Insurance OUTRAGE **UPDATE — The Bump
Special Needs


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edited February 2014 in Special Needs
I just wanted to update this post in the event others are going through the same insurance headaches. The health care advocate rep called me two days ago to let me know that my son's speech therapy WILL be covered. She can't fully explain what happened but it appears the initial claim denial was put through on a different code. Fast forward to now and SO far, all of his sessions have been covered at 90%. She said the code was changed to a medical diagnostic code (Chronic ear infections) I don't fully trust that everything will continue to be covered but for right now, in this moment, I will do a happy dance. Moral of the story: Do NOT take no for an answer!!!!

Need to vent. Early in December, my company's healthcare concierge (middleman/advocate) did some legwork and told met DS' speech therapy evaluation AND services would be covered. They gave me a list of providers. I found a great place from the list. The office manager told me the pre-auth went through and I should be good to go. Fast forward to today and a phone call saying "Sorry but unfortunately Aetna has denied coverage."
I immediately called our advocacy hotline. They are at a loss as well. I haven't gotten a straight answer yet. He saw a different private speech therapist in the fall and both sessions went through Aetna and were fully covered. Who knows, it could be a bad diagnostic code, a simple clerical error but I'm not so sure. I'm now looking at $75 per 30min session 2x a week. That's a big chunk of change each month. I went the private route because EI services are on a sliding scale here in NJ and I would have to pay $101 per session. I will pay whatever I have to pay to help my boy but I am just so frustrated that it costs SO much to get him the help he needs. 
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Re: Insurance OUTRAGE **UPDATE

  • It is really frustrating. We got denied speech because it is not 'medically necessary'. If we went the ACC route they would probably fork over the 8 grand needed for a device. It makes no damn sense.
    WAY 2 Cool 4 School

  • Thanks ladies. It sounds like the speech therapist we are using now used a different diagnosis code which was denied. I don't understand why they can't use the code the previous therapist used (the code that worked) The "advocate" told me that each provider uses a different coding system. They are going to appeal it for me. I am just so fed up. They told me not to lose hope just yet but it doesn't really sound too hopeful.

    On the bright side, his therapy sessions are going well. The first couple of sessions he didn't want me to leave, had a meltdown and barely made a peep the entire time. Yesterday, he walked right into the office and didn't even look back at me. He had a blast playing with the therapist. He didn't want to leave. He also had a new word this weekend..."nanas" for bananas. I need to stay focused on the goal which is to help him.  The rest will work itself out. Thanks for listening to me.

    BabyFruit Ticker
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  • How frustrating. Here's hoping they win the appeal or just change the code so you don't have to worry about this any more.

  • How frustrating!  Insurance drives me crazy.  It took 8 months before they would approve DS2 for a speech evaluation.  He was only slightly behind at the start but 8 months later he was really behind.  Our pediatrician fought with them because he is a huge advocate for private therapy.  After multiple letters and phone calls it was finally approved.

    Samuel  2.26.06 41w ASD/ADHD
    Eli  6.18.09 35.5w
    Silas  1.25.13 35.4w 10 days NICU, allergies/asthma, gluten intolerant

  • Oh gosh I 'm so sorry.  I feel your pain- I've got Aetna too and have had similar challenges with them denying coverage based on stupid errors.  Yes, ultimately it gets resolved, but they do not understand the stress they put us under.

    Hopefully it'll turn out to be another stress-inducing error and you can get the help you need for your little guy.
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  • malcivar- Thanks. Aetna is infuriating. I just don't understand why one therapist got it approved, and another was denied. It should not be this hard.
    BabyFruit Ticker
  • Thanks. The new therapist is in network. I think I am more angry at the health care advocate my company uses to help us navigate insurance issues. I spent two hours on the phone with them weeks ago ensuring that this would be covered. They saw the code used by his previous private in-network therapist and said his services would be covered. I was incredulous at the time but I trusted them. I am just hoping this can be worked out. 
    No matter what I will pay the $600/month if necessary. I'm already encouraged by his progress after only 4 sessions. He seems to be enjoying it and his therapists have been so encouraging to both of us. 
    BabyFruit Ticker
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