Medical NecessityWhy I am a private pay provider
Americans are used to paying for medical treatment and services with their insurance. If they are become sick or injured they make an appointment with their physician and anticipate paying for these services by presenting their insurance card at check out.
It’s how the medical model and/or system works. People carry medical insurance so that when they get sick or injured and need to see a doctor, the cost is covered by the insurance company. What people don’t always consider is that the insurance company is driven by a medical treatment model. More specifically, the principle of “medical necessity.”
What is Medical Necessity?
Medical necessity is the standard by which the insurance company decides if the services you receive meet the criteria for a specific illness or medical condition. In other words, to be reimbursed by an insurance company for treatment, the physician you see must provide the insurance company with a medical diagnosis that satisfies their criteria and justifies the payment.
Without the medical diagnosis, the principle of medical necessity will not be satisfied and payment will not be approved.
Medical Necessity and Psychiatric Diagnosis
Because medical necessity is typically defined as the need for a service to be reasonable and necessary for the diagnosis or treatment of a disease, condition, illness, injury, or defect…claims that are submitted for insurance reimbursement must clearly identify a specific medical condition, illness, and/or diagnosis.
In the mental health field that means providing a diagnostic code from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). In short, for a person to use their medical insurance for mental health benefits and reimbursement they must meet the criteria for some type of mental or psychiatric disorder and that disorder must be the focus of treatment.
Protected Health Information
In addition to providing a diagnosis, the treating professional must release, to the insurance company, the person’s protected health information (PHI) which includes information about the person’s health status, medical records, laboratory results, etc.
Permanent Medical Records
This information then becomes a part of the person’s permanent medical record.
This can be an especially relevant subject for individuals who are concerned about the future implications of having some type of psychiatric diagnosis attached to their medical record.
Impact on Career & Insurance
For individuals who work as an attorney, pilot, first responder, are in the military or simply want to keep their therapy sessions private, the presence of a psychiatric diagnosis can be especially troublesome. As it can be for individuals seeking to purchase any type of life or personal protection insurance.
Relationally Focused Therapy
As a marriage and family therapist, my primary focus is on helping people develop relational harmony in their family, work, congregational and community systems. Relationally focused therapy, however, is generally not covered by insurance companies because such services are not considered medically necessary.
This means that couples, families, individuals, partners, parents, and organizations who wish to expand and further develop some facet of their relational self or relational structure are not considered medically appropriate for medical treatment and medical reimbursement.
Safe and Secure
As a private practice therapist, who does not transmit PHI electronically to an outside entity, I am not obligated or required to release any type of client information to any outside entity.
This means that I will never release any information about your relational therapy sessions without your permission and a client-directed reason to do so.
Limits to Confidentiality
Indiana law does provide limits on confidentiality. In brief, these include
- Individuals who are a danger to themselves or others.
- Abuse of an elder, child or dependent adult.
In such cases, safety is always the first priority and every effort will be made to maintain a safe and secure therapeutic experience.
You can rest assured that what you say in therapy will stay in therapy.
My goal is to provide all of my clients with a safe, supportive and confidential therapy experience.
Private, discreet therapy in a cozy, home-like setting.
Choosing a Private Pay Therapist
Choosing to work with a private pay therapist is an individual decision. For some people paying for therapeutic services via their insurance company seems appropriate because they feel it is a good value and they don’t want to miss out on the “benefits” of using their insurance.
A good number of people, however, recognize and embrace the therapeutic process as an investment that provides long-term relational, emotional, behavioral, and spiritual benefits. While it is correct to say therapy is a significant investment of both time and money it is an investment that will pay dividends for a lifetime.
Seeing a private therapist might not be the best choice for everyone.
But, if you are a person who recognizes the value of investing in personal development, believes their therapeutic work should be confidential, private and self-directed, if you want the freedom to choose the therapist you see, the number of sessions you want and believe therapeutic work shouldn’t automatically include a psychiatric diagnosis…
Private, relationally focused therapy just might be the perfect place for you to begin your journey to a more authentic, happy, and harmonious life.
Discover the freedom of private, client-directed therapy!
Get started today by calling…