insurance issues

February 27, 2004

Hi,

Welcome to the group! I'm sure you will get replies from group

members who have had various insurance battles, but you may be able

to start your research in some of the reference areas here at the

group site.

If you would like a basic snapshot of different insurance

experiences, take a look at the DATABASE section of the group, WHO'S

INSURANCE PAID WHAT? database.

The CAPPSkids website also has a great insurance help page that

lists some of the common denials and countermeasures you can take in

the appeals process. The links to CAPPSkids insurance help, as well

as other helpful reading is in LINKS section, INSURANCE folder.

Additional insurance help and information is in the FILES section of

the group, INSURANCE HELP folder.

I just wanted to get you started with some suggestions; we ended up

using repositioning only to treat our daughter Remy's plagio, so I

don't have personal experience with insurance issues.

Please let us know how the appointment goes tomorrow,

Christie (Mom to Repo'd Remy)

> We are just learning about plagiocephaly and Crainiosynostosis

from

> our doctor who feels that our 6 month old son has plagio and will

> most likely need to be treated with a helmet / band.

>

> Again, we are in the very beginning stages of this (our son is

> scheduled for a CT scan tomorrow) but our Doctor has stressed to

us

> that insurance generally does not pay for the treatment of plagio

and

> if they do cover it's not without a long hard battle. He has

> suggested that we begin doing our research now as it will help us

> later in our attempt to have our sons treatment covered.

>

> Obviously our main objective and goal is to do what is best for

our

> child whatever the treatment may be no matter the cost but it

would

> be nice to have alittle assistance from our insurance...

>

> Has anyone experienced difficulty (denial of coverage and / or non-

> authorization for treatment)? If so what advise and or

suggestions

> do you have that may helpful to us?

February 27, 2004

Hi and welcome to the group! I wanted to second what Christie had

told you. What insurance do you have? Maybe someone at the group

has first hand experience with that particular company. Many have

fought to get payment and WON, many have had to just file a claim to

get paid. Hope we can help. YAY to your dr. for being on the ball

with this. Good Luck witht he CT Scan. Keep us updated.

Dustie

> We are just learning about plagiocephaly and Crainiosynostosis

from

> our doctor who feels that our 6 month old son has plagio and will

> most likely need to be treated with a helmet / band.

>

> Again, we are in the very beginning stages of this (our son is

> scheduled for a CT scan tomorrow) but our Doctor has stressed to

us

> that insurance generally does not pay for the treatment of plagio

and

> if they do cover it's not without a long hard battle. He has

> suggested that we begin doing our research now as it will help us

> later in our attempt to have our sons treatment covered.

>

> Obviously our main objective and goal is to do what is best for

our

> child whatever the treatment may be no matter the cost but it

would

> be nice to have alittle assistance from our insurance...

>

> Has anyone experienced difficulty (denial of coverage and / or non-

> authorization for treatment)? If so what advise and or

suggestions

> do you have that may helpful to us?

February 27, 2004

Hi,

I see you've already been referred to our database, but it may be

helpful to add where you live and what type of ins you have to your

subject line to draw attention from others in your area. We did get

both bands paid in full, but like you said it was after a long hard

fight (and having to put $6,000 on our credit card!)! Good luck.

, mom to Hannah, DOCgrad

Cape Cod, Ma

> We are just learning about plagiocephaly and Crainiosynostosis

from

> our doctor who feels that our 6 month old son has plagio and will

> most likely need to be treated with a helmet / band.

>

> Again, we are in the very beginning stages of this (our son is

> scheduled for a CT scan tomorrow) but our Doctor has stressed to

us

> that insurance generally does not pay for the treatment of plagio

and

> if they do cover it's not without a long hard battle. He has

> suggested that we begin doing our research now as it will help us

> later in our attempt to have our sons treatment covered.

>

> Obviously our main objective and goal is to do what is best for

our

> child whatever the treatment may be no matter the cost but it

would

> be nice to have alittle assistance from our insurance...

>

> Has anyone experienced difficulty (denial of coverage and / or non-

> authorization for treatment)? If so what advise and or

suggestions

> do you have that may helpful to us?

February 27, 2004

Hi Tony,

It really depends on the insurance....actually, it even seems to depend on the person you get at the insurance company reviewing your case. I've seen here that the same insurance company will approve one person with no questions asked, and then give another person a hard time....it's so odd.

