Fight for Insurance Reimbursement for Evidence-Based Treatment

Due to the shortage of clinicians specializing in the treatment of OCD, severe anxiety disorders and phobias, and Body Focused Repetitive Behaviors, such as hair pulling or skin picking (Trichotillomania or Dermatillomania), you can apply and petition to receive reimbursement for out of pocket costs for treatment. The following article is a guide for this process.

This article focuses on the treatment of OCD but if you are seeking reimbursement for phobias or other anxiety disorders, you can substitute the word "OCD" for your specific diagnosis. If you are being treated for Trichotillomania, Dermatillomania, or a tic disorder, you will go through the same steps but instead of asking about Exposure with Response Prevention as the treatment, you will substitute this for Habit-Reversal Training or C.O.M.B. (for Trichotillomania or Dermatillomania) or CBIT (for tic disorders). Please ask Dr. Solomon any questions about adapting this article more specifically to those disorders if necessary.

There is also a program that some of my patients have used that has helped them with reimbursement. I have no professional or financial affiliation with this program. This link is for informational purposes only. https://reimbursify.com/

Fight for Your Rights: Getting Your Insurance Company To Pay For OCD (and related disorders) Treatment

This handout is adapted from an article by Fred Penzel, Ph.D. and is for informational purposes only.

There is a little secret that your insurance doesn't want you to know about. The rules say that your company is responsible for providing you with adequate treatment by properly trained practitioners. This is particularly so if you belong to an HMO, are required to see doctors who are a part of your plan and are not covered for the services of professionals outside of your plan. Specialists in OCD, severe anxiety disorders and phobias, and BFRBs are, unfortunately, in short supply, and chances are good that you will not find one within your company's list of providers. The plain truth is that many specialists do not work for insurance plans. This is also true of most specialists in OCD and related disorders.

Remember to BE PERSISTANT. Many insurance companies "default" answer is to first deny a claim, and even an appeal. If you get a denial, this does not always mean it is a dead end.

STEP 1:You will most likely start by calling your insurance company to ask someone in customer service whether or not they have any practitioners who treat OCD. If the customer service representative is not helpful or tells you that your request is not possible, you can ask to speak to a manager or ask if they have a Care Advocate or Patient Advocate you can speak to.

Before you make this first call, read this article in full. Always be sure to take notes of every conversation you have with anyone there, and always get the full name of each person you talk to. Insurance companies have a nasty habit of forgetting things they have promised or information they have given out.

STEP 2: When you call a customer service representative at your plan, and ask for the name of someone local who treats OCD (or phobias and other anxiety disorders) with Exposure and Response Prevention (E/RP)*, you will probably be given many names of providers that say they treat OCD. Unfortunately, many therapists just check a box that they treat these disorders on their application to be part of an insurance panel but they are not trained in E/RP and do not have expertise in the disorder. Find out where they are located, as there may be rules about how far your company can require you to travel to see someone. Usually, you cannot be required to see someone outside a certain radius. Alternatively, they may ask you such things as, "What is E/RP?" Please be aware that MANY providers list OCD as a condition that they treat, however, most have very little, if any, training in E/RP.

*If you have a BFRB, you would do the same as above except you would ask for names of therapists that provide Habit-Reversal Therapy or C.O.M.B. for Trichotillomania or Dermatillomania (Excoriation Disorder).

In the former case, if you call the professionals whose names and numbers they give you, you will most likely find (unless you are particularly lucky) that they are not taking new patients, or do not treat your problem and cannot fathom why the company gave you their name. If they say they do treat OCD (or the related disorders listed above), grill them on how many cases they've treated, what methods they use (Exposure & Response Prevention should be the answer for OCD and anxiety disorders, Habit-Reversal or C.O.M.B. should be the answer for BFRBs), and what kind of training they have had to be able to do this. In most cases, they will not have the right answers and will probably get a bit cagey with you. You can see more specific questions at the end of this article. Sometimes, the numbers you are given may be out of service or that provider does not even take your insurance anymore. DOCUMENT THE DATES YOU CALLED, THE CLINICIANS YOU SPOKE TO, AND THEIR ANSWERS TO YOUR QUESTIONS.

STEP 3: If none of the company's professionals pan out, you graduate to the next step, and are now in a position to make your plan give you permission to see the therapist of your choice. If they actually have the honesty to admit they have no one, this is even better, as you will certainly be able to force them to let you see whom you want, even if that therapist is not officially a part of your plan.

