While I see the benefit of many of my clients using insurance, I am not currently on any health insurance panels. Although, with this, I may be able to issue a client a superbill for the client to seek reimbursement as an out-of-network provider. Update: Given my belief in the importance of everyone having access to quality mental health care, I am in the process of becoming an in-network provider with several insurance panels. Please contact me for up-to-date details.
For many, using insurance is one of the only ways they may be able to participate in therapy and get the help they need. I seek to educate and equip my clients with the below information and knowledge so that each person may be able to make a well-informed decision on whether to use insurance or not.
1. Your therapist must diagnose you to get you reimbursed.
Insurance will not reimburse for therapy for issues such as “I am feeling down,” “I want to live my life to its fullest,” “I’m having a hard time,” or even for “grief/loss”. Insurance companies operate on a medical model, so this means that payment can only be issued when a client holds a diagnosis and insurers will only pay for things that are “medically necessary.” This means, for instance, that even within family therapy, each individual may receive a label. Also, you will have to prove that your challenge is impacting your health on a day-to-day basis. Many folks seek treatment before their issue would meet criteria for diagnosis as a mental health disorder, which is such a good thing. With this, while labels may provide a path to information and clarity to many who receive them, it is worth noting that labels may be part of the client’s official record permanently.
This may never matter to you…if you are one of the fortunate ones who have medical, life, and disability benefits through your employer… you might never worry about this; however, if you’re someone who might ever be unemployed, self-employed, or needs to purchase your own benefits- a mental health diagnosis can make the difference between preferred coverage or none at all.
Children may 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 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). If your child’s condition warrants a diagnosis, you may want to have some say over how that diagnosis functions in their life.
2. Your records are not protected.
If you get diagnosed with something, you should be able to decide who gets access to that info and why. Your insurance company can audit your records at any time they wish. This means any details that your therapist might not have included in the paperwork (perhaps for good reason) is technically open to the eyes of any “claims specialist” the company hires. 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. This may not matter to you. But if you hold high clearance for a job, or have other reasons you want your information to be held confidential- this is vital to know.
3. Your care is dictated by the insurance company
Most insurance companies require some sort of treatment plan to be submitted your therapist. This means that, rather than giving you the care that best fits your needs, the therapist is responsible to the (non-mental health professional) claims representative for how you spend your time in therapy. To put it simply, a therapist fits your needs into the framework of the insurance allowances. It may not matter what you and your therapist decide is in your best interest for optimal care, it will need to fit within their matrix of decisions. It also has to fit within the allotted sessions (usually limited to 6 to 8), which are determined ahead of time, not based on need. With this, I have known insurance companies to admirably accommodate additional sessions (when requested).
4. Insurance almost never pays the full fee
This means you are either going to be responsible for the remainder, which you need to clarify ahead of time, or it means your therapist is working for less than a fair market wage.
So what can you do about it? There are options!
1. If possible, pay cash for sessions.
This ensures that your records and diagnoses are entirely confidential documents. The content of your session stays entirely between you and your therapist. And your care is dictated by what you think you need, not your insurance company.
2. If you cannot afford face-to-face sessions, consider an online platform that offers Telehealth sessions.
Telehealth sessions are typically more cost-effective as the therapist does not have to maintain an outside office space and other associated costs. All you need is a secure platform and a seasoned therapist who knows the legal and ethical ins and outs of telehealth sessions. I work with many experienced clinicians who offer this option as part of a private practice (like I do). Best of all, it allows the client and therapist to maintain control and confidentiality. Please note, not every client is a good candidate for this approach to therapy. Please see the “Telehealth and Online Therapy” section for more information.
Further, in an effort to offer therapy to individuals who truly cannot afford my full fee, I have a limited number of slots available on Open Path, which allows me to offer therapy to dedicated and motivated clients—often at the cost of a co-pay.
Please refer here for more information: https://openpathcollective.org/clinicians/jennifer-hyatt/
3. If you need to bill insurance, you can pay for therapy up front and attempt to submit for reimbursement through an out-of-network provider.
This will cost you up front, and your diagnosis will be recorded, but it gives you the freedom to choose any licensed clinician and their records are more protected than if you go with an in-network therapist.
See if your insurance will reimburse you for out-of-network providers
Though I do not take insurance within my private practice, I am happy to provide you with statements/invoices that many insurance companies require (e.g., a superbill). Please note, I will only issue a superbill to the client, the follow-up and other associated responsibilities will reside solely with the client.
If you are contacting your provider to see about coverage for out-of-network providers, ask the following:
- How many sessions are covered?
- Do I have to meet my deductible first? Is there an out of pocket max?
- Do they require a treatment plan or detailed summary for reimbursement?
- Do they reimburse for V Code 61.1 (for couples counseling)?
- What are the qualifications required of the practitioner? What information do they need from the therapist?
Of importance, these are not the only items insurers base reimbursement on…
Treatment not only includes the procedural code but the diagnostic code. The diagnostic code tells the insurance company what mental illness the client 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 is like trying to get your dental insurance to cover cosmetic whitening. Not going to happen. Insurance companies view relationship problems much in the same way that they view cosmetic dental 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.
4. If you absolutely must bill insurance and see an in-network therapist, do your due-diligence ahead of time.
If they are in-network with your insurer, they should have an idea of what level of transparency your insurer expects. They likely know if their notes will be requested, if a treatment plan will be required, and what diagnoses they will need to give you for coverage. Asking ahead of time can help you decide how you want to proceed.
It is important to note that I am not against using insurance. In fact, I see the benefit of using insurance for many. Rather, I advocate for the knowledge that, while insurance allows access to many clients who would not otherwise be able to afford therapy, I believe that my clients should be fully informed and be able to make the best and well-informed decision possible.
I believe in the golden rule. I think consumers deserve to know the nitty-gritty details. In fact, I think educated consumers are our best shot at system change. And so… there it is.