Submitting Insurance Claims for Toddler Special Needs Therapy

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dcw213
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Submitting Insurance Claims for Toddler Special Needs Therapy

Post by dcw213 » Tue Jun 11, 2019 8:28 am

I posted on the general topic of my son and his special needs a while back and received good advice. I am progressing on this confusing and emotionally challenging journey and have a more specific question regarding insurance, specifically having to submit a claim.

A brief summary, my toddler has demonstrated some significant developmental delays and behavioral issues since he was very young. He started a state Early Intervention service at around 20 months but that is ending. Importantly, due to his young age they suggested holding off on a medical diagnostic until he is older (we have one scheduled for next month which I'm sure will provide a lot more clarity).

In the mean time, our primary care pediatrician and a therapist we work with recommended a therapeutic based preschool for the summer program. All say he needs it and we went in for an "evaluation" last week. I was surprised to hear that the process is that we pay and submit our own insurance claims. While we have documented referrals and evaluations, we have no medical diagnosis yet (it is believed that autism is likely).

I received the pricing for the program this week and it is extremely expensive. I worry that insurance will question the need for the services based on where we are with his diagnosis. Our pediatrician and the program have said that they would advocate as needed but didn't seem to indicate it would be a sure thing.

I am willing to pay for what he needs but the cost for this just seems prohibitive out of pocket, I would not be able to afford it outside of this trial summer program. I'm wondering if any knowledgeable folks have advice or thoughts on this specific insurance claim or how to best handle pursuit of needed services going forward longer term. Thank you!

miamivice
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Re: Submitting Insurance Claims for Toddler Special Needs Therapy

Post by miamivice » Tue Jun 11, 2019 8:31 am

What is the monthly cost of the program?

I think you will need a medical diagnosis first before any chance of insurance paying.

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neurosphere
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Re: Submitting Insurance Claims for Toddler Special Needs Therapy

Post by neurosphere » Tue Jun 11, 2019 8:53 am

A few random thoughts and suggestions. None of which you should take as gospel but reflect my personal experiences and understanding of a complicated issue, which is also affected by state laws and your particular insurance.

-- You don't necessarily need a diagnosis to get therapies paid for, you just need documentation of a symptom which is being treated (e.g. speech delays, etc).
-- HOWEVER, there is no law which says a particular type of therapy or course of action is REQUIRED to be paid by insurance in the case of any particular symptom diagnosis. For example, for "ABA" therapies for autism, this can indeed require an actual medical diagnosis of autism. And even then, funding is commonly denied.
-- You may as well learn from now that the legal definition and medical definition of "medically necessary" vary. Insurance companies are only required to pay for therapies which are "medically necessary". That's defined differently in different contract and different states, but the general idea is that the proposed treatment or therapy must be 1) generally shown or have been shown with good evidence to be effective for a particular condition and 2) be no more costly than other available treatments which also treat that condition.
-- If the proposed school is expensive, it would not be unusual for the insurance company to deny it. This will require an appeal (usually 2 or 3). The 2nd or third appeal (depending on state law) would go to an outside "independent" review organization whose decision is binding. But the provider referring you for the condition would have be state the case that this school's treatment program is the most cost-effective course of treatments for the condition (or alternatively, better that all other available treatments). If the cost is denied, make sure any appeal does indeed get to that last stage. Many docs mistakenly think that just because they talked on the phone to a "peer" in a peer-to-peer review, they have exhausted the appeals process. You MUST get to the independent review process before giving up. Note however, that if your insurance is medicaid, medicaid was exempted from this outside review process (the affordable care act was the law which established mandatory review, but it exempted medicaid, and each state thus was able to decide what type of medicaid review process to implement).

Neurosphere (I seem to have many jobs, but one of them is as a pediatric neurologist, and I seem to have an above average understanding of some insurance issues than my colleagues)
If you have to ask "Is a Target Date fund right for me?", the answer is "Yes".

shorty313
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Re: Submitting Insurance Claims for Toddler Special Needs Therapy

Post by shorty313 » Tue Jun 11, 2019 8:59 am

I have nothing to add about insurance, but does the local public school not offer special ed preschool services? My son went from early intervention to the preschool program, and he qualified for their ESY (extended school year AKA summer school) between the ages of 3-6.

tenkuky
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Re: Submitting Insurance Claims for Toddler Special Needs Therapy

Post by tenkuky » Tue Jun 11, 2019 9:13 am

neurosphere wrote:
Tue Jun 11, 2019 8:53 am
-- HOWEVER, there is no law which says a particular type of therapy or course of action is REQUIRED to be paid by insurance in the case of any particular symptom diagnosis. For example, for "ABA" therapies for autism, this can indeed require an actual medical diagnosis of autism. And even then, funding is commonly denied.
Not quite accurate. Several states have passed specific laws which mandate Medicaid and to some extent commercial (not self-funded) insurances to cover ABA in the event of an ASD diagnosis. Diagnostic requirements (including who can make it and what process/instruments vary)
https://www.appliedbehavioranalysisedu. ... ance-laws/

