Guest guest Posted February 27, 2004 Report Share Posted February 27, 2004 Hi, Welcome to the group! I'm sure you will get replies from group members who have had various insurance battles, but you may be able to start your research in some of the reference areas here at the group site. If you would like a basic snapshot of different insurance experiences, take a look at the DATABASE section of the group, WHO'S INSURANCE PAID WHAT? database. The CAPPSkids website also has a great insurance help page that lists some of the common denials and countermeasures you can take in the appeals process. The links to CAPPSkids insurance help, as well as other helpful reading is in LINKS section, INSURANCE folder. Additional insurance help and information is in the FILES section of the group, INSURANCE HELP folder. I just wanted to get you started with some suggestions; we ended up using repositioning only to treat our daughter Remy's plagio, so I don't have personal experience with insurance issues. Please let us know how the appointment goes tomorrow, Christie (Mom to Repo'd Remy) > We are just learning about plagiocephaly and Crainiosynostosis from > our doctor who feels that our 6 month old son has plagio and will > most likely need to be treated with a helmet / band. > > Again, we are in the very beginning stages of this (our son is > scheduled for a CT scan tomorrow) but our Doctor has stressed to us > that insurance generally does not pay for the treatment of plagio and > if they do cover it's not without a long hard battle. He has > suggested that we begin doing our research now as it will help us > later in our attempt to have our sons treatment covered. > > Obviously our main objective and goal is to do what is best for our > child whatever the treatment may be no matter the cost but it would > be nice to have alittle assistance from our insurance... > > Has anyone experienced difficulty (denial of coverage and / or non- > authorization for treatment)? If so what advise and or suggestions > do you have that may helpful to us? Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 27, 2004 Report Share Posted February 27, 2004 Hi and welcome to the group! I wanted to second what Christie had told you. What insurance do you have? Maybe someone at the group has first hand experience with that particular company. Many have fought to get payment and WON, many have had to just file a claim to get paid. Hope we can help. YAY to your dr. for being on the ball with this. Good Luck witht he CT Scan. Keep us updated. Dustie > We are just learning about plagiocephaly and Crainiosynostosis from > our doctor who feels that our 6 month old son has plagio and will > most likely need to be treated with a helmet / band. > > Again, we are in the very beginning stages of this (our son is > scheduled for a CT scan tomorrow) but our Doctor has stressed to us > that insurance generally does not pay for the treatment of plagio and > if they do cover it's not without a long hard battle. He has > suggested that we begin doing our research now as it will help us > later in our attempt to have our sons treatment covered. > > Obviously our main objective and goal is to do what is best for our > child whatever the treatment may be no matter the cost but it would > be nice to have alittle assistance from our insurance... > > Has anyone experienced difficulty (denial of coverage and / or non- > authorization for treatment)? If so what advise and or suggestions > do you have that may helpful to us? Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 27, 2004 Report Share Posted February 27, 2004 Hi, I see you've already been referred to our database, but it may be helpful to add where you live and what type of ins you have to your subject line to draw attention from others in your area. We did get both bands paid in full, but like you said it was after a long hard fight (and having to put $6,000 on our credit card!)! Good luck. , mom to Hannah, DOCgrad Cape Cod, Ma > We are just learning about plagiocephaly and Crainiosynostosis from > our doctor who feels that our 6 month old son has plagio and will > most likely need to be treated with a helmet / band. > > Again, we are in the very beginning stages of this (our son is > scheduled for a CT scan tomorrow) but our Doctor has stressed to us > that insurance generally does not pay for the treatment of plagio and > if they do cover it's not without a long hard battle. He has > suggested that we begin doing our research now as it will help us > later in our attempt to have our sons treatment covered. > > Obviously our main objective and goal is to do what is best for our > child whatever the treatment may be no matter the cost but it would > be nice to have alittle assistance from our insurance... > > Has anyone experienced difficulty (denial of coverage and / or non- > authorization for treatment)? If so what advise and or suggestions > do you have that may helpful to us? Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 27, 2004 Report Share Posted February 27, 2004 Hi Tony, It really depends on the insurance....actually, it even seems to depend on the person you get at the insurance company reviewing your case. I've seen here that the same insurance company will approve one person with no questions asked, and then give another person a hard time....it's so odd. Anyway, see if you can get the criteria for coverage from your insurance company. We have Aetna and they have a web site with the specific conditions that need to be me for coverage. We were sure to have all of our information compiled, perscription from doctor for the band, a letter of medical necessity from the doctor, and the precise measurements that they do for cranial vault asymmetry and the brachy index. After numerous calls to the insurance company between members services and the preapproval line, we finally found a really nice person who was willing to take responsibility and help us out. We faxed all the info with a letter from us highlighting what criteria our son met and indicating that we had be trying repositional therapy since our son was 2 months old with little improvement. After that we were able to get our preapproval pretty quick. They also paid 90% for the band (which is what our policy says they cover), but they took their time in covering it....about 3 months. So it's possible to get insurance to cover it....it just seems like you have to put up a bit more of a fight for this condition than for other things.... Good Luck! (and /DOCgrad 13-Feb-04/10-14mos./PA)Tony <alicata@...