The Family Room Wellness Associates

Did you know that if you ever used your medical insurance for individual, couples or relationship counseling you were given a clinical diagnosis on record?

I am finding that many of the people who call me have no clue and that this can be both an ethical and legal issue.

We all pay a great deal for health insurance, and we all want our insurance providers to cover the maximum amount of services that we are entitled to. The services we as therapists provide you should not only be accurately stated, but it should reflect what services the therapist is actually providing. Most insurance companies provide coverage for certain diagnoses and exclude other conditions. Therapists may not submit false diagnoses or exaggerate their clients’ problems in order to gain coverage or ensure continuation of coverage. In other words, they can’t make stuff up to get paid by your insurance company. When you go out of pocket there is no requirement for a clinical diagnosis to get the quality and specialized treatment your situation needs. You can pick the person who is most specialized in your area of concern without being told how often, how long and how your professional can work with you with their skill set by your insurance.

You could have called your insurance company and was told something along the following ““A quote of benefits or authorization does not guarantee payment or verify eligibility. Payment of benefits are subject to all terms, conditions, limitations, and exclusions of the member’s contract at time of service.”

I was on the phone once with an insurance company with the client in my office who said ” couples counseling is covered on your plan but its up your practitioner to provide a diagnosis that qualifies for treatment”.

I have received multiple subpoenas over the years that I had to quash with my attorney due to a client being sued and opposing counsel was trying to use their private medical history against them. One subpoena had a list of over 35 different medical professionals. This means your private insurance information, diagnosis and case notes can potentially be used against you if the attorneys find a way.

By “claiming” you are anxious, depressed, or have an “adjustment disorder” in order to provide help for your relationship or even your individual sessions to qualify for ” the discounted fee one pays under mental health insurance” may have serious implications to your life later down the road. Accepting a diagnosis of a clinical mental disorder should be taken seriously. And you should know when you are given one if you do qualify by the professional you are working with. However, that takes a comprehensive conversation that takes into consideration present and past history and meeting certain criteria over a period of time.

Your health insurance benefits is limited to treatment that is considered a “medical necessity” or that is considered meeting full criteria for a psychological/psychiatric diagnosis as met by standards of the Diagnostic Stastical Manual. If you go for “couples therapy,” your therapist must bill for relationship problems (V61.1/Z63.0) as a “diagnostic code.” However, most insurance won’t cover that code unless specifically stated .

Couples therapy isn’t individual treatment with two people. It’s different. Couples therapy treats couples for relationship problems. It doesn’t label one of you as “the problem,” even though each of you may have problems of your own. It treats you as a dynamic “system” that needs to be worked on in order to work more effectively.

I am having this conversation with every client that’s calls so I find it my duty and responsibility to share this information with others out there as well.

if you have any questions, please ask me or your treating clinical professional.