What you do next, in either case, is to inform your insurance company that you have found someone who is considered competent to treat what you have. I should add, at this point, that to make all this work, you need find that competent professional before you set all of this in motion. Also, you need to make sure they are properly licensed, either as a psychologist or a social worker. Dr. Solomon is a licensed clinical psychologist with advanced specialty training and expertise in the treatment of BFRBs, anxiety disorders, and OCD-spectrum disorders using evidence-based psychotherapy interventions that adhere to the expert consensus best practices guidelines for these disorders. Dr. Solomon is a graduate of the BTTI, an advanced training and certificate program by the International OCD Foundation. There are very few clinicians who are trained at this level. You can find a description of these treatments on the following websites: www.iocdf.org, www.adaa.org, or www.bfrb.org. You can send this information to your insurance company.

STEP 4: If your company admits that they have no one who meets the criteria for a specialist in evidence-based treatment of your disorder, they may want to contact the practitioner and negotiate what is commonly known as an "ad hoc," out-of-network, or "single case agreement."  This will enable the professional to be paid part of their fee, without your having to pay more than your usual co-payment. In effect, you will be covered on an in-network basis, not out-of-network.

Dr. Solomon does not do "single case agreements" or negotiate payments with insurance companies, however, you may tell your insurance company that because they have no one to treat your condition, you are requesting that they reimburse you directly for your out of pocket costs. They may deduct the amount of your copay from each session, just as this would be customary if you were seeing someone in-network. You may want to ask them how they plan to reimburse you (by session, monthly, etc.) and negotiate a reasonable agreement regarding a reimbursement schedule. Dr. Solomon will provide you with all necessary codes and copies of your invoices to submit to your insurance company.

If they decide to put up a fight and get difficult about it, they will start by either telling you they simply do not cover out-of-network providers, or, if you have out-of-network coverage, that you are free to see someone outside their list, but that they will only pay out-of-network rates usually 50 percent of a fee that they think the practitioner should be charging (generally a lot lower than the going rate). At this point, you have to get more assertive and say something like, "I'm afraid you don't understand the situation. You have no one in your network who is qualified to treat me, and since you are obligated to provide me with care under the terms of my contract, you must now allow me to see someone out-of-network, but on an in-network basis, and you will have to reimburse me for my out of pocket costs". They may also say that because you have not met your deductible, you are not eligible for out of network benefits. Again, remind them that this may not apply because they do not have anyone available on their panel that is qualified so they must apply the benefits for in-network providers, not out of network providers due to their inability to offer an in-network provider!

If they now realize you know your rights, they will ask for the name and phone number of the practitioner. Dr. Solomon will be happy to complete paperwork or speak to your insurance company to assist in the process but please be aware that these calls can be very timely and charges for Dr. Solomon's time may apply. Usually, it can take more than an hour of phone tag for Dr. Solomon to get to speak with the correct person on the insurance panel as well as advocate on your behalf. Usually, all they want is to send Dr. Solomon a form to complete, which you can request they email her instead of having to speak with her first. In order to communicate with your insurance company, you must fill out a release of information form allowing Dr. Solomon to speak with them.

STEP 5: If the insurance company still resists, you must then ask to talk to a supervisor or request a "care advocate", and assertively explain the situation one more time. If they insist that they really do have a practitioner, ask for that person's name and credentials. Also ask if they are known specialists, and have specific training in treating OCD with E/RP. Also ask how many people with the disorder they have treated. Since you have already called a whole list of people, you may be able to inform them that the professional they have in mind for you, a) really isn't qualified, b) isn't taking new patients, or c) didn't know what E/RP was, etc. Hopefully, at this point, they will recognize they are now in a no-win situation and will give in. Most companies do at this point. If you have an unusually stubborn company that can't tell when they have no case, you may have to contact the state agency that regulates insurance companies. As I mentioned earlier, always be sure to get the full names of everyone you speak to at the insurance company, as you may need them if you file a complaint. *See the additional article below for tips on interviewing potential therapists.

Overall, be assertive, speak firmly, don't lose your cool, and indicate that you know your rights as a consumer. If you get angry, you will be labeled as difficult, and will undercut your own position. Just remember that the insurance company isn't doing you a favor if they let you go out-of-network. You (and/or your employer) are paying good money for your benefits and you are entitled to them. Don't be bullied, put off, or take "no" for an answer. Persistence pays off; so don't let them double-talk you. Never forget that you are dealing with a profit-making business with stockholders, and not a humanitarian organization. They are dedicated to paying out as little as possible and will use every ploy they can in order to do this.