> wrote: We are just learning about plagiocephaly and Crainiosynostosis from our doctor who feels that our 6 month old son has plagio and will most likely need to be treated with a helmet / band. Again, we are in the very beginning stages of this (our son is scheduled for a CT scan tomorrow) but our Doctor has stressed to us that insurance generally does not pay for the treatment of plagio and if they do cover it's not without a long hard battle. He has suggested that we begin doing our research now as it will help us later in our attempt to have our sons treatment covered. Obviously our main objective and goal is to do what is best for our child whatever the treatment may be no matter the cost but it would be nice to have alittle assistance from our insurance...Has anyone experienced difficulty (denial of coverage and / or non-authorization for treatment)? If so what advise and or suggestions do you have that may helpful to us? For more plagio info Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 8, 2006 Report Share Posted February 8, 2006 This is in response to the e-mail from Andriana . I am also fighting with my insurance company (Aetna) for extra speech therapy for my son who also diagnosed with severe verbal apraxia. I actually went to speech therapy because when I called them (Aetna) originally they told me if I stayed in the " network " that all I would have to do is pay my co-pay. When I got to the therapist's office she informed me that I had a 60 day maximum, so I scheduled as much speech as possible. Well, after his third visit, the office called to tell me that my claim was denied because it is a " developmental delay " not a medical issue. So, unfortunately I had to pay the therapist over $250.00 out of my pocket. Well it is now a year later and my son is still not speaking so I am in the process of trying to go through the precertification process to get him some extra help through my insurance company again. I am also very frustrated and was wondering if anyone had any help, if so, I would love to hear from them also. na also spoke of pro-efa, what exactly is that? Also, I have heard some good feedback on " The Listening Program " but it is very expensive. I was wondering if anyone has used that program and been successful. At this point I am willing to try anything to help my son. I am looking forward to hearing from you. Thanks for your time. Theresa Matthaey TAM595@... ----- Original Message ----- > Dear Jeanne, > My name is and i spoke with you 2 weeks ago and i am also on > your mailing list...Next week we have a hearing in newark (BCBS) for my > daughter's 2nd level appeal with our insurance company. Maddie was > diagnosed > with severe verbal apraxia and they are trying to claim that it is > developmental in nature...I was wondering if you could fan this out to > your > e-mail base and have anyone e-mail me back if they have gone through this > before, and if they have any tips as i would like to be prepared. thank > you > so much for all of your help. > p.s. just finished the late talker and it was a great source of info.,also > started on the pro-efa last week and maddie has said a new word. > thanks again, > sincerely, > ajryan1@... > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 10, 2006 Report Share Posted February 10, 2006 I had Aetna. Your company has the authority to include speech therapy in your insurance plan contract. But that is between your insurance and the your work company to work out. If I were you I would talk to the person head your insurance at your company. Good Luck. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 3, 2006 Report Share Posted October 3, 2006 Quick question - when Josh and I lived in a little town in north central IL, we had no problem getting a referral from his ped for ST and OT. Now that we live in a large city in the NW burbs of Chicago, and I had to change insurance (now have HMO Illinois), his new ped said he doesn't want to give a referral for private speech or OT since the insurance would only cover a limited amount of time and really only for " rehab " therapy. I told the doc I thought he was incorrect on that (haven't checked with insurance yet but will put in a call). Anyone know, offhand, whether that's true or have run into similar problems? Also, doc said best bet is to go through some philanthropic organization like Easter Seals - they also need a doc referral and bill insurance so what's the difference?? (we're long-time lovers of Easter Seals - Josh was Little Ambassador a few years back - so I don't mind going to them except it's kind of a pain to get to the center - oh well.) Thanks - Sherry michellerichardslavin <michellelavin@...> wrote: I, too, find this thread very interesting. Our son (2.9) currently has an ASD diagnosis. His dev ped gave it to him since it's so difficult to get appropriate services from the state for a child with an apraxia/motor planning disorder/SPD diagnosis. So, for now, we're holding on to it to (let's all say it together now) get services. Luckily, we have NOT had issues with our insurance company since we use the apraxia diagnosis for his ST. Wouldn't it be nice if we didn't have to add 'label anxiety' into the mix of all of this? > > What I think is so interesting about everything I've been hearing from this thread that the diagnosis you get will give you services in one area and not in another. If your child is labelled with asd, then your insurance will not pay for the therapy because the condition is considered " chronic " , but state and local services will pick up some of the slack. If your child is diagnosed with apraxia, you can get insurance to pay for some of your child's treatments, but government programs close their doors. It seems that no matter what you do, you will end up paying for some of it. