In the reading homework of the studies that most insurance companies use to decide medical eligibility, I was shocked. Over and over again, the words “normal child” was used. The studies regarding therapies such as LOVAS, TEACH, PROMPT, LEAP, etc., it appeared that these therapies were often discouraged because the outcome was not of that of a “normal child”.
I cannot understand. If the assumption is that ASD is a lifelong disability as stated in the studies, why are we expecting an outcome of a “normal child”? Shouldn’t the expected outcome be that of less dependence? A chance to learn skills to be as independent as possible?
Maybe we are weird, but we have pretty much accepted that things will not be normal. With this diagnosis come a different path and set of expectations. While we absolutely still hope and push Little Bug to do his best, we have also changed our expectations. We want him to reach his full potential. We want him to be as independent as possible. We want him to have a life defined on his terms as successful.
It seems like information is missing from these studies. How many families were studied from the time the child was diagnosed into adulthood? Have we verified how many children who received any of the denied therapies were less dependent on adult care? Have we looked at how children grew into adulthood after these therapies and were able to have a job?
Showing posts with label Insurance. Show all posts
Showing posts with label Insurance. Show all posts
Tuesday, October 6, 2009
Wednesday, September 30, 2009
Insurance Update
This week, we got a little more bad news and some really good news. The bad- Little Bug's therapy will need to be reviewed every 25 appointments to verify that it is medically necessary. Based on their communication, this will be based off his records as well as clinical criteria- which is about a 25 page document that we need to read and understand.
The good news is that just about everyone involved in this situation messed up. The information provided to us was wrong again. This time, confirmed with multiple people as my company and our insurance company, we were told that he has unlimited visits for OT and speech based on the fact that he has a neuro-developmental clause.
We also found out that the insurance company wasn't paying attention to the fact that Little Bug was diagnosed with ASD. This in turned messed up the billing, which is why several hundred dollars of claims were denied.
This means, that our average monthly health bills will go from $1166.00 to $700.00 a month! This is wonderful!
The good news is that just about everyone involved in this situation messed up. The information provided to us was wrong again. This time, confirmed with multiple people as my company and our insurance company, we were told that he has unlimited visits for OT and speech based on the fact that he has a neuro-developmental clause.
We also found out that the insurance company wasn't paying attention to the fact that Little Bug was diagnosed with ASD. This in turned messed up the billing, which is why several hundred dollars of claims were denied.
This means, that our average monthly health bills will go from $1166.00 to $700.00 a month! This is wonderful!
Friday, September 25, 2009
&)#^%*# Insurance
Nick and I were given a nasty surprise in more ways than one from our insurance yesterday. Let me give you a brief outline of our insurance situation.
Our insurance premiums are $400 a month. Our co-pays are as follows:
• Regular doctor appointments: $25.00
• Specialist Appointments: $35.00
• Urgent Care: $75.00
• Emergency Room: $100.00
• Hospital Stay: $300.00
Additionally, we each get 60 visits to short term rehabilitation a year- part of the specialist bucket and cost $35.00 each. Originally, we were told that Little Bug’s OT would be considered short term rehabilitation, but not his speech. We were also told that we would need a referral for each service ($25.00 each appointment) every three months- to be sure he still needs the therapy- from his PCP. Also, they would need confirmation of diagnosis from his neurologist ($35.00 each appointment) as well as updated case information, every 6 months. Just to be able to have therapy, we are looking at $170.00 in co-pays.
We found out yesterday that we were misinformed and his speech is part of his short term rehabilitation visits. This means that we only have enough visits for 6 months a year. The co-pays for these visits total $2,100.00. After the six months, we will have to pay for speech and occupational therapy out of pocket. Our speech therapist’s rate is $145.00 and the OT clinic is $210.00. For a conservative estimate of 20 visits each, that will bring our out of pocket expenses to:
SPEECH: $2,900.00
OT: $4,200.00
Our total therapy costs for speech a year will be $3,950.00. Our total costs for OT a year will be $5,250.00.
One year of medical bills for items solely related to Autism is:
$9,200.00
This doesn’t cover a behaviorist. Even if Little Bug only saw a behaviorist once a month that would be another $1,200.00. If he saw them 4 times a month, $4,800.00. Our total medical bills for Autism would be between $10,400.00 and $14,000.00.
