perfectionism and - Obsessive-Compulsive Foundation

6/14/13
SINGLE CASE AUTHORIZATION (SCA)
KNOW YOUR RIGHTS
Allows members with no out-of-network benefits to see a
non-contracted professional.
Certain conditions must exist for a SCA to be made:
• An area that is geographically remote from any innetwork
provider.
• A clinical specialty is not available with-in-network.
Clinical Review: A licensed care manager contacts the
out-of-network clinician to discuss diagnosis, evidencebased
treatment goals, symptoms, and rationale for the
necessity of an out-of-network professional.
If SCA approved, out-of-network provider will receive an
approval letter detailing the certification (e.g., number
of visits, start/end dates).
HOW TO FIGHT FOR YOUR RIGHTS
1) Call your insurance and ask for names of OCD/anxiety
specialists in your area.
2) Find out where these practitioners are
located. Usually, you cannot be required to see
someone outside a certain radius.
3) Call the list of practitioners and grill them on:
How many cases they've successfully treated
What treatment methods they use
Typical length of treatment
What kind of specialized training they have to treat
this
Are they known specialists locally, nationally
4) Inform your insurance that none of their practitioners
are skilled to provide ERP, and you have found an outof-network
clinician who is considered competent.
Disclosure of Allowable Reimbursement / Payment
Determination Request: Insurance form filled out by clinician
to determine reimbursement rate before starting treatment.
Secret insurance companies don't want you to know:
Insurance companies must provide adequate treatment by
properly trained practitioners for both HMO and PPO.
Fact: Most “specialists” do not contract with insurance plans.
Goal: Get insurance companies to admit that they have no
providers who can treat OCD/anxiety.
After many back-and-forth battles, insurance may agree to
contact your chosen out-of-network practitioner to negotiate
an "ad hoc," out-of-network, or SCA.
HOW TO FIGHT FOR YOUR RIGHTS (CONT.)
5) If the insurance denies your request, be assertive and
remind them that they’re required to provide adequate
care under the terms of your contract. Convince them
that you are going out-of-network not by choice, but
because there are no sufficient alternative.
6) Talk to a supervisor and assertively inform them that
you’ve done your HW, and the practitioners they have:
a) Really isn't qualified.
b) Isn't taking new patients.
c) Didn't even know what Exposure & Response
Prevention was, etc.
7) Document EVERYTHING!
SATURDAY
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