Finding a treatment team that specializes in eating disorders is difficult in and of itself. Trying to find specialized clinicians (dietitian, therapist, medical doctors, etc.) that are also in-network with your insurance is near to impossible! This article is designed to be a guide for navigating your insurance plan when trying to find an in-network dietitian that specializes in eating disorders, and what to do if and when your insurance can’t provide you with a certified specialist that is contracted with your insurance plan.*
*DISCLAIMER: This is strictly an informational post, and does not guarantee coverage.
First let’s define what a specialized dietitian’s credentials are going to look like, what this means, and why it’s important to see a dietitian with this level of specialized training if you or a loved one are diagnosed with some form of an eating disorder:
A dietitian that is a certified eating disorder specialist is going to have a title of “CEDRD” in their credentials, or it could also look like “CEDRD-S” (this means that they are a supervisor to dietitians training to get their CEDRD credential).
The extensive training and supervision for a registered dietitian to get this certification usually takes at least 3-5 years to gain. It requires at least 2500 hours of supervised eating disorder patient care experience, along with taking specialized course work, studying through a slew of textbooks, manuals, and other required readings, passing a board exam, and a few other projects and publications to complete. You can have confidence in clinicians that hold, or are in training to obtain, this certification to be up to date with all of the latest research and evidence-based methods to help you or your loved one recover from an eating disorder.
Now that we know the basics of what this certification looks like, let’s get into the process of dealing with your insurance! I will be giving instructions based on trying to get your insurance to cover services with Wellness Coaching & Nutrition Therapy, but if you’re in a different city or state you should be able to apply the same principles to another specialist.
As of the writing of this article, WC&NT is only contracted with BlueCross and BlueShield. If your coverage is through any other health insurance company there are three different avenues to take to try and get coverage for our services by your insurance:
Out-of-network benefits: If your plan has out-of-network benefits, coverage might be better than you’d expect! Some plans do not even require out-of-network deductibles to be met before they will start covering a portion of nutrition services. The best way to find out is by calling your member services line and requesting eligibility and benefit details for nutrition services out-of-network. Use Appendix A attached to the end of this article for more details on this.
Gap Exception/Out-of-network Exclusion: These terms are interchangeable depending on the lingo your insurance will use. This is an exception your insurance will authorize based on medical necessity for you to see a specialized clinician at your in-network benefit rate, even if they are not contracted with your insurance. A gap exception will honor your clinician’s office rates and reimburse 100% of the remaining costs after patient’s in-network rate responsibility.
Single Case Agreement: This is a one-time contract your insurance will set up with an out-of-network provider so you can see this provider at your in-network benefit level. The difference between this and a Gap Exception is a negotiation process that takes place between your insurance and the out-of-network provider. Often this negotiation involves the out-of-network provider to reduce their service fees if they are higher than reimbursement rates for your insurance company’s established contracted providers.
Usually your insurance company is going to be more willing to grant a Single Case Agreement over a Gap Exception, so you’ll want to verify with the out-of-network provider that they are willing to contract with a Single Case Agreement. We here at WC&NT are willing to negotiate with Single Case Agreements, but cannot guarantee approval of all Single Case Agreement contracts.
Here are the steps to take to get the process rolling:
Step 1: Call your insurance’s member services line and ask for a list of in-network registered dietitians that specialize in eating disorders - particularly ask for a list of RD’s that hold the CEDRD certification. If the list is extensive, request the list to be emailed to you. Be sure to document who you speak to and request a call reference number at the end of the call.
Step 2: Once you receive this list, email it to email@example.com and we can help determine if you would be eligible for a gap exception or single case agreement.
Step 3: You may have to call some of the registered dietitians on the list they provided you to see if they truly specialize in eating disorders, and what their experience with eating disorders entails. This might feel pointless and aggravating, but it’s groundwork that needs to be done in order to build a case for the gap exception or single case agreement!
Questions to ask the in-network dietitians:
Do you specialize in eating disorders? If so, what trainings have you attended, or related certifications do you hold related to the field?
What percent of the clients you treat have eating disorders?
