Does my insurance cover that?
I’ve answered this question in many forms over the years, especially as it relates to whether career counseling is covered. But I want to offer a much more technical explanation about how claims are processed in hopes that it helps take the confusion out of billing practices.
Whether you pay your provider directly and file claims yourself or ask your provider to file claims for you, certain information is required for the insurance company to determine whether the provider’s service will be covered under your policy. This information is most often transmitted from a provider’s computer to the insurance company computers but is sometimes entered from a paper claim into the insurance company’s systems.
Here are the important parts of a claim:
Who’s the patient? The computer program looks for the last name, first name, and date of birth along with plan ID to determine who was seen and to identify their coverage.
What’s the diagnosis? The computer program looks for an ICD-10 code that tells it what was being treated. (I use diagnosis F42.2 frequently because I treat OCD)
What’s the treatment? Here, we use CPT or procedure codes to say what we did to treat the diagnosis. Only certain “procedures” are acceptable matches for each diagnosis. (One insurance company will say 90834 (45 min psychotherapy) or 90837 (60 minute psychotherapy) are both OK for OCD and other insurers may limit treatment to 90834).
Who provided the treatment? The computer looks for a provider National Provider Identification or NPI number to make sure that person is qualified to provide treatment for the diagnosis AND then determines if it has a contract with that provider (in network or out of network).
Once the insurance company receives all of this information, and assuming no details are missing, it will designate the communication as a “clean claim.” Only then do they begin the process of deciding whether and how to pay either the provider or you, the patient, for those services. This determination is almost always made by computer programs that reference the patient, provider, diagnosis, and treatment to see if they match a “covered benefit.” If yes, then that benefit is paid out at the rate in the table, for that covered benefit. If any information is missing, the claim comes back as an error or as denied.
Only counseling with a diagnosis and procedure can be covered by insurance.
Some folks call my practice and don’t want a diagnosis assigned to them and hope their insurance will pay for this counseling. Unfortunately, there is no method for asking an insurance company to pay for counseling that’s not coded with diagnoses and procedures.
Every medical professional who codes their visits with clients or patients knows they must be reasonably accurate when coding both ICD-10 and CPT codes. Even if the provider is not contracted with your insurance company, to miscode an invoice on purpose is an ethical violation at best and fraud, at worst. Likewise, if there is no diagnosis, there can be no procedure code to treat it. People come to counseling for all kinds of reasons, not all of them diagnoses. So if the reason you’re in counseling is not to treat a diagnosis, it cannot be cured through psychotherapy and therefore will not include the codes needed to be reimbursed by insurance. No codes = no payment. Yes, there are some providers who have loose ethics and who may be willing to pad invoices with diagnoses and procedures that aren’t quite accurate but that certainly shouldn’t be how any medical provider conducts themselves.
The good news for consumers, is that if you don’t want a diagnosis or a codeable invoice, many practitioners will discount their rates for you, because it’s substantially less time consuming to document and bill therapy that’s not medically necessary. Plus, that type of therapy doesn’t have to focus so much on discrete treatment goals and can be more flexible for the client. So while we cannot ask your insurance to pay for therapy without a diagnosis, not having a diagnosis may have its own benefits.