Guest guest Posted May 5, 2008 Report Share Posted May 5, 2008 i am looking for a way to get unicare of illinois ppo plan to cover speech, my bro told me now that it is considered a neurological speech disorder they should. anyone have any clues on unicare??? -------------- Original message -------------- From: " Herrald " <wherrald@...> we had an impossible time getting speech therapy covered. after about 6 months our speech therapist tried to submit the therapy under a chewing problem which my son also has. Im not sure what the name of this condition is or the code but Im told that most kids with apraxia have a problem chewing their food. It has been covered for 2 years now. > > Hi, > > Does anyone know what the diagnosis codes are for apraxia and auditory > processing disorder that are being reimburse by blue cross blue shield > of michigan???? or by any other insurance company?? I am looking for > codes that do not fall under 'developmental'. Thanks in advance. > > > Mom to JaeKi 5.10 and Jonah 4.8 mths > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 5, 2008 Report Share Posted May 5, 2008 This my sound silly, but don't give up. Keep apealing over and over. get anyone and everyone to write letters telling the insurance co, how important this is and any delay will cot more money in the long run. I fought for a year to get my son a augmemtive speach device. I finally got it approved, so please don't give up. > > > > Hi, > > > > Does anyone know what the diagnosis codes are for apraxia and > auditory > > processing disorder that are being reimburse by blue cross blue > shield > > of michigan???? or by any other insurance company?? I am looking for > > codes that do not fall under 'developmental'. Thanks in advance. > > > > > > Mom to JaeKi 5.10 and Jonah 4.8 mths > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 6, 2008 Report Share Posted May 6, 2008 Hi again-- So, to be more specific, I am actually looking for diagnosis and the codes that are being used to support the 'apraxia as a neurological condition'. We recently moved from St Louis MO to Michigan. Therapist are hard to come by--and--our new pediatrician is having to be walked through these diagnosis and what we need...... So, it is coming down to me leading the way... ALSO--has anyone dealt with auditory processing disorder??? -- In , " Cozza " <ibew90mom@...> wrote: > > This my sound silly, but don't give up. Keep apealing over and > over. get anyone and everyone to write letters telling the insurance > co, how important this is and any delay will cot more money in the > long run. I fought for a year to get my son a augmemtive speach > device. I finally got it approved, so please don't give up. > > > > > > > Hi, > > > > > > Does anyone know what the diagnosis codes are for apraxia and > > auditory > > > processing disorder that are being reimburse by blue cross blue > > shield > > > of michigan???? or by any other insurance company?? I am looking > for > > > codes that do not fall under 'developmental'. Thanks in advance. > > > > > > > > > Mom to JaeKi 5.10 and Jonah 4.8 mths > > > > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 6, 2008 Report Share Posted May 6, 2008 - Where are you at in Michigan? There are some pretty good places that i could tell you about. Email me privatily if you have any questions. [ ] Re: insurance Hi again-- So, to be more specific, I am actually looking for diagnosis and the codes that are being used to support the 'apraxia as a neurological condition'. We recently moved from St Louis MO to Michigan. Therapist are hard to come by--and--our new pediatrician is having to be walked through these diagnosis and what we need...... So, it is coming down to me leading the way... ALSO--has anyone dealt with auditory processing disorder??? -- In , " Cozza " <ibew90mom@...> wrote: > > This my sound silly, but don't give up. Keep apealing over and > over. get anyone and everyone to write letters telling the insurance > co, how important this is and any delay will cot more money in the > long run. I fought for a year to get my son a augmemtive speach > device. I finally got it approved, so please don't give up. > > > > > > > Hi, > > > > > > Does anyone know what the diagnosis codes are for apraxia and > > auditory > > > processing disorder that are being reimburse by blue cross blue > > shield > > > of michigan???? or by any other insurance company?? I am looking > for > > > codes that do not fall under 'developmental'. Thanks in advance. > > > > > > > > > Mom to JaeKi 5.10 and Jonah 4.8 mths > > > > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 7, 2008 Report Share Posted May 7, 2008 Hi -I just pulled the following from the archives quickly. Key notes I learned from the archives -probably try code 784.69 as a few people bring that one up as working - and read The Late Talker (we have an entire chapter on this in there and my co author is a neurodevelopmental pediatrician who knows how to secure services for her qualified patients) Sample of archives on this: ~~~~~~~~~~~~~~~~~~~~ Herrald " <wherrald@... Re: Aetna Insurance We started Aetna on 1-1-07, I had carelink before and they refused to cover st after appeals. Fortunately my employer gives us a few options so we changed to Aetna. we had his pediatrician send a letter of med necessity and his neurologist send a letter stating that apraxia is a neurological disorder and st was me nec. It took some arguing but they agreed to pay for unlimited visits. The code they are using is 784.69 insurance advice " Maureen Welch " <mpwelch2003@...> The book, The Late Talker, has a section on dealing with insurance. They say the key to getting treatment coverage is to be clear this it is a neurological disorder, NOT developmental. Our coverage is just 20 sessions per calendar year of OT, PT, and ST each (60 total). And that is only AFTER an approval AFTER an insurance approved evaluation (which they might deny after we do it- $700) that convinces them this is needed. They will not accept the IEP or EI evaluations that we have. They joys of insurance... After a recent doctor appointment, a diagnosis code of speech delay was entered in his chart. Apparently this is a code 315.31 that is listed as one to avoid as it is considered developmental and flags denial for insurances. The book suggests using other codes like 784.69, 315.40 (most 315 codes are developmental except for this one), or 718.3. 718.3 also covers Motor Planning and Sensory processing, which affects him too. This often increases chances of coverage. Re: [ ] Insurance appeal Q Boo Mom <qboomom@...> The following is from SpeechvilleExpress insurance section: Diagnosis Destinations Apraxia Appealing Insurance Denials Apraxia is " Developmental " . " Developmental delays " are not Covered. Reason for Denial: " Apraxia is developmental. Developmental delays are not covered. " One of the most important things to do when applying for insurance coverage of apraxia-related therapy is to ensure that the evaluator (that is, the speech-language pathologist) does not use the word " developmental " in his or her report, as in " Developmental Apraxia of Speech " or " Developmental Verbal Dyspraxia. " While these terms are common in apraxia and speech therapy literature, for many families these phrases have been the sole cause of denials of insurance coverage. Insurance companies' claims evaluators see the word " developmental " and think, " developmental delay. " Most insurance companies and HMOs do not see it as their responsibility to pay for speech therapy if speech is developmentally delayed, which they interpret to mean " will improve with time, with or without treatment " . The person who is denying claims often does not know that " Developmental Apraxia " is not the same as " developmental delay, " nor may he or she know that " Developmental Apraxia " is used primarily to distinguish the condition from " Acquired Apraxia " (the loss of speech caused by a known incident of stroke or other brain trauma). The therapist should use a term such as " apraxia of speech, " " oral motor planning disorder, " or " speech motor disorder. " The insurance company might also be confusing apraxia of speech with a " developmental disability " . The United States government's definition of " developmental disability " requires that the disability be a mental and/or physical impairment, manifest before the individual is 22 years old, will likely continue indefinitely, results in substantial functional limitations in 3 or more major life activities, and will necessitate special services and supports of either lifelong or extended duration. Apraxia is not a " developmental disability, " though apraxia can co-occur, in some children, with a developmental disability. Regardless of whether or not a child is developmentally disabled, in addition to having apraxia of speech, the insurance company should not deny the claim on the basis of the developmental disability, if oral motor speech disorders would otherwise be covered. Therapists and doctors use diagnostic codes for insurance purposes. Again, the provider should not code a diagnosis for a child with Apraxia of Speech as " developmental delay " (code 315.9) or " developmental speech or language " (code 315.31). Codes to use are: a neurological code (codes 340 - 349) or coordination disorder (code 315.4). It is worth your while to ask the therapist or doctor (depending on if you need your physician's referral) what diagnostic code they will use in the report or referral. If you have already received a denial of insurance because of the " developmental " confusion, you will need to provide documentation to your insurance company or HMO demonstrating that apraxia of speech is not a developmental delay of speech. Apraxia of speech is disordered speech, speech that is not following a typical developmental path, whereas a child with developmentally delayed speech has typical speech patterns, albeit those of a younger child. Sometimes describing apraxia of speech as a neurological disorder or condition seems to help. Therefore here is a quote about the nature of apraxia from a well-known speech-language pathologist who specializes in apraxia of speech in children, Hodge, " ...This disability has a neurological basis of unknown origin. It may reflect neuro-anatomical/physiological differences that are inherited (see Hurst, Baraitser, Auger, Graham, and Norell, 1990; Shriberg, 1993) or damage that occurs pre- or postnatally during the period of speech development (Crary, 1984; Marquardt and Sussman, 1991)... " Re: insurance appeal " howdiette " <mulholland34@...