Anyway, see if you can get the criteria for coverage from your insurance company. We have Aetna and they have a web site with the specific conditions that need to be me for coverage. We were sure to have all of our information compiled, perscription from doctor for the band, a letter of medical necessity from the doctor, and the precise measurements that they do for cranial vault asymmetry and the brachy index. After numerous calls to the insurance company between members services and the preapproval line, we finally found a really nice person who was willing to take responsibility and help us out. We faxed all the info with a letter from us highlighting what criteria our son met and indicating that we had be trying repositional therapy since our son was 2 months old with little improvement. After that we were able to get our preapproval pretty quick. They also paid 90% for the band (which is what our policy says they cover), but

they took their time in covering it....about 3 months.

So it's possible to get insurance to cover it....it just seems like you have to put up a bit more of a fight for this condition than for other things....

Good Luck!

(and /DOCgrad 13-Feb-04/10-14mos./PA)Tony <alicata@...> wrote:

We are just learning about plagiocephaly and Crainiosynostosis from our doctor who feels that our 6 month old son has plagio and will most likely need to be treated with a helmet / band. Again, we are in the very beginning stages of this (our son is scheduled for a CT scan tomorrow) but our Doctor has stressed to us that insurance generally does not pay for the treatment of plagio and if they do cover it's not without a long hard battle. He has suggested that we begin doing our research now as it will help us later in our attempt to have our sons treatment covered. Obviously our main objective and goal is to do what is best for our child whatever the treatment may be no matter the cost but it would be nice to have alittle assistance from our insurance...Has anyone experienced difficulty (denial of coverage and / or

non-authorization for treatment)? If so what advise and or suggestions do you have that may helpful to us? For more plagio info

February 8, 2006

This is in response to the e-mail from Andriana . I am also fighting

with my insurance company (Aetna) for extra speech therapy for my son who

also diagnosed with severe verbal apraxia. I actually went to speech therapy

because when I called them (Aetna) originally they told me if I stayed in

the " network " that all I would have to do is pay my co-pay. When I got to

the therapist's office she informed me that I had a 60 day maximum, so I

scheduled as much speech as possible. Well, after his third visit, the

office called to tell me that my claim was denied because it is a

" developmental delay " not a medical issue. So, unfortunately I had to pay

the therapist over $250.00 out of my pocket.

Well it is now a year later and my son is still not speaking so I am in the

process of trying to go through the precertification process to get him some

extra help through my insurance company again. I am also very frustrated and

was wondering if anyone had any help, if so, I would love to hear from them

also.

na also spoke of pro-efa, what exactly is that? Also, I have heard

some good feedback on " The Listening Program " but it is very expensive. I

was wondering if anyone has used that program and been successful. At this

point I am willing to try anything to help my son.

I am looking forward to hearing from you. Thanks for your time.

Theresa Matthaey

TAM595@...

----- Original Message -----

> Dear Jeanne,

> My name is and i spoke with you 2 weeks ago and i am also on

> your mailing list...Next week we have a hearing in newark (BCBS) for my

> daughter's 2nd level appeal with our insurance company. Maddie was

> diagnosed

> with severe verbal apraxia and they are trying to claim that it is

> developmental in nature...I was wondering if you could fan this out to

> your

> e-mail base and have anyone e-mail me back if they have gone through this

> before, and if they have any tips as i would like to be prepared. thank

> you

> so much for all of your help.

> p.s. just finished the late talker and it was a great source of info.,also

> started on the pro-efa last week and maddie has said a new word.

> thanks again,

> sincerely,

> ajryan1@...

>

February 10, 2006

I had Aetna. Your company has the authority to include speech therapy in

your insurance plan contract. But that is between your insurance and the your

work company to work out. If I were you I would talk to the person head

your insurance at your company. Good Luck.

October 3, 2006

Quick question - when Josh and I lived in a little town in north central IL, we

had no problem getting a referral from his ped for ST and OT. Now that we live

in a large city in the NW burbs of Chicago, and I had to change insurance (now

have HMO Illinois), his new ped said he doesn't want to give a referral for

private speech or OT since the insurance would only cover a limited amount of

time and really only for " rehab " therapy. I told the doc I thought he was

incorrect on that (haven't checked with insurance yet but will put in a call).

Anyone know, offhand, whether that's true or have run into similar problems?

Also, doc said best bet is to go through some philanthropic organization like

Easter Seals - they also need a doc referral and bill insurance so what's the

difference?? (we're long-time lovers of Easter Seals - Josh was Little

Ambassador a few years back - so I don't mind going to them except it's kind of

a pain to get to the center - oh well.)