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 3, 2006 Report Share Posted October 3, 2006 Your HMO is a managed care plan. That pediatrician is the " gate keeper " for those children assigned to him. He only gets paid a certain amount from the HMO to cover all the kids that he sees. This amount can be affected by the amount of money each child costs the HMO. Not sure if this is his motive but that financial crunch keeps many primary care doctors from referring patients to specialists etc. Often it affects the amount that HMO reimburses them or, in other circumstances, the primary care physician is actually " fined " or " warned " by the insurance company. I would return to the pediatrician armed with... 1. a print out of what your policy actually covers 2. print outs on information regarding apraxia and the treatment of plan. Use the words " standard of care " in a sentence many times. This gives the pediatrician ammunition to stand up to the HMO. If the pediatrician still refuses report him to the HMO. Although the HMO is usually the reason that a primary care doctor is denying a referral, this same HMO will then send the doctor a " warning " for denying that care and ask for his written support of the decision he made. In other words, a primary care doctor is between a rock and a hard place when he works with an HMO. In spite of that, care should not be denied due to the fear of financial losses,etc. If you give him the info he needs to defend the referral, often that's all it will take. If he still denies it then he needs to be held accountable for denying that care. Good Luck. Kris P.S. The reason the doctor recommended Easter Seals, etc is because he doesn't realize they will bill the insurance first and he's trying to get you to get the speech services without any notification of the insurance company. On Oct 3, 2006, at 9:29 AM, sherry silvern wrote: > Quick question - when Josh and I lived in a little town in north > central IL, we had no problem getting a referral from his ped for ST > and OT. Now that we live in a large city in the NW burbs of Chicago, > and I had to change insurance (now have HMO Illinois), his new ped > said he doesn't want to give a referral for private speech or OT since > the insurance would only cover a limited amount of time and really > only for " rehab " therapy. I told the doc I thought he was incorrect on > that (haven't checked with insurance yet but will put in a call). > Anyone know, offhand, whether that's true or have run into similar > problems? > > Also, doc said best bet is to go through some philanthropic > organization like Easter Seals - they also need a doc referral and > bill insurance so what's the difference?? (we're long-time lovers of > Easter Seals - Josh was Little Ambassador a few years back - so I > don't mind going to them except it's kind of a pain to get to the > center - oh well.) > > Thanks - > > Sherry > > michellerichardslavin <michellelavin@...> wrote: > I, too, find this thread very interesting. Our son (2.9) currently > has an ASD diagnosis. His dev ped gave it to him since it's so > difficult to get appropriate services from the state for a child > with an apraxia/motor planning disorder/SPD diagnosis. > > So, for now, we're holding on to it to (let's all say it together > now) get services. Luckily, we have NOT had issues with our > insurance company since we use the apraxia diagnosis for his ST. > > Wouldn't it be nice if we didn't have to add 'label anxiety' into > the mix of all of this? > > > > > > What I think is so interesting about everything I've been hearing > from this thread that the diagnosis you get will give you services > in one area and not in another. If your child is labelled with asd, > then your insurance will not pay for the therapy because the > condition is considered " chronic " , but state and local services will > pick up some of the slack. If your child is diagnosed with apraxia, > you can get insurance to pay for some of your child's treatments, > but government programs close their doors. It seems that no matter > what you do, you will end up paying for some of it. > > [ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 3, 2006 Report Share Posted October 3, 2006 Quick question - when Josh and I lived in a little town in north central IL, we had no problem getting a referral from his ped for ST and OT. Now that we live in a large city in the NW burbs of Chicago, and I had to change insurance (now have HMO Illinois), his new ped said he doesn't want to give a referral for private speech or OT since the insurance would only cover a limited amount of time and really only for " rehab " therapy. I told the doc I thought he was incorrect on that (haven't checked with insurance yet but will put in a call). Anyone know, offhand, whether that's true or have run into similar problems? Also, doc said best bet is to go through some philanthropic organization like Easter Seals - they also need a doc referral and bill insurance so what's the difference?? (we're long-time lovers of Easter Seals - Josh was Little Ambassador a few years back - so I don't mind going to them except it's kind of a pain to get to the center - oh well.) Thanks - Sherry michellerichardslavin <michellelavin@...> wrote: I, too, find this thread very interesting. Our son (2.9) currently has an ASD diagnosis. His dev ped gave it to him since it's so difficult to get appropriate services from the state for a child with an apraxia/motor planning disorder/SPD diagnosis. So, for now, we're holding on to it to (let's all say it together now) get services. Luckily, we have NOT had issues with our insurance company since we use the apraxia diagnosis for his ST. Wouldn't it be nice if we didn't have to add 'label anxiety' into the mix of all of this? > > What I think is so interesting about everything I've been hearing from this thread that the diagnosis you get will give you services in one area and not in another. If your child is labelled with asd, then your insurance will not pay for the therapy because the condition is considered " chronic " , but state and local services will pick up some of the slack. If your child is diagnosed with apraxia, you can get insurance to pay for some of your child's treatments, but government programs close their doors. It seems that no matter what you do, you will end up paying for some of it. