Insurance companies are increasingly refusing payment for couples therapy by claiming that their policies do not cover marriage counseling. Although many clinicians and patients have assumed that there is nothing that can be done, in most cases, there is a way to obtain reimbursement for couples therapy. The key to overcoming the denials is understanding the issues and how the denials involve “downcoding to avoid payment.” Armed with this information, assertive clinicians can do something to stop managed care’s erosion of mental health services.

The controversy over payment for couples therapy has a long history. Before the 1980s, many insurance companies did not pay for family therapy of any sort. Based on the idea that only individuals had an illness, the insurance company only paid for individual treatment. When this model was prominent, patients often spent years in individual therapy trying to solve problems that were more appropriately and quickly treated in either couples or family therapy. Today, it is established that family or couples therapy is often the treatment of choice, and therefore a medically necessary treatment that should be covered by insurance.

Moreover, marital problems often precipitate a severe mental health crisis, and one that usually qualifies for a DSM-IV diagnosis. Treating relationship problems is an integral part of mental health care. Denying the benefits of couples therapy to people who have a DSM-IV diagnosis related to marital issues makes a mockery of mental health coverage.

Payment for couples therapy is different than payment for marital enhancement programs and counseling that is unrelated to a DSM-IV diagnosis. These services may be excluded from insurance coverage because there is an argument that can be made that they are not for the treatment of an illness. However, even for these non-medical services, it may be short sighted and unwise to exclude them from insurance. Marriage counseling can be an effective form of prevention of more expensive health care services that result from marital dysfunction.

In 1998, Columbia/HCA Healthcare Corp. was indicted by the Department of Justice for alleged fraud that included charges that they upcoded diagnoses to ones with a higher reimbursement without any medical evaluation to justify the change in diagnosis. An example of upcoding is when a hospital business office changes a diagnosis such as mild pneumonia to a diagnosis such as severe pneumonia solely because the hospital can receive a higher reimbursement for the new diagnosis. Although it admitted no wrongdoing, Columbia has tentatively settled with the Department of Justice for $745 million for the alleged fraud (Brinkerhoff, D, 2000). Because this scandal involved the nation’s largest hospital chain, it has made the industry and regulators aware of the seriousness of upcoding.

When insurance companies reclassify Couples Therapy (1) to Marriage Counseling, the situation is parallel to upcoding. While both treatments have the same procedure code, the patient diagnosis is different for Marital Counseling and Family Therapy or Couples Therapy conducted for the purpose of treating a DSM-IV diagnosis. The different codes are as follows:

The only way that Couples Therapy can be converted to Marriage Counseling is to downcode the patient's diagnosis from a covered illness to one that is a "V" code. Unless there is a medical evaluation to justify a diagnosis change, it is not legal for an insurance company’s business office to downcode a mental disorder diagnosis to a non-mental disorder for the sole purpose of avoiding payment.

It is often difficult to get an insurance company to realize that they are downcoding. Most claims specialists have no training in mental health and consequently do not understand the nature of family therapy or diagnosis. They generally do not know that there is a different diagnosis for Marriage Counseling and Couples Therapy. These non-professionals may not even realize that relationships are normally a focus of mental health treatment. Due to their limited knowledge of mental health, if they see the term, Couples Therapy, they often think that they have enough knowledge to decide that this is actually Marriage Counseling. Even if the claims specialists were able of understanding the problem, they are probably not empowered to solve the problem.

The best strategy in billing insurance is to avoid the confusing term, Couples Therapy, and to specify the treatment as Family Therapy. If the insurance denies payment, it is usually necessary to go up the chain of command to a supervisor and often higher. The company needs to be educated that there are different diagnostic codes for Family Therapy and Marriage Counseling. Explain that their refusal to pay appears to be downcoding, and that if the situation cannot be resolved, you and the patient will file a complaint with the insurance commissioner. It does not hurt to draw a parallel to the Columbia case. In addition, it may be helpful to educate the company about the health care implications of refusing couples counseling, and that it would be more expensive for you to see each family member in individual treatment. If the company is not responsive, it can be helpful to have your state professional association contact the insurance commissioner to support you. While many insurance commissioners are not aggressive in dealing with insurance companies, because the Columbia Hospital scandal has raised the public awareness of the illegality of upcoding and downcoding, insurance companies will be motivated to be responsive.

Sometimes insurance companies refuse payment for couples therapy after a “medical review” of the treatment records. While this may appear to be a competent utilization review, it may not be. At least one insurance company, Humana, uses clerical staff for “medical reviews” regarding covered benefit decisions. Its clerical staff has not been conversant in diagnosis, the nature of family therapy, or mental health treatment in general. If the insurance company is conducting a competent medical review, it will be conducted by an identified mental health professional. This professional cannot arbitrarily change a diagnosis, but must justify that the couples therapy is not medically necessary to treat the diagnosis, and that the treatment is not necessary for a mental disorder.

