About this blog.

My son was diagnosed with PDD-NOS at 24 months. I created this blog to bring meaning to the often-confusing label. Sometimes I have answers. Other times, just more questions.

Thursday, April 2, 2009

A Little Bit Autistic Against the Machine

The insurance machine, that is. After covering occupational therapy for about 10 months, our insurance carrier has denied future services because our insurance covers OT for rehabilitative, short-term purposes only. OT for developmental maladies is regarded as habilitative - gaining new skills - rather than rehabilitative or regaining old skills. So I've lodged an appeal, complete with six enumerated exhibits. (I'm completely serious.) One such exhibit is cutie photos of Brad ostensibly to demonstrate that he had no signs of hypotonia as an infant (whereas he does have hypotonia now, and therefore OT would be rehabilitative). But the real purpose of the pics is to make an emotional appeal. Claims reviewers do have emotions, don't they???

Also, we've put the wheels in motion to try to get one on one OT through the school system. Right now he gets OT in a group setting, which is great but one on one, and the monitoring that goes with that would be better. The road block with the school system is different, but equally impenetrable - I need to make the case that his DCD or whatever impairs his ability to functionally access the classroom. Bottom line: the children who get one on one OT are bumping into stuff or toe walking, and Brad doesn't do either of those things. So this is probably a long shot.

We'll hear back on both fronts in the next month...

20 comments:

Quirky Mom said...

Good luck on both fronts! You are a great advocate. :)

Elizabeth Channel said...

I, too, applaud your vigilance! And I wish you much energy! Because that's what it takes to fight these fun fights!

Shari said...

Good luck to you. It is frustrating to think that insurance office workers get to decide health concerns for your family, but it really does work that way. I hate that our insurance company provides for both speech and occupational therapy, but they hold it hostage until you prove it's needed. My opinion is that if a doctor says it's needed, then it is needed.

I'm not sure what my OT is really working on with my little guy, but he is practicing for a career as a ballerina in the toe walking area. Today I notice him walking on his heels, with his toes up. That was strange.

anything, sweetie said...

i wish i had your tenacity.

and i wish you had the nhs.

Julie said...

Persist with the insurance company! I was ready to pay out of pocket for OT because we had been turned down. But I learned a lot sitting in the waiting room listening to the other Moms telling their stories. Bottom line: after being turned down in the first and second round, we were reimbursed for $8,000 worth of OT services less a $10 co-pay per visit. (Laughing at the $10 co-pay. Yes, this was several years ago. I hope your co-pay isn't too high now.)

The pictures are a GREAT idea!

Nyx said...

Have you already gotten and reviewed a master copy of your insurance policy? I have heard that one major key is to look for language in the policy that says that they will cover neurological disorders. Since your guy has a neurological disorder, that would be a great help to you, I would think. Also, I happen to know that a local organization recently had a continuing education for lawyers lately on helping kids with special needs access services ... sadly I was unable to go ... BUT they told me they would be posting it on the internet and making it available for free in a couple of weeks. I am not sure how difficult it might be for a layperson (or are you a lawyer? I like all those exhibits!!) to follow, but you are obviously good at that sort of thing so I think you really might be able to make use of it. I will try to dig that up soon and post it for you. I have to confess at this point that I am a lawyer, but I'm sorry I know nothing (yet) about this area of the law. I hope eventually (in my spare time????) to learn more about this area of the law (for obvious reasons) but for now I'm really just as clueless as you are. However, I will repeat that in my unexpert opinion, at least, the first step for anyone fighting an insurance company over coverage in general (this is true no matter what your issue is) is to get an actual copy of your policy, which you probably already know is your contract. Oddly though, most of don't actually have a copy of this incredibly important legal document. Also, if you can figure out how to do it and you don't think it will traumatize him, I say TAKE YOUR CHILD IN THERE!! I think that your idea of putting a face on your story is brilliant. One other thing: I read some stuff that sounded like probably pretty good advice in a book by Dr. somebody Agin, I think it's called the late talker or something like that, on how to fight insurance companies and school districts for services. Of course, I have nothing to judge by, so I can't say for sure how good the advice is. Sorry for another gargantuan post. As somebody famous once said (Jefferson?), if I'd had more time, I'd've been more concise!

Laura said...

Thanks everyone.

Shari, toe walking is something insurers have to treat, isn't it? Good luck.

Julie, that's SO encouraging. Thank you so much for sharing. We're at the first level of appeal now, which is internal. If that's denied, we'll get an independent review.

Nyx, well, dark confession here: I'm an attorney too. LOL. I work Mon-Thurs, which is why I blog on Fridays and evenings. I do have a copy of my policy. OT is expressly described as limited to short-term rehabilitation. Brad's private OT told me that Massachusetts policies are unique in this regard; many OTs train in MA and then move to RI or NH to practice for that reason. Brad's EI OT confirmed this, and indicated that's why she works for EI - it's difficult to make a living as an OT in MA otherwise.

(Defamation-happy detractors, take note of my profession. I mean you, Susan. You're on registry.com, so I know where to serve you if I want to.)

Nyx said...

