It can be difficult to explain to a therapy client why sex therapy and couples therapy may not be covered by insurance companies. However, one reason is that insurance companies categorize these types of therapy as not “medically necessary” in the same way as other types of medical treatment. Additionally, insurance companies may have specific requirements or diagnoses that must be met before they will provide coverage for these types of therapy. To add to the confusion, Premera will tell members that couples/family therapy is a covered service code–which is correct. However, if billing accurately, the most common diagnostic code for couples therapy is “Z63.0: Problems in a Relationship with Spouse or Partner,” and insurance does not consider that diagnosis a mental health issue requiring treatment.
Some therapists will simply choose an identified patient, assign a covered diagnosis, and bill insurance for couples therapy so that their clients can get coverage. This strategy is a great way to get coverage for couples therapy, but it leaves the provider vulnerable to an insurance audit. Our insurance contract requires us to assign the most accurate diagnosis possible, so if our notes don’t reflect that billing, Premera can claw back any payments related to the case in question. Because of that risk, we will not bill Premera for couples or sex therapy unless the primary diagnosis is accurate, billable, and not better described by a non-billable code, such as Relationship Issues.
If you have Premera and are beginning couples or sex therapy treatment, we will have you sign an insurance waiver acknowledging that we cannot bill insurance. For non-Premera couples and sex therapy clients, we can provide superbills for out-of-network reimbursement, should your plan allow.
It’s important to note that insurance coverage is constantly changing and evolving, so it’s always a good idea to check with your insurance provider to understand what is covered under your plan and to find out if there are any out-of-pocket expenses you’ll need to pay for couples and sex therapy.