Another sensory and OT question

[HIU8]

DS is currently in OT for SID. His OT thankfully is being covered by our insurance (not fully, but since it usually isn't covered at all I have to be really thankful that we are getting coverage). Anyway, our EOB of the evaluation came back and nothing was covered. Does it seem weird that they are covering services but not the evaluation? I know they figure I'm going to just forget about it and not do a thing. What they don't know is that DH works in compliance/coding/insurance and has really educated me. I'm doing first round calls and if that gets us nowhere, DH is calling someone higher up than a manager and going through them (he wants me to go the usual route first and see if we get anywhere).

Has anyone had this issue--where they cover the OT, but not the eval?

[egoldber]

I would start with the OT's billing office and see what they say. There is often a common, well-known billing issue with a particular insurance. They may know about it and already be taking care of it.

Just FYI, our OT's billing office was NOT on the ball, and after 6 months told us they were having trouble getting paid. At that point it took FOREVER to get straightened out because they had waited so long. And then our insurance just started randomly denying stuff.

Sigh.

[HIU8]

Our OT does not accept ANY insurance. We do it all on our own. They will provide us with the proper paperwork, but they do not submit at all. We are our only advocates with respect to OT and insurance.

[egoldber]

Ugh. Well, in some ways that could be better.

[HIU8]

except now when I have to prime myself for a bit of a fight.

[jess_g]

We have had a similar problem. Our health insurance covers the therapy but only pays for one eval per year. 2 years ago we brought our son into a hospital to do an OT and PT eval. We thought it woulld be covered by our insuance but they ended up refusing to pay because our son had already had an OTeval that year at a different place. We got a couple of those "this is not a bill" bills for $3400 for the 2 hour appointment. I could not believe it. In the end the inusrance did pay but boy that was a big surprise to me. Now I call the insurance first and have them check to see if something will be covered before we do it (unless its something we know they will cover). So I think they will sometimes cover the therapy but not the eval. The Speech place should have checked with the insurace first to see what would be covered.

I hope this helps some,

Jessica.

[Gena]

Originally Posted by HIU8

Has anyone had this issue--where they cover the OT, but not the eval?

Yes, we've had this issue, with both speech and OT. Our insurance would cover therapy, but not evals. (The same was true for psychological services.) So we always had the clinic perform the evaluation during a 60 minute "therapy session" and just bill it as therapy.