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 3, 2006 Report Share Posted October 3, 2006 his new ped > said he doesn't want to give a referral for private speech or OT since > the insurance would only cover a limited amount of time Hi Sherry: I just wanted to tell you that I called my insurance company about the different codes and what was covered. I gave them two codes that I got from my son's private therapist. One I needed a referral from his pediatrician as a medical necessity and the other code I didn't need a referral. We also have an HMO plan. Tina > > > Quick question - when Josh and I lived in a little town in north > > central IL, we had no problem getting a referral from his ped for ST > > and OT. Now that we live in a large city in the NW burbs of Chicago, > > and I had to change insurance (now have HMO Illinois), his new ped > > said he doesn't want to give a referral for private speech or OT since > > the insurance would only cover a limited amount of time and really > > only for " rehab " therapy. I told the doc I thought he was incorrect on > > that (haven't checked with insurance yet but will put in a call). > > Anyone know, offhand, whether that's true or have run into similar > > problems? > > > > Also, doc said best bet is to go through some philanthropic > > organization like Easter Seals - they also need a doc referral and > > bill insurance so what's the difference?? (we're long-time lovers of > > Easter Seals - Josh was Little Ambassador a few years back - so I > > don't mind going to them except it's kind of a pain to get to the > > center - oh well.) > > > > Thanks - > > > > Sherry Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 3, 2006 Report Share Posted October 3, 2006 Your HMO is a managed care plan. That pediatrician is the " gate keeper " for those children assigned to him. He only gets paid a certain amount from the HMO to cover all the kids that he sees. This amount can be affected by the amount of money each child costs the HMO. Not sure if this is his motive but that financial crunch keeps many primary care doctors from referring patients to specialists etc. Often it affects the amount that HMO reimburses them or, in other circumstances, the primary care physician is actually " fined " or " warned " by the insurance company. I would return to the pediatrician armed with... 1. a print out of what your policy actually covers 2. print outs on information regarding apraxia and the treatment of plan. Use the words " standard of care " in a sentence many times. This gives the pediatrician ammunition to stand up to the HMO. If the pediatrician still refuses report him to the HMO. Although the HMO is usually the reason that a primary care doctor is denying a referral, this same HMO will then send the doctor a " warning " for denying that care and ask for his written support of the decision he made. In other words, a primary care doctor is between a rock and a hard place when he works with an HMO. In spite of that, care should not be denied due to the fear of financial losses,etc. If you give him the info he needs to defend the referral, often that's all it will take. If he still denies it then he needs to be held accountable for denying that care. Good Luck. Kris P.S. The reason the doctor recommended Easter Seals, etc is because he doesn't realize they will bill the insurance first and he's trying to get you to get the speech services without any notification of the insurance company. On Oct 3, 2006, at 9:29 AM, sherry silvern wrote: > Quick question - when Josh and I lived in a little town in north > central IL, we had no problem getting a referral from his ped for ST > and OT. Now that we live in a large city in the NW burbs of Chicago, > and I had to change insurance (now have HMO Illinois), his new ped > said he doesn't want to give a referral for private speech or OT since > the insurance would only cover a limited amount of time and really > only for " rehab " therapy. I told the doc I thought he was incorrect on > that (haven't checked with insurance yet but will put in a call). > Anyone know, offhand, whether that's true or have run into similar > problems? > > Also, doc said best bet is to go through some philanthropic > organization like Easter Seals - they also need a doc referral and > bill insurance so what's the difference?? (we're long-time lovers of > Easter Seals - Josh was Little Ambassador a few years back - so I > don't mind going to them except it's kind of a pain to get to the > center - oh well.) > > Thanks - > > Sherry > > michellerichardslavin <michellelavin@...> wrote: > I, too, find this thread very interesting. Our son (2.9) currently > has an ASD diagnosis. His dev ped gave it to him since it's so > difficult to get appropriate services from the state for a child > with an apraxia/motor planning disorder/SPD diagnosis. > > So, for now, we're holding on to it to (let's all say it together > now) get services. Luckily, we have NOT had issues with our > insurance company since we use the apraxia diagnosis for his ST. > > Wouldn't it be nice if we didn't have to add 'label anxiety' into > the mix of all of this? > > > > > > What I think is so interesting about everything I've been hearing > from this thread that the diagnosis you get will give you services > in one area and not in another. If your child is labelled with asd, > then your insurance will not pay for the therapy because the > condition is considered " chronic " , but state and local services will > pick up some of the slack. If your child is diagnosed with apraxia, > you can get insurance to pay for some of your child's treatments, > but government programs close their doors. It seems that no matter > what you do, you will end up paying for some of it. > > [ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 4, 2006 Report Share Posted October 4, 2006 his new ped > said he doesn't want to give a referral for private speech or OT since > the insurance would only cover a limited amount of time Hi Sherry: I just wanted to tell you that I called my insurance company about the different codes and what was covered. I gave them two codes that I got from my son's private therapist. One I needed a referral from his pediatrician as a medical necessity and the other code I didn't need a referral. We also have an HMO plan. Tina > > > Quick question - when Josh and I lived in a little town in north > > central IL, we had no problem getting a referral from his ped for ST > > and OT. Now that we live in a large city in the NW burbs of Chicago, > > and I had to change insurance (now have HMO Illinois), his new ped > > said he doesn't want to give a referral for private speech or OT since > > the insurance would only cover a limited amount of time and really > > only for " rehab " therapy. I told the doc I thought he was incorrect on > > that (haven't checked with insurance yet but will put in a call). > > Anyone know, offhand, whether that's true or have run into similar > > problems? > > > > Also, doc said best bet is to go through some philanthropic > > organization like Easter Seals - they also need a doc referral and > > bill insurance so what's the difference?? (we're long-time lovers of > > Easter Seals - Josh was Little Ambassador a few years back - so I > > don't mind going to them except it's kind of a pain