Wednesday, March 25, 2009

Insurance Woes...

I just read this post by Amalah and it made me weep.  Not just for her precious son Noah, but because it could so very easily be my son.  I realized that I am somewhat of a rookie in terms of what insurance companies make us go through to provide services that are so necessary for our kids.  As Moms it is our job to fight for them.  And of course after reading Amalah's post I am writing-shy because I will never be able to express the frustrations or annoyances in the amazing manner that she can.  But I am going to give it a shot because this is an issue that needs to be talked about.

I wrote back when The Boy turned three about how he graduated from SARC and now I was on my own paying for his individual speech therapy.  He did actually qualify for half an hour of speech therapy through his school district, which he is getting.  But I didn't want to pull him from his private therapy so I have been paying out of pocket for that and submitting the claims to the insurance company for reimbursement.  This is what we had done before we applied, and were accepted, to SARC and the insurance company had reimbursed us for like 80% of the amount.  The Boy's insurance is through The Ex, and fortunately she has great insurance, so I figured it would be a no brainer to do it again.  They had covered it before, so no reason to assume they wouldn't cover it now.  

I started submitting the claims in January right after his birthday and right when I started paying out of pocket.  I have been asking The Ex since then if we have received any checks (since it is her insurance, all checks are made out to her and sent to her) and she just kept telling me that she hadn't gotten anything.  I knew that we had a $250 deductible to meet so I figured the first month's payments were probably going toward his deductible (I pay $67 a week for his therapy so that first month alone would have taken us to our deductible).  So that would have accounted for January.  And you know, sometimes it takes them a while to process and get payments out, so I kept asking The Ex but kept "ignoring it" when she said she hadn't received anything.  Finally around the middle of March I realized something was going on.  I got the information from The Ex to access the website myself (needed her user name and password to gain access to it) and saw the dreaded phrase, "Need more information."  When I clicked through it said the claims were on hold because they needed "proof from a doctor that services are a medical necessity."  That statement was issued in the middle of January.  Everything has literally been on hold since then.  They haven't even been putting my claims toward his deductible.  It is all just stopped.  Pissed that I had let things sit this long and irritated that The Ex had not bothered to look into it at all, I started making phone calls.

I called the insurance company first and asked what specifically they needed.  The Boy has like 8 doctors.  I understood they wanted proof, but from where?  His pediatrician?  His gastro (who diagnosed his failure to thrive)?  His speech therapist?  "I will get you whatever proof you need, I just need to know what the hell that actually is," I told the insurance dude.  As usual, he was totally useless and just kept repeating to me that whatever doctor ordered the services needed to prove to them it was medically necessary.  And even if they could, there is still a chance that they will deny coverage.  Great.  So helpful.  I don't know who actually orders his services.  He has been in therapy since he was 12 months old.  He is three.  He gets assessed all the time, which is what shows that he needs continued services, but that has either been by his speech therapists, or by SARC, or most recently, by the state.  His pediatrician has been involved in the process in that he checks with him at his yearly appointment and agrees that he definitely does need services and that we are continuing to get them for him.  But that's it.  So where the hell do I start?

I called the office where he gets his speech therapy.  They are lovely.  There's a reason I continue to take him there.  I explained the situation to the receptionist who told me that sometimes it is as simple as having the pediatrician write out a prescription on his prescription pad saying that this is a medical necessity that he receives a half hour a week of speech therapy.  Or that sometimes the insurance companies will take a letter from the therapist themselves even though they are technically not a "doctor."  She says she will talk to his therapist, plus the head lady at the place and will come up with a plan, but in the meantime it can't hurt to call his pediatrician and see if they can write him a "prescription" for services.  I thank her profusely and hang up and call his pediatrician.  

They are also lovely (I told you we have great insurance) and told me they would leave the doctor a note and have him take care of it or call me with any questions.  They literally called me back like half an hour later and said it was done and that I could come by and pick it up right away.  They rule.  So I went and picked it up the next day and took it with me to The Boy's weekly speech therapy appointment.  I explained the situation to his therapist and showed her the note from his pediatrician.  It was very brief and just said his name and that he needed half hour a week of speech therapy and it was being provided by [speech therapist's name] and that it was a medical necessity.  His therapist didn't think that would be sufficient given her experience dealing with insurance companies.  She told me she thought we would need a more comprehensive letter talking about his oral difficulties directly affecting his lack of eating which leads to the failure to thrive diagnosis.  That made sense to me, so I held onto the letter from his pediatrician and waited for her to write up a letter putting all that other stuff together.

Friday of last week I got a message from her telling me she needed to get the information about what exactly his weight is and has been, and his current diagnosis etc. in order to put the letter together.  Makes sense, of course she does.  I have written down what he weighs when we take him in, but other than that I don't have the information at my fingertips.  So I needed to call his gastro doctor to get that info to pass along to his speech therapist.  This week has been crazy (eg: cousin in town and working all day Monday, spent all day yesterday at the hospital...) so today was the first chance that I got to call and request a copy of his records.  His gastro doctor cut me off before I could even finish asking the question and told me that I would have to go to their website and put in a request for medical records and then that would go to the medical review board and after everything had been approved, I would be able to access his records.

I just need his weight to tell his speech therapist, I thought to myself.  And that sounds like an awfully long process...  So I cut HER off and explained to her what I needed and why.  She then told me that I had probably filled out a release form when I enrolled The Boy in speech therapy and if they had that on file, then they could just directly fax a request over to the gastro and they would get the records the same day.  Yes, that was definitely the shorter of the two options and probably the easiest.  Great.  Okay, no problem.

So I called back his speech therapy office AGAIN and asked if he had a release form on file.  She said she thought we probably did, and she would pull his records to find out.  And if for some reason we didn't have one on file, she would leave it for me when I come to his regular appointment tomorrow and I could just fill it out.  Once they have that, they can directly request his records, get them to his speech therapist, who can start to put together the letter needed to send to his insurance company.  Jesus Christ, I am exhausted.

So let's recap.  I started paying $67 a WEEK on January 6th of 2009.  It is now March 25th of 2009 and I have been paying out of pocket for his speech therapy that entire time.  I first realized that the claims were being denied at the beginning of March (thanks, Ex) and we are still not even ready to send to his insurance the information they need.  And once we send it over, we have to A) hope that it is sufficient to show medical necessity and B) even if it is, hope that this is something they will cover.  Oh and add to that the minor little fact that I am about to have a baby ANY FRIGGIN' DAY NOW and that will undoubtedly delay the process even further and we are probably looking at sometime in June that we might, possibly be able to receive a reimbursement check.

In the meantime, I am shelling out over $250 a month of money that I DO NOT HAVE (hence the bed rest and no working thing) for him to get his therapy.  I consider canceling it all together because he IS getting some therapy paid for by the state (although I don't think it's as good as his current therapist and situation) and because, dear God, what good will his great speech do if we are living under a bridge?  But then I read the last line in that post by Amalah and I picture someone, anyone, possibly making fun of my precious boy because of the way he pronounces something and I swear that I will NEVER allow that to happen even if I have to sell my house and live in a van...down by the RIVER!!  Sigh...


qweirdutah said...

the only consolation I have is that insurance sucks all over. Sadly that isn't enough...for anyone.

AuntFancy said...

Jeez, what a big giant CF! Let me know if there's anything I can do to help!