How many continuing education courses or classes do you obtain in the field of eating disorders?
What is your philosophy in the treatment of eating disorders? What approaches do you use?
Step 4: Since there likely won’t be anyone on your list that holds a CEDRD or has enough experience in eating disorders, with the information you have gathered you now have the “ammo” you need to request a gap exception or single case agreement.
At this point, you’ll call your member services line once again and explain how none of the dietitians in-network are specialized in eating disorders, and provide some of the information you found to prove this. You may have to explain to them that it is imperative to see a clinician that is highly trained and specialized in eating disorders, and you can use this quote straight out of the Academy of Eating Disorders Medical Care Standards Guide (2016):
“All eating disorders (EDs) are serious mental illnesses with significant, life-threatening medical and psychiatric morbidity and mortality, regardless of an individual’s weight. Patients with EDs have the highest mortality rates of any psychiatric disorder...Early recognition and timely intervention, based on a developmentally appropriate, evidence-based, multidisciplinary team approach (medical, psychological & nutritional) is the ideal standard of care.”
It is your medical right that they start a case to grant a Gap Exception or Single Case Agreement to an out-of-network registered dietitian that does specialize in eating disorders.
At this point you can give them WC&NT’s information. Let them know that all of the dietitians in this practice either hold their CEDRD, or are undergoing supervision from Jill Sechi, MS, RD, LD, CEDRD-S (owner of WC&NT) to attain their CEDRD.
You will be assigned a case manager to initiate the process of a gap exception or single case agreement. Provide your case manager with WC&NT’s contact information. You may also need to provide them with our NPI and/or Tax ID which we can provide to you at that time.
Stress to them that time is of the essence and that you require this be processed STAT for the health and safety of you or your loved one.
Be sure to document who you spoke to on the call, and request call reference numbers each time you speak to someone new. Be sure to also obtain the case reference number once it has been initiated and your case manager’s direct contact information.
Other things that may help your case:
If you’ve been to a treatment center recently, you can request that they write a letter on behalf of your case to recommend continued treatment with a specialized outpatient registered dietitian to give your case manager.
If you have a medical provider that has documented your eating disorder diagnosis, you can request a referral to WC&NT for nutritional counseling services to give your case manager.
Once your case has been approved, it’s important to be aware of any limitations of office visits and the expiration date of the case. These cases can be renewed, but it’s important to start this process at least 3-4 weeks prior to the expiration date of the case for seamless continuation.
So there you have it! A not-so-brief guide to navigating your insurance when finding an eating disorder specialist. I hope this can provide you with some clarity on the process, and also explain the insurance lingo that can be quite confusing and frustrating to understand sometimes!
If you have further questions on this process, or want to get the ball rolling for you or a loved one, please feel free to reach out to us by either calling our office at (713) 997-9613, contacting us on our website, or shooting an email to firstname.lastname@example.org!
Insurance Script for Determining Out-of-Network Benefits
Verification steps to take PRIOR to your initial assessment:
1. Call the member services on the back of your insurance card. Explain that you are seeking nutrition counseling for the treatment of eating disorders and want to verify your out-of-network benefits to see dietitian’s at WC&NT. The following questions are helpful to ask:
Do my out-of-network (OON) benefits cover procedure code S9470 (nutrition counseling/dietitian visit)?
Does my plan only cover visits that are considered “medically necessary”? Do I need to meet an OON deductible first?
If yes, how much is it, and what are the benefits after I meet my OON deductible?
Is there a limit to how many sessions are covered?
Is there an OON co-pay amount for outpatient nutrition counseling? Are there any diagnosis codes that are excluded?
If you’ve been diagnosed with an eating disorder and know the diagnosis code, you can provide it at this time
2) Obtain a reference number of the call for you to keep on file in the case your insurance denies payment of benefits they have just given you.
Please keep in mind that WC&NT has clinician’s that provide reduced rates have on file in case BCBS denies your claim - $125 for initial assessment, and $75 for follow-ups.
Please call Wellness Coaching & Nutrition Therapy at 713-997-9613 with any other additional questions or concerns you have while working with your insurance company!