Submitting Insurance Claims to Blue Cross Blue Shield of TX for speech therapy

[Guest guest]

Hi All -

 

We have been using a private Speech therapist for our 5 year old. Our speech

therapist is listed out of Network by Blue Cross Blue Shield TX. We have already

paid for the services and I would like to submit claims to BCBS to see if they

could cover for the services under the out of network plan.

 

I am looking at the form and would need some asssitance from anyone who has done

anything similar in the past.

 

Qn. Type of Treatment Received and the choices are

1) Injury - Date of Accident

2) IIlness - Date of FIrst Symptom,

3) Pregnancy - Date of Conception

4) Preventive - Date of Service

So, do I pick option 2 of Illness, if so what should I put the first date of

symptom? If I pick a date 2 years prior to '08 will I need to show proof of

insurability for the last couple of years etc

--------------------------------------------------------------------------------\

----------------------------------------------------

Qn. Describe: Diagnosis, Symptoms of Illness or Injury or explain preventive or

routine care received.

 

When discussed with my speech language pathologist, she asked me to to use

diagnosis code 784.69 and CPT code of 92507. Do I go on the internet and look up

code 784.69 and paste the description in there.

 

We have a seperate attachment of invoices and speech notes to go with the claim

form.

 

Any ideas or suggestions are greatly appreaciated.

 

Thanks

sheela

mom of kevin 5

[Guest guest]

Hi Sheela! The code that your SLP gave you is one of the good ones -

but below is a huge archive on more information for insurance you can

probably pull from to help!

Re: Insurance questions...some better than others?

From: " kiddietalk " <kiddietalk@...>

Date: Sun Apr 24, 2005 9:38 pm

Subject: Re: second level insurance appeal

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)

(and there's also a message board for insurance there too!)

http://www.speech-express.com/speech-therapy/insurance.html

for apraxia:

http://www.speech-express.com/diagnosis-

destinations/apraxia/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/therapy. Do you have that book?

http://www.speechville.com/late.talker.html

Letter to Speechville we just got

" support@...

Subject: Thank you

Date: Sat, 23 Apr 2005 20:38:23 +0000

I want to express my gratitude at the service your website provided

me. My daughter was diagnosed with an articulation disorder. Her

therapy was denied by our insurance company. By reading your

recommendations and using specific language in my appeal, I was able

to win the appeal process by proving medical necessity. My daughter

is now covered for private speech therapy until she is reassessed.

The information you provided and your suggestions on what

information to gather and how to present it were invaluable to me.

This has been a lengthy, anxiety ridden process and you walked me

through it. Thank you. "

Re: Health Insurance will not cover speech therapy - Help !!!

In addition to The Late Talker book and

http://www.cherab.org/information/insurance/insurance.html here are

just a few

of the archived messages on insurance. (I included those from

Mikel

-another co founder of Speechville.com (here are just 2 of many pages

on

insurance from Speechville)

http://www.speech-express.com/speech-therapy/insurance.html

http://www.speech-express.com/diagnosis-

destinations/aphasia/insurance.html

Mikel is also the co founder of Apraxia Kids since someone

recently

referenced that site)

Now the next

one to archive insurance will find all these faster than I just did!

From: Mikel <gmmikel@...>

Date: Mon Oct 28, 2002 9:59 am

Subject: Re: [ ] Insurance

I remember a few people having this situation and successfully

appealing it.

They made the case based on the treatment being " medically

necessary " , that

because it was medically necessary that the child receive ongoing

speech

therapy, the limitation would not provide for the medical needs of

the

child. Others have stretched out the benefit by submitting for

different

types of therapy, oral motor speech therapy at one point, speech

therapy at

another point, occupational therapy at another point. My sense about

it

would be that it would be a hard battle to wage. Have you checked

into

lower cost speech therapy through ish Rites, Easter Seals, or a

local

university's speech-language clinic?

> I have Aetna insurance. The policy allows for 60 consecutive days

of

therapy - that's it. They tell me that's not a yearly max - that's a

lifetime max. Has anyone fought this battle before and won? How

would I go

about it?

>

> Thanks,

> Debbie

From: Mikel <gmmikel@...>

Date: Mon Oct 28, 2002 11:51 pm

Subject: Re: [ ] Insurance

Ilene's post reminded me of something... Check your states'

regulations

because those regulations can override the insurance policy. For

example,

this New Jersey legislation (below) indicates that if a physician

states

that speech therapy is medically necessary, and the speech therapy

will be

provided by a speech-language pathologist, then the person will not

be

denied the benefit. This should enable any child in New Jersey to get

speech therapy as long as the pediatrician states that it's medically

necessary (regardless of 60 day limitations in the contract).