to get to the > > center - oh well.) > > > > Thanks - > > > > Sherry Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 4, 2006 Report Share Posted October 4, 2006 I also would like to point out that the less the HMO doctor tests for, the more of a bonus check they may receive from the HMO insurance company for being a good pediatrician who does not like to run ridiculous tests to find out the underlying causes unless it is medically necessary. How do insurance companies advertise to get practitioners on their insurance plans? It will astound you that perks may take first place over the patients. How many of your doctors go on golf junkets to the islands? How do they get invited to workshops and such? Who is paying for all this? The U.S. government needs to stay out of the insurance business and get back to the healthcare of the American people. M2s, Joanne _____ From: [mailto: ] On Behalf Of Haukoos Sent: Tuesday, October 03, 2006 4:56 PM Subject: Re: [ ] Re: insurance issues Your HMO is a managed care plan. That pediatrician is the " gate keeper " for those children assigned to him. He only gets paid a certain amount from the HMO to cover all the kids that he sees. This amount can be affected by the amount of money each child costs the HMO. Not sure if this is his motive but that financial crunch keeps many primary care doctors from referring patients to specialists etc. Often it affects the amount that HMO reimburses them or, in other circumstances, the primary care physician is actually " fined " or " warned " by the insurance company. I would return to the pediatrician armed with... 1. a print out of what your policy actually covers 2. print outs on information regarding apraxia and the treatment of plan. Use the words " standard of care " in a sentence many times. This gives the pediatrician ammunition to stand up to the HMO. If the pediatrician still refuses report him to the HMO. Although the HMO is usually the reason that a primary care doctor is denying a referral, this same HMO will then send the doctor a " warning " for denying that care and ask for his written support of the decision he made. In other words, a primary care doctor is between a rock and a hard place when he works with an HMO. In spite of that, care should not be denied due to the fear of financial losses,etc. If you give him the info he needs to defend the referral, often that's all it will take. If he still denies it then he needs to be held accountable for denying that care. Good Luck. Kris P.S. The reason the doctor recommended Easter Seals, etc is because he doesn't realize they will bill the insurance first and he's trying to get you to get the speech services without any notification of the insurance company. On Oct 3, 2006, at 9:29 AM, sherry silvern wrote: > Quick question - when Josh and I lived in a little town in north > central IL, we had no problem getting a referral from his ped for ST > and OT. Now that we live in a large city in the NW burbs of Chicago, > and I had to change insurance (now have HMO Illinois), his new ped > said he doesn't want to give a referral for private speech or OT since > the insurance would only cover a limited amount of time and really > only for " rehab " therapy. I told the doc I thought he was incorrect on > that (haven't checked with insurance yet but will put in a call). > Anyone know, offhand, whether that's true or have run into similar > problems? > > Also, doc said best bet is to go through some philanthropic > organization like Easter Seals - they also need a doc referral and > bill insurance so what's the difference?? (we're long-time lovers of > Easter Seals - Josh was Little Ambassador a few years back - so I > don't mind going to them except it's kind of a pain to get to the > center - oh well.) > > Thanks - > > Sherry > > michellerichardslavin <michellelavin@ <mailto:michellelavin%40adelphia.net> adelphia.net> wrote: > I, too, find this thread very interesting. Our son (2.9) currently > has an ASD diagnosis. His dev ped gave it to him since it's so > difficult to get appropriate services from the state for a child > with an apraxia/motor planning disorder/SPD diagnosis. > > So, for now, we're holding on to it to (let's all say it together > now) get services. Luckily, we have NOT had issues with our > insurance company since we use the apraxia diagnosis for his ST. > > Wouldn't it be nice if we didn't have to add 'label anxiety' into > the mix of all of this? > > > > > > What I think is so interesting about everything I've been hearing > from this thread that the diagnosis you get will give you services > in one area and not in another. If your child is labelled with asd, > then your insurance will not pay for the therapy because the > condition is considered " chronic " , but state and local services will > pick up some of the slack. If your child is diagnosed with apraxia, > you can get insurance to pay for some of your child's treatments, > but government programs close their doors. It seems that no matter > what you do, you will end up paying for some of it. > > [ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 4, 2006 Report Share Posted October 4, 2006 I like the way you worded this. Do you have any suggestions for dealing with a ppo? Haukoos <catnip9@...> wrote: Your HMO is a managed care plan. That pediatrician is the " gate keeper " for those children assigned to him. He only gets paid a certain amount from the HMO to cover all the kids that he sees. This amount can be affected by the amount of money each child costs the HMO. Not sure if this is his motive but that financial crunch keeps many primary care doctors from referring patients to specialists etc. Often it affects the amount that HMO reimburses them or, in other circumstances, the primary care physician is actually " fined " or " warned " by the insurance company. I would return to the pediatrician armed with... 1. a print out of what your policy actually covers 2. print outs on information regarding apraxia and the treatment of plan. Use the words " standard of care " in a sentence many times. This gives the pediatrician ammunition to stand up to the HMO. If the pediatrician still refuses report him to the HMO. Although the HMO is usually the reason that a primary care doctor is denying a referral, this same HMO will then send the doctor a " warning " for denying that care and ask for his written support of the decision he made. In other words, a primary care doctor is between a rock and a hard place when he works with an