With a diagnosis of OCD, you are legally entitled to the in-network rate coverage from your insurance for a specialist in OCD. The laws that govern health insurance are written to make sure patients can access the care they need, relatively close to home, and have costs for these services covered by the insurance product for which the patient/consumer is paying. A person with OCD has a right to see an OCD specialist for psychotherapy in the same way a cancer patient has a right to see an oncologist. If there is no oncologist within a certain radius of a patient who is in-network, the insurance company is obligated to cover an out-of-network provider who is able to provide the necessary care. The same is true for OCD.
When your insurance company does not have an in-network provider who is a specialist in the condition for which you need care, this is called a "network deficiency" or a "network gap." You are entitled to a network deficiency exception (or network gap exception), which means your insurance would agree to reimburse you at the in-network rate for an out-of-network specialist who is approved by your insurance to provide the appropriate care.
Although SOAR does not accept insurance, Dr. Martinez is passionate about advocating for patient rights. Below is the process she encourages all patients with a diagnosis of OCD to follow in order to maximums their insurance benefits and minimize out-of-pocket expenses. Scroll all the way down for specific details on how this process is implemented at SOAR.
Step 1: Be ready to educate, advocate, document, and keep calm
It's really important to start with the right attitude. Be assertive but also patient, be friendly, and kind to the people you speak to at the insurance company. Unfortunately, with most insurance companies, this process tends to be long, frustrating, and often gets derailed by well-meaning people working within overly complicated insurance systems who just don't understand it's intricacies. It is not uncommon to have a representative unfamiliar with this process steer you in the wrong direction or seemingly stonewall your progress because they don’t know what they don’t know. Departments within some insurance companies do not communicate well--the most frustrating and costly example of this is when one department authorizes an exception, and then the Claims Department does not authorize the reimbursement that was agreed upon. This happens. Be ready for the slough. Get a notebook and a folder. Take notes on every call--note the date, summarize the call, and get the name of who you are speaking with, what their role/title is and their department, make sure they are documenting your call in your file, and if there is a reference number for the call, write it down; keep every piece of mail you get regarding your insurance; stay organized and stay clear. Your advocacy for yourself/your loved one is not over until you cash that last reimbursement check from your insurance company. Keep in mind that any agreement you come to with insurance may have an expiration date. Set alarms and calendar reminders for yourself to revisit authorizations and agreements as these deadlines near.
If you do not feel that you have the time, energy or attitude to manage this process yourself, you may want to look into getting help from a professional advocate or agency, such as Reimbursify (https://reimbursify.com/)
Step 2: Initiate the conversation with your insurance (ideally, do this prior to starting treatment)
Prior to treatment (or as soon as possible), call your insurance provider and ask to speak to a “case manager” or “care advocate” (different insurance providers use different terms for the person in this role) about getting an exception to have an out-of-network specialist covered at the in-network rate. Be prepared for the first person you speak with to not be familiar with this process. Sometimes using the terms “single case agreement” or “letter of agreement” in your inquiry will help you get to the right person. It is uncommon for people with mental health concerns to have a case manager with their insurance company, but it is more common for people with very serious physical illness, like cancer or a complex medical problem, to have one. You may have to ask, “Who would someone talk to in order to coordinate their care if they had cancer?” That might get you to the right person. Also, if your insurance is provided by a corporate employer, there may be a human resources team member or appointed liaison or representative for the insurance company who can help you navigate this process. Ask around and know your resources.
It is best to start this process before your first meeting with me. Start by calling the number on the back of your insurance card. Good luck with the phone tree. Remember to breathe, stay calm, and stay polite. You are likely going to be educating some of the people who work for the insurance company about this aspect of insurance. If you get stuck, you may need to ask to speak to a supervisor or simply end the call and call back. Sometimes conversations can go awry due to a personality or communication conflict and you just need a fresh start.
Step 3: Educate and advocate regarding evidence-based treatment for OCD
Whomever you speak with first will likely tell you that there are several therapists that are in-network with your plan who treat OCD and they will refer you to those providers. By now you/your loved one have likely already seen one of those providers and you know there is a huge difference between a provider who checks a box indicating OCD is one of many disorders they treat and a provider who specializes in OCD. Be prepared for this response. You can do your research in advance by finding this list of providers through your insurance companies “Find a Provider” tool on their website, or you can research the provider names/practices you are given. (Hey, you might get lucky and find a true OCD specialist that takes your insurance! But know what to look for. See SOAR's “Finding an OCD specialist” page)
Once you have researched the in-network options, take your findings back to the insurance company and explain your evidence for the case that these providers are not specialists in OCD and, therefore, are not appropriate providers. There may be other reasons the providers on the list are not appropriate for you: Do they treat the age group you need (fewer providers treat children and adolescents)? Are they within a 10-mile radius of where you live? Make sure to make these points, as well. If relevant, you can also let your insurance company know that you've tried in-network, non-specialist therapists before and it has not been helpful. Ultimately, insurance is interested in cost-effectiveness. They will pay more money over a longer period of time for ineffective therapy because the patient is not getting better. Make the case for them that you are really trying to save them money by getting better faster. Even though it may be a larger upfront investment, effective therapy pays dividends in the long run.