> Look at the procedure codes your professionals are using. We had Blue Cross and have a 20 session limit per year. My son has appraxia, aphasia (codes are 784.3,784.69 & 784.5) Let your PT & OT know your codes for speech/language and not to use any developmental/educational codes. (just medical necessity). Insurance battles are fought and won every day but you have to be persistent. What does their policy state as far speech therapy? Can you tell me the reason for denial? Ask for the master policy -they will tell you there is none. They don't like to give it out -but you need a copy for your appeal. Physicians are busy - if you need a 'good' letter quoting research then write it yourself and ask the medical provider if they would be willing to sign on their letterhead. Here is an archived letter from Sandy in Illinois: SAMPLE LETTER: [DATE] VIA CERTIFIED MAIL/RETURN RECEIPT REQUESTED [iNSURANCE CO INFO] To Whom It May Concern: My son, __________, has been diagnosed with apraxia by his pediatrician, his pediatric neurologist, and his speech and language pathologist. (See enclosed information). To remediate this condition, has been receiving speech and language therapy as well as occupational therapy (the apraxia affects his oral motor musculature as well as his fine and gross motor functions). His progress has been excellent, and all concerned believe continued therapy is crucial to overcome this condition. [HERE I DISCUSSED ENCLOSURES: LETTERS FROM PEDIATRICIAN, SLP, OT] Since apraxia is a relatively uncommon condition, let me explain briefly what it is. Apraxia " 'is a neurological disorder that affects the planning and production of speech. " (, Jakielski, & Marquardt, 1998)'.[it] is a loss in ability to voluntarily position the articulators (e.g., lips, jaw, tongue) on a consistent basis when speaking. This disorder interferes with the child' s sequencing of sounds into words. In other words, the child has the ability to produce the sounds, but when he/she tries to purposefully plan speech, the articulators do not always function together properly. " S. Whitebreak, C. Dvorak, and K. Jakielsi, " Treatment Effect on Speech Intelligibility in Developmental Apraxia of Speech, " Presentation at the American Speech-Language-Hearing Association, 1999. " '.This disability has a neurological basis of unknown origin. It may reflect neuro-anatomical/physiological differences that are inherited (see Hurst, Baraitser, auger, Gramah, and Norell, 1990; Shriberg, 1993) or damage that occurs pre- or postnatally during the period of speech development (Crary, 1984; Marquardt and Sussman, 1991). " It is similar to the condition stroke victims suffer from when they lose the ability to speak after a stroke. In fact, many children initially have speech ability but then lose it (as is the case with , who had a larger vocabulary at 18 months of age than when diagnosed at 25 months of age). As to medical necessity of treatment of apraxia, the American Speech Hearing Association (ASHA) defines verbal apraxia as " a medical condition consistent with the definition of illness and disease.'a disorder of body function.' " (Keystater, the official publication of the Pennsylvania Speech Hearing Language Ass'n, Sept.. 1992; Source: ASHA, Rockville, MD). Apraxia is not a developmental disorder or delay. If left untreated, my son will not develop meaningful speech or coordinated fine and gross motor abilities. Lack of meaningful speech and fine and gross motor abilities would result directly in a deterioration of my son's health and safety, in that he will not be able to communicate medical needs and will be unable to function and do daily life skills. With treatment, however, the prognosis is good. In fact, _____'s progress has been excellent. Speech and occupational therapy are the recommended treatments for apraxia (see enclosed letters). They are the least expensive, least invasive, and most successful forms of treatment, are accepted by the medical community, and are not implemented for the convenience of the child or therapist. See also a Square, " Introduction, " Clinics in Communication Disorders, 4(2) ( " apraxia is a motor speech disorder in the ability to regulate and control oral movement sequences. Apraxia is a separate speech disorder that requires a motor treatment, apraxia is remediable if the clinician knows that this must be the focus of treatment " ); Penelope Hall, Jordan and Robin, " Theory and Clinical Practices " ( " Intensive services are needed for children with apraxia " ); Edythe Strand, " Childhood Motor Speech Disorder Treatment, " ( " The earlier and more intensive the intervention, the more successful the therapy.Children with apraxia really need the intensive individual therapy " ). In fact, the research indicates and experience dictates that apraxic children need intensive consistent therapy. The leading researchers in the field have indicated that this is the best therapeutic route to take. Such researchers include Edythe Strand, PhD., Mayo Clinic; a Square, Ph.D., University of Toronto; and Robin, Ph.D., University of Iowa. The research indicates that the key to success is intensive therapy continually throughout the year. In short, since apraxia is a medical condition and not a developmental delay or disorder, and since speech and occupational therapy are medically necessary, I submit that the enclosed expenses should be a covered benefit under the plan. Thank you for your consideration. Sincerely, contact me privately at mulholland34@... if you have any questions All the best, Joanne Below are some archive files I kept relating to insurance/Aetna. I hope they still work. E-mail me privately if you need more information, Joanne Mulholland I wanted to share with you a really good resource for assistance in getting therapy and/or any other medical costs approved by your health insurance carrier. SNAP(special needs advocates for parents), a not for profit organization has a " medical insurance empowerment program " whereby they will review your insurance policy and medical reports for a processing charge of $10 (that is not a typo) and give you advice on how to deal with your insurance company. I dealt with Marla Kraus whom I found extremely knowledgeable, professional and personable. Their website is www.snapinfo.org (If you download their medical ins. empowerment brochure, please note that the address is outdated and you should use the W. Olympic address on their homepage) There of course is no guarantee that their advice will get the services you are looking for covered by your insurance company... but it is definitely a resource worth looking into. Shana to all, Libby Weil You first need to find out if your plan covers speech therapy through your employer. Then have your developmental pediatrician write a letter of medical necessity using the code 781.49 which indicates an nuero-based motor planning disorder. If they use any other code with a 300 prefix, the insurer will deny based on developmental delay which they will not cover. Once, they receive the letter of medical necessity, it can take up to a month for review at which time, I would follow up on them every other day. They are awful about communicating approval. It took us 2 months of back and forth frustrating follow-up calls, but eventually we won. They cover 60 visits annually. I hope this helps. (Double check the code...look it up in the website...I'm pretty sure it is 781 the ending could be .69). Myra They denied us on the code for Apraxia 784.69 claiming its developmental which we all know it's NOT, but they approved the therapy for the code for Language processing disorder 388.43. A great code to use if you have a child with apraxia is 781.3 which is " lack of muscle coordination /coordination disorder. " This shows a physical diagnosis, which is typically covered, versus a developmental diagnosis, which is typically not covered. We have Blue Cross and have a 20 session limit per year. My son has appraxia, aphasia (codes are 784.3,784.69 & 784.5) Let your PT & OT know your codes for speech/language and not to use any developmental/educational codes. (just medical necessity). all the best, Joanne Mulholland If your policy provides limited or no coverage for speech pathology services: Find out if your employer offers another plan that provides coverage for speech and language services. If so, switch to that plan during the next open enrollment period. Send a letter to your employer requesting better coverage in upcoming insurance plans. Employers have the greatest influence in obtaining better insurance coverage as they negotiate the contracts with the insurance companies. Your company will have no idea of the need for speech therapy coverage unless you inform them that you were denied for coverage. Group insurance coverage for speech and language evaluations and therapy is a relatively inexpensive rider for most companies to add to their existing policies. Inform your employer about any limitations in your plan, especially if your health insurance plan is self-insured by your employer. Your employer may be able to add speech services in future plans. Your state Department of Insurance may have limited jurisdiction over self-insured plans. With self- insured plans, the employer provides the money, decides what benefits to offer and what claims to pay. Theoretically, the insurance company just " follows orders. " The regulator over self-insured plans is the US Department of Labor, Pension and Welfare Benefits Administration at (202) 219-8776. I found this on the apraxia-kids.org website. Regards, Joanne Mulholland Insurance battles are fought and won every day but you have to be persistent. What does their policy state as far speech