• Your health insurance company has determined that all treatments should cost a specific amount. This is called the allowable amount or the negotiated rate.
  • Example: Your insurance company determines that Treatment A should cost $100. The allowable amount for Treatment A is $100. 
• An In-network provider is a healthcare professional who has a contract with your insurance company and has agreed to accept the allowable amount set by the insurance company. If you see that provider for Treatment A, the provider will be paid a total of $100 for the service.
• An Out-of-network provider is a healthcare professional who does not have a contract with your health insurance company. Out-of-network providers, therefore, are not required to charge the allowable amount set by the insurance company, and may set their own rates for treatment.
• Your insurance benefit is the amount or percent of a treatment bill that your insurance company will pay. Insurance companies typically agree to pay more to in-network providers than out-of-network providers, even if the fee is the same.
  • Example: Say your insurance plan has an 80% in-network benefit, and a 20% out-of-network benefit. In this case, your insurance company would pay 80% of the treatment to an in-network provider and you would pay 20%. With an out-of-network provider  the insurance company would pay 15% of the allowable amount for treatment, and you would pay the rest of the fee. With Treatment A, you would pay $20 to your in-network provider, and your insurance company would pay $80. With an out-of-network provider, your insurance company would pay 20% for your treatment, and you would pay the rest of the cost. If the out-of-network provider charges $125 for Treatment A, you would pay $105, and the insurance company would pay $20. If the out-of-network provider charges $80 for Treatment A, you would pay $64 and the insurance company would pay $16.

Many people struggle to find the appropriate in-network treatment provider for their mental health needs. Two reasons that are very relevant to OCD treatment are qualifications and availability.

Qualifications: Most therapists do not receive specialized training in OCD treatment. Though a masters or doctoral degree is required as a therapist, graduate programs rarely focus training on a single disorder. Specialized training in OCD treatment typically occurs during post-graduate training through structured programs, supervision, and ongoing continuing education specific to the disorder. Less than 1 percent of therapists are trained to treat OCD using ERP, and many ERP providers are out-of-network. This means there is a low chance of finding an OCD specialist in-network.

Availability: Shortages in the overall number of mental health professionals also contribute to the struggle to find treatment. Estimates suggest that the number of mental health providers in the US can only meet around 50% of mental health needs, and in some areas of the country, or for some types of providers this is much lower. With this lack of providers, most insurance companies have shortages for all behavioral health providers, and an even greater shortage of specialists. For those specialists who are in-network with insurance, many have long wait times, up to several months.

The low numbers, long wait times, and limited availability of in-network treatment providers for OCD lead many to seek out-of-network treatment. In 2008, the Mental Health Parity and Addiction Equity Act (MHPAEA) was passed to ensures that insurance companies would provide the same access to care for mental health conditions as physical health conditions. This law means that most health insurance companies must pay as much for out-of-network treatment as they would for in-network treatment if no in-network providers are available to provide the type of treatment required. As ERP is the gold standard treatment for OCD, most insurance companies are required to provide reimbursement tor out-of-network care if in-network ERP providers are not available.

As ERP is the gold standard treatment for OCD, most insurance companies are required to provide reimbursement for out-of-network care if in-network ERP providers are not available.

Patients may obtain something called a Network Gap Exemption. A network gap exemption is a provision used to address gaps in an insurance network of contracted healthcare providers. When granted, it allows you to receive care from an out-of-network provider while getting more money back from your insurance company. For example: a network gap exemption would require an insurance company to pay 80% for out-of-network treatment rather than 20%.

This does not mean that all health insurance companies will pay for the full amount of your out-of-network treatment. Several caveats include:

• For some insurance companies these laws may not apply in the same way. This may be the case for HMOs, Medicare, and Medicaid, as well as others.
• Deductibles may still apply, meaning you may not receive any reimbursement prior to meeting your deductible. However, by obtaining a network gap exemption, the money you pay for mental health treatment would count to your in-network deductible, which is typically much smaller than your out-of-network deductible.
• Insurance companies will likely only pay their allowable in-network amount. For example: If the out-of-network provider charges $125 for Treatment A, a network gap exemption would require the insurance company to pay the $80 they would pay for in-network treatment (instead of $20), and the patient would be responsible for paying the other $45 (instead of $105). This still constitutes a considerable savings for most patients and can sometimes be the difference between obtaining treatment and delaying care.

To get a network gap exception, it's important to be prepared for the process. It may take some time to get a network exemption, and you may need to educate people along the way. You may find some people within your insurance company have little knowledge of OCD, ERP, or mental health services overall. If that is the case, try and be patient and help them understand the importance of treatment. You may want to refer them to The Society of Clinical Psychology's Treatments page (Treatments | Society of Clinical Psychology) which provides information about the research surrounding different treatments.

Some key terms that may be helpful to know include:

• Prior Authorization: the process used by health insurance companies to determine if they will cover a treatment prior to starting the treatment. Insurance companies use the prior authorization process to ensure that a treatment is medically necessary and cost-effective. To obtain a prior authorization, a request is submitted to your insurance company. After a review process, the insurance company either approves or denies the request.
• Superbill: an itemized receipt provided by the out-of-network provider after you've paid for services. It includes details like diagnosis codes (ICD-10), procedure codes (CPT), and the cost of services. This is the receipt you will submit to the insurance company for reimbursement.
• Provider Information: Information your insurance company will ask for about your prospective treatment provider. This often includes information like an NPI number & taxonomy code, EIN, Contact Information, and others. Generally, this information is available on your Superbill.
• Treatment Information: Information your insurance company will ask for about your prospective treatments. This often includes a diagnosis code and a procedure/service/CPT code. Generally, this information is available on your Superbill.
• Single Case Agreement (SCA):  a contract between an insurance company and an out-of-network> provider that allows a patient to receive care from that provider at in-network rates. Please note that Burnett CBT will not accept or enter into Single Case Agreements. Any agreements, including network gap exemptions are between you and your insurance company. As such, you will be responsible for the full cost of services at the time of the service. Any insurance reimbursements must be paid directly to the patient.

To get a network gap exception, you may have to prove that it is necessary. Some justifications include:

1. Lack of In-Network Providers: There are no suitable in-network providers available to offer the necessary care.
   - The first step here is to check with your insurance company and see if there any ERP or CBT providers (or ComB providers for BFRB's). Some insurance companies classify ERP under CBT and may argue that they do have available CBT providers. In this case it's important to talk to the insurance company about ERP treatment (see below.) At times you may reach out to the available CBT providers only to find that even they have very long wait times for new patients.
2. Specialized Care: The required treatment is highly specialized and not available within the network.
   - If your insurance company does provide names of OCD/BFRB treatment providers, reach out to the provider to see if they have specialized training in ERP or ComB. Providers who primarily treat OCD or BFRB's are often members of the International OCD Foundation (IOCDF) or The TLC Foundation for Body-Focused Repetitive Behaviors (TLC). Most have also obtained training in OCD or BFRB treatment, such as through the IOCDF's Behavior Therapy Training Institute (BTTI) or TLC’s Virtual Professional Training Institute (VPTI). If providers cannot provide specific information about their training and qualifications in treating OCD/BFRB's, inform your insurance company and refer them to the IOCDF's "how to find the right therapist" page.

If you are able to justify the necessity of a network gap exemption based on a lack of in-network providers and the need for specialized care, you should be ready to submit a formal request. Contact us for a sample Superbill and other information for your insurance company.