Medical Assistance insurance hearing (PA) - advice?
WYEngTeacher
member
Hi everyone. First of all, we live in PA, and I know all this differs so much by state. Background: My DD has apraxia of speech and our primary insurance completely denied us any speech therapy coverage, so we finally obtained medical assistance based on medical need (sometimes called Katie Beckett waiver) last summer. That was great for three months until Gateway (the actual ins. company) decided to deny us continuing speech therapy as well. They state that my DD "already receives adequate services from other providers". By this, they must mean the LIU (like the school system), which does receive funding from MA, but I was always told that that should NOT affect my ability to use the MA for private speech therapy.
Long story short, I have a face-to-face hearing tomorrow to appeal this decision. I don't have a lawyer... just my prescription for speech & language "5 times per week" and her evaluation report with diagnoses from her developmental pedi at Kennedy Krieger Institute (Johns Hopkins).
Anyone face a similar situation or have advice??? Thanks!
ETA: We do also take her to another private SLP, which we pay for 100% out of pocket, as they don't accept the MA (and, as mentioned, primary ins. denied coverage). I suspect they will try to hold that against us because between that and the LIU, she gets speech 3x a week (the place I went to using Gateway was the fourth day). However, I don't see how they can hold that against us seeing as we are completely paying for it out of pocket and no ins. is picking it up. I mean, I could take her there 10x a week if I wanted and it still shouldn't be any of their business, right?
Re: Medical Assistance insurance hearing (PA) - advice?
Thanks for the informative reply! Just a quick update - the hearing turned out to be quite interesting and it looks like we might win afterall. Turns out that Gateway is claiming DD receives private therapy TWO days a week funded by our primary insurance. Couldn't be more inaccurate. As I said in OP, we've never had a single speech therapy session paid for by primary ins., and DD goes to private therapy just one day a week (paid for out of pocket). I have no idea where they got that info, and Gateway's medical director (who was present via conference call) couldn't even say where she got it. This was obviously a huge fact to dispute, and the medical director acknowledged that if what I state is true, she will probably change her decision! Their lawyer requested a two week extension to look into the matter, and as soon as I got home, I faxed the judge and Gateway's lawyer three different letters of denial (from various appeals) for coverage from our primary insurance. She did say that they cover speech therapy and don't deny that Ava needs this service, they just didn't want to pay for it if she already had speech 4 days a week, 2 covered by ins.... which obviously is not the case
We'll see what happens next!
Update: I won and they are immediately resuming covering speech therapy. I should be totally happy about this (and at the end of the day, of course I am), however I can't help but be LIVID that my daughter has been unjustly denied therapy for the past 4 months. I can't tell you how many countless hours I spent on the phone with asinine customer service reps trying to get this straightened out before having to go the the length of requesting this hearing. NEVER at any point did ANYONE tell me the real reason we were being denied (that supposedly our primary insurance was paying for speech therapy), or this could have been resolved so much more easily and quickly. They are claiming that a secretary at the speech therapy provider that MA covered is the person who "told" them that we were going to another provider paid for by primary insurance. When I called that secretary, she said she never would have said that because they would have no knowledge of what my insurance does or doesn't pay for elsewhere. I totally believe this secretary, and I think that the bottom line is that she told them we were receiving therapy from another provider, at which point they "filled in the blanks" with the incorrect assumption of insurance paying for it.
Sorry for the rant. I am just so livid! What a waste of many hours of my life - and what would've been many hours of valuable therapy for my child - all because of incompetent people.
/vent.
Okay, I'm not done. ETA: Just found out that we have to re-start over on the waiting list for therapy, so now it will be another 3+ months until she can even start. So make that 7+ months of lost critical therapy time for my DD.
I've been meaning to reply to your PM...thanks for your response!
The only other place I know of in the area that takes the MA is leg up farm, &?aca is currently #28 on their waiting list 5+ months). I have inside info that one if the 2 SLPs at the hospital is quitting at the end of march, so realistically our wait there will probably be more than 3 months. Is there anywhere else you know of that takes MA without having to drive an hour? my latest lead is that I learned I may be able to get Gateway to provide reimbursement for an out of network provider if none are available within a reasonable amount of time...