therapy? Can you tell me the reason for denial? Contact me at donnamarucci@... and please mention you are from the messageboards. I can send you sample letters of appeal. Donna M. Passing the Buck By PAUL KRUGMAN <http://www.nytimes.com/top/opinion/editorialsandoped/oped/columnists/ paulkr ugman/index.html?inline=nyt-per> Published: April 22, 2005 The United States spends far more on health care than other advanced countries. Yet we don't appear to receive more medical services. And we have lower life-expectancy and higher infant-mortality rates than countries that spend less than half as much per person. How do we do it? An important part of the answer is that much of our health care spending is devoted to passing the buck: trying to get someone else to pay the bills. According to the World Health Organization, in the United States administrative expenses eat up about 15 percent of the money paid in premiums to private health insurance companies, but only 4 percent of the budgets of public insurance programs, which consist mainly of Medicare and Medicaid. The numbers for both public and private insurance are similar in other countries - but because we rely much more heavily than anyone else on private insurance, our total administrative costs are much higher. According to the health organization, the higher costs of private insurers are " mainly due to the extensive bureaucracy required to assess risk, rate premiums, design benefit packages and review, pay or refuse claims. " Public insurance plans have far less bureaucracy because they don't try to screen out high-risk clients or charge them higher fees. And the costs directly incurred by insurers are only half the story. Doctors " must hire office personnel just to deal with the insurance companies, " Dr. Atul Gawande, a practicing physician, wrote in The New Yorker. " A well-run office can get the insurer's rejection rate down from 30 percent to, say, 15 percent. That's how a doctor makes money. ... It's a war with insurance, every step of the way. " Isn't competition supposed to make the private sector more efficient than the public sector? Well, as the World Health Organization put it in a discussion of Western Europe, private insurers generally don't compete by delivering care at lower cost. Instead, they " compete on the basis of risk selection " - that is, by turning away people who are likely to have high medical bills and by refusing or delaying any payment they can. Yet the cost of providing medical care to those denied private insurance doesn't go away. If individuals are poor, or if medical expenses impoverish them, they are covered by Medicaid. Otherwise, they pay out of pocket or rely on the charity of public hospitals. So we've created a vast and hugely expensive insurance bureaucracy that accomplishes nothing. The resources spent by private insurers don't reduce overall costs; they simply shift those costs to other people and institutions. It's perverse but true that this system, which insures only 85 percent of the population, costs much more than we would pay for a system that covered everyone. And the costs go beyond wasted money. First, in the U.S. system, medical costs act as a tax on employment. For example, General Motors is losing money on every car it makes because of the burden of health care costs. As a result, it may be forced to lay off thousands of workers, or may even go out of business. Yet the insurance premiums saved by firing workers are no saving at all to society as a whole: somebody still ends up paying the bills. Second, Americans without insurance eventually receive medical care - but the operative word is " eventually. " According to Kaiser Family Foundation data, the uninsured are about three times as likely as the insured to postpone seeking care, fail to get needed care, leave prescriptions unfilled or skip recommended treatment. And many end up disabled - or die - because of these delays. Think about how crazy all of this is. At a rough guess, between two million and three million Americans are employed by insurers and health care providers not to deliver health care, but to pass the buck for that care to someone else. And the result of all their exertions is to make the nation poorer and sicker. Why do we put up with such an expensive, counterproductive health care system? Vested interests play an important role. But we also suffer from ideological blinders: decades of indoctrination in the virtues of market competition and the evils of big government have left many Americans unable to comprehend the idea that sometimes competition is the problem, not the solution. In the next column in this series, I'll talk about how ideology leads to " reforms " that make things worse. E-mail: krugman@... Hi, and others. Here's a letter I wrote and used successfuly to appeal a denial of insurance coverage on the basis that apraxia is developmental. This letter shows that apraxia is neurological and therefore medical, not developmental. Feel free to use, share, etc. HOpe it helps someone out there! SAMPLE LETTER: [DATE] VIA CERTIFIED MAIL/RETURN RECEIPT REQUESTED [iNSURANCE CO INFO] To Whom It May Concern: My son, __________, has been diagnosed with apraxia by his pediatrician, his pediatric neurologist, and his speech and language pathologist. (See enclosed information). To remediate this condition, has been receiving speech and language therapy as well as occupational therapy (the apraxia affects his oral motor musculature as well as his fine and gross motor functions). His progress has been excellent, and all concerned believe continued therapy is crucial to overcome this condition. [HERE I DISCUSSED ENCLOSURES: LETTERS FROM PEDIATRICIAN, SLP, OT] Since apraxia is a relatively uncommon condition, let me explain briefly what it is. Apraxia " 'is a neurological disorder that affects the planning and production of speech. " (, Jakielski, & Marquardt, 1998)'.[it] is a loss in ability to voluntarily position the articulators (e.g., lips, jaw, tongue) on a consistent basis when speaking. This disorder interferes with the child' s sequencing of sounds into words. In other words, the child has the ability to produce the sounds, but when he/she tries to purposefully plan speech, the articulators do not always function together properly. " S. Whitebreak, C. Dvorak, and K. Jakielsi, " Treatment Effect on Speech Intelligibility in Developmental Apraxia of Speech, " Presentation at the American Speech-Language-Hearing Association, 1999. " '.This disability has a neurological basis of unknown origin. It may reflect neuro-anatomical/physiological differences that are inherited (see Hurst, Baraitser, auger, Gramah, and Norell, 1990; Shriberg, 1993) or damage that occurs pre- or postnatally during the period of speech development (Crary, 1984; Marquardt and Sussman, 1991). " It is similar to the condition stroke victims suffer from when they lose the ability to speak after a stroke. In fact, many children initially have speech ability but then lose it (as is the case with , who had a larger vocabulary at 18 months of age than when diagnosed at 25 months of age). As to medical necessity of treatment of apraxia, the American Speech Hearing Association (ASHA) defines verbal apraxia as " a medical condition consistent with the definition of illness and disease.'a disorder of body function.' " (Keystater, the official publication of the Pennsylvania Speech Hearing Language Ass'n, Sept.. 1992; Source: ASHA, Rockville, MD). Apraxia is not a developmental disorder or delay. If left untreated, my son will not develop meaningful speech or coordinated fine and gross motor abilities. Lack of meaningful speech and fine and gross motor abilities would result directly in a deterioration of my son's health and safety, in that he will not be able to communicate medical needs and will be unable to function and do daily life skills. With treatment, however, the prognosis is good. In fact, _____'s progress has been excellent. Speech and occupational therapy are the recommended treatments for apraxia (see enclosed letters). They are the least expensive, least invasive, and most successful forms of treatment, are accepted by the medical community, and are not implemented for the convenience of the child or therapist. See also a Square, " Introduction, " Clinics in Communication Disorders, 4(2) ( " apraxia is a motor speech disorder in the ability to regulate and control oral movement sequences. Apraxia is a separate speech disorder that requires a motor treatment, apraxia is remediable if the clinician knows that this must be the focus of treatment " ); Penelope Hall, Jordan and Robin, " Theory and Clinical Practices " ( " Intensive services are needed for children with apraxia " ); Edythe Strand, " Childhood Motor Speech Disorder Treatment, " ( " The earlier and more intensive the intervention, the more successful the therapy.Children with apraxia really need the intensive individual therapy " ). In fact, the research indicates and experience dictates that apraxic children need intensive consistent therapy. The leading researchers in the field have indicated that this is the best therapeutic route to take. Such researchers include Edythe Strand, PhD., Mayo Clinic; a Square, Ph.D., University of Toronto; and Robin, Ph.D., University of Iowa. The research indicates that the key to success is intensive therapy continually throughout the year. In short, since apraxia is a medical condition and not a developmental delay or disorder, and since speech and occupational therapy are medically necessary, I submit that the enclosed expenses should be a covered benefit under the plan. Thank you for your consideration. Sincerely, Sandy, Illinois (alpy2@...) Volunteer Co-Webmaster, www.ourchildrenleftbehind.com (IDEA reauthorization too am fighting a battle with CIGNA in order to get treatment authorized for my son's apraxia (for the last year). Coming from a mom, a medical professional and someone having extensive experience working for an insurance type company, I have done the following: (this is not advice, as everyone's situation is different, but just what I feel is most appropriate in my