IF YOUR INSURANCE IS AN HMO, EPO, or MEDICAID:

I am often successful in negotiating with HMOs, EPOs, and Managed Medicaid (Americhoice, HealthPlus, etc.) to cover me as if I'm in-network. If successful, that means your insurance will pay you back everything except your standard copay. It takes a month to get a decision and involves some hassle on the client's part, but it costs nothing to try and is sometimes successful. It requires you to start the process. Please follow the instructions below exactly as they are written.

1.    Please call your policy’s customer service department (on your insurance card) and tell them: “I am seeking a ‘single case agreement’ to cover an out of network psychologist that I am seeing.” (Sometimes it might be called an ‘ad hoc agreement’ or ‘exception authorization’ or ‘exception accommodation.’)

2.     They might transfer you to an “intake” person who will just take down basic facts. Get the names of all people you talked to. Tell them the following:

    a.    “I am seeking a ‘single case agreement’ to cover services of a psychologist I am seeing. I need a male psychologist in my area who treats OCD with exposure response prevention (ERP), and who can provide therapy outside of his office, and I called all the providers on the list and none fit this description.” (If you wish to tell them that you want “a therapist who is religious,” which I happen to be, it will greatly improve your chances; you don’t have to justify why.  If they say you can't choose the religion of your therapist, just say you want someone "initimately familiar" with your religion.)

      b.     Emphasize that “exposure response prevention is the only therapy recommended for OCD” by the Obsessive Compulsive Foundation, which is the national medical organization for the treatment of OCD, and the Expert Consensus Protocol for OCD Treatment.

       c.     Ask them to call Dr. Brodsky at 212-726-2390 "to negotiate a fee" and cover his services. Usually, they will just take the facts (they will not argue with you). Before you hang up, get a “reference number” for your discussion. This will ensure they approve coverage retroactive to that date.

 3.   Usually they tell you they will send your case to a “care manager” or “care advocate” or “utilization manager” who conducts a “clinical review” of yourcase. Next, the care manager will call either you and/or Dr. Brodsky to get further details to justify “medical necessity.”

4.      If they give you a hard time, which is very rare:

               a.     You can prove the necessity of ERP by showing them the attached documents from these 2 organizations, which appear after the followingarticle.

                 b.      Ask to speak to a supervisor if the person you are speaking with can’t help you.

5.      Bottom line, don’t take no for an answer. If they ever give you a hard time,remind them: “You are legally required to cover appropriate treatment of mycondition (even if they are an HMO), and must make alternate arrangements if your providers can’t treat me.” For more details read the article below:

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 using Exposure Response Prevention (ERP) 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. This is also true of most OCD specialists.

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. 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. Alternatively, they may ask you such things as, "What is OCD?" or "What is ERP?"

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 do not treat your problem and cannot fathom why the company gave you their name. If they say they do treat OCD, ask them if ERP is their main method and how many cases they've treated, what kind of training they have to do this, and whether they have other personal qualities they you require in a therapist (for example, male, etc.). In most cases, they will not have the right answers and will probably get a bit cagey with you. If none of their 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 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 out of their network who is considered competent to treat what you have.

If your company admits that they have no one, they will go on to contact the practitioner and negotiate a fee in what is commonly known by a number of terms as an "ad hoc," “out-of-network,” “exception authorization,” 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.

These arrangements are arranged by a variety of administrators, depending on the insurance company. Ask for a “care manager,” or “utilization management,” among others.

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 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, 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 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 use ERP andhave 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) doesn’t use ERP, b) isn't taking new patients, or c) didn't know what 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-of-network. 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 several out-of-network provider contracts with HMOs over the years, and can tell you that in at least 25% of the cases this can be done, and is being done by savvy consumers all the time.

How To Choose a Behavior Therapist

By
Michael Jenike, MD

Optimal treatment for most people with OCD involves the combination of medication plus the behavior therapy techniques of exposure and response prevention.Many psychiatrists are familiar with the use of serotonin selective reuptake inhibitors (SSRIs). It is often quite easy to locate psychiatrists who can prescribe medications. There remains a shortage of competent behavior therapists who have experience in treating OCD patients.