LOL!! No wonder I love your blog and the way your mind thinks. LOL!! Maybe one of these days you could blog on IDEA for me?? (hee hee)

Nyx said...

I've been thinking about this (I can't seem to help it). I can see that the word rehabilitative is a problem. but 2 thoughts: (1) Is there any way you could call to the OT physical therapy instead? seems like I once read somthing about that somewhere; (2) according to the Late Talker book sometimes you have better luck if you get a Rx for "treatment" instead of "therapy." Also, they say getting a Rx for a neurologist can make a big difference. That book is on books.google.com if you want to peek at that section for other ideas. I was amazed to discover that they actually give specific insurance codes in there! And the appendix has sample forms for the doctor to use. Pretty amazing (if it works).

Laura said...

Nyx, you rock, great ideas - esp citing the "neurology" coverage. The problem: I can't get an appointment with a neurologist. I tried once, and they wouldn't give me an apt without referral from developmental pedi. Developmental pedi ran some tests, but said neurology workup isn't indicated. Plus I feel guilty, like there are kids who need a neuro apt more than Brad, you know - I don't want to displace some one who truly needs a neuro. As for PT, I can't bill OT as PT because PT is conditioned upon using an approved PT provider. (It's an HMO.) BUT: if all else fails, I'll probably end up sending Brad to a PT in lieu of his OT.

Nyx said...

It's nice of you to say so, but sounds like I'm batting 0! I think it is so unfair for them to exclude coverage for a small child simply because he never had an opportunity to develop the skill in the first place and therefore can't be said to need "rehabilitation." Naturally, this makes me think it can't be legal. (Cause we know everything unfair is also illegal, right? hardehar.) Well, I couldn't stop, so at the risk of embarrassing myself, I am going to throw out 2 more ideas on something I know nothing about (really, being a transactional lawyer in Georgia has proved to be very unhelpful. ha! OK, here goes: (1) I found this on an Easter Seals website: "The Commonwealth of Massachusetts also requires coverage for any medically necessary early intervention services provided by a certified early intervention specialist for children from birth to three years old at a maximum of $5,200 per year per child and total of $15,600 for the whole period. (MA Gen. L. ch. 175 §47c)" -- I don't know if that's helpful or not, I didn't actually have time to look at all the definitions etc. (like what's medically necessary and what's a certified early intervention specialist), and plus I'll bet you already know all about that law, but just in case I thought I'd send it along; and (2) here's my really wacky idea ... and I know I'm scraping the bottom of the barrel here ... I don't suppose it could constitute age discrimination or something like that? It strikes me that the language in the policy provides coverage to an older person who may have gained a skill but then lost it due to some sort of neurological trauma, but yet denies it to a small child who is unable to gain it in the first place due to analogous trauma ... Maybe your case is less obvious, but what if someone's 13-month-old son had been in a car accident, got partially paralyzed and needed therapy to be able to feed himself ... he can't get it because they can't show that he ever fed himself before the accident? This seems to me to be discriminatory in effect, based on age. I know absolutely nothing about discrimination laws anywhere much less in Massachusetts, but I thought I would throw that out there .... (you know, it's starting to feel familiar ... did you blog about something like that already? LOL, it's probably not even my idea.)

Laura said...

You're good - it's like throwing darts at the dart board, and seeing what sticks. Well the EI coverage is only for under age 3. As for age discrim, I dunno - younger than age 40 is not a protected class.

goodmum said...

I hope this works! If they have hearts at all, the pics should do wonders. :)

rhemashope said...

Yes, very smart move with the pics. Those pictures MELT me! Good luck!

Nyx said...
This comment has been removed by the author.
Nyx said...

I got excited earlier because I thought the mental health parity law would help but of course it doesn’t. What a frustrating and unfair situation. Unconscionable!!

Jann said...

I think you'll find whenever you're dealing with a developmental issue that insurance companies do their darnedest not to be responsible.

After our son aged out of EI, we just used his preschool speech. But those therapists were all over the map in quality, and he wasn't progressing, so we added a private speech therapist on our dime, and have used her the past 3 years.

We attempted to go through our insurance, but they wouldn't pay even though ST was a benefit. You only got it if you had a stroke or you were in an accident.

Unless your state mandates coverage, it's very hard to get.

I guess my point is, if you feel that's VERY key to his development, I would just get my own OT, and sign up for a health savings account to cut down on the costs. It's possible to lose months of possible treatment while you wrangle with insurance.

But you SHOULD be able to get OT through your preschool. And the best track is to point out that it is what's required to get him ready for kindergarten and the whole structured learning environment.

Laura said...

Thanks, guys.

Timely comment, Jann. I'm meeting with the school tomorrow. Thanks for the pep talk, and wish me luck. Ps I'm reading Mislabeled Child - great rec.

Judith U. said...

Working on insurance legislation, both here in MA and now via a federal mandate too. Includes HABILITATIVE care ...

If Brad doesn't have an ASD diagnosis (can't remember if he's lost it "officially" or not) then I know here in MA there is a bill related to habilitative care for OT that's not restricted to autism that's coming down the pike..

Ugh...

Laura said...

Judith, that's MAJOR, thanks for the FYI...