particular situation) -- I will always appeal a denial. Be aware of how many levels of Appeal your plan offers. Follow directions to the tee. -- I have documented the date, time and name of everyone I have spoken with at the insurance company in the last year. -- I request an urgent and expedited appeal. You have the right to request an urgent and expedited appeal on your childs behalf. If you do this in writing the insurance company must make a decision on the appeal within three business days. -- I stick to the facts in my letter and quote research supporting the medical necessity of treatment. -- Physicians are busy - if you need a 'good' letter quoting research then write it yourself and ask the medical provider if they would be willing to sign on their letterhead. -- Read the exclusions of your benefit plan word for word. If you do not have a copy then ask your HR dept for the SPD (summary plan description). -- If your benefit plan excludes treatment that is not 'restorative in nature' then it is your employer's plan that is excluding the treatment. I have personally called the VP of benefits at the company I work for, educating them on the diagnosis, referring them to this website and providing a copy of the recent Michigan ruling etc.. etc.. If a company provides coverage for an adult with apraxia (after a stroke),then a person should not be excluded from treatment just because of their age. -- If all your appeals have been upheld/denied then investigate next steps ie. contacting the insurance commissioner or the Dept of Labor (depending on your plan). -- If all else fails then I will be contacting my state representatives. I, like all of you, do not know how this will all turn out, having a plan makes me feel like I at least know the 'next steps'. I am dissapointed by the responses I have received on the first two appeals thus far, but I am not going to give up on this one without doing all that I can. I didn't mean to make this so long - I feel so strongly about this topic as I know so many of you do too- we are the voice for our kids. I wish you all the best in advocating for your children. If your policy provides limited or no coverage for speech pathology services: Find out if your employer offers another plan that provides coverage for speech and language services. If so, switch to that plan during the next open enrollment period. Send a letter to your employer requesting better coverage in upcoming insurance plans. Employers have the greatest influence in obtaining better insurance coverage as they negotiate the contracts with the insurance companies. Your company will have no idea of the need for speech therapy coverage unless you inform them that you were denied for coverage. Group insurance coverage for speech and language evaluations and therapy is a relatively inexpensive rider for most companies to add to their existing policies. Inform your employer about any limitations in your plan, especially if your health insurance plan is self-insured by your employer. Your employer may be able to add speech services in future plans. Your state Department of Insurance may have limited jurisdiction over self-insured plans. With self- insured plans, the employer provides the money, decides what benefits to offer and what claims to pay. Theoretically, the insurance company just " follows orders. " The regulator over self-insured plans is the US Department of Labor, Pension and Welfare Benefits Administration at (202) 219-8776. Yes, I had Aetna and Guardian. Aetna limited me and I fought back for the summer months b/c he was not in a ESY program, so therefore I had to use a medical based therapy for speech. I appealed 2 times and had a neurologist, speech pathologist, and OT evaluations requesting treatment was necessary due to regression. All reports were in medical terminology not educationally based. If your employer has a medical benefits coordinator you may want to ask for their assistance in writing a letter requesting more therapy treatment sessions due to your child's medical necessity. Good luck! When your insurance company says " no " , it is not usually their final answer. I do believe you have the right to three appeals. Let's hope you get a yes on round two! There are three levels of mediation Written Conference over the phone what you are up to: -the next if needed (or you could ask for) would be an in person conference with a higher up, and perhaps even someone who has a medical background. Good news is that the higher up you go -the more competent the person you are dealing with. While letters from the speech therapist are great, your child's neuroMD (or pediatrician) is in the best position to determine medical necessity for an insurance denial, and can serve as a strong advocate in the appeals process. It is helpful to get a second opinion 'and' to include additional letters of medical necessity from specialists and therapists that support you. Next is information I got years ago from a PhD who asked me never to use her name. Ask for the master policy -they will tell you there is none. Ask to speak to that person's superior and again ask for the master policy. They don't like to give it out -but you need a copy for when you fight for coverage. I was also told that insurance companies deny because they know most won't appeal. Insurance companies know that only 10% will appeal even the first denial -and many claims are denied that should be covered. Out of that 10% only 10% will appeal the second denial. Out of that 10% (which is now down to a minute amount) only 10% will again appeal a denial. By this point however -most do get approval. Based on a thank you note we just got on this topic through Speechville -here's the main link to the insurance page (with the note below) http://www.speech-express.com/speech-therapy/insurance.html Also there is an entire chapter on advocacy for school and insurance in The Late Talker book -with sample letters my co author Dr. Marilyn Agin wrote that your child's MD can pull from to help you secure coverage. Do you have that book? http://www.speechville.com/late.talker.html akb@... Re: [ ] health insurance :-( Insurance companies, if they cover ST, will cover up to a number of day sor dollar amount for DEVELOPMENTAL CPT code. But since apraxia is a Neurological DISORDER the neurologist can write a letter of medical necesaty and then put in the correct CPT codes which are in the 700's (your ST should know exact code) have them put the claim in that way with the letter and many times I have seen them cover and sometimes the members have had to fight and even after the fight have seem the insurance co. cover. Insurance companies try to get around covering all types of therapies because they consider them " developmental " but we all need to go the route of " Disorder " and not use the word " therapy " either. These are all words for denial of service. In the Late Talker book there is a complete section that explains how to work the insurance system-please review-very good info!!!! ~~~~~~~~~~~~~~~end of archives ===== Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 10, 2008 Report Share Posted July 10, 2008 Having a gene test for future diagnosis in a child with no symptoms is probably a mistake as far as future insurance is concerned. Once symptoms appear and treatment is needed, then the diagnosis is going to be made. Elinor Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 27, 2009 Report Share Posted January 27, 2009 I also have BCBS of KC HMO. We appealed once and were still turned down. Our contract actually has a head remlding device exclusion. Have you checked your contract? I know some members have gotten help getting their employer's benefits department involved. I am glad you are seeing a difference in 2 weeks. Angie Insurance Hello Everyone,Has anyone had any luck with Blue Cross Blue Shield of Kansas City. They denied us so we paid out of pocket for our son's helmet. I was just wondering if anyone has appealed to them and won if they had any pointers on how to get them to pay for the starband. Any pointers from anywhere would be helpful. Our son got his band right after he turned 6 months. He had a flat spot since two months. We asked the pedi. and she gave us repo exercises so we did them for two months and tried to keep him off the back of his head as much as possible. At his 4 month appt. she thought his head would round out but gave us the ortho's # if we wanted to check out the band. We went ahead and seen the ortho and they said that he had a moderate to serve case of Plagio. He doesn't have tort or anything else just plagio. so we decided to go with the band. After just two weeks you could see the difference! and now he has been in it for 5 weeks and it looks like a normal childs head, the flatness is almost completely gone. It is amazing how it works and how fast it has made a difference.Anyways, just thought you would need some background info for pointers. Is there any medical info on the effects if plagio goes untreated. I have been doing some research and can not seem to find anything on that.Thanks so much!Jodie Saultz Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 28, 2009 Report Share Posted January 28, 2009 That is what ours says too. We will try anyways, can't hurt to try. I think it is ridiculous that they have the specific exclusion. Our son had a cone shaped head from birth and his head has never been a normal shape. It just makes me so mad that they won't at least help cover the costs. Thanks for your help!!! Jodie > > I also have BCBS of KC HMO. We appealed once and were still turned down. Our contract actually has a head remlding device exclusion. Have you checked your contract? I know some members have gotten help getting their employer's benefits department involved. I am glad you are seeing a difference in 2 weeks. > > Angie > Insurance > > > Hello Everyone, > Has anyone had any luck with Blue Cross Blue Shield of Kansas City. > They denied us so we paid out of pocket for our son's helmet. I was > just wondering if anyone has appealed to them and won if they had any > pointers on how to get them to pay for the starband. Any pointers from > anywhere would be helpful. > Our son got his band right after he turned 6 months. He had a flat spot > since two months. We asked the pedi. and she gave us repo exercises so > we did them for two months and tried to keep him off the back of his > head as much as possible. At his 4 month appt. she thought his head > would round out but gave us the ortho's # if we wanted to check out the > band. We went ahead and seen the ortho and they said that he had a > moderate to serve case of Plagio. He doesn't have tort or anything else > just plagio. so we decided to go with the band. After just two weeks > you could see the difference! and now he has been in it for 5 weeks and > it looks like a normal childs head, the flatness is almost completely > gone. It is amazing how it works and how fast it has made a difference. > Anyways, just thought you would need some background info for pointers. > Is there any medical info on the effects if plagio goes untreated. I > have been doing some research and can not seem to find anything on that. > Thanks so much! > Jodie Saultz > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 28, 2009 Report Share Posted January 28, 2009 Jodie, We have BCBS of Kansas, which I think means Kansas State, not Kansas City. Is this the same? Anyway, if so I don't have an answer since we have not gotten to that stage yet. Our ortho's secretary says she always appeals like crazy but it usually doesn't work. I'll be interested to hear what happens with you. Our story sounds just about identical to yours: flat spot at 2 mos, repo from then 'til 4 mos, and then a band at nearly 6 months. We've had it for three weeks and the results have been awesome! Also a Starband. Just wondering, what ortho are you using? We are with Thom at Hanger at KU. Congratulations on your success with the helmet and good luck with the insurance! > > Hello Everyone, > Has anyone had any luck with Blue Cross Blue Shield of Kansas City. > They denied us so we paid out of pocket for our son's helmet. I was > just wondering if anyone has appealed to them and won if they had any > pointers on how to get them to pay for the starband. Any pointers from > anywhere would be helpful. > Our son got his band right after he turned 6 months. He had a flat spot > since two months. We asked the pedi. and she gave us repo exercises so > we did them for two months and tried to keep him off the back of his > head as much as possible. At his 4 month appt. she thought his head > would round out but gave us the ortho's # if we wanted to check out the > band. We went ahead and seen the ortho and they said that he had a > moderate to serve case of Plagio. He doesn't have tort or anything else > just plagio. so we decided to go with the band. After just two weeks > you could see the difference! and now he has been in it for 5 weeks and > it looks like a normal childs head, the flatness is almost completely > gone. It is amazing how it works and how fast it has made a difference. > Anyways, just thought you would need some background info for pointers. > Is there any medical info on the effects if plagio goes untreated. I > have been doing some research and can not seem to find anything on that. > Thanks so much! > Jodie Saultz > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 28, 2009 Report Share Posted January 28, 2009 Hello , We are also with Thom at KU. Klayton has been in his band now for almost 5 weeks and it has made such a difference. Jill said that most likely the insurance won't pay even after you appeal, but we are going to try just to see what they say. The worst that could happen is they say no and we are still out the money, but it is so worth it! I am not sure if BCBS of Kansas and BCBS of KC are same...but I would think that they would be. I do know that in our contract it says that it will not cover it because it excludes DOC bands. We are from the Bonner Springs, KS area and I don't think that there is any other place that offers the band in the area. We have until June to appeal and will probably take that long to get the appeal written, so I will let you know what happens. Congrats on your success and good luck to you with everything. Jodie > > > > Hello Everyone, > > Has anyone had any luck with Blue Cross Blue Shield of Kansas City. > > They denied us so we paid out of pocket for our son's helmet. I was > > just wondering if anyone has appealed to them and won if they had any > > pointers on how to get them to pay for the starband. Any pointers from > > anywhere would be helpful. > > Our son got his band right after he turned 6 months. He had a flat spot > > since two months. We asked the pedi. and she gave us repo exercises so > > we did them for two months and tried to keep him off the back of his > > head as much as possible. At his 4 month appt. she thought his head > > would round out but gave us the ortho's # if we wanted to check out the > > band. We went ahead and seen the ortho and they said that he had a > > moderate to serve case of Plagio. He doesn't have tort or anything else > > just plagio. so we decided to go with the band. After just two weeks > > you could see the difference! and now he has been in it for 5 weeks and > > it looks like a normal childs head, the flatness is almost completely > > gone. It is amazing how it works and how fast it has made a difference. > > Anyways, just thought you would need some background info for pointers. > > Is there any medical info on the effects if plagio goes untreated. I > > have been doing some research and can not seem to find anything on that. > > Thanks so much! > > Jodie Saultz > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 28, 2009 Report Share Posted January 28, 2009 I have hear wonderful things about Thom. We used ette in 2002 with wonderful results as well. I tihnk those are 2 different insurances but not positive. I gave up after 1 appeal. I wish I hadn't. I hope you both win yours!!!!! Good luck, Angie Re: Insurance Hello ,We are also with Thom at KU. Klayton has been in his band now for almost 5 weeks and it has made such a difference. Jill said that most likely the insurance won't pay even after you appeal, but we are going to try just to see what they say. The worst that could happen is they say no and we are still out the money, but it is so worth it! I am not sure if BCBS of Kansas and BCBS of KC are same...but I would think that they would be. I do know that in our contract it says that it will not cover it because it excludes DOC bands.We are from the Bonner Springs, KS area and I don't think that there is any other place that offers the band in the area.We have until June to appeal and will probably take that long to get the appeal written, so I will let you know what happens.Congrats on your success and good luck to you with everything. Jodie> >> > Hello Everyone,> > Has anyone had any luck with Blue Cross Blue Shield of Kansas City. > > They denied us so we paid out of pocket for our son's helmet. I was > > just wondering if anyone has appealed to them and won if they had any > > pointers on how to get them to pay for the starband. Any pointers from > > anywhere would be helpful. > > Our son got his band right after he turned 6 months. He had a flat spot > > since two months. We asked the pedi. and she gave us repo exercises so > > we did them for two months and tried to keep him off the back of his > > head as much as possible. At his 4 month appt. she thought his head > > would round out but gave us the ortho's # if we wanted to check out the > > band. We went ahead and seen the ortho and they said that he had a > > moderate to serve case of Plagio. He doesn't have tort or anything else > > just plagio. so we decided to go with the band. After just two weeks > > you could see the difference! and now he has been in it for 5 weeks and > > it looks like a normal childs head, the flatness is almost completely > > gone. It is amazing how it works and how fast it has made a difference.> > Anyways, just thought you would need some background info for pointers. > > Is there any medical info on the effects if plagio goes untreated. I > > have been doing some research and can not seem to find anything on that.> > Thanks so much!> > Jodie Saultz> >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 15, 2009 Report Share Posted September 15, 2009 Hi Kay, Welcome back! My understanding of the pre-existing condition thing is that as long as you are continuously covered with health insurance, they cannot deny you coverage when you move from one job/ins company to another. So, if I simply change jobs, I would want to pay for coverage out of pocket to cover myself during the waiting period between when the new job starts and the insurance benefit kicks in. Likewise, when I was laid off for 7 months many years ago, I kept my coverage by paying for COBRA while I was laid off and through the probation period of the new job. In that way, they could not deny me coverage for pre-existing conditions. The problem exists when there is a break in coverage, which could easily happen in this current economy, with people laid off for very long periods of time. The other problem is for people who do not have insurance through their jobs, or who do not have jobs/insurance at all. In that case, if they have a major problem, then that would be considered pre-existing when the person finally did get a job with insurance coverage. This happened to my friend who worked for a small business with no insurance when she was in her early 20s. She had to go to the hospital for abdominal pain that turned out to be endometriosis. Afterward, her doctor actually gave her medical files to her so that insurance companies could not deny her claims in the future. This may not have been strictly legal, but it allowed her pre-existing condition to 'disappear' and was certainly the humane/fair thing to do. > > Hello everyone! > > I have a son who has CMT, is 30, and lives in Oregon. He is on his > employers insurance plan now, but would like to know if he goes to the > doctor now and is diagnosed with CMT...would he later have problems getting > insurance with a new employers insurance company? > > Thanks for your input! > > Kay > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 15, 2009 Report Share Posted September 15, 2009 Kay, First, congratulations on finishing your radiation. I have been thinking about you and appreciate your checking in with us. As to the insurance question, my understanding is that when you get insurance through an employer, your pre-existing conditions are NOT excluded. In other words, they are covered. You usually have a waiting period of at least 30 days after you begin your employment. However, if he were to attempt to get insurance as an individual (not through an employer) then he will likely run into problems with pre-existing condition exclusions. Hope this helps. Warren Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 15, 2009 Report Share Posted September 15, 2009 Hi Kay,  Welcome back! So nice to hear from you. Glad you are doing well!  