Re: Re: Advice for Difficult Insurance Company related issues

January 4, 2011

Hi --

Case Managers act sort of like " Coordinators " within the insurance companies for

more complex cases... such as a child who requires multiple forms of

therapies... Instead of having to call an 800#... and getting who ever answers

the next call, parents and providers can call ONE person... who is very familiar

with the Case. Case Managers must also work under the rules of your Insurance

Company... they cannot change the rules of the insurance Company.

I have some questions for you... you said that you are having trouble with the

Insurance Company paying the Providers, not you, even though the receipt is

marked paid in full.....

I suggest that you tell each provider that the Insurance company will be paying

them.... so you should not have to pay upfront. the provider should be calling

your Insurance Company to get approval for all services BEFORE you go to them.

therefore, they know that they will be paid. If there is any amount not paid in

full by the Insurance company, the provider should send you a bill for the

difference. In this case, I am feeling that the problem is being caused by your

provider.... Again-- typically the provider DOES NOT expect payment from the

patient-- they should wait for insurance reimbursement, and then bill the

patient for the difference.

Next issue... you described how there are old diagnosis codes being used....

This is due to lazinewss on the doctor's offices end... they simply do not

update the codes... I went through this as well. Here is what I did.... I spent

an entire day... (not kidding- a whole afternoon) calling ALL of my son's

Doctor's therapists, etc... I demanded to know what codes they were using...

Some offices refused to tell me... so I called their billing Departments and

found out the codes. From there, it was easy to see who had and who did not

have the correct codes. I have learned to always ASK at each appointment what

codes will be used... It is much ewasier this way. We see various

Specialists... so if one uses a new code that is appropriate, I make sure that

each doctor/Specialist/ therapist updates their codes to include the new one...

Yes-- this is a " pain in the butt " .... but this is the only way that I can make

sure that they are doing things correctly... I also call these provider's

billing offices to MAKE SURE that the new code has been written down to be used!

(soe have told e they will update the code, but they do not)... GRRRRR.

YOU NEED TO GET THOSE CODES FIXED.... if the Insurance company sees a code for

" Developmental Delay " they most likely will NOT PAY! The fault on this issue

falls on the Providers that you are using... they NEED to update and USE the

appropriate Codes! Believe me-- I have found that some offices are not well

versed on the use of APPROPRIATE Codes.... if they " pick the wrong one " ... it

can make a huge difference to the Insurance Company... and it can also cause you

to waste time with the appeals process!

the Code for Apraxia of Speech is 384.69 !!!

Here the codes that have been used for my son... Age 34 months.. who has Apraxia

and Hypotonia as his main issues. These codes have been working well for us so

far....

384.69... as mentioned above

781.3 Lack of coordination

759.9 Congenital amomaly not otherwise specefied (my son has a slight genetic

deletion)

783.40 Unspecefied lack of normal physiological development (I want this one to

be updated)

794.09 Abnormal CNS function Study (my son had an MRI of his brain which showed

mild periventricular leukomalacia)

some of them used to use the code 315.9 (Developmental Delay)... this is no

longer used now!

another suggestion... ask for copies of all tests or formal evaluations for you

son... the codes will be on these... You can then simply carry the " Official

updated codes " from place to place... if a new provider sees a new code on an

" official report " they should have no problem with changing the one that they

use!

Hope this helps...

[ ] Re: Advice for Difficult Insurance Company

related issues

I would love some direction on this topic. Can you tell me what all I can expect

from a case manager? My daughter has one (nonverbal, apraxic, hypotonia) but

every time we request something, the case manager says we have to go somewhere

else. Things like:

- The insurance company consistently pays the providers instead of us when every

receipt is clearly marked paid in full.

- There are old diagnosis codes (developmental delay) that they use to refuse to

pay since she is over 3 so I have to appeal and point out that her current

diagnosis is one that is covered (and I have documented emails and conversations

to prove that but they still deny every time anyway and I have to appeal EVERY

claim)

The only thing that has gotten easier is that I can call the case manager to get

a new referral. other than that, we have not received a lot of help from her.

