Because of how disruptive my OCD has been, I’ve been trying to get into the intensive outpatient (IOP) program at my clinic. IOP treatment is administered by a team of three to five clinicians. It would be doing the same types of exposure therapies I’m doing now, but for longer periods of time every day. It would include frequent visits to administer treatment in my home. It also includes psychiatric consultation to administer and monitor medication. There are two tiers of IOP treatment: 20-hours-per-week and 10-hours-per-week. The clinic likes to start patients off at 20 hours per week because that is proven to be the most effective. It’s designed to be a totally immersive treatment and I’m told it works best when the patient approaches treatment with the attitude that he or she is going to tackle everything all at once and come out the other end in remission.
These treatments are expensive. They are respectively $6000 per week and $3000 per week. There is no way I could pay for this out of pocket. That’s why I was excited when I found out my insurance company would cover the entire treatment (or so I thought).
When I first discussed the IOP treatment option with Dr. Osborne about two months ago he asked me if my insurance was Premera (Premera has a history of covering in full for pretty much all of the their patients who request the IOP treatment). I said yes because I thought it was. My insurance is actually with Blue Cross Blue Shield (BSBC) of Nebraska which shares the same blue cross logo as Premera and I’d seen the Premera name on other insurance forms of mine. Because of this I just thought BSBC was subsidiary to Premera. Turns out that’s not the case. BSBC does contract with Premera to pay claims in the state of Washington (don’t ask me how or why… this insurance stuff is confusing, but this is why I had seen the Premera name connected with my insurance), but Premera has nothing to do with approving treatment in my case. BSBC will be the ones to approve (or not approve). The clinic’s history in dealing with insurance companies other than Premera is that they’re more likely to decline IOP treatment.
Great. This was going to be more complicated than we thought. If my insurance had been held directly with Premera it would have been a simple approval process that would have taken a couple days and I could have started treatment six weeks ago. Instead my clinic had to go through a complicated pre-approval and negotiation.
The first attempt at getting approval for the treatment was not successful. It was clear BSBC didn’t understand the treatment and the coverage the clinic was asking for. The first response was basically “your insurance policy covers x number of mental health visits per year.” They didn’t understand that the clinic wanted to set up an agreement for payment above and beyond what was stated in my policy. It took them a few weeks for them to first understand the treatment and another couple weeks to get on board, but eventually after a phone call with Dr. Osborne they agreed that the treatment is necessary.
But that was only the beginning.
I learned that the people at BSBC who approve the treatment are different from the payments people who determine coverage limits. The payments people initially said they would cover $500 per day. This is well short of the $1200 per day cost of the full IOP option. There was another week or two of negotiations and BSBC eventually agreed to $800 per day (only two-thirds of the $1200). Additionally, BSBC won’t allow the clinic to bill $800 to insurance and then balance bill me the remaining $400 (I’m uncertain why this is). Even if they did, I still wouldn’t be able to afford $400 per day.
It seemed like we were at an impasse… until I asked a question.
I talked to my clinic to get clarification on one point: did BSBC agree to pay for two-thirds of the treatment cost, or did they actually agree to $800 (two different things)? The answer was $800. The reduced 10-hour IOP option of treatment is only $600 per day, so I asked why not just do that. The initial response was that the IOP team usually likes to start people at 20 hours per week because it is the most effective. After a while they typically taper patients off to the 10-hour tier. I had to do some internal negotiations with the clinic to convince them that the 10 hour per week option was still better than nothing, and eventually we all agreed.
So… the pieces are all now finally in place. Dr. Osborne and the clinic are rallying behind me. Work has made accommodations. Insurance is on board and has approved the treatment.
So, after six weeks, it looks like I will finally be able to begin IOP starting next Monday!