Navigating Insurance Reimbursement for Evidence-Based Treatment

Navigating Insurance Reimbursement for Evidence-Based Treatment

At OCD Spectrum, we recognize the scarcity of specialists who treat OCD, severe anxiety disorders, phobias, and Body Focused Repetitive Behaviors (BFRBs) like hair pulling or skin picking (Trichotillomania or Dermatillomania). To assist you in seeking reimbursement for a portion of your therapy costs, we’ve compiled this guide. Although it primarily focuses on OCD, you can apply its principles to advocate for reimbursement for other diagnoses.

Your Right to Adequate Treatment

Health insurance companies are obligated to provide their participants with proper treatment for their specific diagnosis. This entails connecting you with a qualified clinician experienced in addressing your condition. Unfortunately, finding specialists in OCD, severe anxiety, phobias, and BFRBs within your insurance network can be challenging, as many specialists opt not to work with insurance plans.

Tips for Conversing with Insurance Companies

Before reaching out, please read this guide thoroughly. During your interactions with insurance representatives, maintain a record of the conversation, including the full names of those you speak with and reference numbers. Remember, you’re advocating for your mental health, so be assertive, stay composed, and assert your rights as a consumer.

Key Points to Keep in Mind

  1. Insurance companies should not be seen as doing you a favor by allowing and reimbursing you for an out-of-network provider. You and your employer have invested in your benefits, and you’re entitled to them.

  2. Be persistent and do not accept a simple “no” for an answer. Insurance companies aim to minimize expenses, but your determination will pay off.

  3. Understand that insurance companies are profit-driven entities with shareholders. Their primary goal is to minimize expenses, so they may employ various tactics to achieve this.

Steps to Follow:

  1. Contact Your Insurance Company’s Customer Service: Contact your insurance company’s customer service to inquire about local practitioners specializing in your condition. Specifically, ask if they provide Exposure and Response Prevention (ERP) therapy for OCD. If your request is denied or met with unhelpfulness, escalate by requesting to speak with a manager or inquire about a Care Advocate or Patient Advocate.
  1. Determine Provider Locations: If you receive a list of providers, determine their locations, as some insurance plans have geographical limitations. Normally, you cannot be compelled to see a provider beyond a certain distance from your residence.
  1. Call and Evaluate Providers: Call each provider on the list and inquire about their experience in treating OCD. Be cautious, as many providers list OCD as a specialty without being adequately qualified. Ask about their treatment methods and training. Don’t be discouraged if they do not meet your criteria.
  1. Advocate for Permission to See Your Chosen Therapist: If none of the suggested providers meet your requirements, advocate for permission to see your chosen therapist. If they admit they have no qualified in-network therapist, you can push for the right to see an out-of-network therapist.
  1. Inform Them of Your Competent Provider: If your insurance plan acknowledges the absence of a qualified therapist, they may attempt to negotiate an “ad hoc,” out-of-network, or “single case agreement.” Alternatively, you can request direct reimbursement for your out-of-pocket costs, as OCD Spectrum does not engage in “single case agreements.”
  1. Negotiate Reimbursement Terms: Negotiate the reimbursement process, whether it involves deducting your copay per session or other terms. Be prepared to provide any necessary paperwork.
  1. Assert Your Rights in Case of Partial Coverage: If the insurance company states they do not cover out-of-network providers, assert your rights. Remind them of their obligation to provide adequate care and reimbursement under your contract terms.
  1. Deal with Deductible Objections: If they mention a deductible, clarify that their inability to find an in-network provider obligates them to apply in-network benefits to your out-of-network care.
  1. Request to Speak with a Supervisor: If they resist your efforts, ask to speak with a supervisor or request a “care advocate” assigned to your case. Clearly explain your situation once more.
  1. Verify Competence of Provided Therapist: If they insist they have a competent provider, ask for the person’s name and credentials, inquiring about their specialization and training in OCD with ERP. Share any reasons why this provider may not be suitable. Most companies will comply at this stage, as they recognize your knowledge of your rights. If not, consider filing a formal complaint with the state insurance regulatory agency.

If They Agree to Reimburse You

Request a written contract detailing the approved number of visits and reimbursement rates for various services. Ensure clarity on how your standard copayment will be handled. Familiarize yourself with the relevant CPT codes used by insurance companies for billing purposes:

  • 90791: Intake or first visit
  • 90834: Regular 45-minute session
  • 90837: Regular 55-60 minute session
  • 90847: Family session
  • 99203 – 99205: New patient office visit for a psychiatrist
  • 99213 – 99215: Follow-up psychiatrist office visit

Remember, you have the right to quality mental health care. Advocate for yourself confidently, and know that OCD Spectrum is here to support you in your path to healing and well-being.