This doesn’t include home therapy supplies. This doesn’t include doctor’s appointment for things that happen because of his Autism- when he hurts himself because he doesn’t seem to feel pain, when he eats glass or like last night, scratches his actual eyeball when self injuring.
Nick and I are lost. We don’t know what to do. We will run out of visits for this plan year in February. Our visits will renew in April, and then run out again in October.
There is one side that wants to say, we need to set reasonable goals and just do the best we can. Fudge a little- every other week appointments for speech and OT to get them covered with more home therapy. Maybe see a behaviorist on a consultant basis only- think, in case of Autism emergency break glass.
The other side of us says that we should sacrifice everything. Give up our jobs, apartment, and current lifestyle, move in with our family who has so graciously offered, and get it done. Again, this is a huge risk. We don’t know what we would qualify for in terms of assistance. We don’t know if Nick would be able to find full time work we are considering moving as it is a severely economically depressed area of Washington. We know that the area is much more conservative and this will create a whole new set of difficulties for Little Bug and our family.
Bottom line, this is with insurance. Total bills, including premiums, co-pays, and out of pocket expenses for just Speech and OT a year is $14,000.00.
I am assuming that this is normal or even low. Most people don’t put these numbers out like this. I know- its taboo to discuss money. But you know what? If people don’t discuss it, it will never change. People need to see the raw numbers. The debt. The choices faced. We are left wondering what enough is. What is enough for us? What do we do for Little Bug? How do we make this right?
I am certain we aren’t the only ones facing this. Unfortunately, I don’t have the answer. I don’t have a solution.
Our insurance premiums are $400 a month. Our co-pays are as follows:
• Regular doctor appointments: $25.00
• Specialist Appointments: $35.00
• Urgent Care: $75.00
• Emergency Room: $100.00
• Hospital Stay: $300.00
Additionally, we each get 60 visits to short term rehabilitation a year- part of the specialist bucket and cost $35.00 each. Originally, we were told that Little Bug’s OT would be considered short term rehabilitation, but not his speech. We were also told that we would need a referral for each service ($25.00 each appointment) every three months- to be sure he still needs the therapy- from his PCP. Also, they would need confirmation of diagnosis from his neurologist ($35.00 each appointment) as well as updated case information, every 6 months. Just to be able to have therapy, we are looking at $170.00 in co-pays.
We found out yesterday that we were misinformed and his speech is part of his short term rehabilitation visits. This means that we only have enough visits for 6 months a year. The co-pays for these visits total $2,100.00. After the six months, we will have to pay for speech and occupational therapy out of pocket. Our speech therapist’s rate is $145.00 and the OT clinic is $210.00. For a conservative estimate of 20 visits each, that will bring our out of pocket expenses to:
SPEECH: $2,900.00
OT: $4,200.00
Our total therapy costs for speech a year will be $3,950.00. Our total costs for OT a year will be $5,250.00.
One year of medical bills for items solely related to Autism is:
$9,200.00
This doesn’t cover a behaviorist. Even if Little Bug only saw a behaviorist once a month that would be another $1,200.00. If he saw them 4 times a month, $4,800.00. Our total medical bills for Autism would be between $10,400.00 and $14,000.00.
This doesn’t include home therapy supplies. This doesn’t include doctor’s appointment for things that happen because of his Autism- when he hurts himself because he doesn’t seem to feel pain, when he eats glass or like last night, scratches his actual eyeball when self injuring.
Nick and I are lost. We don’t know what to do. We will run out of visits for this plan year in February. Our visits will renew in April, and then run out again in October.
There is one side that wants to say, we need to set reasonable goals and just do the best we can. Fudge a little- every other week appointments for speech and OT to get them covered with more home therapy. Maybe see a behaviorist on a consultant basis only- think, in case of Autism emergency break glass.
The other side of us says that we should sacrifice everything. Give up our jobs, apartment, and current lifestyle, move in with our family who has so graciously offered, and get it done. Again, this is a huge risk. We don’t know what we would qualify for in terms of assistance. We don’t know if Nick would be able to find full time work we are considering moving as it is a severely economically depressed area of Washington. We know that the area is much more conservative and this will create a whole new set of difficulties for Little Bug and our family.
Bottom line, this is with insurance. Total bills, including premiums, co-pays, and out of pocket expenses for just Speech and OT a year is $14,000.00.
