If you have a child with autism, chances are, you've become an expert at appealing denied insurance claims, just for the decision to ultimately remain the same. This or that is not covered with a primary diagnosis of Autism. I honestly don't know how they still get away with this., Supposedly Congress passed the Autism Reform Act quite some time ago, but I'm here to tell you, NOTHING has changed. They can and still do deny everything they possibly can.
The first time I had to deal with insurance companies sucking major weenus was when they cut Amanda's therapy back when she was just a baby. We started PT and OT three times a week, and it didn't stay that way for too long. The insurance did not think it was "medically necessary" for her to be seen that often. Last time I checked, they didn't have anyone come and sit in on her therapies, so how they came to that conclusion, have no idea. They were still allowing her to be seen two times a week, so we'd take that, I guess. This was before I really knew that I had the right to fight them. It wasn't long before they wanted to cut her back to just once a week, I want to say only a month, maybe. The therapists got really ticked at that, and I learned the art of appeals. They really did most of the work in the beginning, and for the most part, they would win, but that didn't last too long. Long before she was ready, she was ultimately discharged from therapy because she had reached what they call MMI or Maximum Medical Improvement. Really? She wasn't even two, and she was at MMI? Well, that's what they said.
Then came speech therapy. We went for evaluations and it was recommended that she have speech therapy. Now a lot of people, including me at that time, do not understand that speech therapy is not only for speaking. It's for learning how to move your tongue, lips, and swallow. Everything that has to do with the mouth really. Well, the people behind the insurance desks said it wasn't medically necessary. These people don't even have medical degrees and they make these decisions? I appealed, it was denied. I did a second level appeal, it was denied. I did a level three appeal, and it was denied. You can only appeal a decision three times, and you're done. It honestly is a hopeless battle. You never win, at least I never won again Medical Mutual. Once they make up their minds, that's it. Final.
Shortly thereafter I learned about The Bureau for Children with Medical Handicaps. Now they don't pay for therapies per se, but they will pay for diagnostic testing and such. This was great. Even though Amanda had insurance, the policy didn't cover office visits. We had a TON of office visits. Neurologists, Endocrinologists, Gastrointerologists, Ophthalmologists, Geneticists, Psychologists, and Medical Mutual did not pay for any of these. Thank God BCMH did. They paid for the office visits, and the many, many blood tests, urine tests, fecal tests (ew), MRIs, CAT Scans, genetic testing, and I'm sure I'm forgetting some. They paid for all of that. I didn't know that as soon as we got the Autism Diagnosis, that they would drop her. But they did. They do not cover any therapies that have to deal with Autism. Sounds like medical discrimination to me, but it's totally legal. Believe me, I checked into it. My hands were tied again.
Amanda was receiving some things through school as I mentioned, but it simply was not enough. This was before Spectrum. Her doc recommended more in-depth Occupation Therapy. Her fine motor skills just are not good. So I called the insurance company. At this time, I had had a lot of experience with prior authorization, since I had to get it so often for Dan's patients. I don't think I mentioned that Dan is a Chiropractor, and I do his billing. So I call the insurance company armed with direct questions.
Me: "I'm calling to get prior authorization for my daughter to receive outpatient Occupational Therapy.
Them: "Prior Authorization is not required providing you have a doctor's prescription for it".
Me: "What are the maximum allowed visits per calendar year?
Them: "Under your policy, therapy is unlimited providing you have a doctor's script"
Me: "What are the restrictions?"
Them: "No restrictions."
Me: "Is there any DIAGNOSTICALLY RESTRICTIVE CRITERIA that I need to be aware of?"
Them: "No"
Me: "So, in review, providing I have a script from my daughter's pediatrician for outpatient occupational therapy, it will be covered under my policy with no restrictions, diagnostically or othweise, or limits. Is that correct?"
Them: "Yes ma'am, that is correct."
Ok, then I covered all my basis. I wrote down this conversation, the time and date I called, and who I spoke with just to cover my butt. We went off to OT. I loved this therapist. She had great insight and great ideas on how to help Amanda. We went for about four sessions before I got the denial from the insurance. YOU'RE KIDDING ME RIGHT?????? Autism is not a covered diagnosis. What part of diagnostically restricive criteria did they not understand? I was pissed! I call the insurance, the told me I had the right to an appeal. I asked them how long they kept the recordings and they needed to dig into their archives and listen very carefully. I had the date and time and the person I spoke with. It'll be real easy to find for them. They wouldn't do it. I should have recorded the conversation myself. Needless to say, I went all the way to a level three appeal. I continued the therapy sessions while I was appealing. I had already spent a fortune on treatments for her, so one more bill wouldn't matter. The answer to the third level appeal was that they would pay for all therapies to date, but no more after that. I small victory I guess, but I basically wasted my breath on the phone call I made to avoid this whole mess. I hate insurance companies.
Bottom line is: If you have a child with Autism, you'll never have any extra money. If you want them to receive all the help they need, be prepared to pay for it all out of pocket. Insurance companies deny autism simply because this is a life long disability that will cost them a fortune. They do it because they can. They get away with it because no one will stop them. Insurance companies suck weenus.
No comments:
Post a Comment