Step 4: Present your insurance company with the name and necessary details about the OCD specialist with whom you would like to work.
There are several numbers and codes that your insurance will need in order to approve a provider to be covered at the in-network rate. All of the information, numbers, and codes that your insurance company needs are on the Superbills (or "Statements for Insurance Reimbursement") that are created for the sole purpose of communicating to insurance companies exactly what services were provided in treatment, by whom, and where. The Superbill is the receipt you (or an in-network provider) would give an insurance company in order to be reimbursed. The hitch, however, is that these Superbills are not created until AFTER a therapy session and you are hoping to get prior authorization for the service--you likely have not been seen by the provider yet.
The information that your insurance will need regarding the provider and services offered by the provider include the following:
- Provider Name
- Practice Name
- Practice Address
- Practice Phone/Email/Fax
- Provider Degree Type (e.g., PhD, MA, MSW)
- Provider License Type (e.g., Psychologist, Licensed Professional Counselor [LPC], Licensed Independent Social Worker [LISW], Licensed Marriage & Family Therapist [LMFT])
- Provider License Number (can be found via the relevant state licensing board)
- Provider Tax ID Number
- National Provider Identification or NPI Number
- Patient Diagnosis Code(s) (e.g., the most common DSM-5/ICD-10 diagnosis code for OCD is F42.2, although there are more than one)
- Procedural Codes/Service Codes/CPT Codes (see more, below)
Your provider may be comfortable giving you most of this information. Some of the details (e.g., diagnosis code, CPT codes) will be specific to the patient and will vary. It is best to always ask your provider directly which codes s/he will be using to report to your insurance company before you pass along any of this information. Communication errors and misinformation are the enemies of a smooth, efficient completion of this process. As OCD specialists sometimes like to say: “Go slow to get there faster.”
The CPT code (aka: Service Code or Procedural Code) is the code that specifically identifies what type of service was provided--e.g., psychotherapy--and for how long. Below are examples of common CPT codes used in therapy at SOAR.
Common CPT codes in psychotherapy, specifically in ERP for OCD:
- 90837 - 53-79 minutes of psychotherapy
- This is the most common CPT code used at SOAR
- Insurance companies tend to prefer that therapists bill 90834 which is a shorter session, but I find longer sessions necessary for ERP. You may have to advocate for yourself to get this code approved.
- If a therapy session goes over an hour, providers may bill “Add On” codes to capture this additional time (see below)
- Modifier 95 or Modifier GT
- This modifier indicates the session was conducted via telehealth, and since the COVID-19 pandemic, it has become very popular.
- Modifier 95 is typically billed for commercial insurance
- Modifier GT is typically used with Medicare/Medicaid
- 90791 - diagnostic intake
- Everyone gets this code for their first visit.
- This code is typically only billed once per patient, although if there has been a break in therapy of one year or longer, it may need to be billed again when therapy is restarted.
- 90832 - 16-37 minutes of psychotherapy
- 90834 - 38-52 minutes of psychotherapy
- 90846 - family therapy without patient present
- 90847 - family therapy with patient present
- 90853 - 1-hr group therapy
- 90839 - therapy for a crisis (unplanned visit or session)
- Add-on Codes for sessions longer than 1 hour
- +99354 - 30-60 min additional time for extended ERP sessions up to 2 hours
- +99355 - 60-120 min additional time for extended ERP sessions up to 3 hours
- Your provider may not know about the option of billing these add-on codes for prolonged sessions; don’t be shy about letting them know!
- Insurance may not cover these, as there are some politics involved in what license type is worthy of billing for extra long sessions, but you might as well ask.
Sometimes an insurance company will allow you to provide them the information above; more likely, the insurance company will want to speak directly with the therapist to get this information. They may also want to do a clinical case review with your provider to determine your eligibility for the services you are seeking. The insurance company has the right to require this; please be patient with the process. In my experience, these kind of calls with insurance typically take about an hour (although, admittedly, a significant portion of that time is often spent trying to navigate complicated phone trees, waiting on hold, or speaking with the wrong person). This is a lot of time for busy therapists to commit to a frustrating task; a task that many of them would prefer to avoid and, for this reason, are out-of-network with insurance; a task that is the reason some providers are hesitant to even tell patients about this process (although, most therapists, like most patients, simply don’t know that this is a route to a higher rate of reimbursement for patients with OCD). All of that said, please understand that out-of-network therapists will likely bill for any significant amount of time that they spend in communication with your insurance company. Most of the time, this will pay off for you in terms of the higher rate of reimbursement you get from insurance over the course of therapy. Unfortunately, sometimes it will not. It is an uncertainty you will have to accept and a gamble you will have to make at the forefront of this journey.