I am assuming that this is normal or even low. Most people don’t put these numbers out like this. I know- its taboo to discuss money. But you know what? If people don’t discuss it, it will never change. People need to see the raw numbers. The debt. The choices faced. We are left wondering what enough is. What is enough for us? What do we do for Little Bug? How do we make this right?
I am certain we aren’t the only ones facing this. Unfortunately, I don’t have the answer. I don’t have a solution.
Friday, August 7, 2009
An Interesting Letter
Let me tell you, our adventures with our insurance company our never boring. They are full of interesting correspondence- back and forths about Speech Therapy, Face lifts, and OT and whether they are *really* needed.
Yesterday took the cake. In June, my neck was broken by Little Bug. I was taking a bath and he wanted to get in. So, with no intent of harm, he jumped over the side of the bathtub and landed on my upper chest, driving my neck into the edge of the bathtub. The force of this jump caused a small fracture in one of my vertebrae.
I went to the urgent care and received x rays and some pain medication. I went over the cause of the injury several times. It was clearly documented that it was a harmless accident and not a big deal.
Imagine my surprise yesterday when I received a letter from my insurance company stating that they had reviewed my injury and had asked a law group to review my claim to see if “another party involved in the accident should be held responsible for your accident and help pay for your medical costs.” They provided several forms that needed to be filled out in order to avoid “complication with your claims”.
I appreciate in this situation; it was probably a miscommunication on the part of the doctors and insurance company- in that they didn’t communicate as the record of the claim filed reflects that this was an accident in my own home while taking a bath.
I thought of the families with older autistic children who had injured someone- people who are considered adults. There have been several articles surrounding the subject of adults with Autism who have hurt someone. Would an adult child with Autism have been held accountable? When we first meandered onto this path called Autism, I would have thought no, of course not! After reading about people being arrested at the age of seven at school for biting a teacher, held in federal prison for killing their parent, and more examples than I can provide, I know these things are no longer let go.
I have to admit that I am scared for when Little Bug goes to school as he self injures and injures others when he isn’t understood or lacks a way to communicate his needs. The little girl who was arrested- over a tussle about a sweatshirt which ended in her kicking and biting a teacher- was in Washington.
Often times, the reaction to behavior can be extreme- like arresting a 7 year old or seeing if a 3 year old can be legally held responsible for an accident. Another example is found in the video link below- be warned, it is extreme.
http://www.cnn.com/video/#/video/us/2009/07/10/boudreau.behind.school.walls.cnn?iref=videosearch
Yesterday took the cake. In June, my neck was broken by Little Bug. I was taking a bath and he wanted to get in. So, with no intent of harm, he jumped over the side of the bathtub and landed on my upper chest, driving my neck into the edge of the bathtub. The force of this jump caused a small fracture in one of my vertebrae.
I went to the urgent care and received x rays and some pain medication. I went over the cause of the injury several times. It was clearly documented that it was a harmless accident and not a big deal.
Imagine my surprise yesterday when I received a letter from my insurance company stating that they had reviewed my injury and had asked a law group to review my claim to see if “another party involved in the accident should be held responsible for your accident and help pay for your medical costs.” They provided several forms that needed to be filled out in order to avoid “complication with your claims”.
I appreciate in this situation; it was probably a miscommunication on the part of the doctors and insurance company- in that they didn’t communicate as the record of the claim filed reflects that this was an accident in my own home while taking a bath.
I thought of the families with older autistic children who had injured someone- people who are considered adults. There have been several articles surrounding the subject of adults with Autism who have hurt someone. Would an adult child with Autism have been held accountable? When we first meandered onto this path called Autism, I would have thought no, of course not! After reading about people being arrested at the age of seven at school for biting a teacher, held in federal prison for killing their parent, and more examples than I can provide, I know these things are no longer let go.
I have to admit that I am scared for when Little Bug goes to school as he self injures and injures others when he isn’t understood or lacks a way to communicate his needs. The little girl who was arrested- over a tussle about a sweatshirt which ended in her kicking and biting a teacher- was in Washington.
Often times, the reaction to behavior can be extreme- like arresting a 7 year old or seeing if a 3 year old can be legally held responsible for an accident. Another example is found in the video link below- be warned, it is extreme.
http://www.cnn.com/video/#/video/us/2009/07/10/boudreau.behind.school.walls.cnn?iref=videosearch
Wednesday, February 11, 2009
Which really is the lesser of the two evils?