No, the patient’s self diagnosis does not exclude the patient from insurance benefits. Many times patients will describe their problems in terms that do not coincide with diagnostic categories and treatment codes. It is up to the mental health professional to determine if the patients have the symptoms of a DSM-IV diagnosis, and if couples therapy is a treatment of choice.

A focus on relationships or marriage does not mean that couples therapy is not treating a DSM –IV diagnosis. Mental health is inherently involved with the health of relationships. Individual therapists discuss marital relationships with their patients. Family therapists can use marriage counseling techniques. If an insurance company has advertised that it provides mental health benefits, then it is committed to treatments that involve the improvement of relationships.

An insurance company has a right to exclude treatments from coverage. It probably could refuse to pay for any Family Therapy that only includes the spouses. However, insurance companies are unlikely to publicly admit to having such a policy because it would demonstrate an irresponsible disregard for an essential mental health service. In addition, physical health care professionals routinely include spouses in the treatment of many illnesses, and it would be outrageous for mental health to be the only area that excluded payment when spouses were involved.

Some mental and physical health problems are quite mild. An insurance company could conduct a medical necessity review and argue that the mental health diagnosis is so mild that payment for Family Therapy is not justified. The insurance company could also have a public guideline for how severe a problem needs to be before they would pay for treatment. However, neither of these procedures would involve downcoding a diagnosis. Instead, these legal procedures require a utilization-review professional conducting a thorough review to determine that the Couples Therapy is not medically necessary, and the clinician having an opportunity for an appeal of the medical necessity review.

On the other hand, there are several good arguments for insurance paying for the treatment of mild mental health diagnoses. What appears to be mild at first may upon further investigation be more severe. Because insurance advertises an emphasis on wellness and prevention, treating problems before they become severe fits with their advertising claims. Mild problems tend to resolve quickly, and consequently cost so little that the treatment is cost-effective. Moreover, there is a well-documented medical cost offset from the treatment of all mental health problems.

Proper treatments in health care try to resolve the underlying problem. Many problems in mental and physical health have symptoms that come and go. In physical health, patients do not stop their antibiotic when symptoms subside, but instead continue it until the underlying infection is resolved. The same is true in mental health. If the depression, anger and anxiety over a relationship subside early in treatment, it is still important to continue to improve the couples interpersonal functioning to the point that future problems with depression, anger, and anxiety will be lessened.

If financial gain is the only justification for upcoding or downcoding, then it is deceitful. Clinicians should be careful that they do not assign a DSM-IV diagnosis that is inaccurate in order to gain reimbursement. In addition, it is important to document the symptoms on which the diagnosis is based.

The insurance industry is attempting to refuse payment for couples therapy based on the principle that medical insurance should not have any responsibility for marital relationships. This argument does not hold up once the insurance advertises and promotes that it covers mental health. Relationship issues are a major cause or a major result of most mental health problems. Removing the treatment of intimate relationships from insurance coverage compromises the mental health benefit so severely that it is deceptive to advertise that mental health treatment is covered. When insurers advertise a health care benefit, they must also deliver the benefit when the patient is in need of treatment.

At this point, the arguments in this paper have been presented in response to one Blue Cross/Blue Shield company and Humana Employers Health Insurance when they attempted to deny payment for Couples Therapy. Both companies were reluctantly responsive, and reports from other psychotherapists indicate that following the confrontation with Humana, it has backed off of its refusal to pay for Couples Therapy.

Mental health services have been cut by managed care more than physical health sevices. In spite of a growing awareness of the need for mental health services and a profusion of parity legislation, managed care has greatly decreased the availability of mental health services (Mechanic, D. & McAlpine, D. D., 1999). Denying Couples Therapy is just one aspect of the erosion of service, but it is one that usually can be confronted and reversed. When insurance companies refuse to pay for Couples Therapy, we can do something to change the system so it is better for our patients.

1. Capitalization of the terms Couples Therapy, Family Therapy and Marriage Counseling indicates that these terms refer to a formal combination of procedure codes and diagnostic codes. When the terms are not capitalized, they refer to the general discussion of these treatments in the professional literature.

Ivan J. Miller, Ph. D. is a psychologist in Boulder, Colorado and is a Board Member of the Patient Advocacy Coalition, an organization that is developing better strategies for using patient protection laws to solve problems in managed mental health care. When consumer protection laws are inadequate, he advocates for increased regulation or for alternatives to managed care. He is the author of The Mental Health Consumer’s Protection Manual: A Guide to Solving Problems with Insurance and Managed Care, which can be purchased for $12 by calling the Boulder Psychotherapists’ Guild, 303-444-1036. Dr. Miller welcomes reports about other strategies to help patients obtain their managed care treatment benefits.

This article is intended to be widely circulated. Permission is granted for it to be photocopied and distributed by e-mail. For permission to publish it in print or on a web site free of charge, contact — Ivan J. Miller, 350 Broadway, Suite 210, Boulder, CO 80305, 303-499-3888 or by e-mail at IvanJM@aol.com.