----------------------------------------

http://www.njleg.state.nj.us/cgi-bin/om_isapi.dll?

clientID=219452 & Depth=2 & de

pth=2 & expandheadings=on & headingswithhits=on & hitsperheading=on & infobase

=statutes.\

\

nfo & record={69E7} & softpage=Document42

http://insurance.lawyers-and-laws.com/new-jersey/insurance/p-health-

insurance-po\

licy-to-cover-certain-audiolo.html

http://www.njleg.state.nj.us/9697/Bills/PL97/419_.HTM

17B:26-2.1p Health insurance policy to cover certain audiology,

speech-language pathology services.

4.Notwithstanding any other provision of chapter 26 of Title 17B of

the New

Jersey Statutes, benefits shall not be denied to any eligible

individual for

eligible services, as determined by the terms of the policy or as

otherwise

required by law, when the services are determined by a physician to

be

medically necessary and are performed or rendered to that individual

by a

licensed audiologist or speech-language pathologist within the scope

of

practice. The practices of audiology and speech-language pathology

shall be

deemed to be within the provisions of chapter 26 of Title 17B of the

New

Jersey Statutes and duly licensed audiologists and speech-language

pathologists shall have such privileges and benefits in the scope of

their

practice under that act as are afforded thereunder to licensed

physicians

and surgeons in the scope of their practice.

L.1997,c.419,s.4.

From: Mikel <gmmikel@...>

Date: Tue Oct 29, 2002 11:34 am

Subject: Re: [ ] Insurance/

,

Using Michigan as an example, I went to Google

(http://www.google.com) and

typed in " michigan state government, " looking for the state's home

page. I

found that and then looked for " legislature " , which led me to

http://www.michiganlegislature.org. I then clicked on " chapter

index " and

came to this page,

http://www.michiganlegislature.org/mileg.asp?page=chapterIndex. The

chapter

index for each state lists the main topic areas for which there is

legislation. This is applicable to educational legislation as well as

insurance legislation, for those of you who might need to know what

your

state requires of the schools (usually provides more detail than

what the

federal legislation provides for).

Once you get to your state's legislature's chapter index, you can

either

search the entire database (if they offer that) using words

like " speech

therapy " " speech language pathologist " " occupational therapy "

or " physical

therapy " to see what the legislation provides for, or you can click

on the

specific chapter that pertains (Michigan's include Chapter 550

GENERAL

INSURANCE LAWS) and either search there or just start reading

through stuff.

When I did this in Texas, I found information stating, for example,

that

therapists (speech, o.t., and physical) fell under the guidelines

that the

medical field falls under (ie it is appropriate for them to

diagnosis within

their area of expertise). I also found a statute that an SLP in

Houston had

referred to, one that states that in Texas, if any group of people

will be

provided an insurance benefit, than no other specific group of

people will

be excluded from receiving that same benefit. (In other words, if

adults

will receive speech therapy for a speech problem, then children

shouldn't be

excluded from receiving speech therapy for that same problem simply

because

they're children. In apraxia, the symptoms are often the same and

both

populations should be covered. One shouldn't be excluded from

coverage

because the problem is deemed to be " developmental " .)

Another avenue that can lead you to pertinent statutes is to call

your

state's speech-language hearing association, your attorney general,

and your

state's insurance department. Ask them if they've heard of statutes

that

might apply. Sometimes an email to your senator or representative

can also

help. His/her legal assistant might be willing to check into this

for you.

Speech-language hearing associations for each state are listed here:

http://www.speech-express.com/speech-therapy/associations-state.html.

INSURANCE: DEALING WITH THE BIG GUYS

Dear ,

One of the forces that most of our families with apraxic children

have had to deal at some time or another is the medical insurers. If

a medical professional or speech pathologist writes a report or a

bill for submssion to the insurance company, here are some important

tenets to follow:....

> I need help dealing with the insurance companies. I

> saw on the speechville website a reference to message

> number 263 by Dr. Agin " Insurance: Dealing with the

> Big Guys "

>

> Can anyone reprint or copy that here for me? I would

> like to read a copy of it and better yet, my

> pediatrician's office would love to read it. There

> referral coordinator is very interested in this. I am

> forwarding to her other information about insurance

> companies and apraxia from speechville express.

>

> Thanks.

Re: Insurance questions...some better than others?

Hi and thanks for the praise for The Late Talker! Here's a

bunch of archives about insurance that have helped others over the

years:

Re: insurance

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

=====