Tuesday, March 27, 2012

The Hassles of Therapy

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We have been attempting for almost a year now to get Ayden some occupational and speech therapy outside of the school setting.  To say it hasn't been going well may be a mild understatement.

Speech Therapy
After looking all over our area for a speech therapist that took insurance, we finally found one at Sparrow Pediatric Rehabilitation.  Then called and found the waiting list was six months.  SIX MONTHS.  We were lucky enough to get him in a bit early though, and last September had (yet another) speech evaluation done.  Every time we do this process we have to have another evaluation done.  Mind you, it's the exact same evaluation every.single.time.  It's difficult on Ayden, even more difficult on us and frankly it's a waste of my time when they could just look at the results of the previous one done.  But I digress.  We completed the evaluation and had to wait another 4 weeks for the "analysis" from the SLP who then sent her recommendations for therapy to the insurance company and to us.  I did not expect any difficulties as we have up to 36 visits per calendar year covered for speech therapy in our insurance plan.  In yet another setback though...the claim was denied.  In true Blue Care Network of MI fashion, speech problems that are a result of a developmental problem such as Autism or Fragile X are listed as a specific exception in the "fine print" of our insurance policy. I shouldn't have been surprised, but I was.  We looked into countless other methods, but it simply comes down to the fact that we either make too much money or Ayden isn't bad enough to warrant farther help with medical expenses.  To pay out of pocket for therapy would cost us about $300-$400 for one hour - and they were recommending 2 sessions a week.  So we're at a dead end with this for now.  Thankfully, he is still receiving speech therapy in his ECSE classroom and we are doing all that we can at home.

Occupational Therapy
As with Speech, we were placed on a waiting list for Occupational Therapy too.  We finally received the call in January to come in for an evaluation, and then Ayden ended up being sick the day of his appointment.  The scheduling coordinator and I played phone tag for a while, then Emma was born, and finally we have a new date set for his OT evaluation.  The good news about this one is that we are already approved for at least 6 visits from the insurance company. At that time, they (the insurance company) re-evaluates, but I'll take the six hours for now.  Our evaluation is setup for April.  I am guessing therapy will begin sometime in May or June, which is perfect timing for Ayden being out of school.

Funny how just typing this up and talking about attempting to get Ayden the help he needs is making my head hurt.  I'm amazed at how even though there is a medical necessity for him, our insurance company can get away with not just denying service on a policy but EXCLUDING service based on a disability.  I think I picked a fantastic time for this post though, as Michigan has bills being voted on very soon (maybe even today) to include things like occupational, speech, and physical therapy into insurance plans for those with Autism.  Makes me feel a lot better knowing that the ball is rolling for change!

To read about the bills and autism insurance reform in Michigan, please visit http://www.michigan.gov/autism

1 comment:

  1. Have you tried having it billed ( the therapist would have to do this) under a different code? Instead of billing with the diagnosis code for fragile x see if it is covered under low muscle tone or some other comorbid condition. I met a mom a few years ago who wrote a book called Blessed by Autism in which she discusses how she got services for her kids covered even when they were first denied. The key is the billing code. I am sure most of her advice can apply to fragile x issues as well.