Re: suggestions for dealing with insurance companies?

[Guest guest]

I have never posted but wanted to let you know that I had this same situation.

My daughter was evaluated at 19 1/2 months and we started therapy one month

later. Our insurance, BCBS of Florida, told my therapist that they do not cover

ST. But after filing we found out that they cover developmental therapy up to

$1500/yr. My daughter has since been diagnosed with apraxia and since this is a

neurological disorder not develpomental and the neurologist wrote a letter of

medical necessity, we are getting it covered via insurance.

Hope this helps.

Alissa in florida

---- djfunkgasm <djfunkgasm@...> wrote:

[Guest guest]

Most insurance companies don't cover ST anyway - you have to read the fine

print and see what's covered...although OT is covered usually if medically

indicated (ie low tone, poor coordination). When we started the omega

supplements - what we first got in addition to better coordination and less

falling down - was babbling...but " normal " sounding babbling - which was

something we had never heard from my son before. It quickly progressed to

new words. -

[ ] suggestions for dealing with insurance

companies?

I am about to start dealing with the insurance company for my

daughter. Here's the dilemma, she has been evaluated by the state's EI

program. They suggest intense therapy - as she is 2 years old and at

the level of a 9-12 month old. They can't say for sure it's apraxia

because she wouldn't coorperate with her tongue (don't know how that

matters). At any rate, we are switching insurance companies in 2 weeks

(through my job). I am wondering if they are now going to consider

this a pre-existing condition? Anyone know? I am prepared for an

uphill battle, but will do anything for my daughter. Oh and we started

her on efa's and have been getting more sound out of her in the past 2

weeks (babble, mainly) than we've had in 2 years

[Guest guest]

Same with me...Our nuero-developmental pediatrician wrote a lette of

medical necessity and we are covered for up to 60 visits.

akb@...

Sent by:

@yaho cc: djfunkgasm

<djfunkgasm@...>

ogroups.com Subject: Re:

[ ] suggestions for dealing with insurance companies?

04/18/2006 01:38 PM

Please respond to

I have never posted but wanted to let you know that I had this same

situation. My daughter was evaluated at 19 1/2 months and we started

therapy one month later. Our insurance, BCBS of Florida, told my therapist

that they do not cover ST. But after filing we found out that they cover

developmental therapy up to $1500/yr. My daughter has since been diagnosed

with apraxia and since this is a neurological disorder not develpomental

and the neurologist wrote a letter of medical necessity, we are getting it

covered via insurance.

Hope this helps.

Alissa in florida

---- djfunkgasm <djfunkgasm@...> wrote:

[Guest guest]

If your daughter has continuous medical coverage (meaning that the other

insurance does not cease until the new one starts) they can not look at

preexisting conditions. Our son has numerous major medical issues and we

switched insurance companies when he was about 2. They could not say anything

was preexisting because he had continuous coverage. This obviously doesn't mean

they are going to cover speech therapy, but you should not have to deal with the

preexisting conditions issue.

Jill mom to Logan, 4, apraxia

djfunkgasm <djfunkgasm@...> wrote:

I am about to start dealing with the insurance company for my

daughter. Here's the dilemma, she has been evaluated by the state's EI

program. They suggest intense therapy - as she is 2 years old and at

the level of a 9-12 month old. They can't say for sure it's apraxia

because she wouldn't coorperate with her tongue (don't know how that

matters). At any rate, we are switching insurance companies in 2 weeks

(through my job). I am wondering if they are now going to consider

this a pre-existing condition? Anyone know? I am prepared for an

uphill battle, but will do anything for my daughter. Oh and we started

her on efa's and have been getting more sound out of her in the past 2

weeks (babble, mainly) than we've had in 2 years

[Guest guest]

Just a question ... do most of you who are trying to obtain private

therapy through your insurance companies do so because your state's

Early Intervention Program's (for those with kids under 3) or school

district's (for those with kids over 3) level of service is too low?