It’s that time again- open enrollment for benefits- and we are stuck between a rock and a hard place. On one hand, we can keep the policy we have which means that every month we will have $280 of co-pays for Speech and Occupational therapy alone. On the other, we can go with a different policy that will require us to pay a $300 deductible and then be done with it. Sounds like the logic solution, right?
It gets tricky when you start looking at anything else besides Little Bug’s therapy. Anyone who knows me knows I like to be prepared. I also am a worrier. Having Little Bug in my life has done a lot to assuage my worry- I am more in the moment. At the same time, it has also made me a better long term planner as we have to continuously look to the future and make decisions today for where we hope to be.
Sometimes, looking to the future can include planning for an unforeseen incident. With the second insurance option, we will have to pay 10% of any hospitalization, lab work, X rays, ambulance rides, prescription, rehab, surgery, etc. Given Little Bug’s medical track record- 4 CT scans, 3 MRI, 2 sets of x rays, 1 day surgery, 1 face lift that involved 3 surgeons, 2 anesthesiologists, 5 nurses, and a neurosurgeon, 16 trips to the emergency room, 7 trips to Urgent care, and so many doctor’s appointments we can’t count, it seems like a bad bet.
While both choices are expensive, at least one is certain- finite amounts for any situation- where as one is 10% of any number of unforeseen expenses. All it would take is a couple of ER trips, to make us financially doomed. For now, we will have to go with the lesser of two evils.
What neither of these policies cover is the additional therapy and supports that Little Bug needs- a behaviorist. Again, for this we are stuck between a rock and a hard place. Our first choice is paying someone roughly $100.00 an hour to come in 4 times a month to work with us and Little Bug on things that affect his home life. The second option is a much bigger immediate investment- parent training. Now both sides have their costs- the first is sheer financial to the tune of $4800 a year. The second is limitation. We cannot afford to pay for training in more than one type of therapy- ABA, Floortime, Rapid Prompt (pick one). Secondly, it is limited in that it would only be our input in the therapy. Nick and I are not experts in much besides Little Bug. There comes a time when you have to have outside influence and perspective in order to see the whole situation and make good choices.
We also have one other option that we are contemplating- working with what we have. Simply doing the best we can with the knowledge we have and using a behaviorist only as a last resort. For me, this causes feelings of guilt and worry. Am I considering this because of finances only? If we skip either of the other options, will Little Bug be missing resources? Can we do it ourselves? I know that Nick and I have read volumes of books when it comes to ASD and home therapy solutions. We have resources in the online community that have been amazing to us.
I think for now, we will have to take a leap of faith and trust that we can do this.
It gets tricky when you start looking at anything else besides Little Bug’s therapy. Anyone who knows me knows I like to be prepared. I also am a worrier. Having Little Bug in my life has done a lot to assuage my worry- I am more in the moment. At the same time, it has also made me a better long term planner as we have to continuously look to the future and make decisions today for where we hope to be.
Sometimes, looking to the future can include planning for an unforeseen incident. With the second insurance option, we will have to pay 10% of any hospitalization, lab work, X rays, ambulance rides, prescription, rehab, surgery, etc. Given Little Bug’s medical track record- 4 CT scans, 3 MRI, 2 sets of x rays, 1 day surgery, 1 face lift that involved 3 surgeons, 2 anesthesiologists, 5 nurses, and a neurosurgeon, 16 trips to the emergency room, 7 trips to Urgent care, and so many doctor’s appointments we can’t count, it seems like a bad bet.
While both choices are expensive, at least one is certain- finite amounts for any situation- where as one is 10% of any number of unforeseen expenses. All it would take is a couple of ER trips, to make us financially doomed. For now, we will have to go with the lesser of two evils.
What neither of these policies cover is the additional therapy and supports that Little Bug needs- a behaviorist. Again, for this we are stuck between a rock and a hard place. Our first choice is paying someone roughly $100.00 an hour to come in 4 times a month to work with us and Little Bug on things that affect his home life. The second option is a much bigger immediate investment- parent training. Now both sides have their costs- the first is sheer financial to the tune of $4800 a year. The second is limitation. We cannot afford to pay for training in more than one type of therapy- ABA, Floortime, Rapid Prompt (pick one). Secondly, it is limited in that it would only be our input in the therapy. Nick and I are not experts in much besides Little Bug. There comes a time when you have to have outside influence and perspective in order to see the whole situation and make good choices.