[The former OCF Executive Director] asked me to put together some ideas that may help consumers to locate a competent behavior therapist.

It is important for the consumer to be armed with information and questions that can help them determine if a therapist is indeed competent and experienced. To gather information on this subject, I asked a number of experienced behavior therapists what they would recommend. The following behavior therapists were consulted: Drs. Lee Baer, James Claiborn, William Minichiello, and Nancy Keuthen.

In addition, I reviewed Dr. Jonathan Grayson's article in the April 1996 issue of the OC Foundation Newsletter and Dr. Baer's book "Getting Control." In "Getting Control," Dr. Baer notes that most behavior therapy is done by psychologists, usually at the doctoral level (Ph.D., PsyD, EdD). Although some psychiatrists (MD) and some clinical social workers (MSW) provide behavior therapy too. When consulting a mental health professional, it is important to ask for a behavior therapist that is licensed by the state in which they practice.

Dr. Grayson emphasized the importance of finding a behavior therapist who is willing and able to understand you as a person, not only as an OCD patient. Your relationship with the therapist is of the utmost importance Especially since they will be asking you to do things that you find inherently uncomfortable.

You will need to ask the therapist what technique they use to treat OCD. If the therapist has never heard of exposure and response prevention therapy or is vague about discussing these treatments, it may be best to look elsewhere. You need to know what these techniques involve to understand what you are being told. The exposure part of the therapyinvolves actually confronting the source of the anxiety and/or discomfort. A person afraid of contamination from public bathrooms will be asked to go with the therapist to a bathroom and touch some "contaminated" item in the bathroom. The response prevention part of the therapy occurs when the patient does not wash her hands while feeling contaminated. With repeated sessions, the discomfort diminishes until the contaminated item no longer produces anxiety or discomfort. The behavior therapist then has the patient tackle an even more stressful situation until all of the fears have been confronted. This gradual process of exposing oneself to a fearful situation and not giving in to the ritualistic response is therapeutic for the patient. For many patients, pretreatment with medication makes the process less anxiety provoking and hastens or facilitates the overall improvement.

If the therapist says that his main technique involves relaxation therapy, you can be quite confident that he is not experienced because relaxation is not effective for treating OCD. If the therapist tells you the root of your problem lies in some difficulty with your early toilet training and this is why you have OCD, you should also find someone else. In the not too distant past, parents were told that they had caused OCD symptoms in their child by incorrect toilet training or even some type of abuse. We do not know precisely why OCD symptoms develop, but it is certainly not the parents' fault.

You should ask where a potential therapist learned about this type of behavior therapy. Did they go to a behavioral psychology graduate program or do a post-doctoral fellowship in behavioral treatment? How many patients have they treated with behavior therapy, and what is their success rate? How much of their practice currently involves anxiety disorders and especially OCD. There are other ways that a therapist can learn effective behavior therapy techniques. An American Association of Behavior Therapy (AABT) or Obsessive Compulsive Foundation workshop can help prepare a therapist for this type of work. If your potential therapist is a member of AABT or SBM (Society of Behavioral Medicine), this may increase your confidence that they are heavily involved in behavior therapy.

Another useful and important question addresses the therapist's willingness to leave their office if needed to do the behavior therapy. It is sometimes necessary to go out to touch garbage in the real world, visit public bathrooms as in the example above, drive with the patient, and a therapist that will only sit in his/her own office will not be as helpful as a more active therapist.

These are some broad guidelines that help the consumer determine whether or not a therapist is qualified to do exposure and response prevention. The therapist's response to your questions is a good guide to what you want to know about a prospective therapist. If he or she is guarded, withholding of information, or becomes angry at your requests for information, you should probably look elsewhere. If the therapist appreciates how important a decision this is for you and is open, friendly, and knowledgeable, you may have a gem of a therapist.

