How are we supposed to provide additional therapies?

mommyof4boys · January 2009

I called the insurance company to ask about additional therapies for Matthew and for Christopher and they said that basically if it were something like a cleft palate, etc that it would be paid for but articulation delays and developmental delays don't qualify a child for additional private therapy.

We were told to look into additional outside therapies for each of them and we can't afford OOP therapies.

akimbo · January 2009

ugh - that's cr@p.

Is the insurance company saying that they think the boys have received enough therapies thru insurance and don't feel the boys need any more?

mommyof4boys · January 2009

No, as of now Matthew will be recieving speech therapy through our local school district, IEP meeting on the 2nd. Christopher will be recieving one hour per week of speech therapy, one hour of physical therapy and one hour of congative play therapy and once he gains some in gross motor we will add one hour of occupational therapy. They reccomended addionation outside private therapies so I called the insurance and their policy is that unless their disabilities or delays are a result of a congenital defect, they get no coverage.

akimbo · January 2009

mommyof4boys:
They reccomended addionation outside private therapies so I called the insurance and their policy is that unless their disabilities or delays are a result of a congenital defect, they get no coverage.

(shakes head) I can imagine how frustrated you are. Sometimes I wonder how the heck these companies can get away with it all. How do they classify Autism which currently doesn't have a determined genetic cause? Maybe one of the private therapists will know a way to convince the insurance companies to provide some coverage - this is what we ended up having to do with our private therapists. They spent hours writing reports and talking to insurance. GL!

Pierce3252 · January 2009

Insurance completely sucks doesn't it? It isn't a system to help out those with the most problems, but one that we all pay into so they can just deny things we need!!!! Hope you can find something else in your area to help with the private therapies!!!

aurorabride · January 2009

I'm not on this board often, so pardon me if you've already stated this somewhere...but do you have a case manager at your insurance company? If not, you can request one and they may be able to help you get variances from the "standard" policies. If you've already tried that, are there any therapy schools near your where students could provide therapy with teacher supervision for free or lower than normal rates?

kirbear · January 2009

I remember reading in one of your older posts that the neurologist was thinking that your son is on the autism spectrum? Was this ruled out or is she/he still suspecting it? I am just curious because here in CT, in the birth to three system, even if a child isn't dx with Autism, but shows signs of it, they are eligible for up to 20 hours a week of service!!!! I worked with many children with signs but not a dx yet.

Also, you mentioned the neuro thinking seizure activity may have been self stim. If this is the case, they should be giving you OT now to assess sensory dysfunction, which doesn't need his gross motor skills to develop first. An OT works on fine motor and also the sensory component too.

Maybe you posted something else since then and I missed it but I just wanted to check on the autism piece and self stim and then maybe I can help to point you in a direction for further assistance!!!

Here in CT they just passed a law that if insurance company's cover speech, OT and PT for other reasons (injury etc...) that they now have to cover it for children with Autism as well. Hopefully other states will follow!!

mommyof4boys · January 2009

We go back on the 9th and they will look everything over and send us to a developmental pedi. It's my understanding that it will take some time to get to the diagnosis finalized. He may be over 2 until that happens since when I researched the normal wait time to get into a developmental pedi is at least 6 months.

Kirbear, should we call and ask for the OT component to be put back?

ScarletandGray · January 2009

I am late to replying but I know a lot of states have various programs that cover child fully from birth to 3 years old. They will pick up whatever your insurance does not cover. Our program here in SC even gives you an EI through the service to supplement the service as well. I know your youngest would qualify based on the birthdates in your siggy but your oldest would not, but it is a start. Start asking around, especially your current PT/OT/or SLP they should know if your area has a program like this. HTH!

kirbear · January 2009

I guess in terms of OT and sensory- have you looked into sensory integration dysfunction and do you feel that you son may have this?

Here is a list of many "signs" of sensory integration dysfunction.

https://www.sensorysmarts.com/signs.html

If you feel that you son meets some of these signs, I would definitely speak with your service coordinator and express your concerns and that you would like to have an SI assessment done on him. Part of that is an "eval" with him in which they do different things- touch him, spin him to watch reflex in his eyes, put a sticker on him- see if he likes the feel or how he handles distress etc... and then they will have you fill out a questionare as well.

Has anymore from EI mentioned anything about Autism? If you have concerns you could have them do a screening- such as the M-CHAT which is the modified Checklist for Autism in Toddlers or the BITSEA (brief infant toddler social emotional assessment) This will not dx him, but will flag him if there are concerns for somehng more going on. Often times this "flag" is enough to warrant additional hours of service while you navigate the lovely waiting lists for doctors and specialists. This way you don't lose time while waiting. Sometimes (certain states) also have individuals trained specifically in Autism and can evaluate him and provide an educational dx- different than a medical dx. But this would also get more hours of service for you. Often the EI dept puts out guidelines specific to different disabilities (speech, autism, hearing impaired, visually impaired etc...) and these can be very helpful in seeing what is recommended practice.

Hope his helps!!

OSULori · January 2009

Ugh. Insurance companies can really suck-the number of hoops they've made me jump through for some of my kiddos for ridiculous reasons is mindboggling. Sadly, some insurance companies will not pay for private therapy if a child doesn't have a "medical" dx-, autism, Down syndrome, CP, other chromosomal abnormalities, etc. Does the county you live in offer any kind of funding? Some of the counties here in Ohio will fund private therapies for special needs kids...it may be something to look into.

MichelleWP · January 2009

I wonder if an advocacy group might be able to assist you in dealing with the insurance company?

I agree it's awful. I know our insurance covers so much, then the therapy center writes letters explaining why it needs to continue, which according to them works.

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