We also have one other option that we are contemplating- working with what we have. Simply doing the best we can with the knowledge we have and using a behaviorist only as a last resort. For me, this causes feelings of guilt and worry. Am I considering this because of finances only? If we skip either of the other options, will Little Bug be missing resources? Can we do it ourselves? I know that Nick and I have read volumes of books when it comes to ASD and home therapy solutions. We have resources in the online community that have been amazing to us.
I think for now, we will have to take a leap of faith and trust that we can do this.
Wednesday, January 28, 2009
Today's the Day
On a state and national level, today is a major day for Autism. Many decisions will be made- some specific to Washington regarding a minimum insurance coverage for all families and on a national scale, specific to IDEA, EI, and tons of other services for people with disabilities.
On a personal note, the ball has started rolling for Little Bug's placement to school. This means that I am going to be reading a lot about Wrightlaw and IEPs. It sounds like the process will culminate in April with an IEP meeting, but will include the following steps:
On a personal note, the ball has started rolling for Little Bug's placement to school. This means that I am going to be reading a lot about Wrightlaw and IEPs. It sounds like the process will culminate in April with an IEP meeting, but will include the following steps:
- A home meeting with the Director of Special Education to map out Little Bug's process
- Evaluations at ChildFind
- An evaluation meeting
- An IEP Meeting
Nick and I are really excited because our favorite therapist A will be coming to the last to meetings with us. Our FRC will be coming to the first two, which is also really exciting.
Saturday, November 22, 2008
Insurance
We all know that Insurance and Autism put together usually equals the following for many families:
- Debt, debt, and more debt- as many therapies aren't covered. One aspect that I think doesn't always get press is that even when it is covered, the sheer volume of co-pays due to the number of visits necessary is astronomical
- Stress- Families often spend a lot of time fighting with the insurance companies. I know that when it comes to ASD, I have had to get my employer involved as our insurance company gives us nothing but contradictory information and unclear advise.
- Denials- It is all too common to have claim after claim denied, even when you have insurance and have played by all the rules.
Personally, our company has a nuerodevelopmental clause on their policies which require our Insurance Provider to cover the cost of 36 visits a year. Additionally, there is no age limit on that.
Some of you may have noticed that the number I said was 36 visits- total for all specialists for an entire year. Once Little Bug starts going to speech therapy, he will use those up in 4.5 months. That leaves us with 7.5 months to pay for out of pocket- and we have insurance. We have good insurance.
I bring this up because of the following article:
http://www.chicagotribune.com/news/local/chi-autism-coverage_21nov21,0,4253235.story
I was so excited to hear about this and am hopeful that it will pass for them. I was also shocked by one particular section-
Further, Sen. Dale Righter (R-Charleston) argued the measure would cause the number of people diagnosed with autism to grow, therefore increasing premiums for other policy holders."I am not willing to place at risk a much larger group of people who might lose their health insurance through their employers in order to deal with this issue in this manner," Righter said.
First off, have any studies been done to show that states that mandate coverage for Autism have a dramatic jump in the number of children getting diagnosed? Maybe I am being naive, but I find it hard to believe that tons of people would go through the trouble to trick doctor's into diagnosing their children with Autism so that they can take advantage of this policy. Secondly, lets do the math to figure out the amount per person this would increase premiums:
4500- that's the number of families that qualify
36000- that's the coverage limit
12831970- that was the estimated population in 2006
$12.62 is the average increase per person. I could hang with that. In fact, I am sure that we do all the time. Every time an insurance company adds a coverage that wasn't previously offered, that trickles down to our premiums.
Friday, November 7, 2008
Insurance in California
The link below goes to a story about Feda- a mother of a child who is severely affected by Autism- who has taken on Kaiser through an Independent Medical Review and was granted her requested treatments.
Please read the article and watch the videos. It seems that the crux of the question as to whether an insurance company covers items such as ABA therapy, speech pathology or occupational therapy is whether those services are deemed as "educational" or "medical".
http://abclocal.go.com/kgo/story?section=news/health&id=6493262
Please read the article and watch the videos. It seems that the crux of the question as to whether an insurance company covers items such as ABA therapy, speech pathology or occupational therapy is whether those services are deemed as "educational" or "medical".
http://abclocal.go.com/kgo/story?section=news/health&id=6493262
Subscribe to:
Posts (Atom)