HMO. In spite of that, care should not be denied due to the fear of financial losses,etc. If you give him the info he needs to defend the referral, often that's all it will take. If he still denies it then he needs to be held accountable for denying that care. Good Luck. Kris P.S. The reason the doctor recommended Easter Seals, etc is because he doesn't realize they will bill the insurance first and he's trying to get you to get the speech services without any notification of the insurance company. On Oct 3, 2006, at 9:29 AM, sherry silvern wrote: > Quick question - when Josh and I lived in a little town in north > central IL, we had no problem getting a referral from his ped for ST > and OT. Now that we live in a large city in the NW burbs of Chicago, > and I had to change insurance (now have HMO Illinois), his new ped > said he doesn't want to give a referral for private speech or OT since > the insurance would only cover a limited amount of time and really > only for " rehab " therapy. I told the doc I thought he was incorrect on > that (haven't checked with insurance yet but will put in a call). > Anyone know, offhand, whether that's true or have run into similar > problems? > > Also, doc said best bet is to go through some philanthropic > organization like Easter Seals - they also need a doc referral and > bill insurance so what's the difference?? (we're long-time lovers of > Easter Seals - Josh was Little Ambassador a few years back - so I > don't mind going to them except it's kind of a pain to get to the > center - oh well.) > > Thanks - > > Sherry > > michellerichardslavin <michellelavin@...> wrote: > I, too, find this thread very interesting. Our son (2.9) currently > has an ASD diagnosis. His dev ped gave it to him since it's so > difficult to get appropriate services from the state for a child > with an apraxia/motor planning disorder/SPD diagnosis. > > So, for now, we're holding on to it to (let's all say it together > now) get services. Luckily, we have NOT had issues with our > insurance company since we use the apraxia diagnosis for his ST. > > Wouldn't it be nice if we didn't have to add 'label anxiety' into > the mix of all of this? > > > > > > What I think is so interesting about everything I've been hearing > from this thread that the diagnosis you get will give you services > in one area and not in another. If your child is labelled with asd, > then your insurance will not pay for the therapy because the > condition is considered " chronic " , but state and local services will > pick up some of the slack. If your child is diagnosed with apraxia, > you can get insurance to pay for some of your child's treatments, > but government programs close their doors. It seems that no matter > what you do, you will end up paying for some of it. > > [ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 4, 2006 Report Share Posted October 4, 2006 > " I also would like to point out that the less the HMO doctor tests for, the > more of a bonus check they may receive " " How many of your doctors go on golf junkets to the islands? How > do they get invited to workshops and such? Who is paying for all this? " My reply: I think if you want to be mad at the HMOs, that's fine. But to imply that doctors place a higher value on golf trips and bonuses than patient care is painting them all with a pretty broad brush....and an insulting one at that. This pediatrician may simply be aware that this certain HMO NEVER covers pediatric ST and OT. Not that it is not worth asking the question, but don't shoot the messenger. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 4, 2006 Report Share Posted October 4, 2006 In all honesty, the same tactic applies to a PPO. PPO doctors get hassled by the insurance company as well and are expected to keep down costs but there isn't the same amount of pressure as there is with an HMO. Same tactic applies, including writing a letter to the insurance company if a referral is denied. Most physicians don't want to deny care. Making a parent angry just isn't what they want to do with their time. It just makes the day go longer. They are often caught between doing what is right and risking the financial hardships that could, in all truth, result in them having to close their practice. Good luck Kris Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 4, 2006 Report Share Posted October 4, 2006 I also would like to point out that the less the HMO doctor tests for, the more of a bonus check they may receive from the HMO insurance company for being a good pediatrician who does not like to run ridiculous tests to find out the underlying causes unless it is medically necessary. How do insurance companies advertise to get practitioners on their insurance plans? It will astound you that perks may take first place over the patients. How many of your doctors go on golf junkets to the islands? How do they get invited to workshops and such? Who is paying for all this? The U.S. government needs to stay out of the insurance business and get back to the healthcare of the American people. M2s, Joanne _____ From: [mailto: ] On Behalf Of Haukoos Sent: Tuesday, October 03, 2006 4:56 PM Subject: Re: [ ] Re: insurance issues Your HMO is a managed care plan. That pediatrician is the " gate keeper " for those children assigned to him. He only gets paid a certain amount from the HMO to cover all the kids that he sees. This amount can be affected by the amount of money each child costs the HMO. Not sure if this is his motive but that financial crunch keeps many primary care doctors from referring patients to specialists etc. Often it affects the amount that HMO reimburses them or, in other circumstances, the primary care physician is actually " fined " or " warned " by the insurance company. I would return to the pediatrician armed with... 1. a print out of what your policy actually covers 2. print outs on information regarding apraxia and the treatment of plan. Use the words " standard of care " in a sentence many times. This gives the pediatrician ammunition to stand up to the HMO. If the pediatrician still refuses report him to the HMO. Although the HMO is usually the reason that a primary care doctor is denying a referral, this same HMO will then send the doctor a " warning " for denying that care and ask for his written support of the decision he made. In other words, a primary care doctor is between a rock and a hard place when he works with an HMO. In spite of that, care should not be denied due to the fear of financial