You have a perfect right to ask questions; this is your life and health.

OCF Scientific Advisory Board

The OC Foundation’s Scientific Advisory Board (SAB) is made up of mental health professionals who are treating or researching Obsessive Compulsive Disorder and the OCD Spectrum disorders. Our SAB members are among the best clinicians and investigators in the United States who treat or research OCD and the OC Spectrum Disorders. SAB members are psychiatrists, psychologists and other types of well-trained therapists.

Current membership is as follows:

Michael Jenike, M.D., Chair Mass General Hospital Boston, MA Jonathan S. Abramowitz, Ph.D. University of North Carolina Chapel Hill Lewis R. Baxter, Jr., M.D. University of Florida Gainesville, FL Lisa Jo Bertman-Pate, Ph.D. Tulane University, New Orleans, LA Thröstur Björgvinsson, Ph.D. The Menninger Clinic Houston, TX Nancee Blum, M.S.W., LICSW University of Iowa, Iowa City, IA John E. Calamari, Ph.D. Rosalind Franklin University, NorthChicago, IL Dennis S. Charney, M.D. Mt. Sinai, New York, NY Jim Claiborn, Ph.D., ABPP Northeast Occupational Exchange Portland, ME Vladimir Coric, M.D. Yale University, New Haven, CT Darin D. Dougherty, M.D. Masschusetts General Hospital Charlestown, MA Lee A. Fitzgibbons, Ph.D. Bethlehem, NH Edna B. Foa, Ph.D. University of Pennsylvania,Philadelphia, PA Steven Friedman, Ph.D., ABPP Health Sciences Center Brooklyn, NY Randy Frost, Ph.D Harold Edward and Elsa Siipola Israel, Northampton, MA Wayne K. Goodman, M.D. University of Florida Gainesville, FL Eda Gorbis, Ph.D., M.F.C.C. Westwood Institute Los Angeles, CA Jonathan Grayson, Ph.D. The Anxiety and Agoraphobia Treatment Center Bala Cynwyd, PA Benjamin D. Greenberg, M.D., Ph.D. Butler Hospital, Providence, RI John H. Greist, M.D. Madison Institute of Medicine, Madison, WI William A. Hewlett, M.D., Ph.D. Vanderbilt University Medical Center, Nashville, TN Eric Hollander, M.D. Mt. Sinai School of Med. New York, NY Bruce M. Hyman, Ph.D., LCSW Hollywood, FL Nancy J. Keuthen, Ph.D. Massachusetts General Hospital, Charlestown, MA Suck Won Kim, M.D. University of Minnesota Minneapolis, MN Lorrin M. Koran, M.D. Stanford Univ. Medical Center Stanford, CA

Bruce Mansbridge, Ph.D. Austin Center for the Treatment of OCD Austin, TX Charles S. Mansueto, Ph.D. Behavior Therapy Center of Greater WA, Silver Spring, MD Brian Martis, M.D. University of Michigan Ann Arbor, MI Paul R. Munford, Ph.D. The Cognitive Behavior Therapy Center for OCD & Anxiety San Rafael, CA Gerald Nestadt, MD, Ph.D. John Hopkins Hospital Baltimore, MD Fugen Neziroglu, Ph.D. Bio Behavioral Institute Great Neck, NY Deb Osgood-Hynes, Psy.D. McLean Hospital,Belmont, MA David Pauls, Ph.D. Harvard Medical School, Charlestown, MA Fred Penzel, Ph.D. Western Suffolk Psychological Services, Huntington, NY Aureen Pinto Wagner, Ph.D. University of Rochester Rochester, NY C. Alec Pollard, Ph.D. St. Louis Behavioral Medicine Institute, St. Louis, MO Judith L. Rapoport, M.D. National Institute of Mental Health, Bethesda, MD Steven Rasmussen, M.D. Butler Hospital, Providence, RI Scott L. Rauch, M.D. Masschusetts General Hospital, Charlestown, MA Bradley C. Riemann, Ph.D. Rogers Memorial Hospital Oconomowoc, WI Barbara Rothbaum, Ph.D. Emory Clinic, Atlanta, GA Sanjaya Saxena, MD UCLA Neuropsychiatric Institute Los Angeles, CA Diane S. Sholomskas, Ph.D. Yale University, New Haven, CT Gail Steketee, Ph.D. Boston University,Boston, MA S. Evelyn Stewart, M.D. Massachusetts General Hospital, Boston, MA Eric A. Storch, Ph.D. Univ. of Florida Gainesville, FL Thomas H. Styron, Ph.D. Yale University, New Haven, CT Christina J. Taylor, Ph.D. Sacred Heart University, Fairfield, CT Barbara L. Van Noppen, Ph.D. Brown University, Providence, RI Sabine Wilhelm, Ph.D. Harvard Medical School, Boston, MA Jose A. Yaryura-Tobias, M.D Bio Behavioral Institute Great Neck, NY