Step 5: Understand the agreement, confirm, and follow up
Whatever agreement you come up with, make sure you understand clearly what the agreement is and what each party has agreed to: the insurance company, the treatment provider, and you as the patient/advocate. Get this agreement in writing in as much detail as possible. And make sure you follow up to make sure whatever the agreement is, it is followed through. Is your agreement only about having a certain portion of the service fee reimbursed? Will the amount you pay be going to your in-network deductible (it should!) or out-of-network? Does it count toward your annual maximum (again, it should)? How many sessions and what service codes are covered in this agreement? What are the dates of services covered by this agreement (typically agreements are come to for 6 months to a year)? Understand and negotiate ALL of the details.
At any point in time, you may end up having to go back to an earlier step in this process and repeat it. For example, you may talk to someone who tells you, “No, we do not reimburse patients, we only reimburse treatment providers.” This is a sign that you are not talking to the correct team at your insurance company. Back up and make sure you have a line of communication to someone who can give you what you are looking for.
At some point, you may need to go back to Step 1 and assess how much time and energy you really want to invest in this process. At times it may (accurately) seem that your insurance company is throwing up all the roadblocks to you getting the reimbursement to which you have the right. A last resort option may be to look into legal representation for your case. I am aware of class action lawsuits against at least one insurance provider over their failure to follow laws related to mental health parity. This may be an expensive, time consuming, difficult option, but our legal system is a powerful line of defense in changing unfair, unjust existing power structures.
Acknowledgements to Fred Penzel, PhD, of Western Suffolk Psychological Services for his undying advocacy efforts and for writing the original blog post, "Fight for Your Rights: Getting Insurance to Pay for Your Treatment" that informed so many patients and providers of their rights related to insurance reimbursement: https://www.wsps.info/articles/fight-for-your-rights-getting-insurance-to-pay-for-your-treatment-1
Another good resource on this topic is "How to Pay In-Network Rates for Out-of-Network Care": https://www.verywellhealth.com/get-in-network-rates-out-of-network-1739069
I wish you the best in this effort and hope you have found this information helpful! Good luck to you!
SOAR Policy on Working with Insurance
SOAR accepts neither single case agreements (SCAs), letters of agreement (LOAs) (aka, “ad hoc agreements”). SCAs and LOAs are contracts are between a service provider and an insurance company and, under these agreements, the insurance company typically wants the provider to agree to the terms offered to other in-network providers. SOAR does not enter into these contracts with insurance companies for a number of reasons including the additional time and resources they take and the restrictions they place on the provision of care. SOAR does not go in-network with insurance and does not accept reimbursement from insurance. SOAR does not negotiate rates with insurance or create contracts with them. (For more details, please refer to the section, Why Aren’t Most OCD Specialists In-Network With Insurance?)
Any agreement you come to with your insurance through the process outlined above will be between you and your insurance provider. My fee and practice policy (i.e., full fee is paid at the time of service) remain the same regardless of the outcome of this process. In insurance terms, this means I do “balance bill”; i.e., you are responsible for whatever portion of my fee that your insurance does not reimburse or cover. However, since the insurance companies are required by law to provide services that meet your needs, they should be willing to reimburse you for your care with an OCD specialist at least as much as they reimburse other in-network therapists. They should also count the "allowed amount" portion of your care with a specialist towards your in-network deductible, annual maximum, and any other aspects of your coverage that are different between in- and out-of-network. All insurance plans are different. You will only know how much they will ultimately reimburse you under this agreement by talking to a representative with your insurance company who is familiar with this aspect of your plan. You certainly can argue to have the full amount (minus your co-pay) that you pay me, reimbursed. Some people have been successful at this.
Superbills are created in the Client Portal at the beginning of the month for all sessions in the month prior, or as needed. (There is a document called "Insurance Reimbursement Steps" in the Client Portal that walks you through this.)
Your Insurance may want to call me to see if I negotiate my rates or to ask me for this information directly. I am happy to talk to them, but in fairness to all of my patients, I do not negotiate my rates. Per my practice policy, I do charge for calls and paperwork over 15 min (the charge is pro-rated from my standard hourly fee). This would apply to extended conversations with insurance companies. Feel free to share this information with them when you call. You can also print this information sheet and submit it to your insurance en lieu of having them call me or me call them, if they will accept that.
A note about telehealth sessions: I have been conducting telehealth sessions for as long as I have been specializing in OCD (since 2014). These video-conferencing appointments are a more affordable method of conducting in-home exposure sessions, which are often necessary to really help a person with OCD conquer the challenges they are facing. Telehealth sessions are also useful in the event of travel, transportation issues, forgotten appointments, weather-related travel complications, or urgent issues that make attendance in person difficult. Since the COVID-19 pandemic, all sessions have been moved to my HIPAA-compliant telehealth platform until our government and health officials lift restrictions on in-person social contact.