*** If the insurance company denies your request, you should immediately APPEAL the decision. Many insurance companies automatically deny these requests but grant them on appeal. You should also request a peer-to-peer review, which means that a professional trained in mental health would review your claim.

If your insurance company has agreed to reimburse you for your treatment, it is helpful to request a contract or statement of agreement in writing from the company. The paperwork should state how many visits have been initially approved with the practitioner, and the rate your company has agreed to reimburse you for various services. The standard insurance service code for a first visit/intake is 90791, and for regular office visits of 45 minutes is 90834 and 60+ minutes is 90837, and the contract should clearly state how much will be paid for each. You will also need to know if you your standard copayment will be deducted from this reimbursement.

Although this process is not guaranteed and can be very time-consuming, I have had many patients who have successfully negotiated with their insurance companies and can tell you that this can be done, and is being done by savvy consumers all the time.

How to Find the Right Therapist: Questions to Ask

Finding a therapist who can diagnose and effectively treat OCD is a challenge to many patients and families. Some estimates indicate that it can take up to 14-17 years from the onset of symptoms, to getting an appropriate diagnosis and effective treatment for OCD.

Why the delay?

  • Hiding symptoms. Some people choose to hide their symptoms, often in fear of embarrassment or stigma. This causes many people with OCD to not seek the help of a mental health professional until many years after the onset of symptoms.
  • Not enough public awareness of OCD. Until recently, many people did not know there was even a name for their disorder and with no name, they assumed there was no treatment.
  • Lack of proper training in health professionals. People with OCD often get the wrong initial diagnosis from health professionals and may wind up seeing many doctors and therapists over the course of several years before finally getting the right diagnosis.
  • Difficulty finding local therapists who can effectively treat OCD.
  • Not being able to afford proper treatment.  

The 2013 APA Practice Guideline for the Treatment of Patients with Obsessive Compulsive Disorder recommends beginning treatment with a type of Cognitive Behavior Therapy (CBT) called Exposure and Response Prevention (ERP), which has the strongest evidence supporting its use in the treatment of OCD. Below are some "tips" and guidelines for finding a good ERP therapist.

Tips for Interviewing Therapists These tips have been adapted from "How to Choose a Behavior Therapist" by Michael Jenike, MD

As you begin the search for a therapist, it is important to know that there are many factors that can go into finding the right therapist for you. Your initial consultation may be done over the phone, or in person, but either way, remember:

  • You have a perfect right to ask questions. This is your life and health!
  • If the therapist is guarded, withholds information, or becomes angry at your requests for information, you should probably look elsewhere.
  • If the therapist appreciates how important a decision this is for you and is open friendly and knowledgeable, you may have a gem of a therapist!
  • Your relationship with the therapist is important. Especially since they will potentially be asking you to do things that you find uncomfortable as part of your treatment.

Here are some good questions to ask as you consider whether the therapist is a good fit:

"What techniques do you use to treat OCD?"

If the therapist is vague or does not mention Exposure and Response Prevention (ERP) specifically, use caution.

"Do you use Exposure and Response Prevention to treat OCD?" *

(Habit-reversal Training or C.O.M.B. for BFRBs)

Be cautious of therapists who say they use Cognitive Behavior Therapy (CBT) but won't be more specific.

"What is your training and background in treating OCD and related disorders?"

If they say they went to a CBT psychology graduate program or did a post-doctoral fellowship in CBT, it is a good sign. Another positive is if a therapist says they are a member of the International OCD Foundation (IOCDF), The Anxiety Depression Association of America (ADAA) or the Association of Behavioral and Cognitive Therapists (ABCT). Also look for therapists who say they have attended specialized workshops or trainings offered by the IOCDF like the Behavior Therapy Training Institute (BTTI), The Annual OCD Conference, or TLC Conference for BFRBs.

"How much of your practice currently involves anxiety disorders?"

A good answer would be over 25%.

"Do you feel that you have been effective in your treatment of OCD?"

This should be an unqualified "Yes".

"What is your attitude towards medication in the treatment of OCD?"

If they are negative about medication this is a bad sign. While not for everyone, medication can be a very effective treatment for OCD.

"Are you willing to leave your office if needed to do behavior therapy?"

It is sometimes necessary to go