This might be an obvious question, but I was just curious. We have not

gone that route yet because, luckily, I think is getting

everything she needs (and can tolerate) from Early Intervention (4 x 30

speech, 1 x 60 OT) and will continue this same level of therapy next

year as well (when we transition to school district services).

I just wanted to see if I was missing something or if I should be

pursuing this route. Thanks!

Warm regards,

******************

(Rochester, NY)

Mom to , 2.11 years, Developmental Verbal Dyspraxia

& , 9 months

________________________________

From:

[mailto: ] On Behalf Of

myra.bauza@...

Sent: Tuesday, April 18, 2006 2:18 PM

Subject: Re: [ ] suggestions for dealing with

insurance companies?

Same with me...Our nuero-developmental pediatrician wrote a lette of

medical necessity and we are covered for up to 60 visits.

akb@...

Sent by: To:

@yaho cc:

djfunkgasm <djfunkgasm@...>

ogroups.com Subject: Re:

[ ] suggestions for dealing with insurance companies?

04/18/2006 01:38 PM

Please respond to

I have never posted but wanted to let you know that I had this same

situation. My daughter was evaluated at 19 1/2 months and we started

therapy one month later. Our insurance, BCBS of Florida, told my

therapist

that they do not cover ST. But after filing we found out that they

cover

developmental therapy up to $1500/yr. My daughter has since been

diagnosed

with apraxia and since this is a neurological disorder not develpomental

and the neurologist wrote a letter of medical necessity, we are getting

it

covered via insurance.

Hope this helps.

Alissa in florida

---- djfunkgasm <djfunkgasm@...> wrote:

[Guest guest]

In my case, yes; it was too low. He was only get ST 2x a week for 30 min.

and 30 mins of OT. So, I have him go to private ST for an additional 2x 30

a week. That seems to be sufficient. The older he gets, he's now 4 y.o.,

the more tolerant he is..so I may even increase it even more.

[Guest guest]

You are from NY...the services are pretty good in your state. California is

pathetic. Most kids will not be offered sufficient services. I have a friend

who temporatily moved from Idaho to NYC for 2 years (leaving hubby behind)

to get appropriate services for her son with apraxia (when he was nearly 4

years old). Now her family is back together in Idaho and he is mainstreamed,

now age 8. I now understand why she did this...what I thought was " drastic "

at the time - never imaging at the time that I would someday be dealing with

apraxia as well. States like California fall very short in offering

appropriate and sufficient therapy, and it all comes down to money/lack of

funds. -

Re:

[ ] suggestions for dealing with insurance companies?

04/18/2006 01:38 PM

Please respond to

I have never posted but wanted to let you know that I had this same

situation. My daughter was evaluated at 19 1/2 months and we started

therapy one month later. Our insurance, BCBS of Florida, told my

therapist

that they do not cover ST. But after filing we found out that they

cover

developmental therapy up to $1500/yr. My daughter has since been

diagnosed

with apraxia and since this is a neurological disorder not develpomental

and the neurologist wrote a letter of medical necessity, we are getting

it

covered via insurance.

Hope this helps.

Alissa in florida

---- djfunkgasm <djfunkgasm@...> wrote:

[Guest guest]

,

I am going through the motions with the Child Find and they tell me that they

only give 'Group " therapy. As you know, apraxic children do not do well in

group therapy as well as all of the other research says the same thing. I am in

for a real tough fight but with all of my research, attorney's and professional

backup I look forward to getting what I want from them.

The reason I went for private is that at the time my child was only getting

3x/week in ealry internvention and they would not increase her iuntil her next

eval and even at the next eval they told me they have never given out 4x per

week but guess what with persistence I received. I also did not think the

therapist was doing the best she could. I have found the BEST therapist for my

child and feel that since my daughter has seen her she has progressed.

many people tell me that free is not always the best. I now realized that but

sometimes you can find good free therapy. HArd to find but when you do you are

very lucky.

---- " Oakes wrote:

[Guest guest]

Hi -

I just want to preface this with the fact that I realize how

incredibly lucky we are to have insurance and to have the capacity

to seek out private therapy.

