control so that I can talk to you.”

“You need to know how to talk to me so that you don’t make me annoyed.” 

To avoid confusing the treatment goals, currently, for couple’s therapy, I focus on communication and conflict resolution. For couples with one or both partners with mental health issues, I will work with one of the partners individually to focus on mental health recovery.

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