Re: frustrations with insurance and speech therapy

[Guest guest]

In a message dated 7/6/2006 2:25:54 P.M. Eastern Daylight Time,

emyliemarie@... writes:

Oh no! I have Aetna so I am sure this statement will be coming to my

house as soon as Donovan starts talking.

Maybe and maybe not. Aetna may be the insurance company, but a great deal of

what is covered is not decided by them but by the options your employer

chose.

For instance, ours is an open PPO, which means that I don't have to get a

referral to go see doctors, I can choose our doctors. If the doctor is in plan

then they will pay then directly, otherwise they will reimburse me a

percentage of the costs. However, you could have a plan called the same thing,

but

have it could cover completely different things.

When we were diagnosing Ian's issues, our plan covered the clinical

psychologist as well as the fee for the write-up of his assessment. That's

because

his employer selected those options. There are a bunch of things that could be

covered or not covered, depending on the choices made by the company who

purchases the coverage. Hearing aids aren't covered, prosthetics aren't

covered,

but counseling and therapy like the ones mentioned are covered. It's all

based on what my husband's employer chose when purchasing the coverage.

So, if you are concerned about what is and isn't covered, make a few calls

and ask.

Best -- Jill

[Guest guest]

Forgot to actually say this -- we also have Aetna as our insurance company.

Jill -- who is really senile right now.

[Guest guest]

Forgot to actually say this -- we also have Aetna as our insurance company.

Jill -- who is really senile right now.

[Guest guest]

Forgot to actually say this -- we also have Aetna as our insurance company.

Jill -- who is really senile right now.

[Guest guest]

Oh no! I have Aetna so I am sure this statement will be coming to my

house as soon as Donovan starts talking.

I guess I am naive but I have been so surprised and disappointed by

insurance coverage regarding hearing loss - everyone I tell about

the things that are NOT covered can't believe it.

I hope you get it straightened out.

Emylie

>

> I just got a statement from Aetna that had a remark

that " Additional

> information is needed to determine coverage under the terms of your

> plan. Please ask your physician to submit medical records for this

> service to the address above. "

>

> This is for Speech Therapy through Early Intervention. There was

not a

> problem with payment from the insurance company last year (once we

> figured out that they would actually pay---were given bad

information at

> my husband's work about payment for speech therapy.) Now that we

got

> past the initial deductable for this year, they suddenly want

medical

> records. When I called Aetna, what they said made no sense, which

told

> me the person I was speaking to had no idea what I was talking

about. I

> told her that what she said made no sense and she asked someone

else and

> came back with basicly the same answer---they need medical records

from

> the county services board. The county services board does not have

> medical records for the services provided; that is not what they

do.

> They are not medical doctors.

>

> I called my services coordinator to see whether she can find

someone

> there to figure it out, but who knows how that will go.

>

> Anyone have a similar issue that could give me a hint....I just

hate

> insurance companies....Sigh....

>

> in Manassas, VA

>

[Guest guest]

The problem here is that speech therapy can be medical and/or educational. So

the medical insurance folks don't want to pay for an educational thing, and the

education folks (early intervention) wants to bill medical insurance for speech.

So Aetna wants the records for the speech therapy. It would be a good idea if

you had a doctor's order for the speech therapy - that keeps everyone happy.

The speech thearapist can work in a medical setting or an educational setting

and there is lots of overlap, you just have some extra hoops to jump through

when ins cos are involved.

[Guest guest]

FYI, it is my understanding that billing insurance for anything that comes

through IDEA should be considered as something that is completely voluntary

on your part. The government cannot require you allow them to bill your

insurance as a condition of receiving services through IDEA, because then it

isn't FAPE.

The " medical records " they are looking for are really probably more along

the lines of clinic notes proving what services he received so they can make

sure they match the CPT codes being billed for.

Let me know if they actually issue an EOB refusing to pay, we would be happy

to do an appeal for you (this is free, in case any new families don't know

about the program I run, please visit advocacy.letthemhear.org)

Sheri

[Guest guest]

Oh, I feel for you. I have to jump through these same hoops for the insurance

company, and lately it seems they have increased just what it is they want.

For us, we have to get speech therapy records from our speech therapist. Then

our pediatrician is suppose to review them and then write a letter to our

insurance co referring for speech. So I get the reports from our speech

therapist's sessions, and place a call into our peds office telling them that

it's time to rewrite the letter again. They update the dates on it and forward

to me. Then I forward both things to the insurance company (Don't tell them

that our ped hasn't looked at the speech reports since the first set). What's

ridiculous is our ped writes in the letter that should continue speech

therapy for one hour a week for six months, and the insurance will only approve

it for four months.

is older now and not in early intervention, but if she was, I'm sure we

would still be going through the same thing. So maybe this will help you?

The other hoop that I have to jump through is for her ear molds. We get

financial assistance for hearing related items since our insurance only covers

$500 every two years for hearing related things. We we hit that limit and then

some when we got new aids last year. All I need to have our insurance co. do is

decline the claim and it will be picked up by the state agency. But no, they

sent me a form that needed to be completed by the physician that ordered the ear

molds. I laughed hard when I got that one. So I called them up and explained

that no one " prescribes " ear molds that we just get new ones when the she

outgrows the current ones. I must have thrown them for a loop because they had

to put me on hold to find out what to do. I still had to have our Audi (not

really a Dr) fill out the form. And guess what....they declined paying for

them.

So it's my belief that insurance companies make you jump through all these

hoops thinking that you won't follow through and then they won't have to pay a

dime.

