Tuesday, September 16, 2008

Insurance Battles

Today I have been battling the insurance company. Sigh. It is just not fun.

Our insurance coverage changed in July. Josh's company went with a new policy. Anyway...I want my old insurance back!!! Our old insurance company paid for everything! We paid our co pays and deductibles and that was it. It seems like our new insurance doesn't cover anything. nothing. nadda. nuttin.

When the GI doctor mentioned that Will would benefit from the estim therapy, I called the insurance company to see if we had coverage. I called three separate times with the procedure code and diagnoses codes, talked with three different people, all three representatives said that we had coverage. They said that they (the insurance company) would pay 90% of each bill and we would be responsible for 10% until we meet the $2000 out of pocket maximum, then the insurance company would pay 100%. That was all they said. I questioned, asked "are you sure"? Yep. Okay, Cool! Off we went with the therapy.

Now, we found out that the insurance will only pay for 20 visits of each type of therapy per year. So he is entitled to 20 visits of speech, 20 visits of occupational, 20 visits of physical and 20 visits of developmental therapies each year. What a joke. We are talking about a child that is going to have to have some sort of therapy until, until, well the end of time.

The only one that we are mostly concerned about is speech therapy. Will has Ms. Patti coming to our home once a week for speech therapy. The estim therapy is done by a speech pathologist so therefore considered speech therapy, even though it is swallowing/feeding therapy, which he does three times a week. It is not going to take long to reach our 20 visits.

Because of the Early Intervention program through the state of IL, the therapist that come to our home will continue. What our insurance doesn't pay, the state of IL will. So those therapies will not stop BUT because they bill our insurance first, they count towards our 20. Which I don't understand...the Early Intervention program is for "developmental delays" not medical. If we didn't have any insurance the state would pick up the entire tab but since we do, they bill them first. So, if Will would break his leg (God forbid) and would require physical therapy at the hospital, our insurance would not pay for it because they had already been billed for 20 physical therapy visits through Early Intervention. Will could get the physical therapy at home with the physical therapist with Early Intervention but not at the hospital. It just doesn't seem right that they are charging our insurance. But anyway...

The 20 visit maximum was NEVER mentioned to me during my three phone calls to the insurance company. I am still working on it but I am sure that Josh and I will not be able to swing the $1300 per visit for the estim. Yikes! I have called the GI doctor that referred us for the therapy and she is writing a letter of "medical necessity" so we are appealing our insurance company. I hope that it works and that they will pay for the therapy because I really think that it is helping. I have got my boxing gloves on and ready to step in the ring. We will see...

Will also drinks pediasure, a toddler "formula". He receives 100% of his daily nutrition from the pediasure, so it is a MUST have. Our old insurance covered it, no problems. Our new insurance, not so much. I have called 3 times and was told that it was covered all 3 times. Aperia (the home health supply folks that provide it for us) has called 3 times and told that it is NOT covered all 3 times. GGGRRRRR!!! So the very helpful lady at Aperia and I call the insurance company via a conference call and we both talk to them together. "Sam" said that we have coverage and that they will pay for it. So we will see if they pay for it. I am not holding my breath but I do have the reference number for our conversation with "Sam" so if they don't at least I have some ammunition.

I miss our old insurance that paid for everything and didn't have any maximums.

7 comments:

Mama G said...

Man this is frustrating! I can't imagine the phone calls you must go through. Insurance is such a pain! Hopefully your dilligent hard work will pay off and WIll can continue with all of his needed therapies. I'll be saying an extra prayer for you guys.

Jessica mommy to Alex/ RTS said...

We are gong through the same thing right now with Alex's "formula". Insrenece is necessary, but evil!
I pary you get it smoothed out.

Blogversary said...

Oh, so frustrating. Keep up w/ the phone calls. We are still battling for Lucas' hospital stay which was deemed a medical emergency by our Dr. I know not really the same thing, but I am thinking of you.

Kristi said...

Sounds a mess Myssie. Thinking of your family. Hugs to Will

Michelle said...

Wow, that is rediculous. Every time I hear someone complain about their states policies and insurances, it really puts me in my place. I can't imagine having to fight for your child like that. It's absurd! Glad you're ready to "duke it out" but hopefully it won't come to that.

Cindy said...

If anyone will straighten them out, it will be you! So sorry to hear you're going through this.

Queen of the Urban Jungle said...

here's a prayer sent up for your family that common sense will prevail at the insurance company and you will get therapies covered that need to be covered!