But I don't know who to ask about what exactly we can expect from a case manager

because the insurance company won't tell me.

By the way, the only way I knew to request a case manager was because I got a

broad hint from someone somewhere along the line at the insurance company. It

was obvious that they could not directly tell me about getting a case manager,

but if I knew enough to ask, it could be done.

B.

>

> Hi Guys-- Happy New Year!

>

> If any of you have multiple forms of therapies for your child with Apraxia...

(and multiple headaches from your Insurance Company), PLEASE TRY THIS.... When

you call your Insurance Company, ask for " A Case Management Referral " for your

Child. Be firm about this... because some of the bozos who answer the phone may

not realize that this even exists.

>

> Hugs to all-

>

January 4, 2011

I tried to get a case manager...they were nice but said we couldn't

get one. They said you had to have cancer or be terminal to get

one...ugh!

Noelle

Sent from my iPhone

On Jan 4, 2011, at 5:07 PM, <> wrote:

>

> Hi --

> Case Managers act sort of like " Coordinators " within the insurance

> companies for more complex cases... such as a child who requires

> multiple forms of therapies... Instead of having to call an 800#...

> and getting who ever answers the next call, parents and providers

> can call ONE person... who is very familiar with the Case. Case

> Managers must also work under the rules of your Insurance Company...

> they cannot change the rules of the insurance Company.

>

> I have some questions for you... you said that you are having

> trouble with the Insurance Company paying the Providers, not you,

> even though the receipt is marked paid in full.....

> I suggest that you tell each provider that the Insurance company

> will be paying them.... so you should not have to pay upfront. the

> provider should be calling your Insurance Company to get approval

> for all services BEFORE you go to them. therefore, they know that

> they will be paid. If there is any amount not paid in full by the

> Insurance company, the provider should send you a bill for the

> difference. In this case, I am feeling that the problem is being

> caused by your provider.... Again-- typically the provider DOES NOT

> expect payment from the patient-- they should wait for insurance

> reimbursement, and then bill the patient for the difference.

>

> Next issue... you described how there are old diagnosis codes being

> used.... This is due to lazinewss on the doctor's offices end...

> they simply do not update the codes... I went through this as well.

> Here is what I did.... I spent an entire day... (not kidding- a

> whole afternoon) calling ALL of my son's Doctor's therapists, etc...

> I demanded to know what codes they were using... Some offices

> refused to tell me... so I called their billing Departments and

> found out the codes. From there, it was easy to see who had and who

> did not have the correct codes. I have learned to always ASK at each

> appointment what codes will be used... It is much ewasier this way.

> We see various Specialists... so if one uses a new code that is

> appropriate, I make sure that each doctor/Specialist/ therapist

> updates their codes to include the new one... Yes-- this is a " pain

> in the butt " .... but this is the only way that I can make sure that

> they are doing things correctly... I also call these provider's

> billing offices to MAKE SURE that the new code has been written down

> to be used! (soe have told e they will update the code, but they do

> not)... GRRRRR.

>

> YOU NEED TO GET THOSE CODES FIXED.... if the Insurance company sees

> a code for " Developmental Delay " they most likely will NOT PAY! The

> fault on this issue falls on the Providers that you are using...

> they NEED to update and USE the appropriate Codes! Believe me-- I

> have found that some offices are not well versed on the use of

> APPROPRIATE Codes.... if they " pick the wrong one " ... it can make a

> huge difference to the Insurance Company... and it can also cause

> you to waste time with the appeals process!

>

> the Code for Apraxia of Speech is 384.69 !!!

>

> Here the codes that have been used for my son... Age 34 months.. who

> has Apraxia and Hypotonia as his main issues. These codes have been

> working well for us so far....

