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    Why I Don’t Accept Insurance for Couples/Premarital Counseling

    No Insurance Company in America, Technically, Covers Couples Counseling

    I mean, there’s a code that indicates the counselor saw a couple or family, but it’s weird. You can use the couples billing code, but you have to diagnose one partner with a mental illness, and then write your documentation — treatment plan, progress note for each session — to correspond to this diagnosis.

    Ethical problems, labeling problems, client harm problems

    The problem, from my perspective, is that I’m not comfortable 1) diagnosing a person with a mental illness who I really don’t believe has one; and 2) writing up my entire treatment as if it’s for some specific mental illness as a pretense for doing couples treatment. This is an ethical issue for me, not to mention any diagnosis I send to an insurance company becomes part of a person’s permanent health record. Later on they may be disqualified from a certain job they want, or from getting life insurance, because of said diagnosis. If the diagnosis is real, and the client chooses to take that risk, that’s one thing, but getting disqualified from important things because a specious diagnosis was given in order to save money on counseling that wasn’t actually covered–that’s something else entirely.

    Financial risks

    When a provider contracts with an insurance company, he/she agrees that the insurance company can audit their records anytime, and obtain any information they ask for. They can ask for my treatment plan, results of any/all assessments I might administer, my progress notes for any specific dates of service, or even all of my records for you from the day we began treatment. They can go over this with a fine-toothed comb and if they find something they don’t like–if in their opinion my progress notes don’t adequately make the case that you fit criteria for the diagnosis I gave you, or don’t sufficiently refer back to the treatment plan, or the treatment plan isn’t specific enough, or uses interventions they determine aren’t appropriate, or if they feel I have not met their “standard of care” (which every insurance company, of course, defines differently), they can do a “claw-back,” where they demand I refund their money for specific dates of service. They could even make me pay them back all the money they have sent me for the entire time I’ve treated you. And of course they have a vested interest in finding a problem with whatever I send them. If this were to happen, and the insurance company demanded I pay them back $3700 for treatment I did for you, would you mind if I passed that on to you as my client and asked you to pay it? Of course you would mind, and you would be right to be upset about that! That’s why I have to make the decisions about what risks I’m willing to accept, because I and I alone will bear the burden for whatever happens as a result.

    This is the long way of saying that when I agree to accept insurance to see a couple, and I diagnose one of them with a mental illness that maybe doesn’t technically meet all the criteria so I can help them [which I want to do because a) I care about people and want to help them, which is why I do what I do to begin with, and b) I have an obvious financial incentive to offer that help], I am exposing myself to significant financial risk. And it’s not just claw-backs I worry about. An insurance company can even accuse me of insurance fraud. This can come with enormous financial and criminal penalties.

    No thank you!


    The stress and anxiety this caused when I was taking insurance eventually became overwhelming and I decided I didn’t want to do it anymore, and didn’t need to.

    Client care issues

    If I have to write the treatment plan, and all my progress notes, as if it’s really about whatever diagnosis I have given, when it’s actually about helping the relationship, then I’m not able to write progress notes that adequately help me document what I’m actually doing with the couple, and that affects my efficiency and the quality of care I can provide as a counselor. For a few years I was taking insurance for couples and was actually writing two progress notes per session, one that I hoped would pass insurance company muster, and one I kept in a private place that showed what I was really doing. Of course the fact that I had to do this was, in itself, a sign that there was as problem I needed to solve. I solved it when I stopped accepting insurance.

    Low reimbursement rates

    I have written of the stress and anxiety many providers often feel due to the very difficult position we are in if we accept insurance, but you have to add to that that reimbursement rates are low. Therapists are, at the very least, Masters-level providers and most of us have a lot of student debt we have to repay. You have plumbers and electricians making $80/hour and they often graduated high school, went to a trade school for 18 months and were out in the work force. An average Bachelor’s degree takes about five years now, and a Masters program takes about three years if you go full time, and both cost a lot of money. For some stupid reason, insurance companies pay less money for a code 90847 (couples or families) than a 80837 (individual). (Again, remember, even with the code for couples or families, we still have to diagnose and basically treat one person.) The difference between those two codes can be $50 per session or more. Times five sessions a day, times five days per week, equals $1,250 a week. That’s $5000/month, or $60,000/year. And what if it’s only half that? Very few therapists are at a place in life where they can leave $30,000 a year on the table.

    You might think, “Well, if you can really only diagnose and treat one person, why not see the couple but bill under the individual code?” The answer: Insurance fraud, which we have talked about.


    Every therapist has to do their own work with this and follow their own conscience. I’m glad there are therapists who are willing to stay in the insurance game, because there will always be people who absolutely have to use their insurance, and if every provider gets out of the game, they’ll be the ones who suffer. They’re not going to be my clients because I’m priced too high, but they should be able to get treatment.