To Claim or Not to Claim? THAT is the Insurance Question


 

You are indeed fortunate to have coverage, especially in todays current state of healthcare. Many people feel that therapy is an expense that they cannot manage without.

Let me first encourage you to think of a second option before arriving at an informed decision regarding your health care.  You can always decide to use your benefits, but you cannot “undo” many of the negative consequences of using them.

The required diagnosis of a mental illness

Insurance companies only pay for things that are “medically necessary.” This means that someone has to actually diagnose you with a mental health disorder AND prove that it is impacting your health on a day-to-day basis. Many of life’s problems are not mental health disorders.

Many people seek treatment before their issue would meet criteria for diagnosis as a mental health disorder, and THAT is a good thing! And THAT is exactly why Christian Counseling helps! We give God and prayer first chances at helping us heal and mend!

Your insurance company will tell you, “A quote for benefits does not guarantee payment…” This means that you can be told over the phone that something is covered. You can be given an authorization number. And you can still be denied once they review the diagnosis. So if you think you are using health insurance to cover counseling, and the therapist receives a denial of the claim, you are still responsible for that.

If you are thinking of using health insurance to cover counseling for your marriage, be wary when an insurance company says that “cover couples counseling”. They are not referring to marital and relationship counseling. They mean that they cover a procedural code for a spouse to be present in therapy.

The procedure code tells insurance how the therapy happened; were you seen alone, with your spouse, or other family members? Most insurance will cover more than one person being in the room. So, they will tell you that they cover couples counseling because they will permit your spouse to be in the room with you while you receive counseling for your diagnosed mental health disorder. Your spouse is being considered a support to you in your treatment. This is typically Procedural Code 90847: “Family psychotherapy, conjoint psychotherapy with the patient present.”

This isn’t the only thing they look at.

Treatment not only includes the procedural code, but the diagnostic codeThe diagnostic code tells the insurance company what mental illness the patient is being treated for. This is what they base medical necessity on. The diagnostic code for couples counseling is V-61.1, Counseling for Marital and Partner Problems. 

This is the code that is typically rejected by insurance companies for not being medically necessary. It’s like trying to get your dental insurance to cover cosmetic whitening or veneers. Not going to happen. Insurance companies view relationship problems much in the same way that they view cosmetic procedures – they may be great, but they aren’t medically necessary. Using health insurance to cover counseling is not always straightforward. They want to see you using health insurance to cover counseling for things like depression, anxiety disorders, etc. Not relationship problems.

If you want to investigate using health insurance to cover counseling, ask your insurance if they cover the relational V-Code 61.1, not just “do you cover couples counseling?” Be specific, because they will just tell you that they cover whatever you need unless you press them with actual code numbers.

In using health insurance to cover counseling for couples, the therapist will typically have to diagnose one of you with a mental health disorder, and then state that the other person is there in support of the partner.  That is not what marriage counseling is, and it is unethical to call it anything else just to make it medically necessary. One partner may have a diagnosed disorder, but that alone is not the focus of the treatment.The focus is on the relationship.

You may be diagnosed with a “light” condition (that most people could fit the criteria for if they are in enough distress) such as Adjustment Disorder. But nonetheless, do you want a mental health diagnosis in your file if you don’t need it?

There is also the real risk that labeling one person as the “patient” will unbalance the treatment and pathologize the partner. Couples issues are best seen as something that the pair of you are addressing together, and even subtle notions that someone’s diagnosis can be blamed for all of the issues can create difficulties in therapy.

Even if one person does have a diagnosis, or several, this is not the primary focus of couples work and it is unethical to label it as such. We don’t contort our ethics for coverage.

The main point is this: Do you want to  put any kind of insurance in charge of the route to save your marriage? Do you want an Insurance diagnosis to be permanently attached to your files? The investment in a good couples counselor is something that is highly personal. So personal in fact that many decide to pay for their counseling -right out of their own pockets.

Understanding What a Diagnosis Means

If you get diagnosed with something, you should be able to decide who gets access to that info and why. You lose control of that information when it is in your file being faxed to anyone in the health care industry. A diagnosis says nothing about how you cope, what your strengths are, and which of the many symptoms you actually have. But a diagnosis will speak for you and may negatively impact your eligibility for things.

Children have a more difficult time in many ways when they are given a diagnosis. This diagnosis can follow them around in school, on to college, and be a barrier to doing certain things such as working with the Air Force or military, landing federal jobs, security clearances, aviation, and any other jobs requiring health-care related checks (many schools and healthcare institutions are now instigating these policies to screen out employees who may be unstable or cost too much money in mental health care and lost work days).

Don’t get me wrong…many conditions warrant a true diagnosis in which case insurance coverage is ideal.

Anything that is part of your file becomes a permanent part of your file. This means that when you apply for new health insurance, life insurance, and many types of jobs, they can require an authorization to release information to view your entire medical record. With health care reform, being denied coverage due to a preexisting condition is thankfully less of an issue, however, companies can charge much higher premiums because of having ever been treated for a mental health issue.

A diagnosis is not the only thing that becomes part of your file. Insurance companies require treatment plans, progress reports, and many other types of personal information to determine what, if anything, they will cover. These details about your treatment should be private, but instead they are open and available to anyone with access. This could include potential employers.

The average insurance claim passes through 14 people while it is being processed.

The insurance company has several processes to approve treatment. They often only approve a certain number of sessions, even if more are necessary. They will often deny your claim and it could take months to get reimbursement, if at all. This can interrupt treatment. It can also take the form of a claw back, where they tell you something is covered and then end of denying it anyway, leaving the therapist to come back to your for compensation because you are ultimately responsible for treatment fees.

It should be between you and your therapist to determine what comes next in your treatment and how much of it you need. But, imagine an insurance agent sitting next to you in your session, clipboard in hand, making decisions about whether you truly “need” this therapy or not.

The rule of thumb when using insurance (directly or by reimbursement) is to contact them before treatment begins and get approved.

You have a Choice when you take your Counseling in your own hands!

Many insurance companies do not give you a choice of what therapist you can see. They have preferred providers and you must choose one of them.  Even if you are happy with your provider, as I said, you don’t have a choice about what information is put into your file and shared with everyone. You don’t get to take that information out of your file once it is there.

You are the only person who can decide what is right for you.

You have a choice in who you see, whether you see them for a long or short amount of time, and whether you’d rather use your insurance or pay for counseling out of pocket. Just consider your options.

For a Christian seeking a therapist there is a very important consideration. In the Scriptures it is clear that God is very concerned about “thinking,” and refers to the importance of “renewing the mind.” (Rom 12:2) Likewise, a counselor often attempts to “renew the mind” in therapy through the appropriate use of techniques and interventions, regarding the Bible, prayer and spiritual disciplines. So, again, it is critical that when one submits to look for “Christian Counseling, it is with a counselor who is a “like-minded.” It is not to say that Christians can only see Christian Counselors…but one should regard they type of counsel they seek with great care.

 

So if you’re physically sick, go to a good doctor. If physical illness, disease, or injury is the problem then the competence of the physician rather than world view may be a more important factor in choosing who to see. On the other hand, if the issue is a matter of the heart, then competence and worldview are equally important in choosing who to see.

Finally let me encourage you, by all means, receive the care you feel you need. If this means that you must use insurance to afford it, just be sure to ask questions beforehand.

Above all, receive the help you need!

additional reading http://www.apa.org/helpcenter/parity-guide.aspx

 

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