Debbie, mom to , 7, moderate SNHL and , 3, hearing

Letiecq laura@...> wrote:

I just got a statement from Aetna that had a remark that " Additional

information is needed to determine coverage under the terms of your

plan. Please ask your physician to submit medical records for this

service to the address above. "

Some men see things as they are and ask why. Others dream things that never were

and ask why not. G.B Shaw

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[Guest guest]

I don't think Early Intervention should bill you for whatever your insurance

doesn't pay.

At least that is how it works here in NY. We had some difficulties with our

insurance

paying for speech services, but I just let Early Intervention work it out

with the

insurance company. I believe the funds for Early Intervention come from the

county,

and they are the ones who swallow the costs if the insurance doesn't pay. So

it

is up to them to be aggressive (and our county is!)

Our county required a doctors statement for the physical therapy services,

but

not for speech services.

Bonnie

>

> I just got a statement from Aetna that had a remark that " Additional

> information is needed to determine coverage under the terms of your

> plan. Please ask your physician to submit medical records for this

> service to the address above. "

>

> This is for Speech Therapy through Early Intervention. There was not a

> problem with payment from the insurance company last year (once we

> figured out that they would actually pay---were given bad information at

> my husband's work about payment for speech therapy.) Now that we got

> past the initial deductable for this year, they suddenly want medical

> records. When I called Aetna, what they said made no sense, which told

> me the person I was speaking to had no idea what I was talking about. I

> told her that what she said made no sense and she asked someone else and

> came back with basicly the same answer---they need medical records from

> the county services board. The county services board does not have

> medical records for the services provided; that is not what they do.

> They are not medical doctors.

>

> I called my services coordinator to see whether she can find someone

> there to figure it out, but who knows how that will go.

>

> Anyone have a similar issue that could give me a hint....I just hate

> insurance companies....Sigh....

>

> in Manassas, VA

>

>

>

[Guest guest]

> I just got a statement from Aetna that had a remark

that " Additional

> information is needed to determine coverage under the terms of your

> plan. Please ask your physician to submit medical records for this

> service to the address above. "

>

> This is for Speech Therapy through Early Intervention. >

We have not got Aetna, but it seems Speech is a difficult one to get

with just about any insurance. The insurance companies think that

the school should be providing it and the schools are undermanned

when it comes to STs. When we were in EI in CA all services were

covered by the state. I believe EI is a federally mandated

program. They had to provide all services listed in our IFSP our

insurance paid for nothing. The same goes for when we were in

England... because we were US military service members the base had

an EI office there that had teachers and therapist.

We did get extra speech outside of school because was D/HOH the

pedia. said it was necessary for him to have any chance at

developing speech or understanding speech. He was only getting 30

minutes of group speech a week at school. This was not intensive.

So pedia wrote letter requesting intensive speech, Speech

pathologist at Audi office (UCLA)wrote recommendations for intensive

speech, and we got the reports from the STs evaluations/progress.

Sent all of that in with IEP and got speech at home for 2 hours

extra a week.

Good luck in fighting for services. I too hate insurance companies.

Kim in FL

[Guest guest]

In Georgia, EI is the payor of last resort. Meaning they bill your insurance

company or medicaid or a state program, then if stuff is on your IFSP and no

one has paid for it, then EI pays for it. Of course they also write crummy

IFSPs based on what they want to offer not what the child truly needs. Georgia

also has a policy of " loaning " equipment - think FMs etc. Each region has a

lending closet. If your region doesn't have an FM, your child won't have the

use of one. It might be sitting in a closet unused two counties away! And your

child might get it for 6 months then its the next child's turn. So EI is

federally funded but varies widely from state to state as to how it is

administered. In GA, kids with hearing loss have to have bilateral severe to

profound hearing loss to qualify for EI.

[Guest guest]

Thanks for the information. I did get a call back from my early

intervention services coordinator and she is checking on this. She said

that the billing department person that is in charge of dealing with the

insurance companies will check on it since she said that we should not

have to provide anything to the insurance company. We will see what

happens.

in Manassas, VA

> FYI, it is my understanding that billing insurance for anything that

> comes

> through IDEA should be considered as something that is completely

> voluntary

> on your part. The government cannot require you allow them to bill

> your

> insurance as a condition of receiving services through IDEA, because

> then it

> isn't FAPE.

>

> The " medical records " they are looking for are really probably more

> along

> the lines of clinic notes proving what services he received so they

> can make

> sure they match the CPT codes being billed for.

>

> Let me know if they actually issue an EOB refusing to pay, we would be

> happy

> to do an appeal for you (this is free, in case any new families don't

> know

> about the program I run, please visit advocacy.letthemhear.org)

>

> Sheri

>

>

>

>

>

--

Letiecq laura@...>

[Guest guest]

> I don't think Early Intervention should bill you for whatever your

> insurance

> doesn't pay.

> At least that is how it works here in NY. We had some difficulties

> with our

> insurance

> paying for speech services, but I just let Early Intervention work it

> out

> with the

> insurance company. I believe the funds for Early Intervention come

> from the

> county,

> and they are the ones who swallow the costs if the insurance doesn't

> pay. So

> it

> is up to them to be aggressive (and our county is!)

>

Early intervention CAN bill you for whatever insurance does not pay, as

long as they have a sliding fee scale. We don't qualify on the scale

for EI to pay for speech unless we have speech more than twice a month,

which is what we have now.

in Manassas, VA