Re: Insurance Wording - need guidance

[Guest guest]

Don't know the insurance company, but have you checked the Michigan Insurance

Commission's 2004 ruling? Also, have you checked out slaw.com? I found

both extremely helpful in our " disagreement " with the insurance company.

From: svraciu@...

Date: Sat, 4 Sep 2010 02:27:59 +0000

Subject: [ ] Insurance Wording - need guidance

Hello all.

Our insurance provider is about to change and, although our current provider has

covered Speech THerapy with no problems, our new insurance might not be so easy.

Wanted to post my new coverage details in the hopes someone has seen this

language before and been able to overcome it. We haven't yet been denied, but we

haven't fully switched over yet and I'm preparing my pre-determination

documentation as we speak.

New policy states: Insurance covers unlimited speech therapy for REHABILITATIVE

services but will not cover ST for developmental delays. Additionally, they will

not cover ST for:

- Developmental disability: disability that occurred before 19 & has a

substantial disability which results from mental retardation, cerebral palsy,

epilepsy or other neurological disorder AND which is diagnosed by a Physician as

a permanent or long-term continuing condition.

This wording scares me b/c although we know apraxia isn't developemntal

delay/disability, it is neuro-based and long-term. I am concerned that they've

covered all potential bases so as NOT to cover services. I can say it's not

developmental, but when I say it's neuro-based and requires intensive therapy,

etc I'm afraid they'll knock me for it.

Thoughts? Similar experiences? I have letters of necessity from ST and

pediatrician, the ASHA definition and template letters from Cherab archives, but

the wording stumps me on the angle I can take.

Any input appreciated.

Sharon

[Guest guest]

Our insurance has denied speech therapy on the grounds that it is not

rehabilitative in nature and must be restorative in nature. There has been

nothing we can do since that clause is in there to get it approved. Is there any

way you can keep the insurance coverage you have now? You are very lucky to have

had it covered, most insurance companies won't cover it!

 

From: vraciup <svraciu@...>

Subject: [ ] Insurance Wording - need guidance

Date: Friday, September 3, 2010, 9:27 PM

 

Hello all.

Our insurance provider is about to change and, although our current provider has

covered Speech THerapy with no problems, our new insurance might not be so easy.

Wanted to post my new coverage details in the hopes someone has seen this

language before and been able to overcome it. We haven't yet been denied, but we

haven't fully switched over yet and I'm preparing my pre-determination

documentation as we speak.

New policy states: Insurance covers unlimited speech therapy for REHABILITATIVE

services but will not cover ST for developmental delays. Additionally, they will

not cover ST for:

- Developmental disability: disability that occurred before 19 & has a

substantial disability which results from mental retardation, cerebral palsy,

epilepsy or other neurological disorder AND which is diagnosed by a Physician as

a permanent or long-term continuing condition.

This wording scares me b/c although we know apraxia isn't developemntal

delay/disability, it is neuro-based and long-term. I am concerned that they've

covered all potential bases so as NOT to cover services. I can say it's not

developmental, but when I say it's neuro-based and requires intensive therapy,

etc I'm afraid they'll knock me for it.

Thoughts? Similar experiences? I have letters of necessity from ST and

pediatrician, the ASHA definition and template letters from Cherab archives, but

the wording stumps me on the angle I can take.

Any input appreciated.

Sharon

[Guest guest]

Many of us need help with getting speech covered by private insurance. I would

appreciate lots of input on this topic! Sadly, children who qualifiy for

medicaire get rehabiliative therapies, yet the private insurance companies do

not cover " rehabiliative " . Or, if they won't cover it because it is due to

'Down syndrome' or Cerebral Palsy because they are preexisting conditions.

I know that you CANNOT use developmental delay in the wording or they will not

cover after the child is 3yo.

I know you can have pediatricians and therapists write letters on the child's

behalf--tell them to be careful of wording and stick to apraxia or dysphasia

(sp) diagnosis etc.

I know our insurance denied the dysphasia therapy--yet when I called they said

they needed to review the medical records of the swallow study. Sadly, the

therapist still hasn't sent those in????Really?

Truly, we have to be the case managers! And just keep on therapists and doctors

etc to get stuff done. The squeaky wheel gets the oil.

I demanded that my child get 5 sessions one on one a week at the public school

for apraxia that I had diagnosed at the hospital. I brought research backing

this up and read each piece's important part to back up my demand. The head of

the speech therapy for the school system said he didn't agree w/my research, yet

said I could choose a private therapist and he/she could decide how much speech

Nate needed and the school system would pay for that and also continue his group

therapy at school. The school therapists do not have time to do adequate

therapy for an apraxic child. Bring in the research, demand what it says your

child needs, and watch the color drain from the poor, overworked SLP's face.

Then, you might get the school district to pay for it. Because they have to

provide what your child needs no matter cost or whether or not the school

therapist has time. If the school therapist can't do 5 30 min sessions one on

one weekly, then they need to pay for a private therapist to do it.

We have a year left on that contract, so I know I will need to get my private

insurance to pay for speech for a severely apraxic child w/dysphasia and Down

syndrome! So, that will be my next battle...so as I said, any input is greatly

appreciated.

Colleen

Mom to 6 beautiful, wonderful kids

They are my heros:

Nate 6, DS severe apraxia, SI,

Ocean 9 Type 1 Diabetic

Jack 13

Hank 15

Sam 18 Type 1 Diabetic

Meg 20 Type 1 Diabetic/Nursing school