Tricky Insurance Guidance Needed for Counseling

August 19, 2008 7:22 PM

How do I get insurance approval for counseling in a tricky situation?

Okay. Recently married (2.5 months). Already separated (a couple of weeks). Wife was wanting a divorce, but now leaving door open to work through issues first to see where we stand.

We both still love each other (hopefully enough to remain married, not just friends), but need to get our own issues resolved before we can begin to work on our marriage (no cheating, no abuse, etc - just issues that can indeed be worked out if we are willing to and want to).

We both want to see a therapist/counselor (on our own, not together at this time). However, my insurance specifically denies marriage/relationship counseling.

It will cover other counseling, up to 20 visits a year per member.

I would like to get insurance to cover as much of this as possible, as we're talking $40 copay a visit vs $75 a visit without insurance.

I am seeking advice from either anyone who has been in this situation before, a doctor/nurse, or someone who deals with insurance claims. I have to get preapproval and do not know what to say. Since I am not seeking direct marriage/relationship counseling, I am seeking guidance/explanations for my own personal issues (as is my wife), do I just state I need to see a counselor for depression?

I am also concerned about any negative stigma that certain "reasons" may show up as on my medical history.

Please help! This is hard enough to be in this situation with my wife, but I really cannot figure out the insurance part of this either!

posted by anonymous to health & fitness (5 comments total)

Depression's a diagnosis. Don't diagnose yourself too soon, just tell the nice screening people that you feel that you need to talk to someone. You don't have to lie, but I wouldn't get too specific unless they ask something very specific.
posted by fairytale of los angeles at 9:13 PM on August 19, 2008 [1 favorite]

fairytale has good advice. I would also add that depression is not the only reason people seek out counseling. Now, I don't know how problematic your insurance company is going to try to make this for you (hopefully not at all, if they're at all sensitive to mental health). But I think that saying that you need to talk to someone about some personal issues should be enough to get you the pre-approval, don't you think? If they pry (and I think that ethically, they shouldn't), just stick to what affects your life - such as you find it hard to get through each day, you are anxious and worried all the time, you don't feel like your normal self but you can't seem to make yourself feel better. (Those are just examples, use whatever describes you best. But probably best not to mention your wife. Stick to describing your own feelings.)

Also, remember that you are not the professional here. I think it should be up to your counselor to provide the insurance company with a reason for the 20 sessions; how can you be expected to diagnose yourself? (As you can see from this list on Psychology Today's website there's a huge number of diagnoses to choose from...) That's how it works with my HMO, anyway - the counselor has to submit a diagnosis after the first session or two in order to justify the remaining sessions.
posted by inatizzy at 6:41 AM on August 20, 2008

Does your employer, or your spouse's, give you access to an EAP (employee assistance program)? These programs usually provide a limited number of counseling sessions for free (the programs I've seen usually provide 6). You call in to a toll-free number, staffed by licensed clinical social workers and other mental health professionals, and do an intake. They ask you what you want and then they refer you to a list of counselors in your area. It is completely confidential. After the 6 sessions you can continue with the therapist by paying cash (most are quite affordable if you do a sliding scale and the therapist isn't a psychiatrist) or file it against your insurance.
posted by FergieBelle at 8:21 AM on August 20, 2008

There's no reason not to call up your insurance company and ask what the process is for pre-approval of benefits (and don't specify that it's for counseling if you don't want to disclose that). I'm guessing--although obviously I could be wrong here, since I don't know your specific insurance--that pre-approval may require something like a primary-care doctor filling out a request form certifying that you need psychiatric care. So that would be your first step, figuring out exactly what documentation your insurance company needs to approve this. If you get insurance through your work, your HR department might have the info about who to contact regarding pre-approvals.

Just as background: a lot of insurance companies don't cover any mental health benefits because it's seen as something of a black hole of costs with no end. That's because therapy and other mental health services are appropriate for (in the sense that they can legitimately help) everyone from the guy with paranoid schizophrenia who literally cannot function without medication and constant monitoring of said medication down to the relatively well-adjusted guy who is experiencing some interpersonal problems. When insurance companies do offer mental health benefits--in some cases, because states have enacted "mental health parity" laws which require them to--they may be quite stringent about making sure it's a medical issue that is being addressed rather than an interpersonal relationship sort of issue.

All of which is to say: you might find it really difficult to get your insurance company to cover this, and if you do get them to cover it, it may only be possible if you find a psychologist or psychiatrist willing to diagnose with you something serious enough that it will forever blacklist you in the individual insurance market (god forbid you ever lose your job in that case). In general, I think it's a bad thing when people forgo getting mental health treatment because of what it might do for their future insurability, but I think you should really do some research on this and consider whether it's better to go get marital counseling on your own dime. Given the delays that may be involved in getting approved (particularly if you need counseling PRONTO to save your marriage), the trouble you may have in finding a covered counselor and the wait times they may have for an appointment (do you even know how big the network of mental health providers is for your insurance? that should be pretty easy for you to find out and is valuable data in deciding whether it's worth really trying to get your insurance to cover this), and the potential ramifications of a not-quite-honest diagnosis of mental illness if you are in fact psychologically healthy, I'd think really hard about whether all that was worth saving $35 per appointment. Hell, if you go in offering to pay cash, you might even be able to get a discount from the counselor on the fee, since they don't have deal with the headache of reimbursement paperwork.
posted by iminurmefi at 10:48 AM on August 20, 2008

I have Medicare and treatment offered at Clinic A; my partner has private insurance and treatment at Clinic B. We attended counseling together, couples style, but officially I was ahem family support member for my partner who was officially ahem being seen individually. Hurray for the therapist who had no problem finding the loophole we needed to get our collective noodles back in the bucket.

Good luck to you.
posted by mcbeth at 2:57 AM on August 21, 2008