insurance will not pay

[redhookmom]

My DS has a speech delay/disorder and stupid insurance will not pay for therapy. Some lady called today to say blah, blah, blay we will not pay. How can they say something is not covered when it has not even been established exactly what the problem is? I cried for about a half hour and DS did see me. When I was done he asked if he could take me for a walk because the fresh air would make me feel better. That was the only good part and the fresh air did help.

[JElaineB]

I'm so sorry! I hate insurance. I hope you are able to find a way to get them to pay or work something out. Hugs!

Jennifer
mom to Jacob 9/27/02

[deborah_r]

I'm so sorry. I hope something works out for you. Keep trying - I think they are trained to say no just to see if you'll accept it or if you'll keep pushing (I have no factual basis for this claim, just my own conspiracy theory paranoia!)

[egoldber]

We had the same issue through our insurance as well. Since it is not considered a medical problem, our insurance wouldn't cover it. We did, however, just switch to services offered through our local school district, and those services are free. Actually, I think the person we are seeing now is much better than the SLP we saw before that we were paying $150/hour for!

Good luck! I know it stinks!

[flagger]

How is she doing with that therapy by the way. I have been meaning to ask?

[egoldber]

Actually, she's doing really well! :) The new SLP has given us lots of new things to try that seem to be helping. Since the first of the year we've seen a tremendous increase in vocabulary. But her articulation is still very poor. Our main focus right now is getting her to say entire words (she says "buh" for book) and not to use word approximation (like "ki-ki" for kitty). But the new SLP is always coming up with new tricks/games for us to use with her that seem to be working.

[barbarhow]

Jessica-firstly, I am so sorry that you are being treated this way by your insurance co. It is hard enough to go through what you are without the added stress. Secondly-Fight it, fight it, fight it. Insurance company reps are trained to reject coverage on the first go around. I do know this for a fact as I know several people who have worked in the industry. A year ago I had trouble getting them to fully cover my delivery-It was a pain in the butt but I sent letter after letter and fought it tooth and nail. I threatened them with the commisioner of insurance and let them know that I was informing everyone I knew about their shady practices. 5 excruciating months later they agreed to pay. It infuriates me that our healthcare system works this way. It is so shortsighted of them to not see that an investment in your childs future will probably save alot of money in the long run. Unfortunately they only seem to care about the bottom line. I feel badly for the elderly and others who do not have the courage, ability, or strength to navigate the system and fight. Done with my rant, sorry.
Good luck to you. I hope you can't make them do the right thing.
Barbara-mom to Jack 3/27/03

Edited for spelling.

[kwc]

Jessica,
That really sucks! I just wanted to echo what Beth said about getting the school district involved... I don't know how old your DS is (but if he can take you out for fresh air, that's great!) but here in Califiornia (and maybe all states), I think that kids 3 and up with known language delay are often eligible for speech/ language evaluation and therapy, often as part of the Early Start program... many people are not aware of this because we don't really think of involving the schools before they enter kindergarten. You may want to enlist the help of your ped in this one...

Good luck!
Karen

[kransden]

I would like to echo what Barbara said. Keep badgering the insurance company. My co-worker has a son with cleft palate. He was ready for his last of several operations. The insurance company denied it saying it was purely cosmetic!!!! WTF!!!??? It took them 6 mos, but it finally got approved. Can you believe that!


Karin and Katie 10/24/02

[redhookmom]

Thanks for all of the kind thoughts. Strength. Strength is what I sorely lack right now.

It was through the school district that he was diagnosed with Oral Myofunctional Disorder. We went through the testing because his preschool teacher observed some fine motor issues. While he will get help with the fine motor skills the Oral Myfunctional Disorder was not perceived as an educational issue.

I thought maybe we could pay for the therapy ourselves but we cannot afford $150.00 and hour. I have been all over the internet to try to get info on how I can help him but havn't found anything yet...

I will follow throgh with an appeal to the insurance company. Or I should say get my DH to. I get weepy when I have to deal with this.

[cara1]

It was my understanding that if the child is a candidate for Early Intervention (I don't recall how old your child is), then the County hopes that the insurance co. foots the bill, but otherwise, the County is supposed to cover the costs. This only applies if the child qualifies for services through the county. Is this the route you are going through?

[egoldber]

Actually Early Intervention programs (at least the ones that are associated with the federal IDEA program) have a sliding fee scale. All assessments and such are free, but for the actual services you get billed at a sliding rate depending on how they assess your ability to pay.

Perhaps in some states, the state or county may make up the cost difference. But in VA, that is not the case. We were fortunate because in VA, the Early Intervention program through the school system is free for children ages 2 and up. So as soon as she turned 2, we switched from the county program to the school district's program.

And whether or not insurance covers services depends on the type of services. For example, if my DD had needed physical therapy, that would have been covered. But speech therapy services are not defined as "medical" benefits (at least by my insurer).

But it never hurts to dispute the case with your insurer. We did that and they still denied it. :(

[Kimberly H]

Jessica, I'm an insurance claims processor and while all insurance policies and companies are different - I work for TRICARE which serves the military community - we're not trained to deny claims but do require more documentation than a lot of providers routinely supply on the first go 'round.

I would get ahold of your FULL policy and know what it does/doesn't cover, get the therapist's billing service involved, and appeal with good medical documentation. They may still deny your services but you have a much better case with med notes from the therapist and being able to quote policy.

GOOD LUCK!

[jal]

Definately check your insurance policy and make sure to gather all the facts and documentation to try to make the case why the insurance company should cover it.

Sometimes, just the odd ways things work out will cause a situation to be rejected by the insurance computer system and you just have to find the right person who can "over-ride" the "system" and get your claim covered if you are in the right.

Here's our recent example. We recently found out that we were pregnant with our 2nd child. The blood work is showing low progesteron(sp?) levels, so a progesteron suppository perscription was given. After a week of the suppositories, the level was still low, so the doctor added a perscription for injectable perogesteron. When we initially tried to get the 2nd perscription filled, insurance rejected it because thier computers showed that we had filled a perscription for progesteron within the last 30 days. It took the pharmasist a few minutes with an insurance manager to explain that this was not a refill but a 2nd perscription in which BOTH were being administered. The manager was able to quickly get the override, but the next problem was that the injectable version is more expensive than the suppository version, but is sounded like the insurance wanted to cover both drugs at the same rate because it's the same active ingrediant. I was so glad to hear the pharmasist say that they would only charge us the standard co-pay and THEY would fight the insurance company to make sure they are reimbursed at the higher rate for an injection medication. Of course the worst case will be that the pharmasist will loose that battle, in which case we will have to pay MORE when we refill the perscription.

Of course this does remind me of the battle we lost over medications with the insurance company. DS was having a reflux problem and the doctor perscribed prilosect (sp?). Because this was for an infant, the medication had to be compounded and placed in a liquid suspension. Towards the end of our need for this medication (thank goodness), prilosect became available over-the-counter and the insurance company wouldn't cover it any more. Of course this totally ignores the fact that an infant CAN NOT TAKE AN OVER-THE-COUNTER PILL!!!! But that argument was lost on the insurance company because the "active ingrediant" was still the same as this OTC medication. This drug was not cheap as a compound. Like I said, thankfully we paid full price for the drug once and DS didn't need it beyond that last refill.