This is the work of Bob and Norm, who tried and tested and found this to work.
At our last Ins TF meeting it was suggested we offer this to members thru the member's only section of ICA web.
Also I discussed this with a ICA member who is also a representative of a major Insurance Co. She corroborated that an "ad hoc" non-paneled provider is easily approved by this method (it's one of her jobs) AND she stated our theory that ad hoc's are NOT removed from their database after the one 'out of network / ad hoc' approval, thus opening the door for other clients under that plan to be seen by our member. I will include a caveat that ins co's state that " there is no guarantee of payment even if approved by the ins co. And that the client is always responsible if an ins co decision for approval is reversed for any reason".
Back-Door Method for Gaining Access to Managed Care
In most states, up to 80% of the top companies will pay a mental health provider third-party reimbursement. To be eligible for payment from these insurance companies, the clinician may need to apply to each company and earn provider status, which means inclusion on the insurance’s approved mental health provider panel. But what if the mental health clinician is not on the new client’s panel? What if that panel is closed in that particular area?
Through the years, we have learned how to “get in the back door” of managed care companies. The back-door method helps the clinician become an AD HOC provider; that is, they are accepted for that one client. In many cases, once accepted in the insurance company’s system, the mental health clinician is given provider status and may even be referred new clients from the managed care company.
The back-door system is predicated on a few factors; the first is the motivated client. When a new client calls—especially if the call is based on a doctor, teacher, or friend’s strong recommendation—the client is highly motivated to make their insurance work. The mental health clinician must ask the client to petition the employers in a clear, polite way, requesting that the insurance/managed care company consider paying the chosen mental health clinician. The letter should point out the credentials, license and experience of this therapist, and explain that the therapist meets the requirements of the state for licensure as a professional. If a physician referred the client, that information should be included as well. The letter is sent to the benefits manager or whoever coordinates insurance for the company. A copy (cc) is sent to the insurance or managed care company’s provider relations director, as well.
The second letter of the response comes from the licensed mental health clinician (who must always obtain a release from the client prior to sending these letters). The letter is sent to the managed care or insurance company with a copy (cc) to the client’s employer benefits manager or HR Department. In this letter, the clinician requests consideration of payment for services; the request should include an outline of professional qualifications and an explanation of why the clinician is a good fit for the client. The insurance company’s provider relations department should respond to the request within two weeks; after two weeks pass, follow-up phone calls will help expedite the process. In the meantime, it is recommended that a payment plan be arranged with the new client, charging what the insurance company would pay. An agreement should be made that the money will be reimbursed once the insurance company responds with payment. And as always: " there is no guarantee of payment even if approved by the insurance company . And that the client is always responsible for payment if an insurance company's decision for approval is reversed for any reason".