Successfully Getting a Single Case Agreement/Network Exception Request
We at the DBT-Linehan Board of Certification™ (DBT-LBC™) are committed to helping all individuals receive quality DBT services regardless of financial situation. We understand that the process of identifying high fidelity providers and programs who accept insurance can be an extremely difficult task, in the midst of what is already an incredibly overwhelming time. If you are unable to find an in-network provider and/or program or are struggling to assess whether a provider is actually qualified to provide DBT as designed and researched, we have created the following to help you in that process. There are clinicians and programs that provide quality DBT that may not be certified by DBT-LBC™, but those that have been certified by DBT-LBC™ have met certain high certification assessment standards and that often helps in getting your insurance company to agree to cover the treatment. If there are no DBT-LBC™ certified clinicians or programs within your physical vicinity, we encourage you to make sure that any clinicians who claim to provide DBT meet all of the other criteria stated in this document before proceeding with getting an SCA.
Often if a client is seeking specialized therapy and there is no provider or program in-network who offers it, they are entitled to receive the service out-of-network with the in-network copay/deductible.
Many clients have been able to get a “Single Case Exception” or a “Single Case Agreement” for DBT in order to go out-of-network and still only pay their normal in-network copay. The insurance company covers the remainder of the therapist’s normal full fee. This makes out-of-network therapy the same cost as in-network therapy for the subscriber.
Your insurance company may tell you that they have a specialist on their panel/in-network who can meet your needs. However, it is very unlikely in most situations, that you will actually be able to find a DBT-LBC™ certified clinician (or even a trained DBT therapist) or certified program who is in-network. What we suggest is that you call any therapist or program who your insurance company says provides in-network DBT and ask a few questions. Included here are some guidelines to help you determine whether or not the provider is actually offering comprehensive DBT.
Dialectical Behavior Therapy (DBT) consists of four components:
***Note--in DBT continued participation in treatment requires that clients are improving on structured assessments like the diary card. This is different than many other treatments where clients stay longer in the therapy if they are NOT improving.
Without every one of the above components, it’s not DBT
It is worth asking the following specific questions to any providers that the insurance company has given to you to make sure that they are actually providing comprehensive DBT.
Very often when clients ask “DBT in-network” clinicians the above questions they have found that the clinician:
If you find that the therapists or program whose names you have been given by your insurance company are not DBT therapists, go back to your insurance company and ask for them to authorize out-of-network treatment under a single case exception or single case agreement. Some states actually have laws that will help support you in these requests. Our clients tell us that they are most successful when they appeal and act assertively. Do not expect to get an immediate “yes” or approval for your request. It may take going up the chain a bit to find someone who is familiar with DBT.
Here is a possible script for you to use when calling your insurance:
First say, “I would like to request a Single Case Agreement/Exception to see an Out-of-Network provider and/or program who is certified by Dialectical Behavior Therapy-Linehan Board of Certification™ (or specializes in Dialectical Behavior Therapy).” (It is best to say the whole name of Dialectical Behavior Therapy instead of DBT because insurance companies often think people are saying CBT).
Second say, “I have tried to find a Dialectical Behavior Therapy- Linehan Board of Certification™ program/clinician who is in-network with (name of insurance plan) and have not found any. I cannot afford to see an out-of-network provider without a single case agreement because I do not have out of network benefits/I have out of network benefits with a high deductible and co-insurance.”
This may be the point where the insurance company gives you names of providers in-network who “do DBT.” You will then need to call those names and ask the questions that were discussed above to assess whether they really are trained DBT clinicians providing DBT therapy. After you call the names given to you and you do not find a DBT clinician in-network, call the insurance company back and continue with the following:
Third say, “I have called the clinicians and programs that you provided to me on (say the date of your initial call) and upon speaking with them discovered that they are not certified by DBT-Linehan Board of Certification™ or trained in Dialectical Behavior Therapy and/or do not follow the researched and evidence based model of Dialectical Behavior Therapy in their practices.”
Fourth say, “Through my own research I found a clinician and/or program who is certified by the DBT-Linehan Board of Certification™. I have asked if (name of clinician referred to in previous statement) will consider a single case agreement and they have said yes. What is the next step I need to take?”
Once you start the process for getting a single case agreement/exception you may be asked by the insurance company to “justify” why you need this specialized treatment in order for them to agree to cover it. Many insurance companies will require that you have the symptoms or behaviors associated with Borderline Personality Disorder, emotional dysregulation and/or behavioral dysregulation (e.g. self-harm, suicidal behavior and thoughts, psychiatric hospitalizations, etc.). That is because DBT has been shown by research to reduce these issues and reduce the need for other higher levels of care (e.g. partial hospital). As a result, DBT is a therapy shown to reduce overall expenses for the insurance companies in the long-term. This cost reduction has been confirmed by research on ADHERENT DBT PROGRAMS ONLY that deliver all four components discussed above in a manner that is consistent with the design and research of the treatment.
Many insurance company representatives are not familiar with different types of therapies and do not know the difference between them. If you are running into roadblocks with a particular insurance company representative it may help to say the following, “Is there a representative or supervisor I can speak with who has specific experience and knowledge of Dialectical Behavior Therapy?” It is common that once a person knowledgeable about the treatment modality becomes part of the process that things start moving along more smoothly.
Please know that the process of getting an SCA differs widely between states and from insurance company to insurance company. If you are having difficulties or have questions after trying these steps, please read the FAQs, ask a DBT-LBC™ Certified provider in your state or contact DBT-LBC™ for assistance in identifying a provider who might be able to answer your questions.
