Wednesday, March 03, 2010

New insurance...

Means new headaches. And trust me...I am very grateful that I have insurance. I still have the insurance statements rolling in from Sophie's brain surgery and I am very fortunate to NOT have to pay all the charges STILL going through.


Our new insurance covers therapy. Sophie's physical therapy went through just fine. But her speech therapy was rejected with the following note...


Charges for speech therapy are covered only when the speech therapy is expected to restore speech function or correct a speech impairment resulting from non-chronic conditions, acute illnesses and injuries, or gross anatomical defect present at birth. Based on the information provided, this charge is for speech therapy which does not meet this coverage requirement.


I have put in one phone call so far with no answers. I am still planning on making a few more later this afternoon. But just wondering if anyone else has gone through this. I am not sure if epilepsy or brain surgery falls within the above category.

8 comments:

Dora's Daddy said...

It would make sense that the brain surgery was designed to deal with the epilepsy which was caused by a "gross anatomical defect (in the brain) present at birth."

I love/hate insurance companies and believe they have a special department called the "Department of Delays and Appeals." I figure that their job is to make it as unpleasant as possible for people to "re-submit" claims that some simply give up and pay out of pocket. I'll bet they "save" quite a lot of money that way.

God bless you all.

Angelique said...

Insurance companies can be very frustrating to deal with. It seems like everything has to be a fight. I've had trouble with Hayden's insurance coverage too. Have her doctors, physical therapist, speech therapist all write letters to the insurance company advocating for Sophie and speech therapy can benefit her. That was something that helped us.

nchlsgdk said...

I've read your blog for a while...I have a 12 year old who had IS and then 10 seizure free years until they started again....we went through the whole speech therapy thing-it was covered while we were on an HMO, but when we had to switch to a PPO, we lost coverage for the same reason as what was stated. The way it was explained to me was that a medical insurance company will cover speech therapy if it is restoring something that was lost-for example, you were in a car accident, had a TBI and had speech problems after. If the speech was not there to begin with, then that would be considered educational-ie, speech would need to be taught. The reason that the speech is not there in the first place is irrelevant. It's very frustrating-we paid for 9 months of speech out of pocket because the inital claims were approved. When I questioned them about why a subsequent claim was not approved, I was informed that the first claims should not have been approved and that they were going to reprocess them...Ugh! We were lucky to get about 3 1/2 years of speech while he was on the HMO.

Karen, Mom to Thomas, age 12

Colby said...

I was lucky to never have had this problem when Colby. His insurance covered therapy from birth (also, remember there wer no seizures until he turned 8 yrs. old, so his Dx would be different than Sophie's)...But then my ex changed jobs, and I was terrified...By that time, though, Colby was entering a special preschool program which provided all therapies...When he turned 5, his special needs school was REQUIRED BY LAW to provide it for him 3/week during school hours....At no charge, of course....(It has to be written into the IEP, of course...)

I am sure things have changed since Colby was Sophie's age (many moons ago!), but I would also do as suggested above...Get every doc and therapist involved to write a letter and STRESS the positive outcomes in children who have gone through the surgery and have gained speech...Hopefully they will agree to cover it...I think alot of companies will argue until you push and push...Fingers crossed!

Another thing would be to make certain you have tapped into any other schools or agencies that might help provide or supplement the cost...I worked for Easter Seals for years, and one of the things that we paid for was PT, OT and Speech...You should have an office in your state and could try them...Or United Way may make a referral for assistance...

Does your state offer the TEFFRA Medicaid program? It covers disabled children with Medicaid, no matter the parents' income (but the children receive no SSI check)...Look into that...A few of us parents lobbied to get it TEFFRA started here in SC some years ago...(It's also called the Katie Beckett Bill)

Eventually, when Sophie is in an actual public school program, you shouldn't have any trouble getting that service for her through school if she is still in need of it....

So sorry about this....We are having TERRIBLE budget issues here in SC w/Medicaid, so I know how you feel!!! We parents have enough to deal with!!!

Cyndi

Sinead said...

Insurance company told me that their insurance policy is designed for people who get sick and not for people who have special needs. We get 30 hours of speech therapy a year but the nearest therapist is 70 miles away.

Jonathan said...

I wonder if she would qualify for Traumatic Brain Injury in your state? It came up on the hemi board today.

I hate insurance. No two ways about it. I think it started out as a good realistic tool. And...like all things...time has morphed it into a greedy pocket lining mess!

But that's just my two cents.

...danielle

Jackson's Blog said...

Frustrating!!! I agree with Danielle's comment. I think it has to do with coding, etc. They denied Jackson at first, but we worked to recode it and they cover now. PT/OT was a lot easier to cover initially, but now they are covering Speech. I will try to look back to see what our says and what we did differently.

Sophie's Story by Elaine said...

Thanks everyone for your advice. Our pediatrician is working on writing a letter. I passed on your suggestions to her.

Sophie does get ST in preschool through our local school district. But she also gets one hour a week of private ST. It is the same therapist that
she has been seeing since she was 23 months old. So she has been through it all with us. The therapist at preschool has already changed once and it will change again when she starts kindergarten. So it is just nice to have someone who knows the history first hand. Someone who will most likely be with us for years to come.