We sought out private therapy FIRST because of my general

understanding of EI and of the district's therapy. First of all, it

rots in my area. Enough said. Second, however, is an important

point regardless of where in the US you live: If you go through EI,

to whom is the therapist reporting? To whom are the beholden? Not

to you, the patient, to the state/district who pays their fees.

These folks can not recommend your child attend therapy 5x a week 52

weeks a year because they cannot afford it nor do they have the

therapists to cover it. With insurance, those kinds of issues are

NOT supposed to factor into approvals or not. We all know it does

to a certain degree, but we also know that our money DIRECTLY pays

for therapy and for insurance. They work for us.

I hope this makes sense. I frequently counsel folks to go get

private evals if they can. Often insurance won't cover the therapy,

but they will cover an eval if you have a referral. At least that

gets you a baseline from an unbiased person about how they would be

treated in the real world. It's all about choice. I have all my

life been FOR socialized medicine, but now I wonder if it will

create enough progress.

Hope this makes sense!

Marina

>

>

>

>

>

>

[Guest guest]

Actually, we do both because either one alone is inadequate. With

private insurance, we're getting 1x 30 minutes ST/week (should be

2x/week, but they're overbooked). This is for 16 sessions. We have to

drive 1 1/2 hours to these. This is the ST I just posted about who

wants to strap my son down. With EI, we're getting 2x 45 minutes

ST/week, in home. Two different people - one knows some ASL, the other

doesn't.

Once you get into the local school system, it's even worse. I had my

older daughter evaluated, and it was a nightmare. They won't offer

services until a child is academically behind. My daughter has pretty

severe social anxiety disorder with selective mutism. They would do

nothing for her. Not even going to try with my son. Once he's 3 and

out of EI, we'll go solely through private insurance, or maybe try the

school district we'll be homeschooling in and see if it has any better

services.

Oakes, wrote:

> Just a question ... do most of you who are trying to obtain private

> therapy through your insurance companies do so because your state's

> Early Intervention Program's (for those with kids under 3) or school

> district's (for those with kids over 3) level of service is too low?

>

> This might be an obvious question, but I was just curious. We have not

> gone that route yet because, luckily, I think is getting

> everything she needs (and can tolerate) from Early Intervention (4 x 30

> speech, 1 x 60 OT) and will continue this same level of therapy next

> year as well (when we transition to school district services).

>

> I just wanted to see if I was missing something or if I should be

> pursuing this route. Thanks!

>

> Warm regards,

> ******************

> (Rochester, NY)

> Mom to , 2.11 years, Developmental Verbal Dyspraxia

> & , 9 months

>

[Guest guest]

Yes, that makes sense. Thank you for your response to what some might

consider a dumb question. I am grateful (okay ... grateful is an

understatement) for the wonderful services that receives. We

seem to have a lot of therapists in this area and I think the quality of

our therapists is superb. I used to complain about New York State's

ridiculously high taxes, but never again!

Warm regards,

******************

(Rochester, NY)

Mom to , 2.11 years, Developmental Verbal Dyspraxia

& , 9 months

[Guest guest]

Thank you for the informational reply. That makes sense. As parents,

we do what we have to do to help our children. We feel blessed that

is making great strides with the services that she receives. If

she wasn't, you can bet that I'd be " fighting the good fight " too.

Please keep us posted about what happens with your efforts.

Thanks again!

Warm regards,

******************

(Rochester, NY)

Mom to , 2.11 years, Developmental Verbal Dyspraxia

& , 9 months

[Guest guest]

Thanks Marina! That makes sense. This is good information for future

reference.

[Guest guest]

I'm shocked to learn this about California! It seems like such a

progressive state. I've always thought that if we lived someplace

like CA or NY we'd have better options and resources, so this is a

surprise.

It's a shame services aren't standardized from state to state.

>

> You are from NY...the services are pretty good in your state.