The responsibilities of the OCF SAB include:

•

Provide expertise on the scientific issues with which the OCF and its constituency are concerned;

•

Review and evaluate the research proposals submitted to the OCF for funding;

•

Provide clinical treatment for people with OCD;

•

Do research into the causes and treatment of OCD;

•

Provide training for mental health professionals interested in treating OCD and OC Spectrum Disorders;

•

Write articles on OCD for their colleagues and the public;

•

Give presentations on topics of interest to the OCD community

EKS® - Expert Consensus Guidelines®

The Expert Consensus Panel for Obsessive-Compulsive Disorder

The following participants in the Expert Consensus Survey were identified from several sources: participants in a recent NIMH consensus conference on OCD; participants in the International Obsessive Compulsive Disorders Conference (IOCDC); members of the Obsessive-Compulsive Foundation Scientific Advisory Board; and other published clinical researchers. Of the 79 experts to whom we sent the obsessive-compulsive disorder survey, 69 (87%) replied. The recommendations in the guidelines reflect the aggregate opinions of the experts and do not necessarily reflect the opinion of each individual on each question.

Margaret Altemus, M.D. NIMH Jambur V. Ananth, M.D. Harbor-UCLA Medical Center Lee Baer, Ph.D. Massachusetts General Hospital David H. Barlow, Ph.D. Boston University Donald W. Black, M.D. University of Iowa Pierre Blier, M.D. McGill University Maria Lynn Buttolph, M.D. Massachusetts General Hospital Alexander Bystritsky, M.D. UCLA School of Medicine Cheryl Carmin, Ph.D. University of Illinois, Chicago Diane Chambless, Ph.D. University of North Carolina-Chapel Hill David Clark, Ph.D. University of New Brunswick Edwin H. Cook, M.D. University of Chicago Jean Cottraux, M.D. Universit� Lyon, France Jonathan R. T. Davidson, M.D. Duke University Medical Center Pedro Delgado, M.D. University of Arizona, Tucson Paul M. G. Emmelkamp, M.D. University of Groningen Brian A. Fallon, M.D. Columbia University Martine Flament, M.D. La Salpetriere, Pavillon Clerambault Martin Franklin, Ph.D. Allegheny University Mark Freeston, Ph.D. Universit� Laval Randy Frost, Ph.D. Smith College Daniel Geller, M.D. McLean Hospital Wayne K. Goodman, M.D. University of Florida College of Medicine

