Insurance denials

iVillage Member
Registered: 09-17-2011
Insurance denials
5
Sat, 11-05-2011 - 10:09pm
Has anyone had any issues with continued denials for payment by insurance company for PT, OT and ST? This is very distressing! any ideas or info is greatly appreciated. They are saying developmental delay is a chronic condition that they will not cover.

Mir
iVillage Member
Registered: 12-11-2006
Sun, 11-06-2011 - 12:14pm

we had it denied several times over the years but we always appealed and had it reversed (my husband, who carries the insurance, works for the small company and the human resource person is the most helpful and always fighting for us with the insurance broker to get the straight answer why we've bee denied and what to do to get approved)

when we've been denied we usually had to change diagnosis for the more specific one like: apraxia or language disorder for SLP; motor planning (dyspraxia) for OT/PT and such; you can check with the insurance (although they are not quick to offer that to you) for the list of covered diagnosis codes and then check which of the conditions is the one experienced by your child and have the doctor or therapist use this code when billing; you may also need to ask your doctor to change the diagnosis on the referral or to write the medical necessity letter;

I hope that helps,

iVillage Member
Registered: 06-08-2010
Sun, 11-06-2011 - 8:14pm

We are very limited.

iVillage Member
Registered: 09-17-2011
Sun, 11-06-2011 - 10:47pm
I didn't think to speak to my HR rep. . . I'll start there for sure. I've appealed and they just did a denial of appeal. Mia is 8 months old and I know the therapy is important she's made such progress in the last 4 months I can't imagine not takin her but we're going through our savings at a break neck speed and I cant forsee keeping up paying out of pocket for all her therapy. Thank you for the tip of group therApy I didn't even know that was an option. Definetly have to look into that to cut cost as well. I live in Miami FL will check and see if there are established groups here. Thank you ladies so much . . .
Avatar for jessthemom
iVillage Member
Registered: 03-26-2003
Fri, 11-11-2011 - 2:03am
You can also ask your insurance company if they have Case Management. We are in Case Management with both of Madison's insurance companies (one private and the secondary is the state coverage). So I have one nurse that works for the insurance company that helps guide me through what is covered and what isn't. They both also fight for us when we need to have anything appealed. For instance, Madison needs to receive Syntagis shots this winter to help protect her lungs from RSV due to her weak lungs and heart condition, the case manager for both companies worked on the appeals to get her approved for the shots (about $1000 each) and for home health to come into the home and deliver the shots so we don't have to go to the office and be exposed to germs.

Also if this is the therapy provided by Early Intervention they have different ways to bill to get you more services. Also like Ania said, can the therapist be more specific about the diagnosis to help coverage kick in.

Hugs and I am hoping you see some thing change for the better quickly!
iVillage Member
Registered: 04-04-2011
Tue, 11-15-2011 - 10:51am

you should be able to get therapy through your state. In CA we have california children services, which cover all therapy if your child qualifies as needing the help. Also, your local early intervention services should be of great help.