I’m guilty. I’m yet another therapist with a specialty niche who doesn’t accept insurance. Why? Insurance often dictates how, when, & where a session can take place. For #OCD and related disorders, it can be difficult to provide quality treatment while sticking to the rules dictated by insurance. For example, in #Exposure and Response Prevention (ERP) it’s often essential for therapists to conduct home visits, have sessions within the community, or sessions via telehealth. Also, sometimes sessions need to be longer or happen more than once a week. Many insurance policies offer a once weekly in-office 50 minute session and these restrictions simply may not work for each individual’s treatment plan.
When you are seeing an out-of-network therapist you may receive a coded statement so that you can potentially get reimbursement from your insurance. This is great but, sometimes requires you to first meet your deductible and, if you are relatively healthy, perhaps that hasn’t happened in the calendar year. This is where the magic of a Single Case Agreement comes in. A single case agreement is an a one time contract between you (the patient), your insurance company, and the therapist. If this agreement is made, the patient can expect to receive 40-80% of their fees reimbursed depending on the quality of the policy. You will likely still pay your therapist out of pocket but, the hope is that you get those fees directly reimbursed to you. Your argument: you cannot access the appropriate treatment in-network and are requesting to see someone out-of-network at the benefit level of an in-network provider. For many many people, this is easily justified but you will have to do your due diligence first and follow these steps.
Build your case: You must make sure (and sometimes prove) that there is no one in-network that can adequately meet your treatment needs. You can often go through the list of in-network providers and see if they are trained in the treatment you are looking for (ERP & ACT for OCD or CBIT for Tourette treatment), or you can cross reference your in-network list with provider directories from the International OCD Foundation or Tourette Association.
Make the request: Once you’ve done your ground work to prove there is no one in-network, it’s now time to call your insurance to request a single case agreement. Get ready to fully and assertively explain why this is necessary. I provide a script for my patients with all necessary evidence based information and codes but, you can say something like “I am searching for a provider who treats OCD with Exposure and Response Prevention. ERP is the gold-standard treatment for OCD, yet I cannot find anyone in-network. I’d like to request a single case agreement for the out-of-network therapist I would like to see”. It’s also important to note that you will be paying your therapist out of pocket, and would like reimbursement to go directly to you.
Get ready for the run-around: Chances are they will try to sell you on “Dr. Whatchamacallit, who just happens to be 1 block away and says they treat OCD and are in-network!” You may then have to call Dr. Whatchamacallit and ask about in detail about his training. Keep detailed notes of this conversation so that you can show your insurance company that just because Dr. W checked “OCD” along with 29 other things that he treats, doesn’t mean they are adequately trained.
Get ready for a “No”: Insurance companies will often tell you no and hope you give up. If you aren’t the most assertive person, this is where you can illicit the help of a family member. The insurance company may want to speak to the provider to discuss why this is medically necessary for you. Any good specialist will be able to argue your case (if indeed you have one). Typically, this process takes less than 20 minutes. I offer a one-time 20 minute insurance call to all patients at no-cost. However, even if your therapist needs to charge you for this time it could be WELL worth it.
Don’t give up: After your therapist speaks on the medical necessity of this treatment you may get an immediate yes or no or they may bump it up to the next level staff who makes these decisions. This may require yet another call by your therapist but, again, well worth it in the long run. If you get a denial you can and should appeal. Most insurance companies don’t want to deal with the headache of an appeal and, if you can back up your statement, I’ve had many patients note to their insurance that they will seek legal counsel if necessary.
The larger insurance companies are accustomed to this process and will be easier to work with.
Good luck on your journey and don’t take no for an answer.
To your health,