Tana A. Grady, M.D. Duke University Medical Center Benjamin Greenberg, M.D. NIMH Daniel Greenberg, M.D. Jerusalem Mental Health Center, Herzog Hospital John H. Greist, M.D. Dean Foundation for Health Research Gregory Hanna, M.D. University of Michigan Medical Center, Child & Adolescent Psychiatric Hospital William A. Hewlett, M.D. Vanderbilt Medical School Eric Hollander, M.D. Mt. Sinai School of Medicine Bruce Hyman, Ph.D. Hollywood, Florida James W. Jefferson, M.D. Dean Foundation for Health Research Michael A. Jenike, M.D. Harvard Medical School David J. Katzelnick, M.D. Dean Foundation for Health Research Suck Won Kim, M.D. University of Minnesota Health Center Lorrin M. Koran, M.D. Stanford Medical Center Michael Kozak, Ph.D. B James F. Leckman, M.D. Yale University Henrietta L. Leonard, M.D. Brown University Charles Mansueto, Ph.D. Silver Spring, Maryland Isaac Marks, M.D. Institute of Psychiatry, London Arturo Marrero, M.D. Newark Beth Israel Hospital Christopher McDougle, M.D. Yale University School of Medicine Richard McNally, Ph.D. Harvard University Fugen Neziroglu, Ph.D. Institute for Bio-Behavioral Therapy & Research, Great Neck, New York Michele Pato, M.D. SUNY Buffalo, BuffaloGeneral Hospital

Frederick Penzel, Ph.D. Huntington. New York Katharine A. Phillips, M.D. Butler Hospital Teresa A. Pigott, M.D. University of Texas Medical Branch-Galveston C. Alec Pollard, Ph.D. St. Louis University Lawrence Price, M.D. Brown University S. Rachman, Ph.D. University of British Columbia Judith L. Rapoport, M.D. NIMH Steven A. Rasmussen, M.D. Butler Hospital Scott Rauch, M.D. Massachusetts General Hospital Mark A. Riddle, M.D. Johns Hopkins Jerilyn Ross, LICSW The Ross Center for Anxiety & Related Disorders Barbara Rothbaum, Ph.D. Emory University Paul Salkovskis, Ph.D. Warneford Hospital, Oxford University Jeffrey M. Schwartz, M.D. UCLA Neuropsychiatric Institute David Spiegel, M.D. Boston University Dan Stein, M.D. University of Stellenbosch, South Africa Gail Steketee, Ph.D. Boston University Susan Swedo, M.D. NIMH Richard Swinson, M.D. Clarke Institute of Psychiatry Barbara Van-Noppen, ACSW Brown University Patricia Van Oppen, Ph.D. Free University of Amsterdam Lorne Warneke, M.D. University of Alberta, Edmonton Jose Yaryura-Tobias, M.D. Institute for Bio-Behavioral Therapy & Research, Great Neck, New York

I

Guideline 2: Selecting Specific Cognitive-Behavioral (CBT) Techniques
Editors note: Table 2A describes the specific CBT treatment strategies that were endorsed by the experts and table 2B describes the level of care and intensity of services for CBT. Cognitive-behavioral therapy involves the combination of behavior therapy (E/RP) and Cognitive Therapy (CT). Behavior therapy for OCD (BT in CBT) most specifically involves Exposure (E) and Response or Ritual Prevention (RP). Exposure (E) capitalizes on the fact that anxiety usually attenuates after sufficient duration of contact with a feared stimulus. Thus, patients with obsessions related to germs must remain in contact with "germy" objects until their anxiety is extinguished. Repeated exposure is associated with decreased anxiety until, after multiple trials, the patient no longer fears contact with the specifically targeted stimulus. In order to achieve adequate exposure, it is usually necessary to help the patient block the rituals or avoidance behaviors, a process termed response or ritual prevention (RP). For example, patients with germ worries must not only touch "germy things," but must also refrain from ritualized washing until their anxiety diminishes, a process termed exposure and response prevention (E/RP).
2A.Selecting a CBT Strategy (bold italics =treatment of choice)	Summary: The experts consider the combination of exposure and response prevention as the optimal behavioral psychotherapy for OCD, while cognitive therapy may provide additional benefit by directly targeting distorted "OCD beliefs" and/or by improving compliance with E/RP.
	Obsessions	Compulsions
First line	Exposure plus response prevention (E/RP) E/RP + Cognitive Therapy (CT)	E/RP E/RP + CT
Second line	CT Exposure	Response Prevention CT Exposure