Health insurance and speech therapy?

[KirstenB]

Hi guys, I'm hoping someone here has some experience with this. Our dd who's 2 1/2 receives speech therapy once a week through our Early Intervention program. The program has billed our health insurance, United Healthcare for the services. United is denying the claims, because they consider speech under "mental health". Regardless of how they classify it, they have not paid a single claim since May 07. Has anyone else had difficulty getting insurance to pay for therapy?

If I can't get anywhere with them, there's a cap through EI on how much we have to pay out of pocket, thank goodness. Thanks in advance.

 

[Forevryoung]

It depends what your child is receiving services for- autism is still under "mental health" for some insurance companies. You can check your coverage with United and see if they pay for speech services under what diagnosis and go from there. It is a horrible fight.

FYI once your child reaches 3, speech services have to be provided for free by the school district. EI is under the department of health not the department of education.

Best of luck!

 

[Val]

I feel your pain....we have paid for private speech therapy for our DD10 since she was 2. She has moderate bilateral sensorineural + conductive hearing loss. We paid for speech initially because we were in Catholic school, now just to keep DD10 up academically. No insurance coverage for speech ever! Insurance also will not pay for audiology appointments or her hearing aids (try $5000 a pair!). At least I can get the audiology visits for free because we go to the university program where I work. Insurance will pay for therapy she received for balance/dizziness issues due to the SAME condition, however. Apparently it is a medical condition if you are dizzy, but not if you can't hear! We spend, on average, $500/mos for therapy for her because the school only provides 60 minutes of speech/language therapy a week. If she is to meet her academic potential, she just needs more, and so we pay. Good news is that she is an A student and reads way above grade level. Too often hard of hearing/deaf kids are poor readers,and making sure she was a good reader was really important to me. It has been worth EVERY cent we have paid.

Fight the good fight....if you go to http://www.listen-up.org/ they have some good example letters for fighting your insurance company. I know your DD doesn't have hearing loss, but the idea is the same!

Good luck and God Bless!

 

[ecki]

We're in NY and our insurance wouldn't pay for any EI services (because we are in an HMO and the providers weren't part of the group). But we've never had to pay anything out of pocket for EI, and we had 6 hours of therapy (OT, PT, Speech, special instruction) a week and could have requested more.

Now that Kayla is in preschool, the school district is providing more than enough services. However, she is also on a Medicaid waiver, so we are allowed a certain number of visits through that if we wanted, but I don't think it's necessary.

I can't get any PT or OT services through our private insurance with a Down syndrome or Autism diagnosis (won't pay for speech at all). But I could probably get PT through insurance if the reason was for her torticollis or hypotonia.

 

[KirstenB]

Thanks for sharing, everyone. I'm glad I'm not alone...but I'm sorry you guys are dealing with this too! Although Zoe has received an autism dx through a developmental ped, her EI therapists have always said she wasn't autistic. Therefore they wouldn't put that down in billing to United. AAAGHHH! At least she only has 5 more mths before the school system takes over. Because there are 9 mths of bills, EI is billing us for $105/mth, so the bill is over $1000. If insurance won't pay, we will, but I can think of better ways to spend the $$!

 

[1stluvispooh]

First what I would question is the fact that the Therapist isn't putting down the DOCTORS DIAGNOSIS!!! It is not up to the therapist to deiced the diagnosis of autism is correct or not.

Second when my DD was first diagnosed with autism we had United Health and they paid for 20 therapy sessions a year (yes I know everyone insurance is different but hear me out) We never had a problem with them paying for it. At the time that she start speech she was still on the waiting list for the developmental pediatrician. She did have a Rx from a neurologist. So my thought is if you can get:
A) Your therapist to put down the DR"S DIAGNOSIS
B) Get a physical Rx for speech therapy from your Doctor

I am so sorry that you have to fight this battle. You are not alone. The doom of having to pay for therapy weighs heavy on me and I know other parents as well.

 

[SandrainNC]

I can't get any PT or OT services through our private insurance with a Down syndrome or Autism diagnosis (won't pay for speech at all).

My son's private physical therapist told me a long time ago to NEVER EVER put down the reason for therapy was Down syndrome. Down syndrome itself is not treable (and I am betting autism is similar), so insurance will deny it. It needs to be coded for what is being treated. For example, Ryan gets physical therapy because he has hypotonia. He gets speech because he has speech apraxia or something like that. We have never had a problem getting his therapies. There have been limits placed on the amount of therapies they will pay for though. And PT and OT are counted together for that limit.

Sandra

 

[KirstenB]

My son's private physical therapist told me a long time ago to NEVER EVER put down the reason for therapy was Down syndrome. Down syndrome itself is not treable (and I am betting autism is similar), so insurance will deny it. It needs to be coded for what is being treated. For example, Ryan gets physical therapy because he has hypotonia. He gets speech because he has speech apraxia or something like that. We have never had a problem getting his therapies. There have been limits placed on the amount of therapies they will pay for though. And PT and OT are counted together for that limit.

Sandra

This jibes with what I've read over on the Autismspeaks.org boards. A lot of parents say you don't want your child to have autism as the reason for the service, but rather the specific delay. I honestly don't know how EI codes our claims. I do know they've always focused on the "hypotonia" and "speech delay" part of the puzzle with us. More focused on the delay itself and dealing with it, since we're still wrestling with the underlying cause.

Anyway, I called United today, and they said EI needed to treat each 45 min session as one "unit". EI considered each 15 min as one unit, so they were submitting claims that appeared as 3 units for each weekly visit. Then I asked how many sessions of speech therapy they covered per year. The answer was 20, which is woefully inadequate. I certainly don't think once a week is excessive, apparently they do. I called EI back, and they said they always call the insurance at the beginning of new coverage, and that's one of the first questions they ask. They were told United would cover 60 sessions/yr. Good times, good times, agghhh!

If you're still with me, thanks for listening!

 

[LauraVV]

. Our dd who's 2 1/2 receives speech therapy once a week through our Early Intervention program. The program has billed our health insurance, United Healthcare for the services. United is denying the claims, because they consider speech under "mental health".

EI may be billing under developmental services so that's why it may be covered under mental health. You might want to call UHC and ask them. UHC has many different policies. Also, your company could use UHC as administrator for their self insured policy.

With my plan, hearing testing may be billed as a medical claim (hearing) or as a mental health benefit (hearing for CAPD testing) with different coverage. So, you might want to ask your EI agency what diagnostic code they're using. You can google dsm-iv and icd 9 (or 10) along with the diagnostic code to see what diagnostic code they're using for billing. That will help you to understand why they're not covering therapy.

One thing I've discovered with UHC is that you need to appeal things a lot. They deny pregnancy tests (requirement of Xrays, MRIs, etc.) every time. I call and complain and then they usually pay for the test. Persistence seems to be important with them!