10 steps for getting your insurance company to pay for anxiety treatment
These tips are adapted from an article by Fred Penzel, Ph.D. - Fight for Your Rights: Getting Your Insurance Company to Pay for OCD Treatment
While there are great evidence-based treatments for anxiety-related disorders, finding a provider who specializes in these can be difficult. Many anxiety specialists - including the providers at Anxiety & OCD Treatment Services - are considered out-of-network, or private pay only, and do not work for insurance plans. However, it is the responsibility of the insurance company to provide you with adequate treatment by properly-trained mental health professionals.
Fortunately, is is possible - though difficult - to get your insurance company to cover the costs of treatment. For anxiety-related disorders, in particular, there are specific treatments that are considered to be "first-line" or "gold standard" treatments. For example, for OCD, a type of treatment called exposure and response prevention (ERP) is the recommended treatment. Exposure-based treatments are also recommended for social anxiety, illness anxiety, separation anxiety, and phobias. For panic disorder, exposure-based treatments that include interoceptive exposure exercises are recommended. For PTSD and trauma, it is prolonged exposure (PE) therapy. For BFRBs such as excoriation and trichotillomania, it is comprehensive behavioral treatment (ComB). Most providers also include mindfulness- and acceptance-based techniques and motivational interviewing techniques.
Insurance companies are likely to claim that they have many anxiety specialists who are in-network, when in reality, very few - if any - of the providers on that in-network list are likely to provide exposure-based treatments. Therefore, following the steps below may aid you in getting insurance reimbursement for your out-of-network or private pay treatment. Importantly, always be sure to take notes and document your conversations, with the insurance company as well as with the providers.
OCD and exposure and response prevention (ERP) are used as examples, but substitute "OCD" with your diagnosis (e.g., "panic disorder," "PTSD," "trichotillomania," "social anxiety disorder," "health/illness anxiety disorder," etc). Substitute "exposure and response prevention" with the respective treatment (e.g., "prolonged exposure" for PTSD, or "comB" for trichotillomania or excoration, "exposure therapy" for panic/social anxiety/phobias, etc).
1. Contact your insurance company to ask whether or not they have specialists who treat "OCD."
2. Get a list of these mental health providers, along with their locations. Insurance companies oftentimes have rules about how far they can make you travel to get treatment, so you cannot be required to see someone outside of a certain radius.
3. Call the providers whose names/numbers the insurance company gives to you who are within the designated radius. Mention that you are seeking a provider who specializes in, or is an expert at, treating "OCD." You will often find that they do not specialize in your diagnosis or that they are not taking new clients.
4. If the provider does say that they specialize in the treatment of "OCD," ask open-ended questions. For example, ask "what specific type of treatment do you do for 'OCD'?" If they just say cognitive behavioral therapy (CBT) and do not elaborate, or they say talk/supportive therapy, but do not mention "exposure and response prevention (ERP)" specifically, then document that and move on. Here are examples of questions to ask providers.
5. If none of the providers on the list are appropriate, find a specialist who does treat your diagnosis, who specializes in evidence-based treatments, and who is taking new clients.
6. Contact your insurance company to inform them that (a) none of the providers on their list are appropriate specialists for your presenting concern, and that (b) you have found a competent professional who is. Give them the contact information of that provider.
7. If the insurance company is agreeable, they will contact the provider to negotiate an 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.
8. If they are not agreeable, or try to block your request, be assertive. Speak firmly, indicate that you know your rights as a consumer, and do not loose your temper. Tell them that there is no one in your network that is qualified to treat you (or your child), and since they are obligated to provide you with appropriate care under the terms of your contract, they must allow you to see someone out-of-network but on an in-network basis.
9. If they still resist, ask to speak with a supervisor and again assertively explain the situation. They may insist that they have a provider who is adequate, but assuming you have contacted all of the providers on their list, you can ask for the name of the person they have in mind and let them know why they are not appropriate (e.g., the provider really isn't qualified, isn't taking new clients, didn't know what the proper treatment for "OCD" was, etc).
10. If they still resist at this point, which should be unlikely, you may have to contact the state agency responsible for regulating insurance companies to file a complaint. Make sure to reference the names of everyone at the insurance company to whom you spoke.