losses,etc. If you give him the info he needs to defend the referral, often that's all it will take. If he still denies it then he needs to be held accountable for denying that care. Good Luck. Kris P.S. The reason the doctor recommended Easter Seals, etc is because he doesn't realize they will bill the insurance first and he's trying to get you to get the speech services without any notification of the insurance company. On Oct 3, 2006, at 9:29 AM, sherry silvern wrote: > Quick question - when Josh and I lived in a little town in north > central IL, we had no problem getting a referral from his ped for ST > and OT. Now that we live in a large city in the NW burbs of Chicago, > and I had to change insurance (now have HMO Illinois), his new ped > said he doesn't want to give a referral for private speech or OT since > the insurance would only cover a limited amount of time and really > only for " rehab " therapy. I told the doc I thought he was incorrect on > that (haven't checked with insurance yet but will put in a call). > Anyone know, offhand, whether that's true or have run into similar > problems? > > Also, doc said best bet is to go through some philanthropic > organization like Easter Seals - they also need a doc referral and > bill insurance so what's the difference?? (we're long-time lovers of > Easter Seals - Josh was Little Ambassador a few years back - so I > don't mind going to them except it's kind of a pain to get to the > center - oh well.) > > Thanks - > > Sherry > > michellerichardslavin <michellelavin@ <mailto:michellelavin%40adelphia.net> adelphia.net> wrote: > I, too, find this thread very interesting. Our son (2.9) currently > has an ASD diagnosis. His dev ped gave it to him since it's so > difficult to get appropriate services from the state for a child > with an apraxia/motor planning disorder/SPD diagnosis. > > So, for now, we're holding on to it to (let's all say it together > now) get services. Luckily, we have NOT had issues with our > insurance company since we use the apraxia diagnosis for his ST. > > Wouldn't it be nice if we didn't have to add 'label anxiety' into > the mix of all of this? > > > > > > What I think is so interesting about everything I've been hearing > from this thread that the diagnosis you get will give you services > in one area and not in another. If your child is labelled with asd, > then your insurance will not pay for the therapy because the > condition is considered " chronic " , but state and local services will > pick up some of the slack. If your child is diagnosed with apraxia, > you can get insurance to pay for some of your child's treatments, > but government programs close their doors. It seems that no matter > what you do, you will end up paying for some of it. > > [ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 4, 2006 Report Share Posted October 4, 2006 I like the way you worded this. Do you have any suggestions for dealing with a ppo? Haukoos <catnip9@...> wrote: Your HMO is a managed care plan. That pediatrician is the " gate keeper " for those children assigned to him. He only gets paid a certain amount from the HMO to cover all the kids that he sees. This amount can be affected by the amount of money each child costs the HMO. Not sure if this is his motive but that financial crunch keeps many primary care doctors from referring patients to specialists etc. Often it affects the amount that HMO reimburses them or, in other circumstances, the primary care physician is actually " fined " or " warned " by the insurance company. I would return to the pediatrician armed with... 1. a print out of what your policy actually covers 2. print outs on information regarding apraxia and the treatment of plan. Use the words " standard of care " in a sentence many times. This gives the pediatrician ammunition to stand up to the HMO. If the pediatrician still refuses report him to the HMO. Although the HMO is usually the reason that a primary care doctor is denying a referral, this same HMO will then send the doctor a " warning " for denying that care and ask for his written support of the decision he made. In other words, a primary care doctor is between a rock and a hard place when he works with an HMO. In spite of that, care should not be denied due to the fear of financial losses,etc. If you give him the info he needs to defend the referral, often that's all it will take. If he still denies it then he needs to be held accountable for denying that care. Good Luck. Kris P.S. The reason the doctor recommended Easter Seals, etc is because he doesn't realize they will bill the insurance first and he's trying to get you to get the speech services without any notification of the insurance company. On Oct 3, 2006, at 9:29 AM, sherry silvern wrote: > Quick question - when Josh and I lived in a little town in north > central IL, we had no problem getting a referral from his ped for ST > and OT. Now that we live in a large city in the NW burbs of Chicago, > and I had to change insurance (now have HMO Illinois), his new ped > said he doesn't want to give a referral for private speech or OT since > the insurance would only cover a limited amount of time and really > only for " rehab " therapy. I told the doc I thought he was incorrect on > that (haven't checked with insurance yet but will put in a call). > Anyone know, offhand, whether that's true or have run into similar > problems? > > Also, doc said best bet is to go through some philanthropic > organization like Easter Seals - they also need a doc referral and > bill insurance so what's the difference?? (we're long-time lovers of > Easter Seals - Josh was Little Ambassador a few years back - so I > don't mind going to them except it's kind of a pain to get to the > center - oh well.) > > Thanks - > > Sherry > > michellerichardslavin <michellelavin@...