Fred Penzel, Ph.D.
Over the years, I have written a number of articles about the treatment and acceptance of OCD and related disorders. These are all very practical issues, to be sure; however, another practical issue I would like to inform you about has to do with getting your insurance company to cover the cost of treatment. If you are lucky enough to be able to pay for your treatment out-of-pocket, then this article will probably not be of much interest to you. If, however, you rely on health insurance to pay for treatment, then read on.
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. OCD specialists 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 any more. This is also true of most OCD specialists.
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. Before you make this first call, there is one word of caution. 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. When you call a customer service representative at your plan, and ask for the name of someone local who treats OCD, you may be given several names. Depending upon where you live, your company representative may say, “Oh, we have many OCD specialists.” 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.
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, grill them on how many cases they’ve treated, what methods they use (Exposure & Response Prevention should be the answer), 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. 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 tomake all this work, you obviously 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.
If your company admits that they have no one, they will go on 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 their full 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. 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 whole 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 (or my child), 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 negotiate a fee with them.” If they now realize you know your rights, they will ask for the name and phone number of the practitioner, and will call him or her to negotiate a fee.
Before you show up for your first visit, make sure the practitioner has received 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 pay this professional for various services. The standard insurance service code for a first visit is 90801, and for regular office visits of 45 minutes is 90806, and the contract should clearly state how much will be paid for each. You will also need to know if you will be required to pay your standard copayment at each visit.
If the insurance company still resists, you must then ask to talk to a supervisor, and again, 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. 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 proper treatment for OCD 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. The only exceptions that I have ever encountered to all of the above have been special contracts negotiated by employers with insurance companies. These agreements may forbid an insurance company from negotiating fees above set levels. In such a case, the employer has tied the insurance company’s hands, and there is nothing they can do. Fortunately, these types of setups tend to be rare.
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-ofnetwork. 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. I have negotiated many out-of-network provider contracts over the years, and can tell you that this can be done, and is being done by savvy consumers all the time.