>

> 384.69... as mentioned above

> 781.3 Lack of coordination

> 759.9 Congenital amomaly not otherwise specefied (my son has a

> slight genetic deletion)

> 783.40 Unspecefied lack of normal physiological development (I want

> this one to be updated)

> 794.09 Abnormal CNS function Study (my son had an MRI of his brain

> which showed mild periventricular leukomalacia)

>

> some of them used to use the code 315.9 (Developmental Delay)...

> this is no longer used now!

>

> another suggestion... ask for copies of all tests or formal

> evaluations for you son... the codes will be on these... You can

> then simply carry the " Official updated codes " from place to

> place... if a new provider sees a new code on an " official report "

> they should have no problem with changing the one that they use!

>

> Hope this helps...

>

> [ ] Re: Advice for Difficult Insurance

> Company related issues

>

> I would love some direction on this topic. Can you tell me what all

> I can expect from a case manager? My daughter has one (nonverbal,

> apraxic, hypotonia) but every time we request something, the case

> manager says we have to go somewhere else. Things like:

>

> - The insurance company consistently pays the providers instead of

> us when every receipt is clearly marked paid in full.

> - There are old diagnosis codes (developmental delay) that they use

> to refuse to pay since she is over 3 so I have to appeal and point

> out that her current diagnosis is one that is covered (and I have

> documented emails and conversations to prove that but they still

> deny every time anyway and I have to appeal EVERY claim)

>

> The only thing that has gotten easier is that I can call the case

> manager to get a new referral. other than that, we have not received

> a lot of help from her. But I don't know who to ask about what

> exactly we can expect from a case manager because the insurance

> company won't tell me.

>

> By the way, the only way I knew to request a case manager was

> because I got a broad hint from someone somewhere along the line at

> the insurance company. It was obvious that they could not directly

> tell me about getting a case manager, but if I knew enough to ask,

> it could be done.

>

> B.

>

> >

> > Hi Guys-- Happy New Year!

> >

> > If any of you have multiple forms of therapies for your child with

> Apraxia... (and multiple headaches from your Insurance Company),

> PLEASE TRY THIS.... When you call your Insurance Company, ask for " A

> Case Management Referral " for your Child. Be firm about this...

> because some of the bozos who answer the phone may not realize that

> this even exists.

> >

> > Hugs to all-

> >

>

January 4, 2011

Noelle--we have an Aetna PPO--and about 25 something claims a month between OT

and many speech. I only submit quarterly--i can't keep up with the fact that

some you pay in advance for--but can't submit until the end of the month--others

you pay as you go etc..--and especially the OT was processed so haphazardly--it

looked like a bunch of monkeys had done it--and different ones for every session

no less--it was a nightmare--I had to have a matrix with color codes to keep up

with what was paid appropriately, what wasn't paid at all in spite of

submissions and what was paid only in part and this was the hapzhazard part--it

was completely without rhyme or reason--they almost randomly would not cover $10

or $5 or what ever out of each OT segment--and keep in mind that each OT session

of 60 min needs to be split up in 4 15 min units to be covered in

full---otherwise only 60% is covered--of the amount they cover so they were at

some point paing only $40 or so

out of $150--but it was completly off the wall--even that wasn't consistant

even within the same session. i was really loosing it---

i contacted the HR dept at my husband's job and told them i was having trouble

sleeping nights due to the mistakes and worry about paying the next bill---and

if they weren't going to help me get this straightened out they would need to

start paying for mental health treatment too. And i meant it--just taking a kid

to 6 therapy sessions a week and doing the homework, supplements, etc. is a full

time job--I couldn't keep up with insurance claims as a full time job on top of

that.

Anyway--they listened. they put me in touch with the Aetna/company Liaison and

they also listened----I sent all my messed up claims and they saw the

crazyness---and I was given a case manager to whom I've been sending ever since

and getting my checks within a few weeks. i love it. but you have to really

raise awareness for the need through your company HR dept. Show multiple

mistakes etc. and ever since we've been getting everything paid--my appeal went

through at the same time and I've not had to appeal since....we're blessed--but

you have to make a fuss...Good luck.

Elena