Thursday, February 11, 2016

Getting insurance companies to pay for children's therapies: 9 hacks

I've previously covered ways to get the insurance company to pay for your child's therapies, including these tips and the time I was just joking about cc-ing God. (Not to mention my fed-up-with-insurance-companies posts, like this.) I've got new hacks, inspired by some recent success with my insurance company, tips from Facebook readers and one seemingly genius hack shared by reader/parent Dale McCarthy (who just started Respect for All Abilities, which offers customized school disability awareness programs). Here's how to get reimbursed for a child's speech therapy, occupational therapy, physical therapy, ABA therapy and more. 

Find a point person
At our current insurance company, there are no case managers you can be assigned to. But I did find one truly competent and nice supervisor who I could reach out to for help with claims that weren't paid. The next time you're fighting a claim, ask for a supervisor; if he or she knows what they are talking about (not always the case), either get their phone number or ask if you can request them. And then, going forward, either call them when you have a claims issue or get a message to them to call you so you don't waste your time with clueless representatives. As reader Teresa Brown says, "Often the people who answer the phone are the least experienced and knowledgeable, or their authority is limited."

Do it their way
It's simple but something that's easy to forget amid the bazillion other things you have on your plate: Submit claims exactly the way the insurance company wants you to. "Follow the (exquisitely detailed) instructors to the letter—they're often in your statement of benefits or the insurance company's website," notes reader Amber Kay. "Physicians' authorizations must be signed in BLUE ink. Use paper clips NOT staples. Whatever."

Use a different code
The CPT (Current Procedural Terminology) code are the numbers speech, occupational and physical therapists (among others) put on bills for treatments done during a session. If you're getting denied for one code, talk with the therapist about trying a different one on subsequent bills. If that therapist doesn't know, see if she can ask colleagues. Recently, I asked therapists to change the ICD (International Classification of Diseases) code—aka diagnosis code—on our bills. They'd been using "stroke." When we changed it to "cerebral palsy, unspecified" the speech bills previously denied were put through.

Emphasize medical necessity
When speech sessions have been denied, I've had Max's neurologist and pediatrician write letters of medical necessity explaining that oral-motor therapy (part of speech sessions) are a medical necessity to help prevent choking. "For speech, we often use the idea that the child can't communicate hurt or illness as a medical necessity, especially if they have medical diagnoses that are relevant," says Evana Sandusky, a pediatric speech language pathologist and mom of a child with Down syndrome. "I have also used medical necessity if the child can't give basic info like name, age or parents name in case they get separated or lost."

Know your rights
The majority of states now have insurance mandates for autism, meaning they require certain insurers to provide coverage for autism spectrum disorder. Specifics vary between states. See the list of states here and what their plans entail.

Try, try again
If your child was denied a therapy session for lack of medical necessity, ask your child's therapist and doctors to write letters of medical necessity. Include notes from sessions as well. If your child gets therapies at a hospital, see if there is a social worker who works with patients on healthcare insurance and if so, get her to guide you. You can also reach out to the Patient Advocate Foundation, a nonprofit that handles health insurance appeals for free; reach them at 800-532-5274.

And then there's this
While I can't vouch for this strategy as I haven't tried it, it seems worth a shot if you have gotten nowhere.

Keep track
"Keep good notes: date and time of call, name of person, title/dept. and what you were told," says Teresa. "The devil really is in the details."

Doctor doesn't even accept insurance?
"Ask if the office if they are associated with a clinic or office that does accept insurance," recommends reader Shannon Luhrs. "That way, you can see the people you want to see and bill through the associated office."

"Wine. Maybe vodka."
That's the winning tactic reader Marla Huseman Grace recommends for dealing with insurance companies. Cheers!


  1. If only insurance companies covered therapies that look like they benefit autistic people and actually do.

    1. What did you have in mind, Anna?

    2. The term "ABA" is a trigger for many autistic people. This leads to the ABA controversy. Many therapists call their practice ABA so insurance companies will cover the cost, so when parents bring up the term to refer to their child's therapy, it sparks outrage amongst autistics. I don't know why insurance companies favor covering ABA, but this bias is real and rather problematic.

  2. Whenever you post pieces like this, I am ALWAYS thankful for the Medicaid waiver in my state, as it picks up the coverage when the insurance companies say no and/or only cover part (including co-pays). The waiver is harder and harder to get/keep, unfortunately, and there are lots of ongoing fights for this, but I still encourage parents of kids with disabilities to see if their states offer it (TEFRA, Katie Beckett, whatever the state may call it - it is based on medical need/level of care and is intended for those who financially would not qualify for SSDI) and to seek out experts/classes on how to apply/renew, because if you can get it, it is HUGELY helpful.

  3. Sharing a Facebook comment a doctor friend left (thanks, Dina!): Excellent. Remember ICD codes changed completely last October. Numbers and verbage. Even diabetes isn't diabetes and I find myself searching for what should be obvious. BUT all these codes are accessible on line. It helps to be familiar going into the appointment knowing what codes are available

  4. These are all such awesome tips! My daughter got denied for feeding therapy with a speech therapist last year and by the time we went through the entire process of getting them to cover it, she started eating fine on her own. While we're glad she didn't need it, it's such a long process to go through!


  5. I think waivers are also useful. We're in the process of seeing if Noah is eligible for at least one.

  6. We are so frustrated by our insurance. Our son has severe apraxia. He didn't say mom until he was over 3.5 years old and just recently started saying his own name. Our insurance will only cover 60 sessions per year...unless he is autistic. He has a numerological condition that can effect his speech more than a child with autism but we can't get the same coverage. I can't help but think it's discrimination.


Thanks for sharing!

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