OCD SPECTRUM INFORMATION
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. This guide helps you navigate insurance reimbursement for the specialized care you deserve.
YOUR RIGHTS
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 insurance networks can be challenging. When your insurance company cannot provide an adequate in-network provider, you have the right to seek out-of-network care and request reimbursement.
PRACTICAL GUIDANCE
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 are advocating for your mental health, be assertive, stay calm, and be persistent.
STEP-BY-STEP GUIDE
Steps to Follow
- 1Contact Your Insurance Company’s Customer ServiceInquire about local practitioners specializing in your condition. Ask specifically if they provide Exposure and Response Prevention (ERP) therapy for OCD. If denied or met with uncertainty, request to speak with a manager or inquire about a Care Advocate or Patient Advocate.
- 2Determine Provider LocationsIf you receive a list of providers, determine their locations. Some insurance plans have geographical limitations, you cannot normally be compelled to see a provider beyond a certain distance from your residence.
- 3Call and Evaluate ProvidersCall each provider on the list and inquire about their experience treating OCD. Be cautious, many providers list OCD as a specialty without being adequately qualified. Ask about their treatment methods and training in ERP.
- 4Advocate for Permission to See Your Chosen TherapistIf 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.
- 5Inform Them of Your Competent ProviderIf your insurance plan acknowledges the absence of a qualified therapist, they may attempt to negotiate an “ad hoc” or “single case agreement.” Alternatively, you can request direct reimbursement for your out-of-pocket costs. Note: OCD Spectrum does not engage in single case agreements.
- 6Negotiate Reimbursement TermsNegotiate the reimbursement process, whether it involves deducting your copay per session or other terms. Be prepared to provide any necessary paperwork.
- 7Assert Your Rights in Case of Partial CoverageIf 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.
- 8Deal with Deductible ObjectionsIf 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.
- 9Request to Speak with a SupervisorIf 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.
- 10Verify Competence of Provided TherapistIf 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. Most companies will comply at this stage. If not, consider filing a formal complaint with the state insurance regulatory agency.
IF THEY AGREE TO REIMBURSE YOU
Relevant CPT Billing Codes
Request a written contract detailing the approved number of visits and reimbursement rates. Ensure clarity on how your standard copayment will be handled. Familiarize yourself with the relevant CPT codes used by insurance companies for billing purposes:
| CPT Code | Description |
|---|---|
| 90791 | Intake or first visit |
| 90834 | Regular 45-minute therapy session |
| 90837 | Regular 55–60 minute therapy session |
| 90847 | Family therapy session |
| 99203 – 99205 | New patient office visit for a psychiatrist |
| 99213 – 99215 | Follow-up psychiatrist office visit |
WE ARE HERE TO HELP
Start Your Journey with OCD Spectrum
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. Contact us today to schedule a free 10-minute consultation.