I think we’re all aware that there is a mental health crisis in this country. As a result, it can be really difficult to find a therapist who has availability, much less a therapist with availability who is in your health insurance network. Are you stuck paying out-of-pocket for the entire amount? Maybe not.

In the past couple months, I helped a client with her network gap exception request as well as advised a friend how to request one. In both cases, these exception requests were approved. 

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So, what does this mean and how do you get your request approved?

Suppose you have a child with anxiety who needs to be seen by a mental health provider. You request a list of in-network providers from your insurer. You call each provider who is located within a reasonable distance and are told that none of them have any availability for new patients… or perhaps they are taking new patients but only self-pay patients. Your child needs help, so you end up finding someone who will see your child and you pay 100% out-of-pocket.

Now, you should be thinking: I’m going to call my insurer and request a network gap exception!.Call the customer service number on the back of your health insurance card. Tell the representative that you’d like to request a network gap exception. This is the information that you’ll need before you make that call:

– Name, address, phone number of provider

– NPI number of provider (Google the provider’s name and “NPI” or call the provider and ask)

– Tax ID number (EIN) of provider (call the provider’s office)

– Diagnosis (CPT or diagnosis code or, e.g, “OCD”)

– Reason why you are making this request (eg, “I have called all 25 providers who are in-network within a 30 minute drive and none are taking new patients,” or “none of the providers who are in-network treat complex PTSD.”)

It’ll take about 30-45 days to hear back.

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What happens if you are approved?

You may be approved for a set time frame or for a set number of visits

You will have to submit the claims or a superbill to the insurer (ask them for the correct claims form). Remember that your insurer is agreeing to reimburse YOU at their in-network rate. Your provider is NOT agreeing to be an in-network provider. Therefore, you will owe your provider their entire fee. The bonus for you is that you are getting reimbursement for part of that fee..While, I am focusing on mental health providers here, you can request network gap exceptions for any type of provider. 

As always, any time you call a health insurance company, take notes and ask for the representative’s name and a reference number for the call. Good luck with your network gap exception request!

Bottom line: It never hurts to ask!

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Refusing Medical Care: Know Your Rights and the Consequences

When you are a patient in the health care setting it is important for you to realize that the members of your health care team have your best interests at heart. Your absolute safety and security is the ultimate goal of all patient care and the mantra of your health care team is to do “no harm”. While that is the goal, you have only to read a newspaper or listen to the local news to hear stories of health care gone awry, at times with catastrophic consequences to the patient.

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Before refusing care, you must be able to evaluate the consequences of that decision. This means that you need to understand the need for the specific drug, test or procedure that your health team is recommending.

With that being said, you have the absolute right to refuse treatment, procedures, medication, or diagnostic testing at any time. Before refusing such care, however, you must be able to evaluate the consequences of that decision. This means that you need to understand the need for the specific drug, test or procedure that your health team is recommending. If you feel you don’t have enough information to make good decisions about that care, ask your health care team for more information. If you haven’t understood the explanations given to you by your health care team, ask for clarification. Ask for the definition and spelling of unknown medical terminology. Ask for written literature about recommended care. Ask the doctor what he or she is going to do with the results of the recommended test or procedure. Ask who is going to perform it. Ask how many times she or he has previously performed it. Ask why you need a particular drug, procedure or treatment. Ask about the potential side effects of prescribed drugs. Do the benefits of taking the drug out weigh not taking it? Ask about the consequences if you refuse such care. ALWAYS give an explanation as to why you are refusing treatment so that your rationale for refusal becomes part of your medical records. Otherwise, you run the risk of being labeled an uncooperative patient. 

While it is your right to refuse care, you need to be aware that refusing care on a regular basis may interfere with finding out what is wrong with you (making a diagnosis) and the ultimate outcome of your situation (prognosis). In addition, the hospital will be required to report your repeated refusals of care to your health insurance company (Private, Medicare or Medicaid) and that company may refuse to pay for your continued hospitalization. After all, why should they pay for you to be in the hospital to get care when you refuse such care? 

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While it is your right to refuse care, you need to be aware that refusing care on a regular basis may interfere with finding out what is wrong with you (making a diagnosis) and the ultimate outcome of your situation (prognosis).

Unless you are mentally incompetent to understand the consequences of refusing treatment, or are an actual prisoner requiring hospitalization, you can sign yourself out at any time. If you choose to leave against medical advice, expect your health care team to talk with you to find out why you want to leave. Be prepared for that conversation. They want to be assured that you understand the potential consequences of leaving the hospital against medical advice. They will ask you to sign an AMA (Against Medical Advice) Form. This form negates their liability in the event that something catastrophic happens to you when you do leave against medical advice. If you refuse to sign it, 2 members of the health care team will witness and document that you refused to sign it. If the health care team feels that you are incapable of understanding the consequences of leaving the hospital AMA, they can restrain you and call for a Psychiatric evaluation to determine whether or not you are capable of making such a decision for yourself.

If you choose to leave against medical advice, expect your health care team to talk with you to find out why you want to leave. Be prepared for that conversation. They want to be assured that you understand the potential consequences of leaving the hospital against medical advice.

The key is to communicate with your health care team consistently. Let them know what you are feeling and thinking. Let them know your concerns. Ask them any questions you might have. Ask for clarification whenever you are in doubt. Be assertive. Advocate for yourself or have an advocate with you who can make sure your voice is heard when you might not have one. 

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CINTAA Elder care shares useful information regarding healthcare on weekly basis. The post is only for information purpose only. Please check with your health care professional before using this information. To keep yourself updated with many other health tips, stay with us. We provide certified caregivers for seniors at home. If you need any help regarding eldercare, please feel free to call us today at 561-963-1915.