Thanks -

Sherry

michellerichardslavin <michellelavin@...> wrote:

I, too, find this thread very interesting. Our son (2.9) currently

has an ASD diagnosis. His dev ped gave it to him since it's so

difficult to get appropriate services from the state for a child

with an apraxia/motor planning disorder/SPD diagnosis.

So, for now, we're holding on to it to (let's all say it together

now) get services. Luckily, we have NOT had issues with our

insurance company since we use the apraxia diagnosis for his ST.

Wouldn't it be nice if we didn't have to add 'label anxiety' into

the mix of all of this?

>

> What I think is so interesting about everything I've been hearing

from this thread that the diagnosis you get will give you services

in one area and not in another. If your child is labelled with asd,

then your insurance will not pay for the therapy because the

condition is considered " chronic " , but state and local services will

pick up some of the slack. If your child is diagnosed with apraxia,

you can get insurance to pay for some of your child's treatments,

but government programs close their doors. It seems that no matter

what you do, you will end up paying for some of it.

October 3, 2006

Your HMO is a managed care plan. That pediatrician is the " gate

keeper " for those children assigned to him. He only gets paid a

certain amount from the HMO to cover all the kids that he sees. This

amount can be affected by the amount of money each child costs the HMO.

Not sure if this is his motive but that financial crunch keeps many

primary care doctors from referring patients to specialists etc. Often

it affects the amount that HMO reimburses them or, in other

circumstances, the primary care physician is actually " fined " or

" warned " by the insurance company.

I would return to the pediatrician armed with...

1. a print out of what your policy actually covers

2. print outs on information regarding apraxia and the treatment of

plan. Use the words " standard of care " in a sentence many times. This

gives the pediatrician ammunition to stand up to the HMO.

If the pediatrician still refuses report him to the HMO. Although the

HMO is usually the reason that a primary care doctor is denying a

referral, this same HMO will then send the doctor a " warning " for

denying that care and ask for his written support of the decision he

made.

In other words, a primary care doctor is between a rock and a hard

place when he works with an HMO. In spite of that, care should not be

denied due to the fear of financial losses,etc. If you give him the

info he needs to defend the referral, often that's all it will take.

If he still denies it then he needs to be held accountable for denying

that care.

Good Luck.

Kris

P.S. The reason the doctor recommended Easter Seals, etc is because he

doesn't realize they will bill the insurance first and he's trying to

get you to get the speech services without any notification of the

insurance company.

On Oct 3, 2006, at 9:29 AM, sherry silvern wrote:

> Quick question - when Josh and I lived in a little town in north

> central IL, we had no problem getting a referral from his ped for ST

> and OT. Now that we live in a large city in the NW burbs of Chicago,

> and I had to change insurance (now have HMO Illinois), his new ped

> said he doesn't want to give a referral for private speech or OT since

> the insurance would only cover a limited amount of time and really

> only for " rehab " therapy. I told the doc I thought he was incorrect on

> that (haven't checked with insurance yet but will put in a call).

> Anyone know, offhand, whether that's true or have run into similar

> problems?

>

> Also, doc said best bet is to go through some philanthropic

> organization like Easter Seals - they also need a doc referral and

> bill insurance so what's the difference?? (we're long-time lovers of

> Easter Seals - Josh was Little Ambassador a few years back - so I

> don't mind going to them except it's kind of a pain to get to the

> center - oh well.)

>

> Thanks -

>

> Sherry

>

> michellerichardslavin <michellelavin@...> wrote:

> I, too, find this thread very interesting. Our son (2.9) currently

> has an ASD diagnosis. His dev ped gave it to him since it's so

> difficult to get appropriate services from the state for a child

> with an apraxia/motor planning disorder/SPD diagnosis.

>

> So, for now, we're holding on to it to (let's all say it together

> now) get services. Luckily, we have NOT had issues with our

> insurance company since we use the apraxia diagnosis for his ST.

>

> Wouldn't it be nice if we didn't have to add 'label anxiety' into

> the mix of all of this?

>

> >

> > What I think is so interesting about everything I've been hearing

> from this thread that the diagnosis you get will give you services

> in one area and not in another. If your child is labelled with asd,

> then your insurance will not pay for the therapy because the

> condition is considered " chronic " , but state and local services will

> pick up some of the slack. If your child is diagnosed with apraxia,

> you can get insurance to pay for some of your child's treatments,

> but government programs close their doors. It seems that no matter

> what you do, you will end up paying for some of it.

>

> [

October 3, 2006