With regard to employer health insurance, he cannot be denied coverage in Oregon. However, in some circumstances the insurance company can apply a waiting period for treatment related to the CMT, since it's a pre-existing condition. The waiting period can be up to 12 months.  To avoid the waiting period:  1. He can elect an HMO plan. They typically don't have any waiting periods. Or...  2. He can maintain continuous credible coverage. What this means is that if he leaves his current employer and doesn't begin working for another employer right away, he needs to keep his insurance coverage going either with an individual plan or COBRA. As long as he doesn't allow a gap in coverage greater than 62 days, he'll be fine. No waiting periods will apply when his coverage with the new employer begins.  As for getting an individual plan when he's in between employers, health insurers in Oregon may not deny him coverage on an individual basis or apply any waiting periods to his coverage if he has been continuously covered for at least 6 months.  In other words, as long as he continues to be covered, moving from employer to employer will not affect his ability to get health insurance.  As for disability and life insurance, he should always apply when he is initially eligible with a new employer. If he applies when he is initially eligible, there is typically no medical underwriting up to a guaranteed issue amount. If he refused coverage initially but decides he wants it later, then medical underwriting will almost always apply and it's possible he could be denied coverage. The same is true if he takes coverage initially, but later decides to increase his coverage amounts. He may want to consider taking highest amounts from the beginning.  Hope that helps.  From: Kay <omega@...> Subject: Insurance Date: Monday, September 14, 2009, 10:03 AM  Hello everyone! I have a son who has CMT, is 30, and lives in Oregon. He is on his employers insurance plan now, but would like to know if he goes to the doctor now and is diagnosed with CMT...would he later have problems getting insurance with a new employers insurance company? Thanks for your input! Kay Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 15, 2009 Report Share Posted September 15, 2009 I forgot to mention...  State healthcare programs, such as the Oregon Health Plan/Medicaid, would also qualify as credible coverage.  So, let's say for example, that your son was unemployed for an extended period of time and could not afford the monthly premium for an individual plan or COBRA, then he should apply for State assistance, so he could maintain continuous coverage in-between jobs and prevent pre-existing conditions from ever becoming an issue. From: Kay <omegaseasurf (DOT) net> Subject: Insurance groups (DOT) com Date: Monday, September 14, 2009, 10:03 AM  Hello everyone! I have a son who has CMT, is 30, and lives in Oregon. He is on his employers insurance plan now, but would like to know if he goes to the doctor now and is diagnosed with CMT...would he later have problems getting insurance with a new employers insurance company? Thanks for your input! Kay Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 6, 2009 Report Share Posted November 6, 2009 We had Aetna when my daughter was banded. I don't know specifics about our plan, but they covered the band 100%. We didn't pay anything out of pocket, though they had to send approval to their board to make sure it was necessary before they covered it. I think others on here have had to appeal with Aetna, so I think it depends on your plan. Kristi > > We live in Winter Haven,FL we have to travel to Tampa to get our daughter banded. She gets her band on Tuesday. I was wondering if anybody has aetna and if they cover the banding if so how much did they cover? We had to go in as cash payment. We had to put down 500 dollars as a down payment.My husband just started a new job which means new insurance. We haven't gotten our insurance information yet. But we do know its aetna. Any information is welcomed! Thanks! > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 6, 2009 Report Share Posted November 6, 2009 Hi, We have Aetna. You can find the info about their helmet coverage @ https://xsearch.aetna.com/searchresults.aspx?query=0379 , or aetna.com, and policy 0379 in the search window. We had our helmet done @ Hanger and they asked us to pay in full upfront, so now we are waiting for the reimbursement from the insurance. It will take 45 to 60 days, so we don't know if we'll get anything back. Good luck. Gergana > > We live in Winter Haven,FL we have to travel to Tampa to get our daughter banded. She gets her band on Tuesday. I was wondering if anybody has aetna and if they cover the banding if so how much did they cover? We had to go in as cash payment. We had to put down 500 dollars as a down payment.My husband just started a new job which means new insurance. We haven't gotten our insurance information yet. But we do know its aetna. Any information is welcomed! Thanks! > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 9, 2009 Report Share Posted November 9, 2009 My daughter who is now 6.5 months is about to graduate from the DOC Band in one week. We use CT in Dallas and also live in Dallas. And we LOVE CT! Using hanger or Starband wasn't something I was willing to do (not that it's bad for those who did!) but CT was out of network for us as well and the others were in network. I am in the middle of appealing which it looks like I may have a chance at winning because my daughter's brachy was severe. We have UHC insurance. Also, try and apply for United Healthcare Children's Foundation- we weren't considered because we had already paid for the treatment (Care Credit Card- no interest for 12 months), but since you haven't yet- you may have a chance... the only thing is I don't know if you need to wait to hear if they have approved you or not before you can proceed with a band. My daughter was five months when she finally got the band and will wear it for 8 weeks (one more to go!). Good luck with your decision. Hope that wasn't all useless information. If I happen to find out about my appeal soon- I'll let you know. Swartz Lola (7 wks in DOC Band) > > Hello, > > I am new to the group and have spent hours reading posts. I have finally decided to just ask my question. > > We live in the Dallas, TX area and went to Cranial Tech. this past week. They determined that our 4 month old daughter needs a band. We have spoken to our insurance (UHC) and found that CT is considered out of network and we don't have any out of network coverage. UHC is sending us two other in network providers (hanger & starband). I have read mixed reviews on these two providers and have only read positive reviews for CT. > > We really want to go to CT because after all, this is what they specialize in but the cost is kind of a lot right now. We were told that we could go through the appeals process with UHC. My question is why would they approve our case if in fact there are 2 other in network providers? Also, has anyone gone through the appeals process? What will I need to provide? > > Any information would be greatly appreciated. > > Thanks, > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 9, 2009 Report Share Posted November 9, 2009 Hello , I am also new to the group and I live in Buckeye, AZ and my son will be getting his band tomorrow afternoon from CT. I also was advised that UHC was out of network and I did not have any coverage. I just received in the mail today a letter from UHC stating that ' band would be covered so now I will have to do the appeal process as well. I have never done it but I'm in the process of researching it, I will keep you inform as to how it works. As for now, we are on the Care Credit program because we also preferred CT rather than Hanger but everyone has their own opinions on the two. I believe that the people who work at CT were a little more heplful. Once I receive more information I will advise. Thanks Rosemary (mother of 10 montrh old Nicky) From: <cmoesser@...