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neurosphere
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Re: Submitting Insurance Claims for Toddler Special Needs Therapy

Post by neurosphere » Tue Jun 11, 2019 9:33 am

tenkuky wrote:
Tue Jun 11, 2019 9:13 am
neurosphere wrote:
Tue Jun 11, 2019 8:53 am
-- HOWEVER, there is no law which says a particular type of therapy or course of action is REQUIRED to be paid by insurance in the case of any particular symptom diagnosis. For example, for "ABA" therapies for autism, this can indeed require an actual medical diagnosis of autism. And even then, funding is commonly denied.
Not quite accurate. Several states have passed specific laws which mandate Medicaid and to some extent commercial (not self-funded) insurances to cover ABA in the event of an ASD diagnosis. Diagnostic requirements (including who can make it and what process/instruments vary)
https://www.appliedbehavioranalysisedu. ... ance-laws/
I agree with you. I think maybe my original wording is confusing. When I wrote "can indeed require" I was emphasizing that yes, autism-->ABA in many cases. Meaning, imagine two kids with identical symptoms, one diagnosed with autism, and the other with Condition X. An official diagnosis of "autism" might unlock ABA therapy, while Diagnosis X might not. ABA has been defined or codified by some states as "medically necessary" for autism is the simplest way I think about it. I don't believe there is a national law which covers ABA or autism and thus it still gets denied. But it's been years since I've had to write letters of medical necessity for autism (I thank my lucky stars every day for the developmental pediatricians I work with!).

If the child in this case is indeed autistic, it can be very helpful to make that diagnosis explicit and agreed upon by all parties. This can have the effect of qualifying for payment of certain services not available to other diagnoses with very similar symptoms.

Glancing at the list you linked to, there can be significant limitations in the amount of frequency of coverage (see Idaho, which does not cover ABA at all, but also Alabama, Alaska, Arizona, Kentucky, Wyoming).

Also see the disclaimer in the first sentence of my quoted post about "State laws". :D
If you have to ask "Is a Target Date fund right for me?", the answer is "Yes".

OnTrack2020
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Re: Submitting Insurance Claims for Toddler Special Needs Therapy

Post by OnTrack2020 » Tue Jun 11, 2019 9:37 am

As others have mentioned, there are two routes to take.

#1. Your school district. Has your child been evaluated by your school district. If not, please contact them to have your child evaluted. They normally have 30 days to do this. Do not let them tell you they cannot because of summer break, although some states may have different rules. In your child's IFSP,--IEP once your child turns 3, you could ask for summer therapy services through your school district. However, even schools are getting particular about this. And I'm not sure how intensive the services would be during the summer. It would basically be enough so that there is no regression when the child starts playgroup/pre-school/school, etc.

#2. Medical. We've done this route also. The doctor typically writes a letter/documentation for therapy, etc. The therapist contacts the insurance company to make sure it will be covered, etc. However, we had an actual diagnosis. There's none of this you paying for it and submitting your own bills to the insurance. That's just crazy! I'd be leery of any therapist who said this. I would wait until you have a proper diagnosis and then move forward with treatment you decide upon. Typically a developmental pediatrician can give a "proper" diagnosis, but the wait times to see them can be months.

Also, now would be a good time to check your insurance benefits. Actually find the documents and read through. I know autism is now covered under our insurance, so possibly it is covered under yours also. I'm not sure about speech therapy services covered under medical though. Therapy may need to be piece-mealed--some through medical and some through educational.

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dcw213
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Re: Submitting Insurance Claims for Toddler Special Needs Therapy

Post by dcw213 » Tue Jun 11, 2019 10:19 am

Thank you very much for the responses, this has all been very helpful. One detail is that our son is not 3 for another 7 weeks or so which seems to be a milestone that the school district advised to wait until. I will do some more research based on this guidance, thank you again.

shorty313
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Re: Submitting Insurance Claims for Toddler Special Needs Therapy

Post by shorty313 » Tue Jun 11, 2019 1:15 pm

dcw213 wrote:
Tue Jun 11, 2019 10:19 am
Thank you very much for the responses, this has all been very helpful. One detail is that our son is not 3 for another 7 weeks or so which seems to be a milestone that the school district advised to wait until. I will do some more research based on this guidance, thank you again.
We were advised by EI to start the paperwork 3 months before he turned three, it takes a while to churn through the system.

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