> wrote: > I, too, find this thread very interesting. Our son (2.9) currently > has an ASD diagnosis. His dev ped gave it to him since it's so > difficult to get appropriate services from the state for a child > with an apraxia/motor planning disorder/SPD diagnosis. > > So, for now, we're holding on to it to (let's all say it together > now) get services. Luckily, we have NOT had issues with our > insurance company since we use the apraxia diagnosis for his ST. > > Wouldn't it be nice if we didn't have to add 'label anxiety' into > the mix of all of this? > > > > > > What I think is so interesting about everything I've been hearing > from this thread that the diagnosis you get will give you services > in one area and not in another. If your child is labelled with asd, > then your insurance will not pay for the therapy because the > condition is considered " chronic " , but state and local services will > pick up some of the slack. If your child is diagnosed with apraxia, > you can get insurance to pay for some of your child's treatments, > but government programs close their doors. It seems that no matter > what you do, you will end up paying for some of it. > > [ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 4, 2006 Report Share Posted October 4, 2006 > " I also would like to point out that the less the HMO doctor tests for, the > more of a bonus check they may receive " " How many of your doctors go on golf junkets to the islands? How > do they get invited to workshops and such? Who is paying for all this? " My reply: I think if you want to be mad at the HMOs, that's fine. But to imply that doctors place a higher value on golf trips and bonuses than patient care is painting them all with a pretty broad brush....and an insulting one at that. This pediatrician may simply be aware that this certain HMO NEVER covers pediatric ST and OT. Not that it is not worth asking the question, but don't shoot the messenger. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 4, 2006 Report Share Posted October 4, 2006 In all honesty, the same tactic applies to a PPO. PPO doctors get hassled by the insurance company as well and are expected to keep down costs but there isn't the same amount of pressure as there is with an HMO. Same tactic applies, including writing a letter to the insurance company if a referral is denied. Most physicians don't want to deny care. Making a parent angry just isn't what they want to do with their time. It just makes the day go longer. They are often caught between doing what is right and risking the financial hardships that could, in all truth, result in them having to close their practice. Good luck Kris Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 5, 2006 Report Share Posted October 5, 2006 My pediatrician wrote a script for speech therapy to no avail with my insurer, United HealthCare HMO. After I took my son to a pediatric neurologist and he gave me " physician's orders " for speech therapy they started to pay for it! *My pediatrician told me as she wrote the script that it probably wouldn't help at all but she accomodated my request for help. This pediatrician may simply be aware that this certain HMO NEVER covers pediatric ST and OT. Not that it is not worth asking the question, but don't shoot the messenger. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 5, 2006 Report Share Posted October 5, 2006 My pediatrician wrote a script for speech therapy to no avail with my insurer, United HealthCare HMO. After I took my son to a pediatric neurologist and he gave me " physician's orders " for speech therapy they started to pay for it! *My pediatrician told me as she wrote the script that it probably wouldn't help at all but she accomodated my request for help. This pediatrician may simply be aware that this certain HMO NEVER covers pediatric ST and OT. Not that it is not worth asking the question, but don't shoot the messenger. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 6, 2006 Report Share Posted October 6, 2006 I usually lurk, but thought I'd chime in on the insurance issue. Each policy is different, so I think you'll have to read the specific wording in you insurance policy. But I have a Blue Cross Blue Shield insurance. And our policy will not pay for speech regardless of a developmental or neurological disorder. Our policy specifically states that they will pay for 60 *consecutive* days of speech therapy if it is the result of brain injury due to head trauma. Nice, huh? I thought this was unusual since they are awesome insurance on everything else (we get 100% maternity coverage with no co-pays and they did pay for my dh's PT when he hurt his back) I didn't check out the OT because we were looking into speech only at that time. so is it possible that you doctor knows that your insurance policy simply will not pay for any speech even if they refer you to someone? Fran > > This pediatrician may simply be aware that this certain HMO NEVER > covers pediatric ST and OT. Not that it is not worth asking the > question, but don't shoot the messenger. > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 6, 2006 Report Share Posted October 6, 2006 United's official policy is 20 visits of speech therapy per year if your child had an " injury, stroke, or congenital anomaly " . When I called the person parroted the exact terms above PLUS the term " Autism " . This to me means their book is different from mine and fighting it is worthwhile even when the outcome may be not what was hoped for. I have learned through experience that the policy's terms are flexible if you know how to work the system. > > > > This pediatrician may simply be aware that this certain HMO NEVER covers pediatric ST and OT. Not that it is not worth asking the question, but don't shoot the messenger. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 6, 2006 Report Share Posted October 6, 2006 I usually lurk, but thought I'd chime in on the insurance issue. Each policy is different, so I think you'll have to read the specific wording in you insurance policy. But I have a Blue Cross Blue Shield insurance. And our policy will not pay for speech regardless of a developmental or neurological disorder. Our policy specifically states that they will pay for 60 *consecutive* days of speech therapy if it is the result of brain injury due to head trauma. Nice, huh? I thought this was unusual since they are awesome insurance on everything else (we get 100% maternity coverage with no co-pays and they did pay for my dh's PT when he hurt his back) I didn't check out the OT because we were looking into speech only at that time. so is it possible that you doctor knows that your insurance policy simply will not pay for any speech even if they refer you to someone? Fran > > This pediatrician may simply be aware that this certain HMO NEVER > covers pediatric ST and OT. Not that it is not worth asking the > question, but don't shoot the messenger. > Quote Link to comment Share on other sites More sharing options...
Recommended Posts
Join the conversation
You are posting as a guest. If you have an account, sign in now to post with your account.
Note: Your post will require moderator approval before it will be visible.