>Plagiocephaly Sent: Mon, November 9, 2009 1:13:41 PMSubject: Insurance Hello,I am new to the group and have spent hours reading posts. I have finally decided to just ask my question.We live in the Dallas, TX area and went to Cranial Tech. this past week. They determined that our 4 month old daughter needs a band. We have spoken to our insurance (UHC) and found that CT is considered out of network and we don't have any out of network coverage. UHC is sending us two other in network providers (hanger & starband). I have read mixed reviews on these two providers and have only read positive reviews for CT. We really want to go to CT because after all, this is what they specialize in but the cost is kind of a lot right now. We were told that we could go through the appeals process with UHC. My question is why would they approve our case if in fact there are 2 other in network providers? Also, has anyone gone through the appeals process? What will I need to provide? Any information would be greatly appreciated.Thanks, Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 28, 2010 Report Share Posted September 28, 2010 Dear Group, Since I couldn't find the post I prepared for showing the differences for some of the countries on how insurance is dispensed and funded, I decided to give you a general idea of what each county faces. It would give you an idea of how your insurance stacks up to others. I didn't spend nearly as much time doing this one, but you are free to browse and read the articles at the websites. Every country's insurance comes with its own set of problems. For the citizens in the USA, I didn't think we needed an explanation, we are living it. LOL ________________________ " Reuters) - The French government is looking at ways to plug a gaping hole in its health care budget and may charge patients more for hospital stays, Budget Minister Woerth said on Monday. France's health system is largely financed by the state and has been hailed as the best in the world by the World Health Organization. It is also one of the most costly and the government constantly struggles to control spending. " http://www.reuters.com/article/idUSTRE5863CN20090907 ______________________________ " The NHS and private healthcare are not providing good enough basic care to a large portion of the population in England, especially older and frailer people, according to a study published on bmj.com. Overall, only 62% of the care recommended for older adults is actually received, conclude the authors. " The large-scale independent study of quality of care involved 8 688 people aged 50 and over and looked at 13 different health conditions including heart disease, diabetes, stroke, depression and osteoarthritis. The research team led by the University of East Anglia studied whether effective healthcare interventions were received by people aged 50 and over with serious health conditions. " They used questionnaires, face to face interviews and medical-panel endorsed quality of care indicators, for both public and privately provided care, as part of the English Longitudinal Study of Aging (ELSA). Results showed huge variations by health condition in whether or not people with particular health conditions received the appropriate intervention or care they should. 'Treatment for ischaemic heart disease rated well with 83% of appropriate care actually being given, but just 29% of recommended care was received by people with osteoarthritis. Overall, there were 19 082 opportunities for care to be delivered to people, but actual care was only given in 11 911 (62%) of those opportunities. The researchers also found that substantially more care was provided for general medical conditions (74%) than for geriatric conditions (57%), the latter comprising falls, osteoarthritis, urinary incontinence, vision problems (cataract), hearing problems, and osteoporosis. " http://www.sciencedaily.com/releases/2008/08/080814210004.htm _____________________________ " Ireland has come second-from-bottom in an EU league table of most consumer-friendly healthcare systems, and it has also been rated as having the poorest value for money in the EU in terms health consumer-friendliness. If you read Irish news every day - and why should should if you live in Missouri or Kansas? - well this would come as no surprise to you. " And what does the Irish Department of Health say? That the report doesn’t reflect improvements in waiting times, childhood vaccinations, GP service improvements, or legislation currently in progress, etc. Well it does actually; it just shows that despite those improvements Ireland still ranks 25th out of 26 countries. Perhaps other countries are improving too, rather than waiting for the Irish to get their act together. " http://irishkc.com/surprise-irish-health-system-almost-worst-in-europe.htm ________________________________ Canada's provincially based Medicare systems are cost-effective partly because of their administrative simplicity. In each province each doctor handles the insurance claim against the provincial insurer. There is no need for the person who accesses health care to be involved in billing and reclaim. Private insurance is only a minimal part of the overall health care system. Competitive practices such as advertising are kept to a minimum, thus maximizing the percentage of revenues that go directly towards care. In general, costs are paid through funding from income taxes, although three provinces also impose a fixed monthly premium which may be waived or reduced for those on low incomes. There are no deductibles on basic health care and co-pays are extremely low or non-existent (supplemental insurance such as Fair Pharmacare may have deductibles, depending on income). " A health card is issued by the Provincial Ministry of Health to each individual who enrolls for the program and everyone receives the same level of care. There is no need for a variety of plans because virtually all essential basic care is covered, including maternity and infertility problems. Depending on the province, dental and vision care may not be covered but are often insured by employers through private companies. In some provinces, private supplemental plans are available for those who desire private rooms if they are hospitalized. Cosmetic surgery and some forms of elective surgery are not considered essential care and are generally not covered. These can be paid out-of-pocket or through private insurers. Health coverage is not affected by loss or change of jobs, as long as premiums are up to date, and there are no lifetime limits or exclusions for pre-existing conditions. " Pharmaceutical medications are covered by public funds for the elderly or indigent, or through employment-based private insurance. Drug prices are negotiated with suppliers by the federal government to control costs. Family physicians are chosen by individuals. If a patient wishes to see a specialist or is counseled to see a specialist, a referral can be made by a GP. Preventive care and early detection are considered important and yearly checkups are encouraged. Early detection not only extends life expectancy and quality of life, but cuts down overall costs. Those suspected of abusing the system by over-frequent or frivolous use can be tracked by the doctor through the ID on their health insurance card and may have to wait longer than those with more urgent needs. " http://en.wikipedia.org/wiki/Health_care_in_Canada ____________________________ " Keep Canada out of the U.S. debate. We've never suggested exporting our system. We have our own debates and our own issues, and because of the moral choices we made 40 years ago they are different from the American paradigm. We should be proud of what we have, but we need to keep the focus on how to improve it, how to combine access, excellence, and innovation. We shouldn't treat health care as some kind of taboo subject. We should keep what we have and make it better. And hope our friends in the U.S. will find their own answers to the questions that lie at the heart of health care everywhere. " http://www.themarknews.com/articles/402-keep-canada-out-of-the-us-health-care-de\ bate ____________________________ " Ten percent of the population are voluntarily insured. " German sickness funds are required to be financially self-sufficient and premiums are set as a percentage of income. This percentage varies from fund to fund, with an average of 14 per cent, to fall to 13 per cent under Schroeder reforms. The premiums are deducted from pay packets with employer and employee paying half each. Since the early 1990s German governments have been trying to increase competition. Insurers can easily be compared on the Internet, and for those without web-access, there are magazines and rankings by independent consumer organisations. The result has been a large-scale shift away from the traditionally dominant funds, although competition is muted compared with America. " People who have seen a large chunk of their pay packet disappear each month make demanding patients and expect both immediacy of treatment and value for money. They 'shop around', go for second opinions, and change doctors frequently. No money changes hands at the point of service. Instead, physicians are reimbursed by sickness funds via their regional physician associations. People who have opted for private insurance, however, generally pay by invoice for treatment received. " http://www.civitas.org.uk/pubs/bb3Germany.php ______________________ " Medical care in Buenos Aires is generally good, but it varies in quality outside the capital. Hospitals have trained personnel, many of whom have studied abroad. In some other parts of Argentina, the hospitals may not have the most up-to-date equipment, but what is available is adequate for an emergency situation. " Serious medical problems requiring hospitalization and/or medical evacuation to the United States can cost thousands of dollars or more. Doctors and hospitals often expect immediate cash payment for health services. A visit to a doctor in Argentina costs anything from $17 to $50 (for a specialist). Foreign visitors requiring medical attention are advised to go to the British and German hospitals. Most pharmaceutical drugs can be purchased over the counter without a prescription. The pharmacist can also recommend remedies for common ailments, such as flu, stomach disorders, headaches, etc. " http://internationalliving.com/2007/06/health-care/ ______________________________ " Russia has an entrenched, albeit underfunded, system of socialized medicine. Basic medical care is available to most of the population free of cost, but its quality is extremely low by Western standards, and in the mid-1990s the efficiency of the system continued the decline that had begun before the collapse of the Soviet system. In the first four post-Soviet years, that decline was typified by significant increases in infant and maternal mortality and contagious diseases and by decreases in fertility and life expectancy. " The decline in health is attributable in part to such environmental and social factors as air and water pollution, contamination (largely from nuclear accidents or improper disposal of radioactive materials), overcrowded living conditions, inadequate nutrition, alcoholism, and smoking, and in part to a lack of modern medical equipment and technology. In 1991 life expectancy