When a patient can't afford your fee, you don't have to lose them.
I get your out-of-network patients covered at in-network rates, often up to your full fee, using the network-adequacy rules that govern their plans. You stay private pay, submit nothing to the insurer, and sign no network contract. It's success-based, paid only if it works.
Network rates are getting cut, and patients can't absorb the gap. The law already provides a path that's rarely used: when a plan can't offer an in-network provider who fits a patient's needs, it can be required to cover your out-of-network care at in-network rates. Securing that approval is what I do.
Patients stay in care, and you keep your full rate.
No one leaves over cost
The patients who would have left over an out-of-pocket number get covered at in-network prices, so the work you started doesn't end over money.
Paid at up to your full rate
In most gap-exception approvals the plan reimburses your full rate, not the thin out-of-network amount a standard claim returns.
Almost no work on you
The patient signs the forms and the insurer deals with me. Your only role is brief clinical input, handled behind the wall of confidentiality.
The first question every clinician asks: am I exposed?
Short answer: a gap exception changes nothing about how you practice. A single case agreement adds a few defined obligations, on the cases that take that route.
You sign nothing with the insurer
Your only agreement is with me, and it holds me to clinician-grade confidentiality.
Minimal clinical input
A short summary in general terms: presentation, history, and plan. Never your treatment notes or full record.
No audit, no clawback under a gap exception
You have no contract with the plan, so there's nothing to audit and no rate to claw back. You can still balance-bill.
One practical ask
Be willing to carry a single intake session before approval lands, so there's a clinical picture to submit.
Gap Exception vs. Single Case Agreement
These get confused constantly, and the difference decides what, if anything, is asked of you. In practice, the great majority of cases resolve as a gap exception.
For private-pay clinicians who don't bill insurers, the gap exception is almost always the right path. I'll tell you up front which one a case is heading toward.
Coverage turns on a documented access barrier, not a preference.
Access
No appropriate in-network option that's actually available: long waitlists, providers not accepting patients, or a needed language the network can't supply.
Clinical risk
A high-risk or time-sensitive picture, where delay or disrupting active treatment raises real clinical concern. Risk is what turns "wait" into "approve now."
Specialty & modality
A specialty or method the network can't supply: child and developmental specialists, speech and occupational therapy, perinatal and lactation care, or specific evidence-based modalities.
Cultural & identity fit
When a specific cultural, religious, or identity fit is a documented clinical access barrier rather than a stated preference, it can support an exception.
Covered services span behavioral health, specialized and developmental care like speech and occupational therapy, and perinatal and related care, billed under standard codes. Unlicensed coaching and anything outside covered codes are not.
Commercial plans, reliably.
This works best with commercial plans, the coverage your patients get through an employer or buy privately. Aetna, Cigna and Evernorth, Blue Cross Blue Shield and Anthem, and UnitedHealthcare all approve these, though some take more persistence than others. Medicaid and Medicare generally don't allow a member-initiated exception, though a single case agreement is sometimes possible if you're willing to bill.
Before taking anything on, I screen the plan and give an honest read on whether it's likely to work. I'd rather tell you no early than waste your patient's time.
Free consult
You or your patient books an intro call. I qualify the case and give a realistic read on the odds before anyone commits.
Agreements signed
An engagement agreement that protects you, plus an authorization that lets me speak to the insurer directly.
I open the request
Some plans are phone-driven, some form-driven. I handle the insurer end and the back-and-forth.
You add brief input
A short clinical summary in general terms. Where there's genuine risk and you know the patient, the grounds are strongest.
Approval
A decision can take up to 15 business days by law, often less. A gap exception typically lands with full reimbursement and in-network cost-sharing.
Success-based, with no financial risk.
There's no charge to start and no fee unless a case succeeds. When it does, the fee is three times the per-session rate I secure, billed once. If the approved amount or duration comes in below the goal, I prorate it. If it doesn't work out, there's nothing to pay.
Who covers the fee is arranged up front and varies by case: sometimes the patient, sometimes the practice. Practices that refer patients receive a standing discount on those referrals.
Someone in mind, or a panel of patients who left over cost?
Book a consultation to talk through a specific case or your whole list of out-of-network patients. If you're in a provider group and willing to share, that's the thing I'm most grateful for, and you'd be passing along a real option most of your colleagues don't know exists.
How long does an approval last?+
Typically a set number of sessions over a year, often weekly, and sometimes much more where the clinical need supports it. If the plan later identifies an in-network option, coverage doesn't just vanish; the exception can be revisited and extended when the match genuinely doesn't fit.
How is confidentiality handled?+
I'm not a covered entity under HIPAA, but I commit to abide by it and hold myself to that standard. The tools I work with are HIPAA-compliant and covered by business associate agreements, and I follow minimum-necessary handling: only the brief clinical detail a request requires. That commitment is written into the engagement agreement you sign.
Does this include ongoing billing or claims management?+
No. My work is securing the approval, not running your billing. Under a gap exception, the patient submits their own superbill and handles any follow-up if a claim needs reprocessing; your practice isn't pulled into ongoing claims work. Under a single case agreement, you'd submit claims as you normally would for an in-network patient.
What happens if a case is denied?+
It can happen, which is why I screen carefully up front and why the fee is success-based. If it doesn't work out, there's no fee. Where there are grounds, denials can be appealed.
Why haven't I heard of this before?+
It's a niche area, and the people you'd normally ask, including front-line insurance reps, often don't know the path exists or how to push it through. This isn't a favor an insurer grants; it's grounded in parity and network-adequacy law.