Advice for Difficult Insurance Company related issues

[Guest guest]

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.

All insurance Companies have " Case Management Staff " who handle complicated

cases. You should be able to request this Service if your Child has multiple

therapies. what this will mean to you is that you will have ONE PERSON-- who

you can call directly with any Insurance Related Concerns. this same person

will aLSO ASSIST YOU with helping to get things approved... (within the realm of

your coverage-- and if the Service is appropriate).

Here is my story.... my son has a Dx. of Moderate to Severe Apraxia. He also

has Hypotonia, Sensory Issues which affect his Feeding abilities, and global

delays. We take him to private ST 2x per week.. plus are involved with a

Special Ed PK 4 days per week. We decided that it would benefit our Son to add

both Feeding Therapy and OT.

the feeding therapy will be conducted at a different facility than the ST and

OT. The Feeding therapy Staff consist of an OT and a ST. they bill for OT AND

ST-- but they are using a " Feeding Related ICD-9 Code when billing Insurance.

My insurance Company was trying to deny the Feeding therapy because they felt

that we were having " the same services at 2 different places " .... DUH-- could

they not tell that the codes for feeding therapy differed? I spent 4 hours on

the phone calling back and forth between the insurance Company and the Facility

that I wanted to take my child to for Feeding Therapy.... Yep.... 4 hours....

while my 2 kids begged for my attention and were screaming in the background. I

was caught up in the proverbial " he said, she said game... and stuck in the

middle " .

In my frustrated and tense state, it dawned on me to ask for a Case Management

Referral... (I am a BSN RN- and worked at an insurance Company for part of my

Nursing days before being a SAHM).

A Case Manager called me today.... she heard my story... was able to check into

what I was saying.... and she said that I indeed make sense. She will work to

help me and my son.... Best of all-- I have a direct Phone # to reach her... and

I can share this # with all Facilities who are requesting approval for

Services...

the really crazy part of all of this is that we have also obtained Medical

Assistance for our Son... (the State of PA is good with giving out this

Secondary Insurance to qualified kids). Medical Assistance will pick up a lot of

what is not covered by our Primary Insurance.... BUT... (and this is a BIG

BUT)... the Primary Insurance must validate the reason for any request... and

the reasomn for their denial before it goes to the Secondary Insurance. If our

Primary Insurance denies Services for reasons that " we are going to 2 facilities

for the SAME Service " , the Secondary WILL NOT cover it!

the Case Manager was able to see that Feeding therapy and ST are 2 seperate

issues... (but the bozos who dealt with the initial calls could not see this....

come on... 2 seperate ICD-9 codes were used)!

Now- my Son WILL get the Services he needs.... ALL IS WELL.... People.. please

request " A Case Management Referral " from your Insurance company... especially

iof your child has multiple Services... this will make your life SOOO much

easier!

Hugs to all-