in Russia was 74.3 years for females and 63.5 years for males. By 1994 the figure for males was 57.3 years. The male-to-female ratio in the population reflects the higher male mortality rate and the enduring impact of losing millions more males than females in World War II. (In all age-groups below thirty-five, there are more males than females.) In 1993 the overall ratio was 884 males per 1,000 females, and experts predicted that the figure for males would decline to around 875 by the year 2005 (see Demographic Conditions, ch. 3). " http://countrystudies.us/russia/53.htm _____________________________ " The Australian healthcare system is mixed. Responsibilities for healthcare are divided between the federal and state governments, and both the public and the private sectors play a role. Australia spends about 8.5% of gross domestic product on healthcare, which compares favorably to spending in countries such as the United States (13.7%), Canada (9.5%), and England (7.0%). " Government programs underpin the key aspects of healthcare. Medicare, which is funded out of general tax revenue, pays for hospital and medical services. Medicare covers all Australians, pays the entire cost of treatment in a public hospital, and reimburses for visits to doctors. There is no limit on fees charged by doctors. There is, however, a government-set fee schedule. Doctors can bill patients or send their bills directly to the government insurance authority, the Health Insurance Commission (HIC). If sent to the HIC, the payment is 85% of the government-set fee for out-of-hospital expenses and 75% of the government set fee for in-hospital services; the money is paid directly to the doctor, and the doctor is not allowed to charge the patient an additional fee. About 75% of family physician services are directly billed to the HIC. If a doctor bills the patient directly, the patient then applies for the rebate of the government set fee. " Public hospitals are owned by the state. About 70% of beds are in public hospitals, and major teaching hospitals are public hospitals. Budgets for public hospitals are usually set on the basis of their case-mix, using an Australian version of Diagnosis Related Groups. In the past, the majority of private hospitals were owned by charitable organizations, but for-profit corporations – which are listed on the stock exchange – now own an increasing proportion. Private, freestanding surgical centers are a rapidly growing phenomenon. Few private hospitals have emergency departments, so, in an emergency, most Australians rely on the public hospital system. " http://www.medhunters.com/articles/healthcareInAustralia.html _________________________________ FYI, Lottie Duthu Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 5, 2010 Report Share Posted November 5, 2010 Hi b -here is an archive that may help! For those of you who are having trouble securing insurance...one of our http://www.apraxia.org members at Facebook had asked a question about this and I posted a huge list of archives from this group. I have shared them here after -but just want to give an update that the original person that asked the question just wrote: " Willert Colburn I have great news!! Using one of these letters as a template, I wrote to my insurance company, appleaing their decision to deny benefits. I sent the letter in late March. Called MANY times to follow up on it. FINALLY heard back the beginning part of JUNE...they ARE going to cover therapy up to $3,000. We can rack that up pretty quick but at least it's SOMETHING!!! Then, in addition to that, I found out about a non-profit organization called Small Steps in Speech that give away grants for children with speech issues. I applied and received money from them! They'll pay for one hour a week for 15 weeks (basically to get us through the summer bc our school district doesn't offer summer school). I am SO excited!!! " Please read and share this page with anyone that wants some insurance tips for coverage! http://www.facebook.com/topic.php?uid=115029735601 & topic=13830 ===== Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 5, 2010 Report Share Posted November 5, 2010 Not sure if it would be helpful, but we made the case to our insurance company (United Healthcare) that my son's verbal apraxia/CAS is a neurologically-based congenital anomoly - and they approved us for coverage. I'm happy to share the letter I sent and supporting docs if you think it might be helpful (it does stress the congenital anomoly part more than the neurological part, but the neurological wording is definitely in there too). Email me offline directly and I'll share what I have. - On Fri, Nov 5, 2010 at 2:02 PM, b_isler <bdihaiicee@...> wrote: > > > Does anyone know a good way to get insurance (Cigna) to pay for Speech > Therapy with speech apraxia as the diagnosis? They are denying payment > stating that speech apraxia is not a neurological or medical diagnosis and > that speech therapy would be considered " nonrestorative " !! > > > -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - M I C H E L L E W A L DO I N T E R I O R S stylish + inviting contemporary spaces w. http://www.michellewaldointeriors.com e. michelle@... p. 215-500-9070 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 5, 2010 Report Share Posted November 5, 2010 - wish I had a simple answer for you. I have had some success with them this past year, but it has been a fight. First, call and ask for the Authorization dept, request a health administrator, they should be able to tell you exactly what hoops to jump through to get the pre- authorization. Also I'd try and get a letter from your Doctor stating that it is neurological. We needed to send a very thorough Speech and language progress report (including current & long term goals) from our SLP, along with a request for reimbursement of speech services.( make sure it's specific in #!) They also spoke to her several times on the phone. I couldn't have done it without her help. All of that said, they are not very consistent. Sometimes I think they just got tired of me calling because I started to see results before I had finished jumping through their hoops! So keep trying. Don't give up. Good luck. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 5, 2010 Report Share Posted November 5, 2010 Get a letter from your Developmental Pediatrician or Neurologist. Apraxia is a Neurological disorder. Make sure the letter states your child has oral apraxia and verbal apraxia. We also got coverage working on oral motor and feeding therapy- we stated out daughter was choking on food -having a hard time using the muscles in her mouth. Good luck ________________________________ From: Waldo Interiors <michelle@...> Sent: Fri, November 5, 2010 9:26:21 PM Subject: Re: [ ] insurance  Not sure if it would be helpful, but we made the case to our insurance company (United Healthcare) that my son's verbal apraxia/CAS is a neurologically-based congenital anomoly - and they approved us for coverage. I'm happy to share the letter I sent and supporting docs if you think it might be helpful (it does stress the congenital anomoly part more than the neurological part, but the neurological wording is definitely in there too). Email me offline directly and I'll share what I have. - On Fri, Nov 5, 2010 at 2:02 PM, b_isler <bdihaiicee@...> wrote: > > > Does anyone know a good way to get insurance (Cigna) to pay for Speech > Therapy with speech apraxia as the diagnosis? They are denying payment > stating that speech apraxia is not a neurological or medical diagnosis and > that speech therapy would be considered " nonrestorative " !! > > > -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - M I C H E L L E W A L DO I N T E R I O R S stylish + inviting contemporary spaces w. http://www.michellewaldointeriors.com e. michelle@... p. 215-500-9070 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 5, 2010 Report Share Posted November 5, 2010 We got everything covered with doctor's letter of medical necessity---ASHA definition cut and pasted-SLP eval with ASHA definition--neurological disorder and recommended treatment etc. --cut and pasted from ASHA doc--your letter requesting coverage mentioning the two documents and send them a copy of the ASHA doc as well-and that should do it--I didn't even have to appeal it--even though i had been told initially that they only cover " restorative " --that to get coverage a child must have had speech and lost it etc etc...all nonsense--they try to BS their way but really--784.69 should be covered. Aetna conveniently has it list dunder exclusions not covered because they say it is developmental. Obviously it is notbut the claims staff who looks it up finds it listed as such and showing them the definition will jolt their memories. So they play tricks--list it under developmental--exclusions---and that pretty much guarantees it will be denied--that's what they want. An appeal--or two--soemtimes 3 will take care of it. Always ask who reviewed the appeal, A nurse is not acceptable nor a regular pediatrician or MD----it has to be a neurologist--though God help them they know very little about apraxia in children--but at any rate soemone who stands a chance to know apraxia is neurological and at least be able to read those docuemnts you send with the ASHA definition cut and pasted in the documents. Don't worry about redundancy there--just have everyone cut and paste--can't say it often enough-- " NEUROLOGICAL'--all neurological things have to be covered--it is loss of a body function---to deny coverage is discrimination--an adult with apraxia would get coverage. Good Luck Elena From: b_isler <bdihaiicee@...> Subject: [ ] insurance Date: Friday, November 5, 2010, 2:02 PM Does anyone know a good way to get insurance (Cigna) to pay for Speech Therapy with speech apraxia as the diagnosis? They are denying payment stating that speech apraxia is not a neurological or medical diagnosis and that speech therapy would be considered " nonrestorative " !! ------------------------------------ Quote Link to comment Share on other sites More sharing options...
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