* This information applies to USA health insurance companies only *
We are fee-for-service specialists and do not participate in any insurance company except Medicare. By remaining independent of insurance constrains, we can give you our undivided attention, design a treatment plan that is most suitable to your needs, schedule as many visits as required for a full resolution, and spend as much time with you as needed during treatment and after hours.
The good news is that our services ARE covered by most insurance companies under one of the following parameters:
- You have out-of-network benefits and can go to any healthcare provider you choose. If this describes your medical benefits, then you will need to submit our paid receipts for reimbursement as per your policy’s allowances.
- You do not have out-of-network benefits and must use doctors in-Network only: follow instructions below for getting an Exception (In-for-out).
To find out what type of coverage you have, call your insurance company and ask them if you have out-of-network benefits for physical therapy and for mental health; there may be 2 different numbers to call, one for each.
If you have out-of-network benefits:
- Inquire about your remaining annual deductible (the money you need to pay out of pocket before they begin to reimburse), and
- Find out if you need prior authorization and/or a referral for our services, billed under physical therapy and mental health (psychotherapy). Make sure to take care of it in advance or you may find that they reject your claim, and
- Find out how to obtain a claim form, or ask us to print one for you when we meet.
- If you come for the 2-week program for vaginismus, inquire about their coverage for twice-daily sessions.
- We accept all modes of payment: cash, bank checks, certified checks, wire transfer, travelers’ checks, and all major credit cards.
If you do not have out-of-network benefits:
- You may want to seek an Exception, which is coverage at in-network fee for an out-of-network provider. An Exception is sometime called an In-for-Out or PPO Waiver.
- An Exception will typically be granted only for the physical therapy (medical) part of our services, and rarely for mental health; however, do not hesitate to inquire about both. See below what to say for physical therapy exception. For mental health exception, tell them you are seeking the services of a licensed social worker who specializes in counseling women with vulvodynia/pelvic floor disorders.
- Before calling the insurance company, make sure to read the rest of the text below.
- Also read Fighting Insurance for Approval, a step-by-step description of the process as reported by a former patient.
- Call the insurance and initiate the process of an Exception. Write down what they tell you that you need to do. Typically, the date you call is the effective date of your request and the Exception, when granted, will be retroactive to it. If possible, ask for a confirmation number, a written confirmation, or any other such proof.
- Once you made that initial call, you will, typically, need to show them that there is no suitable clinician within a 30-mile radius of your home, but some insurers will insist that you try a local participating provider (for 1-3 visits) before they would entertain an Exception; some insurers will do their own investigation. To establish the lack of availability of a local provider, you will need to call 3-4 physical therapy practices that are on your Participating Providers list (or search for them here) and inquire if they treat what you have (see list of conditions at the bottom of this page). Keep a log of the date you called, the time, and the name of the person you spoke with as the insurance may ask for it. Sometime the insurance company will do this checking for you and then advise. When inquiring with providers, do not hesitate to ask them how many such patients do they treat per week, how long is the treatment process, what results are expected and how fast, what is their success rate, etc. — you should be looking for a clinician with expertise, experience, and with an established treatment methodology!
- Once you ascertain that there are no suitable physical therapist within network, call the insurance back with the information and expedite your Exception.
- At times, you may need to speak with more than one insurance representative until you will get one (a female?) who will be sympathetic to your problem (see below what to say/not say!).
- The insurance company will contact us, if needed, to verify details.
- A letter from your physician, specifically referring you to us because of our specialized services and because there are no suitable providers In-Network, may help your case a great deal. Let us know if you want a sample letter emailed to you.
- Even if your Exception is approved, you will need to pay us and submit our invoices for reimbursement as per the Exception‘s monitory arrangement, which we cannot control. We accept all modes of payment: cash, bank checks, certified checks, wire transfer, travelers’ checks, and all major credit cards.
- Did the insurance deny your request? Do not give up but rather embark on the process of an Appeal; it may take up to 3 Appeals to get approved but nearly everyone who persevered (fought through the Appeal/s) got approved. You may want to read Vaginismus treatment – an appeal letter to insurance. Contact us if you need further assistance for the Appeal.
If you have The Empire Plan (NYSHIP) plan and live in the five boroughs of New York City/Long Island/Westchester: you must first come in for the initial evaluation, and give us a copy of your insurance card so we can submit an authorization request to cover that visit and subsequent visits. They will typically reply to us via fax within 3 business days.
As of March 2017: OptumHealth/Oxford seems to approve Exceptions at a fairly favorable rate of reimbursement. You will need to start the process: call the number on the back of your card and ask to be transferred to the Prior Authorization department; once there, give your information and ask for an Exception/In-for-Out. They may ask that we call, at which case email us with their info & a photo of your insurance card & your date of birth. Once they will ascertain that there are no available providers in-network who offer the same treatment as we do, they will contact us to discuss rates. If approved, they will note your record for the ‘agreed rate’ less your co-pay, annual deductible, and approximately a 10% service fee reduction (their regulations). Bottom line: you will pay us the agreed-upon amount per session, then submit for reimbursement.
If you are insured by UnitedHealthcare Community Plan: your referring physician needs to call them to initiate an Exception to come to us.
If you are insured by Palladian Health: they, too, have been favorable with granting an Exception to our patients. You may need to keep on top of them for a while so be patient yet persistent.
How to describe ‘the problem’ to the insurance representative (only if they ask!):
- Vulvodynia or Vulvar Vestibulitis: vaginal/vulvar pain and/or burning, burning during urination, sensitivity or pain to genital touch.
- Pelvic floor muscle spasms that come and go throughout the day/night, extremely painful gynecologic exam/vaginal ultrasound, muscle spasms that disrupt voiding
- Pelvic floor muscle weakness
- Prolapse of uterus, bladder, rectal canal
- Incontinence (urinary and/or fecal).
Sadly, female sexual problems are not covered conditions so do not speak about vaginismus or about painful sex!
Sounds complicated? Not really, as long as you follow the instructions above. We routinely treat patients who persevered and were nicely reimbursed.
It is up to you and your finances to decide if to start the treatment regardless of insurance approval and fight for reimbursement later, or to defer the treatment until you are approved by the insurance. We will help you either way.
Contact Us if you need treatment codes for further discussion with your insurance company