I'm including this post on behalf of current clients and potential ones who are seeking insurance reimbursement for their body-focused, repetitive behavior (BFRB) treatment.
If you have a PPO: You have the freedom to choose any healthcare provider you want (which includes me!) and receive benefits. You are guaranteed some financial assistance; however, your out-of-network reimbursement (e.g. 40%) will not be as generous as your in-network reimbursement (e.g. 80%). (These numbers are for illustration, you will have to speak with your insurance company to learn the details of your particular plan.) If you are feeling ambitious and would like to pursue the higher reimbursement rate, the following is for you...
If you have another type of plan, like an EPO or HMO: You must stay within the contracted network of providers (which does not include me) to receive benefits. You will be paying out of pocket to see me... unless you get an exception. The following will guide you on how to get your insurance company to help pay for your BFRB treatment...
The magic term here is a "network gap exception." Insurance companies won't advertise it because of the cost to them, but these provisions were designed for cases like BFRBs. This article (<-- click there!) provides a more detailed explanation:
"A network gap exception is a tool health insurance companies use to compensate for gaps in their network of contracted health care providers. When your health insurer grants you a network gap exception, also known as a clinical gap exception, it’s allowing you to get health care from an out-of-network provider while paying the lower in-network cost-sharing fees."
In short, if an insurance company does not have an in-network provider for your condition nearby, by law they must cover you to see an out-of-network specialist. In an attempt to not have to subsidize, they will provide you with a list of names of providers who treat "anxiety" or "depression" or "OCD" or maybe have seen a patient or two with hair pulling issues, but THIS IS NOT AN APPROPRIATE REFERRAL. You need a BFRB SPECIALIST and I still have not encountered a single insurance company who has one on their panel. Your insurance company may also refer to a "single case agreement," but THIS IS ALSO NOT WHAT YOU WANT. You need them to bridge the gap in their network as your right and their obligation.
I recommend you read over this (<-- click there!) article as well, and consult me for further advice and the necessary diagnostic and procedure codes for your inquiry. Keep good documentation of your conversations (including reference #'s), and remember to set your network gap exception to the maximum allowable time frame. BFRB work is long-term work! Dealing with insurance companies will test your will and patience, but if you stay committed you can prevail!