California is

> pathetic. Most kids will not be offered sufficient services. I

have a friend

> who temporatily moved from Idaho to NYC for 2 years (leaving hubby

behind)

> to get appropriate services for her son with apraxia (when he was

nearly 4

> years old). Now her family is back together in Idaho and he is

mainstreamed,

> now age 8. I now understand why she did this...what I thought

was " drastic "

> at the time - never imaging at the time that I would someday be

dealing with

> apraxia as well. States like California fall very short in

offering

> appropriate and sufficient therapy, and it all comes down to

money/lack of

> funds. -

[Guest guest]

-

I can't answer for the therapists that have treated your child, but

as a practicing PT involved in EI, I can assure you that I am not

beholdened to the state. I am responsible for treating the patient

and communicating effectively to the parents the patient's

improvements and shortcomings. In fact, here in NY, I am able to

provide more effective treatments with more favorable frequencies and

durations to my EI pediatric patients then I can ever get from my

neurologically involved adult patients through an HMO, where I can

only get visits handed out in snippets of 2 weeks at a time, often

times waiting weeks to get permission to continue treatment.

Most home care therapists in my area are independent

contractors, we only get paid for visits performed. It is therefore

financially in our best interests to fight for the appropriate

services for the child. We cannot get 5 times per week for 52

weeks, but I'd love to see which HMO would allow that, and I'll sign

up all my adult patients on the spot!!

What is important is that your therapist provide appropriate,

realistic and time sensitive goals. For example when treating a 6

month old, riding a tricycle should not be a realistic goal. You can

laugh, but I've seen it as a long term goal. That just shows the

state that the therapist is already determined to keep that kid until

the age of 3 whether its needed or not.

Standardized tests are used to help reduce therapists milking the

system. I've had instances where a child should not have qualified

for services based on his test score, but I could explain to the

coordinator that a particular skill was lacking in this child that

would cause regression down the road, and got permission to treat the

children with very specific goals. I don't keep kids on program who

don't need it. The coordinators know this, so when I ask for

something, they know the child really needs it.

P.S. If you think your premiums in an HMO go " directly " to the

therapy, you are sadly mistaken. HMO's are for profit companies who

are " beholden " to their SHAREHOLDERS. Private health insurance

companies routinely have much higher administrative costs then

Medicare or even Medicaid.

I'll get off my soap box now lol

-- In , " marina3029 "

<philipmary@...> wrote:

>

> Hi -

>

> I just want to preface this with the fact that I realize how

> incredibly lucky we are to have insurance and to have the capacity

> to seek out private therapy.

>

> We sought out private therapy FIRST because of my general

> understanding of EI and of the district's therapy. First of all,

it

> rots in my area. Enough said. Second, however, is an important

> point regardless of where in the US you live: If you go through

EI,

> to whom is the therapist reporting? To whom are the beholden? Not

> to you, the patient, to the state/district who pays their fees.

> These folks can not recommend your child attend therapy 5x a week

52

> weeks a year because they cannot afford it nor do they have the

> therapists to cover it. With insurance, those kinds of issues are

> NOT supposed to factor into approvals or not. We all know it does

> to a certain degree, but we also know that our money DIRECTLY pays

> for therapy and for insurance. They work for us.

>

> I hope this makes sense. I frequently counsel folks to go get

> private evals if they can. Often insurance won't cover the

therapy,

> but they will cover an eval if you have a referral. At least that

> gets you a baseline from an unbiased person about how they would be

> treated in the real world. It's all about choice. I have all my

> life been FOR socialized medicine, but now I wonder if it will

> create enough progress.

>

> Hope this makes sense!

> Marina

>

[Guest guest]

-

Great perspective! I have to say that I have been nothing but impressed

with the level of service that gets through Early Intervention

here in New York State. Our therapists have asked for much-needed

service increases for and never had any problems with getting

them. While, of course, things like this need to get approved through

various channels and there are rules and regulations, I have never been

given the impression that our therapists are answering to anything else

but 's progress. And believe me, we are grateful for this.