The legislative committee of the DBT-LBC™ would like to share our greatest appreciation for those organizations and clinicians who have gone before us in helping to support patients and their families in getting Single Case Agreements for DBT! These include Emotions Matter Inc. https://emotionsmatterbpd.org/resources2 [emotionsmatterbpd.org] and their publication “Utilizing Single Case Agreements to Access Treatment for Borderline Personality Disorder: A Strategy to Support Health Care Consumers and Clinicians" (2017), and Judi Sprei, PhD, Britt Rathbone, LCSW-C, Brian Corrado, PsyD of the DBT Metro Consortium www.dbtmetro.com [dbtmetro.com]
Frequently Asked Questions
Why can’t I find a DBT-LBC™ Certified clinician or program that is in-network with my insurance?
First, as you have probably gathered from the information on this website, DBT is a highly specialized treatment that requires extensive training, ongoing education and that the clinician works with a team of other DBT trained clinicians. This specialization means that there are fewer trained DBT therapists than there are general therapists. Also, because of the time, energy, and cost of providing DBT, many therapists do not participate with insurance companies, Medicaid, or Medicare due to the low reimbursement that they provide, something that DBT-LBC™ is also trying to change!
Second, there are currently only a small number of DBT-LBC™ Certified Clinicians and Programs compared to non-certified clinicians and programs. This is due largely to the fact that DBT-LBC™ clinician certification only came into effect in 2014, and DBT-LBC™ certification of programs started in the middle of 2017.
We expect that as time goes by the number of DBT-LBC™ Certified Clinicians and Programs will grow significantly. We also hope to work towards the long-term goal of increasing reimbursement so that more DBT-LBC™ Clinicians and Programs will become in-network within insurance companies, Medicaid and Medicare.
What is the difference between using my out of network benefits and attempting to get a Single Case Agreement/Network Exception?
The primary differences are related to the amount of effort the consumer will need to put in to get the services paid for AND the amount of money the consumer will have to lay out for services. Here are some additional differences:
Out of Network Benefits
Single Case Agreement/Network Exception
I followed the single case agreement/network exception scripts and have called all of the in-network providers who “do DBT” according to my insurance company and none of them are DBT-LBC™ Certified nor do they provide DBT in the way you describe the treatment on your website. My insurance company denied my request even after I shared this information with them. What is my next step?
Your next step is to follow the appeals process that your insurance company has in place. Sometimes you will need to get the help of a patient advocate assigned through your insurance company. Sometimes you or the provider you want to see will have to complete additional paperwork and send in additional clinical information. You or the provider may be asked to speak with an insurance company clinician to plead your case. Whichever next step is required by your particular insurance company, it makes sense to keep pushing forward! Many times a single case agreement/network exception request is authorized with only one additional appeal.
What if I keep getting denied for a single case agreement/network exception request after multiple appeals?
We know this can be frustrating and discouraging. Unfortunately, some insurance plans will not approve single case agreements/network exception requests without a significant fight from the consumer (and some will never agree to one). Some consumers have even attempted to get a lawyer or other advocate involved. There is no one route that promises success. Using the single case agreement/network exception scripts can help, as can responding to specific requests from insurance companies related to data on the “efficacy of comprehensive DBT” and soon to be published data on the increased success of DBT treatment when it is provided adherently. It is also important to know your rights within your particular state. Some states, like Maryland, have laws in place that require insurance companies to agree to single case agreements/network exception requests in certain situations.
Does DBT-LBC™ offer any scholarships for DBT treatment if I don’t have out of network benefits and I can’t get a single case agreement/network exception?
At the current time DBT-LBC™ does not provide scholarships for DBT treatment. However, there are some organizations that provide scholarships for treatment if a consumer has a particular diagnosis like an eating disorder or Complex-PTSD or has experienced particular traumas in their life. It may be helpful to google these scholarship opportunities and apply if you meet their criteria.
I live in an area where there are no DBT-LBC™ Certified clinicians or programs or the DBT-LBC™ Certified clinicians and programs are not taking any new clients. I have found a clinician/program that is not certified by DBT-LBC™ and they seem to be meeting all of the criteria you mention in the single case agreements/network exception script. Should I try to get a single case agreement/network exception with that clinician/program?
We at DBT-LBC understand that the availability of DBT-LBC™ Certified Clinicians and Programs is still very limited. We expect that as time goes by the number of DBT-LBC™ Certified Clinicians and Programs will grow significantly. We are committed to making the process for certification accessible to clinicians and programs so that the availability will increase. Please know that clinicians and programs who have undergone the intensive process required for certification have met high assessment standards in providing DBT treatment in a manner consistent with the research on the efficacy of the treatment. Clinicians and programs that are not yet certified by DBT-LBC™ may provide high quality DBT treatment that meets all of the criteria listed in the single case agreements/network exception scripts. If you are unable to find a DBT-LBC™ Certified clinician or program, clinicians and programs providing adherent DBT services in line with the criteria listed in the single case agreements/network exception scripts are the next best option. However, getting a single case agreement/network exception request authorization specifically for DBT with a clinician or program that does not meet the criteria for adherent DBT may ultimately hurt future consumers by having an insurance company pay for a treatment that is not supported by research and may not have the successful outcomes of adherent DBT. Insurance companies may then become less willing to agree to cover adherent DBT because of unsuccessful outcomes of non-adherent DBT and the fact that they may not know the difference between the two.