Ethically Billing for Couple Therapy
Author: James McCracken, MSW, LCSW
A common post on psychotherapist referral forums and a common request by clients is for a couple therapist who bills these services to Medicare or commercial health insurance as an in-network provider. From a consumer’s point of view, this makes perfectly good sense to want and expect this: couple therapy is considered a type of psychotherapy provided by a licensed psychotherapist, so health insurance should cover this, right? Unfortunately, the answer is usually “No,” and the arrival to that answer is not what most clients anticipate. This causes concern, confusion and consternation for both clients and psychotherapists alike, but I hope my post, based on legal counsel we received plus additional trainings I have received, can be helpful to both clients and providers of these services.
To start, when a couple (or any romantic relationship, however they define themselves) presents for what we often call “couple therapy”, “relationship therapy,” “marriage therapy,” or “couples counseling” (all similar if not synonymous), they are asking for help in improving their romantic relationship or discerning if they need to end their relationship, and in some cases figuring out how to civilly and peacefully uncouple (more on that in another post sometime). Therapists who are specially trained to provide these services these days usually engage these clients in “systemic” therapies such as Emotionally Focused Therapy (EFT), Gottman Method Couple Therapy, Imago, Relational Life Therapy, Transformational Couples Therapy, etc., as these methods were specifically developed to address dynamic issues between both partners (although often attending to matters within each partner at the same time). This is a crucial point: in these therapies (which most clients are requesting and being provided) treat BOTH partners… not just one.
So, if we are honest about what we are doing and follow this logic, then when a couple is provided these services, the patient is “Partner A & Partner B” (and is indicated this way in healthcare records) rather than the patient being “Partner A” and Partner B being a supportive but included family member (side note: there are cases where this latter presentation is appropriate and recommended when an individual patient needs to include their family members in treatment to support their individual recovery, but this is different than relationship therapy). The “Partner A & Partner B” being patient and having a shared record means that both partners must consent to treatment, must approve treatment planning, and must authorize disclosures of protected health information. This also means that the therapist cannot keep any information for one partner and from the other because they are both joint holders of the record and all of the rights and privileges associated with this. This is important for many reasons, but chief amongst those is privacy rights, which HIPAA law outlines clearly. A therapist can’t be in compliance with privacy laws and do anything differently here.
So, what’s this have to do with billing? Well, this means that the patient is two or more people, and health insurance, using 1-person, 1-body medical thinking, does not recognize a patient as any more than 1 person. In order to bill health insurance or Medicare, a therapist must submit a bill under one person who has been diagnosed and given a treatment to address their diagnosis, but in the case of couple/relationship therapy, that is not what is actually happening: the therapist is treating two consenting adults simultaneously as a relational unit for a relationship dynamic problem (not an individualized diagnosis for one partner). This means that there are no billing codes that capture this service, and there is no medical billing structure in modern practice (for those who understand it, CPT Code 90847 and 90846 do not capture relationship therapy services… these capture when an individual patient’s family is included in treatment to support their individual recovery from a psychiatric diagnosis).
To ethically bill couples/relationship therapy, we set up the record under both/all partners names, have both/all partners consent to treatment, and assign an internal billing code for our services (same as when you see any other professional who doesn’t bill health insurance). Our therapists have reduced fee options for people who can’t afford our full fees (because we think as many people as possible who want it deserve relationship therapy services), and we provide invoices and statements for people to give to their tax accountants to see about tax deductions for healthcare services not covered by health insurance. And we DO NOT assign one partner as the patient, diagnose that one partner, and bill Medicare or health insurance for these services (we believe, based on legal counsel, this would be health insurance fraud). Billing the way we do, our therapists uphold privacy laws, rules and regulations, respect the rules for medical coding and billing, and give ethical access to these services to as many clients as possible.
If you see a therapist who provides you and your partner relationship therapy services but bills one of your health insurance, or if you are a therapist who does this, consider these questions before continuing to bill health insurance for relationship therapy services: Who is being treated (one partner or the whole relationship)? Who, legally, has rights/privileges for the record? What if the record is requested by one partner to give to someone else (i.e. their attorney)? What if the partner whose name is on the record asks the therapist not to share a secret with the other partner whose name is not on the record? If Medicare or insurance audits the records and determines the services have been improperly billed and claws back reimbursed expenses, who has to pay back the insurance company/Medicare?
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