Warm regards,

******************

(Rochester, NY)

Mom to , 2.11 years, Developmental Verbal Dyspraxia

& , 9 months

________________________________

From:

[mailto: ] On Behalf Of fopt

Sent: Wednesday, April 19, 2006 9:53 PM

Subject: [ ] Re: suggestions for dealing with

insurance companies?

-

I can't answer for the therapists that have treated your child, but

as a practicing PT involved in EI, I can assure you that I am not

beholdened to the state. I am responsible for treating the patient

and communicating effectively to the parents the patient's

improvements and shortcomings. In fact, here in NY, I am able to

provide more effective treatments with more favorable frequencies and

durations to my EI pediatric patients then I can ever get from my

neurologically involved adult patients through an HMO, where I can

only get visits handed out in snippets of 2 weeks at a time, often

times waiting weeks to get permission to continue treatment.

Most home care therapists in my area are independent

contractors, we only get paid for visits performed. It is therefore

financially in our best interests to fight for the appropriate

services for the child. We cannot get 5 times per week for 52

weeks, but I'd love to see which HMO would allow that, and I'll sign

up all my adult patients on the spot!!

What is important is that your therapist provide appropriate,

realistic and time sensitive goals. For example when treating a 6

month old, riding a tricycle should not be a realistic goal. You can

laugh, but I've seen it as a long term goal. That just shows the

state that the therapist is already determined to keep that kid until

the age of 3 whether its needed or not.

Standardized tests are used to help reduce therapists milking the

system. I've had instances where a child should not have qualified

for services based on his test score, but I could explain to the

coordinator that a particular skill was lacking in this child that

would cause regression down the road, and got permission to treat the

children with very specific goals. I don't keep kids on program who

don't need it. The coordinators know this, so when I ask for

something, they know the child really needs it.

P.S. If you think your premiums in an HMO go " directly " to the

therapy, you are sadly mistaken. HMO's are for profit companies who

are " beholden " to their SHAREHOLDERS. Private health insurance

companies routinely have much higher administrative costs then

Medicare or even Medicaid.

I'll get off my soap box now lol

[Guest guest]

It clearly depends on where you live and the monies available.

>

> -

>

> Great perspective! I have to say that I have been nothing but

impressed

> with the level of service that gets through Early

Intervention

> here in New York State. Our therapists have asked for much-needed

> service increases for and never had any problems with

getting

> them. While, of course, things like this need to get approved

through

> various channels and there are rules and regulations, I have never

been

> given the impression that our therapists are answering to anything

else

> but 's progress. And believe me, we are grateful for

this.

>

> Warm regards,

> ******************

> (Rochester, NY)

> Mom to , 2.11 years, Developmental Verbal Dyspraxia

> & , 9 months

[Guest guest]

At 08:53 AM 4/20/2006, you wrote:

>It clearly depends on where you live and the monies available.

Not to mention the staff available. My son was always supposed to get two

hours a week of speech, but EI was always so short-staffed they rarely

provided it. For much of the two years we were there they had only one SLP

and she also worked three days a week with the public schools. That didn't

leave much time for her to see all the kids in EI who needed it.

Miche

[Guest guest]

HI,

This post is in response to the health insurance question. I am an SLP and

have to frequently deal with insurance companies. Unfortunately, many of them do

not approve services for children with developmental speech disorders. I

encourage the parents of the children that I evaluate to get a letter of medical

necessity from a medical doctor to submit to the insurance company. Most

companies will cover speech therapy if there is a medical reason i.e., hearing

loss, tongue tie, abnormal oral/pharyngeal physiology (cleft palate). If you

have not received a medical diagnosis from a doctor as a reason for your child's

speech difficulty, get a second opinion. Have your child seen by a developmental

pediatrician, ENT, Pediatric Neurologist. I also highly recommend that you

contact your political representatives if you do not get the services that you

believe you deserve. I think that it is extremely unfair that children whose

parents pay for their health insurance are denied

services, but children on medicaid receive all of the services that they need.

Good Luck!!

Elissa